The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXIII	Number 2	June 2020

Summaries

89	COMPREHENSIVE PERCEPTION OF BURN CONVERSION: A LITERATURE REVIEW (Wardhana A., Basuki A., Aurora L., Marsigit J. - Indonesia) Burn conversion is the conversion of stasis zone into both greater burn area and burn depth. It may hamper the patient's condition since morbidity and mortality are expected to be higher with the increase of burn size. To gain a comprehensive perception of burn conversion, this study aims to collect the latest updates regarding therapy, diagnosis, etiology and prognosis. A literature search was carried out on online databases, namely PubMed, SCOPUS and PROQUEST. The keywords "Burns AND (Conversion OR Progression OR Expansion)" were formulated. The inclusion and exclusion criteria were applied. Twenty-six articles were found, which were divided into diagnosis of burn conversion (11%), etiology of burn conversion (8%), prognosis of burn conversion (0%), and therapy of burn conversion (81%). All of the research was performed on animals. One of the best tools to diagnose burn conversion was the forwardlooking infrared (FLIR) imaging, having sensitivity up to 96% and specificity up to 100% to predict scar depth ?3 mm. The main etiology was ischemia, reactive oxygen species and inflammation. Most of the research regarding therapy showed benefit in preventing burn conversion. However, no side effects were investigated and not all of the research was statistically significant. More research on burn conversion prognosis and treatment side effects should be performed. Further research involving trials in humans should be conducted, since animal and human trials may differ.
97	ETHNIC AND SOCIAL FACTORS IN TODDLERS WITH EXTENSIVE BURNS IN THE BULGARIAN PAEDIATRIC POPULATION: PROBLEMS, DILEMMAS, SOLUTIONS (Argirova M., Arnautska E. - Bulgaria) The treatment of major burnsin toddlersis a serious challenge, even for the best physicians. Children's delicate organism decompensatesfast and even a small delay orslight mistake in therapy can lead to fatal consequences. The aim of this study is to create a profile for children at risk through a retrospective analysis of ethnic origin, citizenship, lone parent families and age of parent. Demographics, profile of the parent raising the child, burn size, and location of the incident were also recorded. A total of 100 children of both genders, no older than 36 months and treated in the clinic between 2012 and 2019 were included in the analysis. All had burns above 10% and were treated in the intensive care unit: 43% of the children were raised by single mothers, 57% by both parents; 27% of the mothers were minors; 58% were from distant non-urbanised regions; 39% were Bulgarian, 9% Bulgarian-Muslim and 50% gypsies. For 57% of the cases, burn had happened in the kitchen, for 26% in the bathroom and for 17% in other parts of the home. Children at risk come from poor and distant regions, and the suburbs of urban areas. They mostly have lone parents with bad socialstatus and low educational level. That is why lowering the level of household burns is a very hard task.Awell-structured national program to educate young parents and parents raising toddlers, and control household conditions is needed.
101	THE OUTCOME OF FUNGAL INFECTIONS IN A BURN INTENSIVE CARE UNIT: A STUDY OF 172 PATIENTS (Horta R., Tomaz D., Egipto P., Silva A. - Portugal) Burned patients are an especially fragile population in which infections are a leading cause of death and morbidity. Fungal infections have become increasingly prevalent in Intensive Care Units (ICUs) and burn ICUs. Management of fungal colonization and infection still constitutes a challenge for clinicians. The aim of this retrospective cross-sectional study was to characterize the population of burn patients with fungal infections admitted to our Burn ICU between January 2013 and December 2015. Patients were characterized according to age, gender, date of admission and exit, type of burn, type of exit, total body surface area (TBSA) and presence of inhalation injury. Positive fungal cultures, causative pathogen and site of sampling were also registered. Statistical analysis centred around the presence of fungal infection/colonization was performed using IBM SPSS Statistics. A total of 172 patients were included, 38 (22.1%) had a positive fungal culture and of these 8 (21.1%) died. Patients with fungal infection/colonization stayed more days than those without infection. However, this tendency did not reach statistical significance when patients that died in the ICU were excluded. No relationships were found when comparing positive fungal cultures with TBSA, burn aetiology, inhalation injury or mortality. Fungal infections are a major cause of morbidity and mortality despite TBSA, burn type or presence of inhalation injury. Efforts should be made to improve management of fungal infections, especially in burn patients and other critically ill groups.
107	PRISE EN CHARGE D'UNE MUCORMYCOSE DISSÉMINÉE CHEZ UN PATIENT POLYTRAUMATISÉ ET BRÛLÉ: INTÉRÊT DES INSTILLATIONS LOCALES, RAPPORT DE CAS ET REVUE DE LA LITTÉRATURE (Lherm M., Shipkov H., Fayolle- Pivot L., Boibieux A., Taverna X-J., Braye F., Brosset S. - France) Les mucormycoses sont des infections fongiques à champignons filamenteux rares mais grevées d'une mortalité élevée (20 à 50%). Du fait d'une symptomatologie peu spécifique, dominée essentiellement par des nécroses tissulaires, le diagnostic est souvent tardif, impactant négativement le pronostic. La prévalence de cette infection est augmentée chez les patients brûlés- polytraumatisés du fait de la contamination environnementale lors de l'accident et du terrain d'immunodépression. Nous présentons le cas d'un patient de 38 ans victime d'un accident de tracteur. Durant la prise en charge, surviennent à deux reprises des ruptures spontanées de l'artère humérale droite. Les prélèvements per- opératoires et des hémocultures mettent en évidence la présence de Lichteimia spp. La prise en charge, médico- chirurgicale, a associé un traitement systémique par amphotéricine B liposomale puis posaconazole, des parages chirurgicaux itératifs de la nécrose, un pontage huméral droit avec mise en place d'allogreffe artérielle et une couverture axillaire par un lambeau musculaire pédiculé de grand dorsal droit. Au traitement de référence ont été ajoutées des instillations biquotidiennes d'amphotéricine B. Les mucormycoses doivent être recherchées au moindre doute chez les patients brûlés et/ou polytraumatisés. Le diagnostic précoce et la prise en charge médico- chirurgicale rapide et adaptée sont des facteurs clés de la survie du patient. Nous pensons que les instillations d'amphotéricine B permettent une amélioration du pronostic fonctionnel chez des patients qui nécessitent des parages de nécrose itératifs. L'intérêt et les modalités de leur utilisation restent à définir et à évaluer.
112	INFLUENCE OF INHALATION INJURY ON RESTING ENERGY EXPENDITURE AND PLASMA METABOLIC HORMONES IN ADULT BURN PATIENTS (Lam N.N., Khanh P.Q., An N.H., Luong N.V., Tien N.G., Kien N.X. - Vietnam) The aim of thisstudy wasto investigate the influence of inhalation injury on resting energy expenditure (REE) and some plasma metabolic hormonesin adult burn patients.Aprospective study was conducted on 16 adult burn patients admitted to the burn intensive care unit, National Burn Hospital, Vietnam. Eight patients with inhalation injury were matched with 8 non-inhalation injury patients by burn extent and age. REE measurements were obtained within 48h of admission and every week after burn. Plasma levels of epinephrine and cortisol were determined on admission and on the 7th day after burns. The results showed that, apart from REE at admission, all values of REE were significantly higher than basal metabolic rate (BMR) at all time points (p < .005). Over time, REE of both groups significantly increased and reached peak values on the 7th day after burn (1964 ± 300Kcal/m2 and 1991.8 ± 467.8 Kcal/m2 ;REE/BMR: 1.5 vs. 1.6 respectively).These valuesthen steadily reduced, but no remarkable differences of REE and REE/BMR were seen between the two groups at any time point (p > .05). In addition, plasma concentrations of epinephrine and cortisol were notsignificantly different in each group and between the two groups of patients with and without inhalation injury. In conclusion, inhalation injury may not affect metabolic response state in adult burn patients as measured by REE and metabolic hormones.
116	LOSS OF VISION IN A PATIENT WITH MAJOR BURN INJURY, INCLUDING A REVIEW OF THE LITERATURE (Fernández-Quinto A., Galeiras-Vázquez R., Rodríguez-Pérez E., Bugallo-Sanz J., RogelVence R., López-Suso M.E., García-Barreiro J.J., García-Sancho C., Cerdeira-Pena P., Valero-Gasalla J.L. - Spain) Vision loss is a rare complication due to decreased blood flow through the optic nerve, which has been described in certain groups of postoperative patients and as a major complication in polytraumatisms that need massive fluid resuscitation. However it has rarely been described in burned patients. We describe a patient with ischemic optic neuropathy (ION) as a major burn injury complication, focusing on his massive fluid resuscitation and hospital course and comparing it with previous case reports related to burn injuries in the literature. A 37-year-old male was admitted to the Burn Care Unit with an 85% total body surface burn injury caused by high temperature water vapour with traces of caustic soda. He underwent escharotomies the day of admission and sequential enzymatic and surgical debridement. An ophthalmological follow-up was conducted, with no fundoscopy alterations, and ION and vision loss was subsequently diagnosed. ION is an uncommon and currently irreversible condition, prevention therefore being the principal objective. Thus, minimization of risk factors such as anaemia, significant blood loss and massive fluid resuscitation, is advisable.
121	CRACK COCAINE INDUCED UPPER AIRWAY INJURY (Vandjelovic N.D., Larson A.K., Sugihara E.M., Stern N.A. - USA) The paper describes the presentation and management of patients presenting with crack cocaine induced upper airway injury. The study involved a retrospective clinical series of six patients with crack cocaine induced upper airway injury. Demographics, symptoms, physical exam, flexible laryngoscopy findings, treatment and intervention were recorded. All patients with crack cocaine induced thermal injury presented with mouth or throat pain plus at least one other laryngeal symptom, such as globus sensation, dysphagia or throat tightness. On physical exam, the supraglottis was the most common subsite of endolaryngeal injury. The only statistically significant finding was the number of subsites on initial physical exam and flexible laryngoscopy and need for airway intervention (p = 0.001). Airway intervention was required in one patient, while the remaining patients were closely observed until resolution of symptoms. Upper airway injury should be suspected in patients who present with pain and laryngeal symptoms after smoking crack cocaine.
126	THE EFFECT OF FREQUENCY OF DRESSING REPLACEMENT WITH 0.1% BETAINE-POLYHEXANIDE SOLUTION ON THE FORMATION OF COLLAGEN AND EPITHELIAL TISSUE IN ALBINO WISTAR RATS WITH GRADE IIA BURNS (Kristianto H., Paundralingga O.T.K., Purwantiningrum D.A., Maknun L., Primasari R.O., Waluyo A. - Indonesia) Moist wound healing is a method of retaining moisture to increase migration of epithelial cells and synthesis of collagen. One of the liquids that can be used is 0.1% betaine-polyhexanide solution. This study aimed to determine the effect of frequency of dressing replacement with 0.1% betaine-polyhexanide solution on the formation of collagen and epithelial tissue in albino wistar rats with grade IIA burns. The study used the randomized posttest-only control group design to investigate within a period of 13 days 25 male rats, which were divided into 5 groups, each comprising 5 rats. The groupsincluded the control group and the treatment groups with dressing changes every 12 hours, 24 hours, 36 hours, and 48 hours. The variables measured in this study were the epithelium and collagen percentages. One-way ANOVA test revealed a significant difference in the synthesis of collagen with a p-value of 0.002 (p < 0.05) but no significant difference in the formation of epithelial tissue with a p-value of 0.561 (p > 0.05). The highest score was found in the group with a dressing change every 24 hours. It can be concluded that the treatment of grade IIA burns with 0.1% betainepolyhexanide solution once every 24 hours can optimize the formation of collagen and epithelial tissue.
134	SPRAYED CULTURED AUTOLOGOUS KERATINOCYTES IN THE TREATMENT OF SEVERE BURNS: A RETROSPECTIVE MATCHED COHORT STUDY (Karlsson M., Steinvall I., Olofsson P., Thorfinn J., Sjöberg F., Åstrand L., Fayiz S., Khalaf A., Divyasree P., El-Serafi A.T., Elmasry M. - Sweden) The standard treatment of burnsis early excision followed by autologousskin grafting.The closure of extensive deep burns poses a considerable challenge. Cultured autologous keratinocytes have been used since 1981 in an effort to improve healing. However, the time required to culture the cells and the lack of a dermal component limit the expectations of outcome. Our aim wasto compare the duration of hospitalstay between patients who were treated with autologous skin grafts and cultured autologous keratinocytes and those who were treated with autologous skin grafting without cultured autologous keratinocytes. In this retrospective study all patients treated with cultured autologous keratinocytes between 2012 and 2015 were matched by size and depth of burn with patients not treated with cultured autologous keratinocytes. Multivariable regression was used to analyse associations between duration of hospital stay and treatment adjusted for age, mortality, size and depth of the burn. Then, we investigated the possibility of differentiation of human bone marrow stem cell line to keratinocyte-like cells as a future direction. The regression analysisshowed a coefficient of 17.36 (95% CI -17.69 to 52.40), p= 0.32, for hospital stay in the treatment group, compared with the matched group. Our results showed no difference in the duration of hospital stay between the two treatments. Autologous stem cells should be considered as a future modality of burn management, although further studies are needed.
143	THE USE OF THE ALT PERFORATOR FLAP FOR RECONSTRUCTION OF SEVERE PEDIATRIC BURN SCAR CONTRACTURES (Karami R.A., Atallah G.M., Makkawi K.W., Ibrahim A.E. - Lebanon) Pediatric burn injuries are frequently complicated by burn scar contracturesthat often create functional limitations. Usually release followed by skin grafts, local flaps or tissue expansion is adequate. In rare instances, when the contracture issevere and simpler forms of reconstruction have failed, microsurgical free tissue transfer becomes essential. Even though in pediatric patients it can be technically more demanding and there is a reported risk of vasospasm, free tissue transfer has proven to be a good alternative. It is a one-stage procedure that guarantees decent functional outcomes. The perforator anterolateral thigh flap is a workhorse flap in microsurgery. The versatility of this flap allows it to be used in various anatomic locations. In this paper we report its use in neck, wrist, foot and face reconstructions. Flap successrates were 100%, with no cases of partial or complete flap loss. No acute or chronic complications were noted. Only one patient required reoperation for thinning of the flap to allow proper shoe fitting. All patients had good functional outcomes and the contractures were fully released. Joint function was regained in all patients except one that required wrist fusion. When indicated, the free perforator ALT flap is an excellent option for challenging reconstructions.
149	CONTEMPORARY RECONSTRUCTION OF A SEVERE NEUROPATHIC FOOT BURN INJURY (Vasilopoulos G., Kourakos P., Kiskhra O., Moraitidis T., Polikandrioti M., Avramopoulou L., Castana O. - Greece) The neuropathic foot in diabetic patients constitutes a special clinical entity that needs particular care and ministration. A burn on such a foot requires special care and attention in order to avoid amputation, especially when the burn is a deep partial or a full-thickness burn. The indication for early excision and coverage of a diabetic foot is taken under consideration in clinical practice. An 80-year-old male diabetic patient with deep partial and full-thickness burns on both his feet after a long hot footbath is presented. Even though feet appearance indicated the need for amputation of both feet, we performed gradual surgical debridement and primary coverage with human skin allografts. Both feet were finally covered with partial thickness skin grafts. Considering age, general condition and severity of the burn injuries, the final results were very satisfactory. We believe that the gamma-radiated allograft is another useful adjunct to the reconstructive armamentarium of the surgeon.
154	END-OF-LIFE (EOL) COMFORT CARE AND WITHDRAWAL OF LIFE SUPPORT (WLS) OF SEVERELY BURNED PATIENTS: A REVIEW OF THE LITERATURE (Atiyeh B. - Lebanon) Ensuring burn patients get appropriate care without pursuing futile treatment has always constituted a challenging balance for burn surgeons. Patients with no prospect of cure who eventually die should potentially experience more comfortable and peaceful end-of-life (EoL) care. Recognizing that death for some patients is inevitable and can only be postponed but not avoided would open the way to a more humane comfort care for such patients. Though comfort EoL services are still not universal in burns intensive care units (ICU) and disparities still exist in access, and use of palliative care appears underutilized, its integration in the burns ICU has increased over the past decade with undeniable benefits. Palliative care consultations should be considered in select burn patients for whom survival is highly unlikely.
162	COMPARISON OF PREPARATION OF SELECTED TARGET GROUPS IN THE FIELD OF FIRE PROTECTION IN THE VISEGRAD 4 COUNTRIES (Kovácová L., Drotárová J., Losonczi P. - Slovakia) The aim of the paper is to compare the safety awareness and preparation of children and adolescents for an extraordinary event, with an emphasis on fire protection. The Fire Prevention Programme in Poland is a unique preventive and educational initiative developed by a team of fire and rescue experts in Poznan. These experts have worked with colleagues in the UK for many years and have benefited from their experience with similar programmes that have produced measurable results in improving the safety of local communities. The priority of the pre-school fire prevention programme in Hungary is to contribute to the active learning of the surrounding world of children, to the formation of safe lifestyles. In the Czech Republic, the preventive programme "Education of children in the field of fire protection and protection of the population" is implemented to a good level. There is absolute inadequacy and out-dated study materials in the area in the Slovak Republic. There is no separate subject dealing with emergencies. Fire protection and extraordinary events are only dealt with in "Protection of Man and Nature", whose content only complements other teaching subjects.
170	CASE REPORT: BURNS THROUGH METAL - UNIQUE PATTERN OF FIRST LIGHTNING STRIKE INJURY IN ISRAELI ARMY (Kruchevsky D., Sadeh O., Dominsky O., Levanon S., Ramon I., Ullmann Y. - Israel) This case report presents a 19-year-old Israeli soldier who sustained injury as a result of a lightning strike during an outdoor military activity. The patient was found in a state of altered consciousness and respiratory distress. He suffered multiple second-degree burns to the neck, chest and abdomen area, corresponding to the locations of his metal identification tag, rifle and belt buckle. Lightning transmission through these metal objects caused considerable thermal burns at contact sites. The patient was treated conservatively until wound healing and stabilization of respiratory function. This is the first reported case of military personnel injured by lightning strike in Israel. Although rare in the Mediterranean region, safety guidelines and regulations should be implemented to avoid the associated serious and permanent injuries that may be caused by lightning strikes.

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