The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXIII	Number 4	December 2020

Summaries

267	PRE-HOSPITAL CARE OF PATIENTS WITH SEVERE BURNS IN GERMANY: A REVIEW OF 29 YEARS OF EXPERIENCE (Schiefer J.L., Perbix W., Grigutsch D., Ribitsch B., Fuchs P.C., Schulz A. - Germany) Despite the high number of burn injuries worldwide, pre-hospital care differs across regions. Data documenting pre-hospital care of severe burn injuries in Germany are scarce. Nevertheless, efficient prehospital care of burn patients is crucial for later outcomes. Therefore, we retrospectively analyzed pre-hospital care in patients admitted to the burn intensive care unit of a specialized burn center in Germany from 1989 to 2018. Approximately one-third of all admitted patients arrived intubated to the burn intensive care unit. Mean total burned surface area was higher in intubated patients than in non-intubated patients. Hypothermia prevention measures were undertaken in most patients.Although cooling was performed in only 36 primarily admitted patients, it did not have an effect on temperature at admission. Instead, in the regression analysis a positive influence on mortality could be found (p=0.03). Inhalation injury was a reason for intubation and corticosteroid therapy. Corticosteroid use declined over the years and had no significant influence on mortality (p=0.38). Inhalation injury could be diagnosed in only 50.68% of patientsreceiving corticosteroids. Furthermore, especially in recent years, most patients with inhalation injuries did not receive corticosteroids. Although efficient prehospital care is crucial for later outcomes, standard pre-hospital care through first aiders and emergency personnel has not been applied. Therefore,strategiesfor information exchange, leading to standardized pre-hospital treatment guidelines,should be given high priority with special attention on pre-hospital cooling. In the future, data from registries and surveys can help expand information regarding pre-hospital burn treatment.
276	POST-TRAUMATIC STRESS DISORDER (PTSD) FOLLOWING BURN INJURIES: A COMPREHENSIVE CLINICAL REVIEW (Lodha P., Shah B., Karia S., De Sousa A. - India) Burns are a global public health problem with a large number of psychosocial and psychological problems that may ensue after burn injuries. One of the commonest psychological problems seen after burn injuries is depression, anxiety and post-traumatic stress disorder (PTSD). The following paper reviews the existing literature on PTSD following burn injuries. The concept of PTSD is explained for the non-psychiatrist involved in burn rehabilitation. The various psychosocial factors that determine the causation and course of PTSD following burn injuries are discussed. PTSD following burn injuries in special populations like women, children and adolescents, intentional burns and self immolation are also discussed. The role of cultural factors in the development of PTSD are elucidated and future research needs are laid out. PTSD is a very common occurrence after burn injuries and needs a multidisciplinary team evaluation for its management.
288	BRÛLURES ET ÉPILEPSIE : À PROPOS D'UNE SÉRIE TUNISIENNE (Dghaies A., Mokline A., Messadi A.A. - Tunisie) L'épilepsie et la brûlure sont deux problèmes de santé publique qui, quand elles s'associent, peuvent laisser des séquelles lourdes et handicapantes au patient, malgré les progrès techniques de la médecine et de la chirurgie. Nous avons mené une étude descriptive rétrospective s'intéressant à des patients épileptiques brûlés lors d'une crise convulsive, pris en charge dans le service de réanimation des brûlés de Tunis entre le 01/01/2011 et le 30/06/2019. Cinquante dossiers associant brûlure et épilepsie ont été revus. Vingt patients présentaient une brûlure secondaire à une crise d'épilepsie. L'âge moyen de nos patients était de 46 ans, il s'agissait de 11 femmes et de 9 hommes soit un sex-ratio H/F de 0,6/1. La surface cutanée brûlée moyenne était de 15%. Chez nos patients, la maladie épileptique était non contrôlée dans 75% des cas et 35% de nos patients ne recevaient aucun traitement antiépileptique. Les brûlures étaient d'origine domestique dans 95% des cas dont les 2/3 étaient en rapport avec une chute sur un brasero. Les lésions étaient de 3ème degré dans 70% des cas nécessitant une excision des tissus nécrotiques. Deux patients seulement ont bénéficié d'une greffe dermo- épidermique. Une amputation a été nécessaire chez 5 patients. La mortalité était de 25%, en rapport avec un état de choc septique réfractaire.
293	BLOOD LACTATE AND LACTATE CLEARANCE: REFINED BIOMARKER AND PROGNOSTIC MARKER IN BURN RESUSCITATION (Muthukumar V., Arumugam P.K., Narasimhan A., Kumar S., Sharma U., Sharma S., Kain R. - India) Adequate resuscitation of acute burn patients is important to ensure end organ perfusion and oxygenation. The ideal marker to the endpoint of burn resuscitation is still not established. We aimed to evaluate the role of blood lactate and lactate clearance in burn resuscitation and their association with mortality and sepsis in burn patients. The retrospective study included patients (18-50 years) with thermal and scald burns with total body surface area of 30% to 60% over a period of 9 months who had achieved target urine output of at least 0.5ml/kg/hr within 24 hours of resuscitation. Patients were divided based on their admission blood lactate levels (Group A < 2 mmol/L and Group B > 2 mmol/L). Group B was further subdivided into Group B1 in whom blood lactate levels reached less than 2 mmol/L within 24 hours of burn resuscitation and Group B2 in whom it did not. Total patients included were 203. Mortality (M) and sepsis (S) rates in subgroup B2 were higher (M=57.9%; S=43.5%) and rates in subgroup B1 (M=25.8%; S=27.4%) were comparable to Group A (M=27.8%; S=26.4%). Persistent lactic acidosis at 24 hours was independently associated with significantly increased mortality and sepsis. Our data suggests a correlation of blood lactate levels and lactate clearance within 24 hours of admission with mortality and sepsis related to burn injury.
299	ROLE OF INTRAVENOUS IRON OVER NONSURGICAL TRANSFUSIONS IN MAJOR BURNS (Carbajal-Guerrero J., Gacto-Sanchez P., Mendoza-Prieto M., Cayuela-Dominguez A., Manuel Lopez-Chozas J. - Spain) Anemia is a frequent condition in burn patients due to a mixture of blood loss and chronic inflammation. Transfusions increase the probability of serious infections and reduce overall survival, especially when unrelated to perioperative blood loss. Once the surgical phase in burn patients is completed, the role of parenteral iron administration in the reduction of subsequent transfusions is not well established. Burn patients subjected to at least two surgeries and presenting progressive anemia after concluding the surgical phase, without major symptoms, were selected (n=12). Those patients with confirmed iron deficiency were treated with intravenous(i.v.) ferric carboxymaltose (n=8). Subsequently, these patients were compared with a group of 18 control patients selected from our historical database (n=1375), matching controls by age (±5 years), sex, and TBSA burn (±6%). The objective was to verify if i.v. iron administration reduced the need for blood transfusions after the surgical phase. The analysis concluded that none of the casestreated required transfusions compared to 44% of the controls. There were no side effects related to the i.v. iron infusion. This result suggests that i.v. iron supplementation with ferric carboxymaltose could be an alternative in anemic patients without major symptoms once the surgical phase is completed. Iron deficiency should be assessed and i.v. supplementation must be administered if required in burn patients showing progressive anemia.
304	COLONISATION ET INFECTION À PSEUDOMONAS ÆRUGINOSA DANS UN SERVICE DE RÉANIMATION DES BRÛLÉS: ÉTUDE SUR 8 ANS (Frigui S., Messadi A.A., Thabet L. - Tunisie) Pseudomonas æruginosa est parmi les germes les plus incriminés dans les infections chez les brûlés. Les souches isolées sont souvent multirésistantes, compliquant la prise en charge de ces patients. Notre objectif était d'étudier les densités d'incidence de la colonisation et de l'infection à Pseudomonas æruginosa ainsi que la résistance aux antibiotiques des souches isolées chez les patients hospitalisés dans le service de réanimation des brûlés du Centre de Traumatologie et des Grands Brûlés (CTGB) en Tunisie. Il s'agit d'une étude rétrospective incluant 1 649 souches non répétitives de Pseudomonas æruginosa isolées durant une période de 8 ans (2012-2019). Pseudomonas æruginosa était le germe dominant de l'écologie bactérienne dans le service de réanimation des brûlés au CTGB (15%). Les densités d'incidence de la colonisation et de l'infection à Pseudomonas æruginosa étaient de 16,1? journées d'hospitalisations (JH) et 16,5? JH, respectivement. Une corrélation positive et statistiquement significative a été retrouvée entre la colonisation et l'infection à Pseudomonas æruginosa (rs=1; p=0,004). Les souches de colonisation étaient essentiellement des souches de colonisation cutanée (25,1%) et de cathéters centraux (22,3%). Les bactériémies dominaient les infections (19,5%). Elles étaient à point de départ cutané dans 22,1% des cas et liées aux cathéters dans 18,3% des cas. Les taux d'antibiorésistance étaient élevés allant jusqu'à 72,4% pour la pipéracilline- tazobactame (TZP), 49,4% pour la ceftazidime (CAZ), 74% pour le méropénème (MEM), 70,5% pour l'imipénème (IPM), 74,6% pour l'amikacine (AMK), 56,5% pour la ciprofloxacine (CIP) et 35,3% pour la fosfomycine (FOF). Aucune souche n'était résistante à la colistine (CST). Le taux des bactéries multi-résistantes était de 78%. Le taux des souches productrices de métallo-carbapénèmase était de 14,4%.
312	THE PROFILE OF SEVERE BURN INJURY PATIENTS WITH SEPSIS IN HASAN SADIKIN BANDUNG GENERAL HOSPITAL (Soedjana H., Nadia J., Sundoro A., Hasibuan L., Rubianti I.W., Putri A.C., Septrina R., Riestiano B.E., Prasetyo A.T., Harianti S. - Indonesia) Burn injury remains a major global health issue. An estimated 180,000 people die annually due to burn injury, and most cases occur in low- and middle-income countries, including Indonesia. Several complications of burns may lead to mortality, and sepsis is one of the major threats, with the risk of developing multi organ dysfunction syndrome. This study applied a descriptive-retrospective method on 3-year medical records of severe burn injury patients. The data were classified according to age, etiology, outcome, antibiotic resistance, and pathogens of sepsis. There were 100 medical records of severe burn injury, and 55% of them were accompanied by sepsis. The highest number of sepsis cases was found in the age category of 40-50 years old. Nearly 80% of the cases were fire-related burns. Blood and burn wound culture of recovered patients showed 55% contamination with gram-positive bacteria, and 50% of them with Staphylococcus hominis. Contamination of blood and burn wound culture of deceased patients with gram-negative bacteria was 100%, 60% of them with Pseudomonas Aeruginosa. There is a more than 50% chance of severe burn patients falling into septic conditions. More than half of the patients were infected with gram-negative bacteria. Pseudomonas aeruginosa remains the main culprit of septic burn-related death.
317	ANTIBIOTIC USAGE AFTER PROCALCITONIN-GUIDED THERAPY ALGORITHM IMPLEMENTATION IN A BURN INTENSIVE CARE UNIT (Zbyrak V., Reverón S.L., Smoke S., Mehta A., Marano M.A., Lee R. - USA) The study investigated antibiotic utilization after the implementation of a procalcitonin (PCT)-guided antibiotic algorithm in the burn intensive care unit (BICU) to minimize antibiotic exposure appropriately. An algorithm established the ordering of an initial procalcitonin level, an additional level following 48 hours post- admission, and upon suspicion of sepsis. The primary endpoint was the percent of days on antibiotics in the BICU. Secondary endpoints were the percent of patients reinitiated on antibiotics, length of BICU and hospitalstay, and 30-day mortality. Desirability of Outcome Ranking (DOOR) and ResponseAdjusted for Duration ofAntibiotic Risk (RADAR) methodology aided in antibiotic usage evaluation. The retrospective and prospective phasesinvolved five and seven patientsin the final analysis, respectively. The median percent of days on antibiotics in the BICU was 33.3% versus 14.3% in the retrospective and prospective phases, respectively (p=0.222). Secondary outcomes evaluated were percent of patients reinitiated on antibiotics at 80.0% versus 28.6% (p=0.242), the median length of BICU stay at 38 days versus 31 days(p=0.465), the median duration of hospital stay at 39 days versus 37 days (p=0.624) and 30-day mortality of one versus zero cases (p=0.417) in the retrospective and prospective group, respectively. The probability of better DOOR with a PCT-guided antibiotic algorithm versus the control group was 95.7% (95% CI, 81.4-99.5%). The benefit of a PCT-guided antibiotic algorithm implementation cannot be determined based on the smallsample size producing a lack of internal validity. Future studies warrant utilizing DOOR/RADAR to evaluate antibiotic stewardship strategies in the burn patient population.
323	ACUTE AND SUB-ACUTE RECONSTRUCTION OF PERIORBITAL THERMAL BURNS INVOLVING THE ANTERIOR LAMELLA OF THE EYELID WITH SIMULTANEOUS FULLTHICKNESS SKIN GRAFTING AND AMNIOTIC MEMBRANE GRAFTING (Reed D.S., Plaster A.L., Mehta A., Hill M.D., Zanganeh T.S., Soeken T.A., DeMartelaere S.L., Davies B.W. - USA) Thermal burns of the periorbital region offer a particular challenge to surgeons in terms of satisfactory operative reconstruction. Several approaches currently exist, including full-thickness skin grafting following scar excision. The authors present a novel technique for the reconstruction of periorbital thermal burns involving the anterior lamella of the eyelid with simultaneousfull-thicknessskin grafting and amniotic membrane grafting.Aretrospective review ofsix patients with periorbital thermal burn injury involving the anterior lamella of the eyelid(s) who underwent operative reconstruction utilizing this technique was performed. The operative and post-surgical outcomes were evaluated. In total,sixteen graftsites were examined.All graftsites demonstrated appropriate coverage and healthy re-epithelialization over the previously necrotic and burned areas. No evidence of cicatricial changes orlagophthalmos was noted.The postoperative outcomes demonstrate excellentfunctionality and cosmesis. By providing acute reconstruction, the risk of ophthalmic damage and vision loss secondary to cicatricial eyelid changes may be avoided.Additionally, utilizing only a minimal amount of tissue for reconstruction preserves vitalskin. This analysis demonstratesthe viability ofsimultaneousfull-thicknessskin grafting and amniotic membrane grafting for the acute and sub-acute reconstruction of periorbital thermal burn injury.
329	AESTHETIC RECONSTRUCTION OF POST-BURN EYEBROW ALOPECIA WITH A SUPERFICIAL TEMPORAL ISLAND SCALP FLAP: A CASE REPORT AND REVIEW OF THE LITERATURE (Amouzou K.S., Hissein H.A., Mokako L.J., Diouri M. - Togo) Eyebrows have a critical functional and aesthetic role on the face. Alopecia on the eyebrows has multiple origins, including scars formed after deep burns on the head and neck region. Reconstruction of the eyebrows represents a challenge for plastic surgeons due to their particular anatomical structure and variations inside of genders. Follicular Unit Transplantation (FUT) is believed to be the gold standard for the treatment of all sorts of alopecia, including that located on the eyebrows. However, FUT is technically demanding and requires skills, extensive anatomical knowledge, and equipment. In settings where FUT is still not feasible, flaps such as the superficial temporal artery island scalp flap remain reliable options. A 32-year-old male patient presented at the National Burn and Plastic Surgery Center, Casablanca (Morocco), with right eyebrow alopecia caused by fire burn on the face. We reconstructed the alopecia using a superficial temporal artery island scalp flap. The result was excellent. The patient and the physician were both very satisfied, and the patient stated that he was more comfortable with his social relationships. Among the current procedures used for the reconstruction of eyebrow alopecia, the superficial temporal artery island flap remains a versatile solution, especially after burn injuries in male patients.
334	EXPLORING CADAVER SKIN FOR STANDARDIZATION OF RABBIT AND PORCINE BURN MODELS IN RESEARCH (Ajit A., Krishnan L.K., Harikrishnan V.S., Varkey P., Sabareeswaran A. - India) Burn animal models provide substantial insights into burn pathophysiology. Choice of the apt model is important for determining the clinical efficacy of new medicines. Therefore, standardization of burn models is crucial for scientific research. Use of common techniques like hot water, electricity and incandescent instruments to generate animal burn models is widely reported. However, great discrepancy in employed temperature and exposure times demands user-dependentstandardization of the animal model prior to research. Establishment of custom generated in vivo burn models giving consideration to reduced use, suffering and risk of the experimental animal is equally crucial. Accordingly, this pilot study demonstrates a novel approach using rabbit and porcine cadaverskin forstandardization of burn parameters prior to use in live animal models. Using a custom-made soldering iron coupled to a 16cm2 surface area copper plate, burns at randomly chosen temperatures of 80?C and 120?C, with exposure times ranging from 60s to 180s, were produced on rabbit and porcine cadaver skins. On gross and histopathological analysis, parameters required to generate characteristic changes for deep partial and full thickness burn involvement were established. The identified temperature and exposure time parameters were further validated in live animal models. In vivo validation established the success of this approach, highlighting reduced animal use, ease, reproducibility and efficacy in burn model standardization. The findings of this study will hopefully encourage researchers to opt for cadaver skin to determine parameters required to generate a specific degree of burn prior to its use in live animals for burn research.
341	ANALYSIS OF DEVELOPING POSSIBILITIES OF VOLUNTARY MUNICIPAL FIRE BRIGADES IN THE VIEW OF THEIR PERSONS IN AUTHORITY (Drotárová J., Roznák P., Reitspís J., Palko P. - Slovakia) This article takes up a series of questionnaire researches focusing on the importance of and the need for voluntary fire brigades in the view of various target groups. The questionnaires are part of a solution of the project IP44/2016/VSBM. The study based on the project conducts an analysis of possibilities of how to develop voluntary municipal fire brigades in the view of the main representatives of the respective municipalities, namely persons in authority, primarily chairmen and commanding officers. Since 2014, voluntary municipal fire brigades have been supported by the state in the form of a flat rate per organisation. In previous years, the Ministry of the Interior of the Slovak Republic provided a lot of fire engines, flood equipment trailers and other fire brigade technical equipment. Some questions concerning the activity of organising firemen, e.g. permission for members of voluntary municipal fire brigades to intervene in the event of extraordinary events, are still not solved. This article summarizes possibilities for optimizing voluntary municipal fire brigades, and opinions of persons in authority of voluntary municipal fire brigades regarding their position within the Integrated Rescue System of the Slovak Republic.

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