The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXIV	Number 2	June 2021

Summaries

125	EPIDEMIOLOGY AND OUTCOMES OF RADIATOR BURNS AT A HIGH THROUGHPUT BURNS CENTRE (Brewer C.F., Mabvuure N.T., Pinto-Lopes R., El-Muttardi N. - UK) Indoor radiator burns can cause significant morbidity and mortality, especially in vulnerable patients. However, the epidemiology and clinical outcomes are poorly characterized. A retrospective study of all radiator burns referred to a tertiary regional burns centre between 2013-2019 was conducted. Four hundred and forty-seven patients (median age 25.6 years, male:female ratio 1.4:1) were referred; 109 (24%) admitted, 201 (45%) managed in outpatients and 137 (31%) managed locally. The incidence of burns leading to referral was 0.65/100,000/year, but increased annually. Contact burns consisted of 99.6%.Age distribution was bimodal: <5 years (43%), >65 years (27%), although all ages were affected. Median TBSA was 0.75% (0.1-11.5%), but 79% had injuries <2%. Childhood burns were predominantly superficial dermal grab injuries, usually manageable as outpatients. Elderly patients had larger burns usually secondary to falls or impaired sensorium, and were more likely to die (p<0.05). Burns due to impaired sensorium were deeper and more likely to require surgery (p<0.05). Sixty-three (14%) patients required surgery. Thirty-day mortality was 1.1%. Age was the only significant predictor of mortality. This study quantifies the epidemiology and outcomes of a growing problem. It identifies at risk populations (extremes of age), and important features of the clinical assessment.
135	HYPERNATREMIA RISK FACTORS AND PROGNOSTIC IMPACT IN BURN PATIENTS: A CASE CONTROL STUDY (Sedghiani I., Mokline A., Fredj H., Bouguezzi N., Gamara F.Z., Ben Saad M., Thabet, Messadi A.A.. - Tunisia) Hypernatremia is associated with poor outcomesin critically ill patients. Hypernatremia risk factorsin burned patients are not well studied. We aimed to identify hypernatremia risk factors and to evaluate outcomes in burned patients admitted to our burns intensive care unit. A case control study was conducted in adult burned patients hospitalized between January 1st 2017 and December 31st 2019.Cases who developed hypernatremia (>145 meq/L) during hospitalization were matched 1:1 with controls based on age and total burn surface area.There were 57 cases and 57 controls with a mean age of 41±18years.The majority of patients had major burns(n=99, 86.8%). The time onset of hypernatremia wasseven days post burn.Compared to controls, the case group mostly consisted of transferred patients with longer time from injury to intensive care unit admission. Inhalation injury, mechanical ventilation, intravenous fosfomycin and colistin were associated with hypernatremia. Admission to the intensive care unit after six hours post-burn was the independent risk factor (OR=4.5). Hypernatremia was associated with longerlength ofstay and with highermortality.We conclude that delayedmanagement, inhalation injury,mechanical ventilation, fosfomycin and colistin administration are the main hypernatremia risk factors in burned patients.
140	ASSESSMENT OF CREATINE PHOSPHOKINASE (CPK) CHANGES IN PATIENTS WITH HIGH-VOLTAGE BURNS (Tien N.G., Chi L.D., Lam N.N.. - Vietnam) The aim was to evaluate change in creatine phosphokinase (CK) enzyme in high-voltage burn patients. A retrospective study was conducted of 104 patients (aged from 16 to 83 years old) who suffered from burns due to high voltage and were treated as inpatients at the National Burns Hospital. Patients were divided into two groups: patients with limb amputations in group A and patients without limb amputations in group B. Analysis was conducted on medical records of testing for plasma CK level immediately upon admission and during treatment. Testing of CK plasma enzyme was performed on an AU480 machine manufactured by Beckman Coulter. Data were processed using SPSS 20.0 software. Average plasma CK index increased on the first day of admission. In group B, plasma CK enzyme index increased from 5.5 to 22.4 times, and in group A this index increased from 5.6 to 46.5 times compared with the plasma CK index of normal people (170 U/l). The mean plasma CK enzyme index in the amputation group (n=20) was higher than in the non-amputation group (n=84). In patients with limb amputations, CK levels significantly decreased after deep necrosis incision and after amputation (p=0.00001). In patients with burns due to high voltage, plasma CK levels rise in the first days after burns. Increased plasma CK enzyme levels are directly proportional to total burn surface area (TBSA) and burn depth. After escharotomy and amputation, plasma CK levels decreased significantly compared to preoperation levels.
145	CHARACTERISTICS AND OUTCOME INFLUENCE OF INCREASED PLASMA TRIGLYCERIDE LEVEL IN SEVERELY BURNED ADULT PATIENTS (Lam N.N., Khanh P.Q., An N.H.. - Vietnam) The aims of this study were to investigate the profile of serum triglyceride level and its influence on outcomes in adult patients with severe burns. An observational study was conducted on 62 patients with burn extent from and over 20% TBSA. Results indicated that serum triglyceride level steadily increased from 1.9mmo/l on the 3rd day to 2.5 mmol/l on the 14th day before reducing on the 21st day after burn. Remarkably higher triglyceride level was seen in patients with full thickness burn area >20% TBSA and in inhalation injury (p < .05). Liver size significantly increased over time and was greater in increased triglyceride patients, but the difference was not significant (p > .05). In addition, patients with elevated serum triglyceride level had significantly higher rates of multiple organ failure and death compared with the remaining group. Further studies need to be conducted to understand and determine intervention for increased plasma triglyceride levels in severely burned patients.
150	PREVALENCE OF MULTIDRUG-RESISTANT BACTERIA ISOLATED FROM BURN WOUNDS IN ALGERIA (Tchakal-Mesbahi A., Abdouni M.A., Metref M. - Algeria) We conducted a thirty-four-month retrospective study in the Burns Center from June 2015 to 30 April 2018.Atotal of 1585 burn wound swabs were taken from 258 admitted patients, of both sex and average age from 2 to 84 years old. Out of the 1585 burn wound swabs, 79.12% were positive for bacterial growth. Gram-negative bacteria were the most common bacteria isolated from burn wound swabs (68.95%), followed by cocci gram positive (28.62%), which were represented mainly by Staphylococcus spp. and Enterococcus spp. species, and then other species such as candida spp. (2.41%). Staphylococcus aureus was found to be the most common isolate (of the 70 Staphylococcus aureus, 52 were methicillino-resistant MRSA) followed by Pseudomonas aeruginosa (n=58; 25.71%), Klebsiella pneumoniae (n=43; 20.15%), Acinetobacter baumannii (n=18; 18.70%), Proteusspp. (n=17; 7.91%), Escherichia coli (n=14; 5,75%), Enterobacterspp. (n=8; 3.22%), Candida spp. (n=6, 2.41%), Stenotrophomonas maltophilia (n=2; 1.73%), and lastly Enterococcus spp. and Citrobacter freundii (n=1; 1.73%). P. aeruginosa was the most frequent Gram-negative bacteria isolated (33.91%). Most of the speciesisolated were multidrug-resistant (MDR). Knowledge of the bacteria responsible for infectious complications and their antibiotic susceptibilities is a prerequisite for treating burn patients.
157	RELATIONSHIP BETWEEN SERUM ALBUMIN LEVELS AND THE OUTCOME OF SPLIT-THICKNESS SKIN GRAFT IN BURN INJURY PATIENTS (Soedjana H., Lukman K., Harianti S. - Indonesia) . Burn injury is still a global health problem due to its high incidence. Healing of burn wounds requires an optimal state of the body that is characterized by serum albumin level, especially in the category of patients that require skin graft to cover the wound caused by the deep burn. This study investigates the relationship between albumin levels and the outcome of split-thickness skin graft (STSG) and obtains a tolerance limit for albumin levels that can be successful in STSG. This was a prospective cohort study at our Plastic Surgery Center in Bandung, West Java, Indonesia from June 2019 to November 2020. Fortyseven burn injury patients who had undergone STSG qualified as the study subjects based on the criteria set. Of these patients, 85.11% were male and 68.08% were in the productive age. Preoperative albumin level has no significant correlation with graft outcome (P>0.05). Area Under the Curve (AUC) is 0.758; (95% CI: 0.605, 0.910). The optimal cut-off point for albumin levels is 2.175 (sensitivity of 0.78 and a specificity of 0.714). In our study, graft healing has no significant correlation with albumin levels. Further study is needed to assess the relationship between serum albumin levels (preoperative and postoperative) with outcome of the graft, and assess infection status.
163	SHOULD WE WORRY ABOUT NUTRITION OF ADULTS WITH MINOR BURNS? AN AUDIT OF THEIR INTAKES (Lengelé L., Bruyère O., Fadeur M., Verbrugge A-M., Martin F., Hans N., Misset B., Rousseau A-F. - Belgium) Small burn injuries are managed in an outpatient setting by surgeons and/or nurses. Nutrition in minor burn patientsisrarely investigated. This observationalstudy aimed to quantify their nutritional intakes, and to compare them to theoretical adequate values. Their average daily food intakes since injury were evaluated by a dietician using a ten-point visual assessment of consumed portions during the last meal (SEFI tool) and a food anamnesis. Macro- and micronutrient intakes were compared to nationalrecommended dietary allowances(RDA) for healthy subjects: intakes <66% RDAwere considered inadequate. Forty-two patients with a median age of 45 (34-56) years, BMI of 25.9 (23.5-28.9) kg/m2 , and burn surface area (BSA) of 2 (1-3) % were included. Energy and protein RDA were reached in 28.6 and 71.4% of the patients, respectively. Intakes of n-3 fatty acids were inadequate in 80.9% of the patients.ASEFI <7 was associated with insufficient intakesregards both energy and proteins.Inadequate intakes of different micronutrients were frequently observed, but no risk factors could be detected. Vitamin A and C were the most impacted: 71.4% of the patients had inadequate intakes. Vitamin D intake was low: 225 (56-431) UI/d. In contrast, intakes of iron, selenium and zinc were adequate in at least 61.9% of the patients. In conclusion, this audit highlighted that a majority of macronutrient and micronutrient intakes did not reach the levels recommended by the RDA. Such data should help in designing further studies aimed at assessing the impact of optimized nutrition on outcomes.
170	EFFECTIVENESS OF REACTIVE OXYGEN SPECIES IN AN OIL-BASED MEDICATION FOR HEALING BURN WOUNDS: A CASE SERIES (Cipriani F., Lucattelli E., De Rosa M., Di Lonardo A. - Italy) . Oxygen is considered a key element in the complex tissue repair process. O3-Oil antiseptics are obtained from the chemical reaction between ozone and unsaturated fatty acids of vegetable oils. The purpose of this study was to assess the effectiveness of a commercially available O3-Oil in the management of recalcitrant burn wounds. This study involved 20 patients with mid-deep and deep burn wounds (average TBSA approximately 23%, range 7-35%). Patient average age was 47 years (range 26-74 years), 8 were male. The presence of exudate, pain and delayed re-epithelialization, absence of tissue necrosis and/or sepsis were the inclusion criteria for the topical use of O3-Oil. In each patient two clinically similar areas were identified and treated every 48 hours with O3-Oil (Group 1) and conventional medication (Group 2). All the patients had positive bacterial culture results before treatment. A quicker reduction of exudates and pain and a progressive and faster bacterial load reduction was observed in Group 1. Negative cultures were obtained after 4 days on average in Group 1 (range 1-7 days) and 8 days in Group 2 (range 5-11 days). The present study demonstrated that Novox® provides a significant antibacterial effect, while stimulating reparative processes. According to our experience, the use of gel or pad is useful for re-epithelializing lesions, while the impregnated gauzes, which tend to adhere to the wound, are better used on lesions with granulation tissue.
175	L'UTILISATION DE LA POUDRE À CANON DANS LA FANTASIA: ACCIDENTS ET PRÉVENTION (Ribag Y., Badaoui Z., Elhafidi N., Achbouk A., El Khatib M.K. - Maroc) La poudre à canon est un mélange déflagrant, régulièrement utilisé au Maroc pour charger les fusils des cavaliers au cours des spectacles de Fantasia. L'explosion de cette poudre, quand elle n'est pas mortelle, entraîne des lésions tissulaires graves et variées, nécessitant une prise en charge urgente et souvent délicate. Dans cet article, nous rapportons deux cas cliniques d'accidents secondaires à l'explosion de la poudre noire, nous discuterons les aspects lésionnels et nous proposerons des mesures préventives.
180	SHOULDER FUNCTION ASSESSMENT AFTER HEAD AND NECK RECONSTRUCTION WITH PEDICLED SUPRACLAVICULAR FLAP (Ali H., Hyder S., Pervez M., Sami W., Ahmed E., Naresh K., Hussain T., Ali A. - Pakistan) The supraclavicular artery flap is used for reconstruction of defects of the head and neck. One of the major implications of this procedure isinjury to the nerve roots ofC3 andC4 of the superficial cervical plexus, which providessensation over the clavicle, shoulder and proximal chest, thereby causing problems in overall shoulder function. The objective of this study was to assess shoulder function, range of motion, pain, daily activities and overall satisfaction of the patient after using thisflap.Thisstudy was conducted at the Department of Plastic & Reconstructive Surgery, Dow University of Health Sciences & Dr. Ruth KM Pfau Civil Hospital Karachi, Pakistan, from May 2015 to November 2018. Supraclavicular flap was used in 35 patients who underwentsoft tissue reconstruction of defect of the neck after release of post burn contracture. Penn Shoulder Score and Constant Murley Score were used as assessment tools.Assessment by Penn Shoulder Score resulted in 25 (71.4%) patients within the upper quartile and 10 (18.6%) patients within the lower quartile.Constant Murley Score showed 19 (54.2%) of patients had 161°-180° shoulder abduction and lateral elevation. Forward flexion of 161°-180° wasseen in 17 (48.5%) patients, 17 (48.5%) had internal rotation till the inter scapular region, 15 (42.8%) had no impairment of external rotation, 19 (54.2%) patients had no impairment of work/recreation, 25 (71.4%) had felt no change in their sleep and 22 (62.8%) were able to position their arm above their head. Overall parameters indicate better function, good range of motion, less pain, resumption of daily activities, and overall satisfaction.
187	A MODIFIED METHOD TO CREATE A PORCINE DEEP DERMAL BURN MODEL (Seswandhana R., Anzhari S., Ghozali A., Dachlan I., Wirohadidjojo Y.W., Aryandono T. - Indonesia) Development of an experimental burn model is essential to studying burn wound pathophysiology and progressivity, and identifying the best therapeutic choice before treatment can be applied clinically. Pigs are preferred as animal models for burns because their skin structure and wound regeneration resemble that of humans. We made a novel model to create a deep dermal burn using prospective methods that are easy to use, safe, and consistently reproducible. A custom-made burn device was used to create deep dermal burn wounds. A cylindrical plate made of stainless steel with a diameter of 2cm was connected to an electric heating device that was set to reach temperatures varying between 82-100°C. The hot cylindrical plate was applied perpendicular to the pig's skin with a pressure of 1kgf mechanical force for various periods of time (10-25s). Burns were created on the dorsum of a male Yorkshire pig sedated under anesthesia and analgesia. At the 7th day post burn, the burn wounds were evaluated macroscopically, and when one fulfilled the criteria for deep dermal burn, tissue was harvested for further histological analysis using hematoxylineosin staining. At the end of the study, the burn wounds created by the temperature 92°C for 20s showed tissue damage that meets the criteria for deep dermal burns. The development of this model might be useful for further study on burn wound healing.
192	ALGORITHMS FOR MANAGEMENT OF POST-BURN CONTRACTURE IN UPPER EXTREMITY IN CHILDREN (Terziqi H., Sopjani I., Gjikolli B., Muqaj G., Mustafa M. - Kosovo) The aim of this study is to describe the management and outcome of surgical treatment for post burn contractures in different parts of the upper extremities in children, and provide a final decision algorithm that can be a useful guide for the Resident regarding surgical approach to contracture management. This was a retrospective study conducted in the Clinic of Plastic and Reconstructive Surgery, Pristina-Kosovo, between 2014-2016. All cases continued check ups in the Gentiana-Grelor private clinic in Pristina until 2019. Followups were conducted for no less than 6 months with respect to the viability and healing of the repaired area. Patients of both genders, aged from 0 months to 18 years with post-burn contracture in upper extremity, were included in the study. For the sake of presentation, we divided them anatomically into four main areas: axilla, elbow, wrist and hand. We start with a reconstructive ladder using skin grafts (STSG, FTSG), and local flaps such as advancement flaps, Z-plasties, V-Y or Y-V advancement flap, abdonimal/groin pedicled flap, cross finger flap, radial forearm flap were used. Patients were called for follow-up lasting a minimum of one to up to three years. The study included 144 patients. Their age ranged from 9 months to 18 years, the mean age being 12 years. Ordering them by location, post-burn contracture percentage in upper extremity in children was 68% on the hands, 18% on the elbows, 8% on the axilla and 6% on the wrist. A classification and treatment algorithm aids in achieving significant improvements in both joint motions and aesthetic deformities.
199	LETTER TO THE EDITOR - ABDOMINAL COMPLICATIONS AFTER MAJOR BURN INJURY COMPLICATIONS ABDOMINALES APRÈS BRÛLURE ÉTENDUE (Metin Nizamoglu - UK) Abdominal complications in patients with major burns without abdominal injury has been described. We identified this complication within our burns centre, both during acute resuscitation and later during the inpatient stay. We sought to define incidence, outcomes, and associated factors contributing to abdominal complications in major burns. We examined all patients admitted to our regional burns centre with major burns (>40% TBSA) and abdominal pathology between November 2003 and May 2016.

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