The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXVI	Number 3	June 2023

Summaries

183	COST ANALYSIS AND INFLUENCING FACTORS AMONGST SEVERE BURN PATIENTS (Lam N.N., Hung N.T., Khanh N.N.) This study analyzed the structure and determined the factors affecting the cost of treatmentof severe burns patients. The results showed that the average total costs for a patient was 3275.9 USD. Thedaily cost of hospitalization was 113.3 USD, the treatment cost for 1% burn surface area was 109.5 USDwith the highest proportion for medication and consumable medical equipment (43.2%), followed by surgeryand procedures (30.2%). The treatment costs increased with increasing age, burn extent and deep burn area(p < .05) and were significantly higher in the group of patients with inhalation injury, electrical burns andin non-survivors (p < .01). Multivariate regression analysis found that burn extent, deep burn area and inha-lation injury independently influenced the treatment cost of burn patients.
189	OCCUPATIONAL HEALTH SERVICES HAVE A RELEVANT ROLE IN PROTECTING THE HEALTH AND SAFETY OF PARAMEDICS (Chirico F., Nucera G., Szarpak L., Nowrouzi-Kia B.) In this Letter to the Editor, the authors point out occupational health and safety risks for para- medics, and highlight the relevant role carried out by multidisciplinary occupational health services in the prevention of occupational risks and the promotion of physical and mental well-being of these workers.
191	CLINICAL OUTCOMES AMONG ELDERLYPEOPLE WITH BURNS (Almeida A., Alvarenga V., Egipto P., Costa-Ferreira A., Horta R., Martins de Carvalho F. - Portugal) Burns in the elderly are a public health concern. This study aimed to analyze etiology, clinicalcharacteristics, and independent risk factors for outcomes of burns in elderly patients. This retrospectivestudy included elderly patients (65 years and over) admitted to a major burn unit between 2006 and 2016.Demographic data, clinical characteristics and outcomes were analyzed. One hundred and thirty patientswere included. Most were female (56.2%) and the highest incidence was among those aged 75-84 years.The median burn area was 10.5%. The incidence in winter (50%) was higher (p<0.001) and flame burnspredominated (p<0.001). The mortality rate was 32.3%. Independent risk factors for death were older age,larger extent burns, need for escharotomy, and cardiac disease as comorbidity. Amongst the survivors, themedian length of stay was 36 days. Development of pressure sores, need for skin grafts, larger extent burns,presence of full-thickness burns, and cardiac disease were shown to be significantly associated with increasedlength of stay amongst survivors. Preventive measures should target women aged between 75-84 years.Flame burns occurred more frequently in winter. Prognosis is related to age, extent of burns, need for escha-rotomy at admission, and cardiac disease.
202	NOSOCOMIAL INFECTION AMONG BURN PATIENTS ADMITTED TO A TERTIARY CARE HOSPITAL OF BANGLADESH: A CROSS-SECTIONAL STUDY (Dey P.K., Galib A., Sardar A., Islam M.T., Sharif H.M.Z., Zaman F., Hannan N., Rafi M.A. - Bangladesh) Nosocomial infection is a major challenge for the appropriate management of burns. The presentstudy aimed to investigate incidence, risk factors, and causative organisms of nosocomial infection in burn pa-tients of Khulna, Bangladesh. This cross-sectional study was conducted among patients admitted to the Burnand Plastic Surgery Department of Khulna Medical College Hospital (KMCH) from January to December 2020.Relevant data were collected from the patients’ hospital records. Samples of wound swabs and blood were col-lected and cultured in the microbiology laboratory of KMCH. Logistic regression models were used to determinerisk factors for infective complications in burn patients. All statistical analyses were carried out using SPSS ver-sion 26.0. A total of 100 burn patients were included. Mean age was 29.2 years with a male-female ratio of1.3:1. Flame burns were most prevalent among the patients (41%), followed by scald (23%) and electric burns(15%). Almost 40% patients had full thickness burn. The incidence of nosocomial infection was 42% (woundinfection 33% and septicemia 9%). Total body surface area of burn >40% (OR 7.56, 95% CI 2.89-19.81), fullthickness burn (OR 34.40, 95% CI 3.25-97.14) and prolonged hospital stay (aOR 1.31, 95% CI 1.15-1.51) weresignificant risk factors for nosocomial infection. Staphylococcus aureus was the most commonly isolated or-ganism (45%), followed by Streptococcus (24%), Pseudomonas aeruginosa (19%) and Escherichia coli (12%).As the epidemiology of nosocomial infection is not the same in different health facilities, a facility-based com-prehensive burn management protocol considering the local epidemiology and causative organisms of burnwound infection is crucial for the prevention and management of nosocomial infections in burn patients.
209	CHALLENGES IN TREATING COVID-19 PATIENTS WITH SEVERE BURN INJURIES (Certic B., Jovanovic M., Karamarkovic M., Zivkovic M. - Serbia) Here we present a case report of a young female patient with severe burn injury inflicting27% of total body surface area (TBSA) associated with COVID-19 infection. Upon admission, Acinetobacterspp. (sensitive only to Colistin) was isolated from the wound swabs of the right arm, hand and thorax. Onthe fifth day after admission, a surgical excision was performed and 12% of TBSA was covered with homo-transplants. The following day the patient had a sudden drop in oxygen saturation with hypotension (85/45mmHg). Additionally, agitation, visual and auditory hallucinations were noticed. We found a massive pleuraleffusion on the left side and pneumonic foci on the right side. On the thirteenth day after admission the finalsurgical excision and homotransplantation of the skin were performed. In the following days, debridementof all necrotic tissue and covering of all the burned areas with homotransplants were done. Hemodynamicinstability of the patient progressed along with the finding on the chest radiography, despite the local findingincluding adherent homotransplants with no signs of lysis or local infection at the wound beds. Due to lowoxygen saturation, the patient was intubated on the fourteenth day after admission. Despite the measurestaken, the lethal outcome occurred on the twenty-fifth day after admission to our Clinic. A decision on theright timing for surgical treatment in severely burned COVID-19 patients needs to be investigated in orderto enable surgeons to make evidence-based decisions during the pandemic.
214	THE IMPACT OF THE COVID-19 PANDEMIC ON SELF- INFLICTED BURN INJURIES IN PATIENTS WITH PREVIOUSLY DIAGNOSED BIPOLAR DISORDER (Ćertić B., Jovanović M., Karamarković M., Vasović D., Isaković-Subotić J., Živković M., Rašić D.) Here we present a case of a 52-year-old female patient who was admitted to the Clinic in December2021 due to the presence of right side facial burns which were caused by a cigarette lighter under suspicious con-ditions. Her past medical history revealed she was diagnosed with bipolar disorder at the age of 20 and was hos-pitalized multiple times for the treatment of manic episodes. The last psychiatric hospitalization took place inOctober 2021. She had deep second-degree burns on the right side of the face, head and neck, with a total bodysurface area involvement of approximately 3%. On hospital day 18, she was found unresponsive, dyspnoic, withno palpable pulse and measurable tension. Electrocardiogram (ECG) monitoring revealed sinus bradycardia fol-lowed by cardiac asystole. After the first few minutes of cardiopulmonary resuscitation, heart and lung actionwas re-established. Due to the presence of ECG changes in the form of ST depression and negative T waves inV2-V6, D1 and aVL, also higher blood level of high sensitivity troponin T, she was urgently transported to theCoronary Unit where she was diagnosed with non-ST-elevation myocardial infarction. On hospital day 27, dueto the presence of sub-febrile temperature and non-productive cough, she was tested for COVID-19 infection andtransported to the COVID Hospital Batajnica. She was discharged with stable laboratory parameters and normalchest radiography 37 days following initial admission. Considering the great psychological impact related to theCOVID-19 pandemic, extensive mental health support and regular monitoring of critical groups is indicated.
217	DESCRIPTION OF ASPARTATE AMINOTRANSFERASE AND ALANINE AMINOTRANSFERASE IN BURN PATIENTS AT THE BURN UNIT OF DR. HASAN SADIKIN GENERAL HOSPITAL (RSHS) BANDUNG (Soedjana H., Putri A.C., Arsyad M., Andalu N. - Indonesia) Burn injury is trauma with several metabolic reactions including hepatocytes that can causeapoptosis and necrosis. Proliferation occurs to compensate for this reaction but complicates with the loss ofprotein of the injury. The aim of this study is to describe the level of aspartate aminotransferase (AST) and ala-nine aminotransferase (ALT) in burn injury. This study was a descriptive retrospective design using secondarydata from medical records of patients at the Burns Unit of Dr. Hasan Sadikin Hospital Bandung (RSHS) in theperiod August 2017 to July 2019. Total samples in this study were 116 people. Normal level of AST and ALTwas found in 23 people (19.8%), elevation of AST in 31 people (26.7%), elevation of ALT in 5 people (4.3%)and elevation of both AST and ALT in 57 people (41.3%). Increased levels of AST and ALT mostly occurredin men (51%), aged 45 years (56%), with injury due to electricity (26%), 20-29% burn area (32%), and occurredin the first week of wound onset. Most cases of burn injury showed increasing levels of AST and ALT. Thismight be due to the metabolism of hepatocytes in burn cases. Elevation of AST and ALT was mainly found inburn injury cases at RSHS notably in the first week of onset. Further research is needed to verify the relationof this condition. Elevated levels of AST and ALT should be the consideration of clinicians in giving therapy.
222	THE EFFECT OF NEGATIVE PRESSURE WOUND THERAPY ON VEGF AND ANGIOGENESIS IN DEEP DERMAL BURN INJURY: AN EXPERIMENTAL STUDY (Seswandhana M.R., Kurniawan I.D., Anwar S.L., Humani H.M.A., Gabriela G.C., Dachlan I., Wirohadidjojo Y.W., Aryandono) Burn injuries are the fourth most common type of trauma worldwide, after traffic injuries, fallsand interpersonal violence. Vascular endothelial growth factor (VEGF) is one of the most critical proangiogenicfactors. Failure in angiogenesis is often associated with chronic, non-healing wounds. This study aimed tocompare the effect of sterile gauze with normal saline (NaCl) 0.9%, intermittent negative pressure wound ther-apy (NPWT), continuous NPWT, and silver sulfadiazine dressing on increasing VEGF and angiogenesis indeep dermal burn injury. This experimental laboratory study involved six Yorkshire pigs. Twenty burns weremade on each pig’s flank and dorsum areas, which were divided into four treatment groups: sterile gauze withNaCl 0.9%, intermittent NPWT, continuous NPWT, and silver sulfadiazine dressing. Skin biopsies were doneon days 1, 3, 7, 14 and 21 to evaluate VEGF histoscore and mean microvascular density (MVD). We used im-munohistochemical staining of VEGF-165 as VEGF’s protein marker and hematoxylin-eosin (HE) to countthe MVD. There was a significant difference in mean VEGF histoscore on evaluation day 14, in which con-tinuous NPWT had the highest score compared to sterile gauze with NaCl 0.9%, intermittent NPWT, and silversulfadiazine. The elevated VEGF histoscore could significantly increase the MVD.
229	TREATMENT CHALLENGES IN A PREGNANT PATIENT WITH SEVERE BURN INJURY AND WOUND CARE USING AMNIOTIC MEMBRANE: A CASE REPORT (Rosadi Seswandhana M., Prawoto A.N., Rachman I.T., Wahdini S.I., Vityadewi N., Ramli.N., Dachlan I. - Indonesia) We report a case of severe burn injury in a 42-year-old pregnant patient referred to our hos-pital’s burn unit after experiencing a scald burn injury that burned her neck, chest, trunk, abdomen andlimbs. The patient had burn wounds distributed on her neck, all four extremities, the chest and abdomen,with a total burn area of 46.5%. The burn wounds were treated with surgical debridement and then coveredwith silver sulfadiazine and damp gauze. The patient’s wounds were treated every three days. The patientdelivered a healthy baby full-term through a spontaneous, vaginal delivery. After delivery, the amnioticmembrane from the patient was used as an amniotic membrane graft and was planted on the patient’s chest,right arm and right thigh. The amniotic membrane in this patient helped to accelerate the preparation of thewound bed for skin grafting. Split-thickness skin grafts were then used on the wounds and the patient wasdischarged from the hospital one week later. Patients that present with burn injuries during pregnancy requireintense monitoring and careful management from a multidisciplinary team. A collaborative effort needs tobe made in order to plan the best outcome for the mother and fetus. Precise and early resuscitation is thefirst step to treating such cases. The administration of fluids should be titered based on the patient’s hemo-dynamic condition and urine output. Wound management can also be optimized using the amniotic mem-brane as a temporary dressing before skin grafting.
243	FLIR ONE ® THE COMBINATION OF STROMAL VASCULAR FRACTION CELLS AND PLATELET-RICH PLASMA INCREASES FIBROBLAST GROWTH FACTOR 7 AND PROMOTES ANGIOGENESIS IN FULL THICKNESS BURN INJURY: RAT EXPERIMENTAL STUDY (Josh F., Soekamto T.H., Windura C.A. - Indonesia) Our previous study on how the combination of stromal vascular fraction cells (SVFs) and platelet-richplasma (PRP) affect deep dermal burn healing showed promising results. In this study, we assessed the effect on full-thickness burns by evaluating FGF7 serum level and capillary count. Forty-eight Wistar rats were divided into fourmajor groups: (1) locally injected with combined SVFs and PRP; (2) topically applied Vaseline; (3) locally injectedwith placebo; (4) and rats without burns. These groups were divided further into smaller groups based on the day ofeuthanasia (8th hour, 4th day, 7th day, 14th day, and 21st day). FGF7 serum level was measured using ELISA, andcapillaries were counted using a microscope. A one-way ANOVA test, post hoc, and regression tests were used. Onday 4, both FGF7 and capillary counts showed significant differences between groups (p=0.000 and 0.048, respecti-vely). On day 7, only FGF7 result showed a significant difference (p=0.000). On day 14, FGF7 and capillary countsshowed significant differences (p=0.000, 0.018 respectively). The SVFs and PRP-treated groups showed superior re-sults compared to other groups. The injection of combined SVFs and PRP increased FGF7 and capillary counts.
234	EFFICACY OF MEPILEX ® AG VERSUS XEROFORM ® AS A SPLIT-THICKNESS SKIN GRAFT DONOR SITE DRESSING: BAD HABITS DIE HARD (Lisiecki J.L., Buta M.R., Taylor S., Tait M., Farina N., Levin J., Schulz J., Sangji N., Friedstat J., Hemmila M.R., Wang S., Levi B., Goverman J. - USA) Autografting with split-thickness skin grafts (STSG) remains an essential procedure in burn and reconstruc-tive surgery. The process of harvesting STSG, however, leaves behind a donor site, an exposed area of partial-thicknessdermis left to heal by secondary intention. There has yet to be a consensus amongst surgeons regarding optimal managementof the donor site. The ideal donor site dressing is one that allows for expeditious healing while minimizing pain andinfection. Despite numerous studies demonstrating the superiority of moist wound healing, many surgeons continue totreat STSG donor sites dry, with petroleum-based gauze. In this study, two burn centers performed a retrospective reviewof burn patients whose STSG donor sites were treated with either Xeroform® or Mepilex® Ag dressings. Infections weredocumented and in a subgroup analysis of patients, postoperative pain scores were noted and total opiate usage duringhospitalization was calculated. Analysis revealed an overall infection rate of 1.2% in the Mepilex® Ag group and 11.4% inthe Xeroform® group (p<0.0001). Patients with Xeroform® donor site dressings had increased odds of donor site infection(OR=10.8, p=0.002). In subgroup analysis, there were no significant differences in maximum pain scores between Mepilex®Ag and Xeroform® groups, nor were there differences in opiate usage. STSG donor sites dressed with silver foam dressingshave a lower rate of donor site infection relative to those dressed with petroleum-based gauze. Moist donor site dressingssuch as foam dressings (including Mepilex® Ag) should be the standard of care in STSG donor site wound care.
251	EVALUATION OF GASTROCNEMIUS MUSCLE FLAP IN POST-BURN FLEXION KNEE CONTRACTURE (Saurabh S., Khushboo S., Gouranga D., Rupnarayan B. - India) Burn injury and consequent contracture is not a new problem for humans. It is severely dis-abling for the patients, especially if it involves a large joint like the knee. The objective of the study was toevaluate the usefulness of the gastrocnemius flap and improvement in knee joint function following the useof the flap in post-burn flexion knee contracture. This prospective study was performed from January 2016to December 2017. Twenty-five patients with flexion knee contracture were treated with incisional or exci-sional release of contracture and coverage with gastrocnemius muscle flap. The post operative improvementin knee function was evaluated. There was improvement in range of motion of the knee in all the operatedpatients and the patients were able to maintain unassisted bipedal locomotion. There was no flap loss in anycase. In post-burn knee contracture with limited local fascio cutaneous flap options, gastrocnemius flapgives very good functional and aesthetic outcome with no major complication.
257	A RARE CASE OF SEVERE BURN INJURY TO THE OROPHARYNX CAUSED BY A FLARE GUN (Sljivic S., Zdanski C., Williams F., Nizamani R., King B. - USA) Flare gun injuries are rare, and patients often present with complex trauma that may requiremultiple operative interventions. Our objective is to explore a case of a 15-year-old male, who presentedwith second-degree flame burns to the face, left upper extremity and bilateral hands, as well as third-degreeburns to the oropharynx and a tongue laceration after a flare gun was discharged into his mouth. The patientunderwent multiple debridements of the oral cavity and oropharynx, and his hospital course was complicatedby an intra-oral abscess. He eventually made a full recovery and was discharged. This case not only illustratesthe need for early operative intervention, but it also underscores the need for awareness campaigns thathighlight the dangers of flare guns and similar devices.
261	PATTERN OF ACUTE ADVERSE TRANSFUSION REACTIONS IN PATIENTS WITH BURN INJURIES: A NOVEL INITIATIVE TOWARDS HAEMOVIGILANCE AT THE NATIONAL BURN CENTRE OF PAKISTAN (Rehan M., Iqbal T., Sarwar M., Khan M.S., Tariq M.H., Ain Q., Waheed U. - Pakistan) The transfusion of blood and blood components is a life-saving medical procedure, however,it is linked with adverse reactions to transfusions. Information about different types of adverse transfusionreactions (ATRs) will assist in their early identification and subsequent management, as well as in devisingstrategies to minimize the occurrence of adverse reactions related to blood component transfusion. The cur-rent study was therefore executed to analyze the pattern of ATRs in patients with burn injuries at a nationalburn center. This was a cross-sectional, prospective study involving an analysis of immediate ATRs fromJanuary 2020 to June 2021 (18 months). ATRs observed during the study period were documented and an-alyzed. During the study period, 2,220 units of blood and blood components were transfused to 1,075 burnpatients (2.06 transfusions per patient). A total of 27 ATRs were recorded (1.21%). Allergic reactions werethe commonest (55.55%) followed by febrile non-haemolytic transfusion reaction (37.03%). The mean vol-ume of blood unit transfused, when the reactions were noted, was approximately 75 ml (range: 15-230 ml).The mean time at which transfusion reactions were noted was 17 min (range: 5-220 minutes). The ATRswere more common in patients with multiple transfusions compared to those receiving a single transfusion.The common adverse reactions were allergic and febrile non-haemolytic transfusion reactions. It is vital toreport all transfusion reactions to the attached blood center and hospital transfusion committee (HTC) onstandardized reporting forms. Continuous medical education through seminars and sensitization workshopswill support consolidating haemovigilance systems.

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