The Euro-Mediterranean Council for Burns and Fire Disasters

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Volume XXXVI	Number 4	December 2023

Summaries

271	RISK FACTORS FOR DEATH OF BURN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME (Hung T.D, Lam N.N.) The aim of this study was to investigate factors independently affecting outcomes of postburn ARDS patients at the time of ARDS onset. A prospective study was conducted on 66 patients with ARDS, treated in the ICU at the Le Huu Trac National Burns Hospital in Hanoi, Viet Nam, from 2014 to 2017. Patients were divided into a survivor and non-survivor group. Demographic criteria, burn severity, inhalation injury, clinical and subclinical features at ARDS onset were compared between the two groups. The results showed that overall mortality of ARDS patients was 62.12%. Logistic regression analysis indicated that at the time of ARDS onset, serum lactate level (OR=6.71), blood platelet count (OR=.99), static lung compliance (OR=.73) and driving pressure (OR=1.69) were independent risk factors for death, while patients’ demographics, burn severity and ARDS severity did not significantly affect the mortality rate.
276	ASSESSMENT OF SMALL PAEDIATRIC BURNS: A COINBASED SYSTEM (Wilson J.J., Awad L., Allison K.) A review of paediatric burns in our burns facility in the United Kingdom demonstrated variable accuracy of size, and a majority documented as <1% total body surface area (TBSA). Accurate assessment is important for medical records, clinical management and non-accidental injuries. We propose to assess burn size with a coin-based system, where small burns are described by single/multiple sterling coins. Participants were asked about their confidence in evaluating small paediatric burns. Participants were given ten scenarios which included photographs of paediatric patients with small burns. They were asked to assess burn size in their normal manner (TBSA, measurement) and with a coin-based system. The ‘burns’ were drawn on children based on a given coin size and percentage so that the accuracy of the participant’s answer was quantifiable. Participants provided qualitative feedback in a questionnaire on the coin-based system. Thirty nurses and medical staff of varying seniority actively involved in referral/management of paediatric burns took part, creating over 300 responses. In preliminary questions, 66% of participants did not feel confident in estimating paediatric burns and 83% needed to refer to a paediatric burns chart. Accuracy of burn size using TBSA and the coin-based system was 45% and 67%, respectively. The majority (97%) stated estimating size was easier, and 93% found it more accurate. A total of 87% found communication between colleagues easier. Results highlight the improved assessment of small burns in our hospital using a coin-based approach in comparison to TBSA, and could facilitate accurate communication between health care professionals.
281	MORTALITY RATE OF BURN INJURY PATIENTS POST CLOSURE OF BURN UNIT DUE TO COVID-19 PANDEMIC (Soedjana H.) Burn injury is one of the most concerning issues in the health industry. Globally, mortality and morbidity rates associated with burn injuries and their sequelae are exceptionally high. This study aims to determine the mortality rate of burn injury patients after the closure of the burn trauma unit at Dr. Hasan Sadikin Hospital, Bandung, Indonesia. This research is a descriptive-analytic study with a cross-sectional approach. The population in this study are burn injury patients treated at Dr. Hasan Sadikin Hospital during April 2021–September 2021. The inclusion criteria for this study were adult (TBSA >20%) and pediatric (TBSA >10%) patients with severe burn injury. The subjects included in this study were 76 patients and were divided into two groups, patients treated in the burn unit (n=27) and in the non-burn unit (n=49). The number of deaths in a non-burn unit (n=24; 48.97%) was higher compared to patients treated in a burn unit (n=6; 22.22%). There is a significant relationship between the type of care unit and the burn injury mortality rate, as indicated by a p value of 0.022 and an odds ratio (OR) of 3.36.
286	ANALYSIS OF FACTORS AFFECTING BURNS MORTALITY: A NATIONAL BURN CENTRE EXPERIENCE FROM PAKISTAN 2007-2021 (Rehan M., Iqbal T., Sarwar M., Khan M.S., Tariq M.H., Waheed U.) Burns are a public health concern burdening the healthcare delivery system across the globe. Mortality rates are significant outcome parameters after a burn injury. The objective of the current study was to analyze the characteristics of the patients admitted to our burn care center and identify the factors related to mortality in the burn patients. This was a cross-sectional single-center study involving a retrospective analysis of mortality rates in burn patients over a period of 15 years from July 2007 to December 2021. During the study period, 7,866 burn patients were admitted to the ICU of the burn care center. Patients who died [Group 1] were compared to the group of survivors (control cases [Group 2]) to ascertain the contributing factors that might forecast a high risk for mortality. The mortality rate was calculated as 23.16% (1,822/7,866). The majority of the patients (both groups) had a total body surface area (TBSA) of >50% (p 0.001). The average duration of stay at the burn care center was 15.5 days for the survivors’ group (Group 2) while it was 11.4 days for the patients who died (Group 1) during the course of their treatment. About 23.16% of all admitted patients died mostly from flame burns, and sepsis was the commonest cause of death. Patients with risk factors should be classified as high risk for mortality at the time of ICU admission. It is necessary to initiate educational and awareness programs for sensitization related to the prevention of burn injuries.
293	ÉPIDÉMIOLOGIE DES ENFANTS HOSPITALISES POUR BRÛLURE EN GUYANE (Martz N., Sika A., Guemaleu P., Elenga N., Quet F.) Cette étude observationnelle descriptive a pour but de décrire le profil épidémiologique des enfants hospitalisés pour brûlure en Guyane, collectivité territoriale française ne disposant pas de Centre de Traitement des Brûlés, afin d’orienter la prévention vers les populations les plus à risque. L’analyse rétrospective de 665 hospitalisations de patients âgés de 0 à 18 ans hospitalisés pour brûlure au Centre Hospitalier de Cayenne entre Janvier 2010 et décembre 2022 a été réalisée grâce aux données du PMSI. Des analyses descriptives uni et multivariées ont été réalisées sur l’âge, le sexe, la commune d’origine, la date de la brûlure, la durée d’hospitalisation, le mode de brûlure, la localisation, le pourcentage et la profondeur de la brûlure. Quatre cent seize enfants avec un code «brûlure» ont été hospitalisés sur cette période et 358 patients ont été inclus. Les brûlures étaient plus fréquentes chez les garçons (58%) et les enfants de moins de 6 ans (72%). Une majorité des patients étaient citadins et habitaient sur le littoral (70%). Un peu moins de 10% (9,5%) des patients ont été transférés à l’hôpital Trousseau de Paris pour une prise en charge plus spécialisée. Les brûlures étaient causées dans 61,5% des cas par de l’eau chaude et 16,5% par des flammes. La durée d’hospitalisation était en moyenne de 8 jours et la surface cutanée brûlée de 9,5%. Les enfants de moins de 2 ans vivant à Cayenne et sa banlieue étaient les plus à risque de brûlure, mais les brûlures les plus graves, nécessitant un transfert dans un centre spécialisé, étaient plus fréquentes chez les enfants de plus de 3 ans habitant le long du fleuve Maroni et jouant avec des produits inflammables.
299	EPIDEMIOLOGICAL PROFILE OF BURNS IN THE ELDERLY IN LAGOS, NIGERIA: A PRELIMINARY STUDY (Abdulsalam A., Ogunkeyede A.O., Bada E., Chira M.K.) The elderly population is on the increase globally according to the current global demographic changes and is more vulnerable to burn injuries. Despite recent advances in burn care, the outcome of burns in the elderly has only marginally improved when compared with children and younger adults. The objective of this study was to determine the patterns and outcomes of burns in the elderly and eventually proffer prevention strategies. A retrospective review of all the elderly (65 years and older) burn patients managed at the Burn Centre of National Orthopaedic Hospital Igbobi Lagos (NOHIL) between January 2015 and December 2019 was performed. The socio-demographic data, clinical information surrounding the burn injury and management were extracted from the medical records, analyzed and presented. A total of 21 patients were included in this study, with a male to female ratio of 1:1.1. Flame burns represented the commonest cause of burns (85.7%) and the majority had pre-injury comorbidities (57.1%). All the patients with %TBSA of less than 40% were successfully managed and discharged while death occurred in all the patients with %TBSA of 40% and above, with a mortality rate of 11.1%. This study provided an epidemiological profile of elderly burn patients in Nigeria. One in five burn admissions is elderly, with flame burns being the major cause of burns. Most of the burns occurred indoors and were related to cooking activities. Prevention strategies were recommended to improve home safety and make the home a safer place for the elderly.
307	SUICIDE BY SELF-IMMOLATION IN THE PEDIATRIC POPULATION (Fredj H., Tarchella D., Mokline A., Ben Saad M., Gasri B., Jami I., Messadi A.A.) Self-immolation is a violent way of committing suicide. Few studies have focused on this phenomenon in children. The aim of this study was to determine the epidemiological profile of children who committed suicide by fire. A retrospective descriptive study was conducted in an intensive burn care department in Tunis, over a period of 10 years (2011-2020). Of a total 3077 patients, 761 were admitted for burns by suicide attempt, among them 62 children and adolescents (8%). The number was on average six per year. The highest annual prevalence was noted in 2011 (27% of cases). The mean age was 16 and a half years old. The majority of cases were adolescents aged 15 or older. There is a male predominance (sex ratio:3). Total burn surface area (TBSA) was on average 44%. The act of self-immolation occurred in public places in 58% of cases. Socio-economic environment was unfavorable in 60% of cases. The suicidal act of self-immolation was due to a family conflict in 34% of cases (n=21). Seven patients (11%) had a history of mental illness. Forty-three patients (70%) required mechanical ventilation. The length of hospital stay was on average 30 days. The mortality rate was 56.5%. In conclusion, self-immolation is frequent in the pediatric population; it induces severe burns associated with a poor prognosis.
313	BRÛLURE PAR EXPLOSION DE CASQUE AUDIO (Cherkaoui G.B., Ankiz A., Oufkir A.A.) L’explosion de casque audio est un incident rare, non rapporté dans la littérature, responsable de brûlure grave mettant en jeu le pronostic fonctionnel et esthétique avec un retentissement psychologique majeur. Nous rapportons ici le cas d’un jeune garçon dans le but de sensibiliser la population et attirer l’attention sur ce risque.
317	THE SILENT THREAT - ALKALI FOOT BURN: A CASE REPORT (Machado P., Barbosa T., Jarnalo M., Mendes M., Brito I., Horta R., Egipto P.) Despite current workplace protection measures, chemical burn accidents are not uncommon.Among these, alkali burn is the most challenging due to its silent behaviour and aggressive mechanism. Characterized by its initial painless onset, allowing a prolonged exposure, it tends to result in deeper and more destructive burns, creating major reconstructive and therapeutic challenges. This case concerns a 53-year-old male who sustained a full thickness burn of his left instep foot after prolonged contact with an alkali substance. The wound was submitted to several surgical debridement procedures, with preservation of the major tendinous and vascular-nervous structures. The skin defect was then repaired with skin graft. Early recognition and prompt management with copious and prolonged wound irrigation is paramount. As in this type of burn it is difficult to initially assess its true depth, even after initial surgical debridement, a more cautious approach is recommended. Chronic pain is associated with chemical burns and it should be treated early in the process with the use of multimodal analgesia in order to prevent future complications. No matter the absence of major complaints in the 4 week-postoperative evaluation, the possible long-term consequences are still unknown. Despite the prolonged exposure time and the initial presentation with a deep burn, after several surgical debridement procedures, preservation of major tendon and neurovascular structures was assured, which allowed a plain approach for reconstruction of the wound with a skin graft. The case illustrates different challenges associated with evaluation and treatment of patients with deep alkali burns. Also, usage auditing and awareness of regular users appear to be essential.
320	THE COMBINATION OF STROMAL VASCULAR FRACTION CELLS AND PLATE LET-RICH PLASMA MEDIATES THE INFLAMMATORY PROCESS IN DEEP DERMAL BURN INJURY (Pakan A.P., Josh F., Soekamto T.H., Laidding S.R., Hendarto J.) The combination of platelet-rich plasma (PRP) and stromal vascular fraction cells (SVFs) was beneficial in accelerating wound healing. This study aims to assess the effect of this combination in balancing the inflammatory process to accelerate burn healing. Thirty eligible Wistar rats were used in this study to establish a deep dermal degree burn wound model. They were randomly divided into four groups: locally injected with the combination of SVFs and PRP (n=9), vaseline (n=9), placebo (n=9), and healthy Wistar rats group (n=3), as treatment group, positive control group, negative control group and healthy control group, respectively. The burn wound tissue was excised from three separated sacrificed rats (8, 24 and 48 hours) to examine polymorphonuclear (PMN) and lymphocyte counts through the standard hematoxylin-eosin procedure and for cyclooxygenase2 (COX-2) expression through the immunohistochemical procedure. The highest PMN, lymphocyte cell count, and COX 2 expression were found at 8 hours in the local injection with the PRP combination SVF group (28,555±11,237, 8,111±3,218, and 4,666±2,309, respectively, p <0.05 except for COX 2). The regression analysis results showed that local injection of a combination of PRP and SVF could reduce PMN cells by 1.068 times, lymphocytes by 1.786 times, and COX 2 by 1.853 times greater than topical application with vaseline. The combined injection of PRP and SVF effectively heals deep burns by acutely increasing the PMN cell and lymphocyte count, and COX 2 expression. Conversely, the treatment decreased the PMN cell and lymphocyte count but not the COX 2 expression in the sub-acute phase of wound healing.
331	QUELLE PRISE EN CHARGE DES SÉQUELLES DE BRÛLURES DES MEMBRES DANS UN CONTEXTE PARTICULIER ? (Adendjingue D.M., Andjeffa V., Sinik F., Mouassede M., Nadji G., Toure A.) Les brûlures sont des lésions fréquentes souvent sanctionnées de lourdes séquelles fonctionnelles quand le patient survit. Elles posent un problème de prise en charge dans les «pays du sud», par défaut de centres spécialisés. Dans cette étude, nous voudrions partager notre expérience. Il s’agit d’une étude rétrospective descriptive concernant 24 patients en 36 mois, traités et suivis dans le service pour une séquelle de brûlure intéressant un membre. Les résultats fonctionnels ont été classés en excellents, bons, assez bons, moyens et mauvais. Sur le plan esthétique, ils ont été classés en satisfaisants, peu satisfaisants et mauvais. Nous avons retrouvé 24 dossiers de séquelles parmi les 1 480 patients hospitalisés durant la période d’étude. La prédominance était féminine (sex ratio de 1,6/1) avec une moyenne d’âge de 24,2 ans [16-40]. Les accidents domestiques (n=19) ont été la première circonstance de survenue avec une prépondérance de brûlure thermique par flamme (n=21). Au membre supérieur, les séquelles touchaient de manière presque équivalent mains, poignets et coudes, quand elles prédominaient clairement au genou au membre inférieur. Les complications majeures comprenaient des brides, des hypertrophies des chéloïdes éventuellement associées entre elles. Parmi les ulcérations chroniques, 2 étaient cancéreuses (ulcère de Marjolin). Vingt personnes ont été traitées dans la première année suivant la brûlure avec des résultats excellents, bons et moyens dans respectivement 10, 9 et 4 cas. Les brûlures peuvent engendrer de séquelles fonctionnelles importantes dont la prise en charge requiert un personnel soignant spécialisé. Une formation spécifique des soignants et l’affectation des moyens nécessaire à la prise en charge initiale des brûlés sont essentielles pour minimiser la survenue de ces séquelles.
337	SURGICAL BURDEN OF TRAUMATIC LOWER LIMB AMPUTATIONS IN THE PEDIATRIC AGE GROUP (Emsieh S., Terro K., Rabay C., Ibrahim A., Atiyeh B.) Although the burden of traumatic lower limb amputation (TLLA) has been well described when it concerns the adult population, there is an evident scarcity in literature concerning this matter in the pediatric population. Our objective is to review the surgical burden and long-term outcome of lower limb amputation among pediatric trauma victims who have experienced lower extremity amputation as the result of an accident or injury. A PICO format was utilized. The population of interest includes only children and adolescents suffering TTLA. The generation of data to be reviewed was executed using MEDLINE and PUBMED. Altogether, all data that includes trauma in the pediatric population in the timeframe 1949-2019 was revised and yielded 13 observational studies. This systematic review includes statistical comparisons between the group of interest of this review and the adult population. Other comparisons include those between the different sources. Our outcomes include a consistent pattern. This consistency between different studies was opposed by certain contradictions. Disparity between the different reviewed studies was displayed in terms of the distribution of the most cited complications of TLLA among different sources and the frequency of additional surgery. The dichotomy in the results of the reviewed studies highlights a gap in the data relevant to TLLA in the pediatric population. In addition to the discrepancies in the available literature, the significant physio-anatomical differences between the pediatric and the adult populations which are relevant to TLLA highlight a requirement for further studies regarding TTLA in the pediatric age group.
347	ENZYMATIC DEBRIDEMENT WITH NEXOBRID® REDUCES SURGERY IN LASER DOPPLER IMAGING-CONFIRMED DEEP BURNS (Claes K.E.Y., De Decker I., Vyncke T., Verbelen J., Dhooghe N., Monstrey S., Hoeksema H.) In contrast to tangential excision, enzymatic debridement with NexoBrid® selectively removes non-viable tissue, allowing some deep dermal burn wounds to still heal conservatively. In this retrospective study, we investigated the reduction in surgery and associated scarring following enzymatic debridement in definitely deep burns as proven by laser Doppler imaging. One hundred two exclusively laser Doppler imaging-blue regions of interest where there was no doubt at all about the surgical indication, were selected for analysis in 32 patients treated with NexoBrid®. The total surface area of the 102 exclusively blue regions of interest was 5,086.4cm². NexoBrid® resulted in a substantial reduction in the need for autografts as 1,986.9cm² (39%) healed with conservative treatment. This corresponded with a significant reduction in patients (56.3%) requiring surgery. Exclusively laser Doppler imaging-blue regions of interest treated surgically with split thickness skin grafts required significantly more time to heal compared to conservative treatment (37.8±17.5 vs. 27.0±10.5 days). A very limited rate of hypertrophic scarring (16.7%) was observed. This is the first paper demonstrating a proven and significant reduction in the extent of autografting as well as in the number of surgical procedures after selective enzymatic debridement in objectively laser Doppler imaging-defined and therefore proven deep burns. Even after extended conservative treatment with prolonged healing times following NexoBrid®, hypertrophic scar formation was limited (5/54 regions of interest, 9.3%). Also in operated patients, the incidence of hypertrophic scarring following a strict regimen of aftercare was low (12/48 regions of interest, 25%).
355	“MINIMALLY INVASIVE” SKIN GRAFTING WITH ENZYMATIC DEBRIDEMENT AND AUTOLOGOUS SKIN CELL SPRAY: A RETROSPECTIVE CASE SERIES (Kahn S.A., Raghava N., Gaweda G., Hink A., Holmes IV J., Hickerson W., Carter J.E.) Minimally invasive surgery is becoming the standard of care across surgical subspecialties. Several new “minimally invasive” options for burn debridement and autografting exist. Enzymatic bromelain-based debridement (BBD) and autologous skin cell spray (ASCS) have independently proven to reduce the rate of split-thickness skin grafting (STSG) and decrease donor site size when grafting is performed. There is a paucity in the literature regarding the combination of these two therapies. The purpose of this study is to characterize a cohort of patients treated with both BBD and ASCS and qualitatively compare data to expected outcomes without these therapies. This retrospective study of a single academic burn center’s experience using BBD and ASCS together included 13 patients with a total burn surface area (TBSA) from 1-30% and all had >50% deep partial thickness. All patients received BBD and ASCS. Deeper burns additionally received STSG with ASCS overspray. Median burn size was 14% TBSA (IQR:5.45,20), donor site size was 225 sq cm (IQR:28.5,556.5), and ratio of donor site area to total treatment area of 0.082 (IQR: 0.039, 0.241) was observed. Median observed length of stay (LOS) was 19 days (IQR:10,27), expected LOS was 15.4 days, and O/E ratio 1.06. Donor sites in both groups of patients were much smaller than expected versus treatment with conventional meshed STSG alone and length of stay is lower than expected based on burn size. An emphasis on expenses and scar development will guide future studies into the patient subset and wound features that are best for this combination treatment.

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