Prise en charge des brûlés graves pendant les 72 premières heures

Early and efficient management of severely burned patients facilitates outcome improvement. Pre-hospital care includes fluid loading with 2 mL-kg¹/% burn over the first six hours, sedation and analgesia, prevention of hypothermia and ventilatory support for either critically burned patients or facial, cervical or pulmonary burn injury. The transient stay in a general hospital before transfer to a burn centre allows extension of inital care, the critical investigation for associated injuries (intoxication, multiple trauma) and to perform initial local treatment with sterile coverage or vaseline gauze after a revises assessment of the burned skin area, and possibly escharotomies. The main aim of care in the burn centre is to control hypovolaemia and to obtain maximal tissue perfusion and oxygen delivery to burned tissues, as well as to healthy organs. To manage the burn shock (initially hypovolemic and later on hyperdynamic) catecholamines are often indicated when appropriate fluid loading remains insufficient. Mechanical ventilation is indicated in case of either a deep extensive burn over 60% of total body surface area, or facial and cervical burns or severe pulmonary burn injury from smoke inhalation, carbon monoxide intoxication, tracheobronchial thermal injury and blast injury.Because of the severity of burn-related pain, and the stimulous linked to intensive care, continuous sedation is usually required.Early surgical treatment such as escharotomies, excision and grafting, which cause significant pain as well as blood loss, and hydrotherapy, often require general anaesthesia. Burn injury can modify the volume of distribution and the pharmacokinetics of anaesthetic agents. Finally, chemical or electrical burn, radiation, associated CO intoxication or multiple trauma, as well as burn injury in infants, raise specific problems. With improvement in early intensive care, the survival rate of the most severely burned patients is obviously improving. New techniques in skin substitution will probably further improve the final outcome.     

Chemical burns: A review

Chemical burns form a significant percentage of mortality from burns and total burns cases reported. There are over 65,000 chemicals available on the market, a large number of which can cause tissue damage. Despite this, they are often mismanaged. The severity of the chemical burn is dictated by the substance responsible, the percentage burn, the concentration, time since exposure, subsequent management and regional skin properties. Burns can be caused by both acids and alkalis. Acid burns cause eschars which limit the extent of the burn. Alkali burns therefore tend to be deeper. Like all burns, the patient should be resuscitated according to the Adult Trauma Life Support guidelines. Copious irrigation forms the mainstay of treatment. Neutralising agents are present for certain chemicals but their use should not delay the irrigation process which may take several hours. We look at the most common chemicals encountered in daily life and explore special considerations when dealing with resulting burns. Chemical burns are often associated with other injuries such as inhalation injury, so it is essential that the patient is considered holistically and all other injuries considered before concentrating all efforts on the chemical burn alone.     

Management of acute calvarial burns in children

BACKGROUND: Although rare, head burns involving the calvarium are a serious complication of burns and electrical injury, and present therapeutic challenges to the surgical burn care team. We evaluated our experiences and compared available strategies to address this challenge. METHODS: Records of all burned children between January 1986 and December 2000 were reviewed. Twenty-seven children (15 boys and 12 girls) with scalp burns extending at least into the outer table of bone were identified and compared with a matched group of 30 patients admitted for acute thermal burns without skull injury. RESULTS: Flame burn was the injury mechanism in 78% of these patients and electrical injury was the injury mechanism in 22%. The incidence of calvarial burns in our patient population was 1.2% for thermal burns and 5.6% for electrical injuries during the study period. The age distribution was biphasic, with maximums in infancy for thermal burns and in puberty for electrical injuries. Eight of 27 patients (29.6%) developed full-thickness calvarial bone defects. In 23 patients, calvarial burn wound coverage was achieved with bone debridement and immediate or delayed placement of autograft skin. In four patients (all with electrical injury), local scalp flaps were required for closure. The length of hospital stay and overall number of acute operative procedures significantly increased for patients with calvarial burns. CONCLUSION: Acute calvarial burns are safely managed by bone debridement in combination with staged autografting or early flap coverage. Although flap coverage reduces the number of required procedures, the extensive wound size in thermal burns restricts acute flap procedures primarily to electrical injuries. Compared with patients without skull injury, length of hospital stay and the number of acute operative procedures are tremendously increased in patients with calvarial burns.     

E-cigarette burn injuries: Comprehensive review and management guidelines proposal

IntroductionElectronic cigarettes (EC) have been reported to be associated with burns secondary to explosions of the device or battery, or contact from overheating, resulting in flame, contact or chemical burns. In addition to this, there have also been reported cases of soft tissue and bony trauma with or without associated burns.Using collective evidence, this review aims to summarise all reported burns associated with ECs, and its implications on immediate management with a particular focus on surgical treatment.MethodsA search was conducted on PubMed, EMBASE and Medline for all case reports, case series and letters to editors published since 2014, using terms “electronic cigarette”, “e-cigarette”, “vaping” and “burn”. The search was repeated by the co-author to avoid bias and a review of the bibliographies of each paper was conducted to ensure all relevant cases were included. The mechanisms, type and severity of burn injury, and management and treatment outcomes of the patients were recorded.Exclusion criteria included non-English articles, explosions with no associated burn and publications with insufficient information.Results90 patients from 19 case series or case reports were included. With the exception of one study, gender was recorded with a male predominance (95.6%). Mean age is 30.1 years (range 18–59). The most common type of burn was flame. However, there were reports of chemical burns associated with ECs. The mean total body surface area (TBSA) affected was 4.9% (range 1–27.25%) with the majority of burns being mixed partial and full thickness.22 patients underwent excision and autologous skin grafting within range of three to 21 days. One patient had a full thickness contact burn excised and closed, one patient received a xenograft following debridement and one had biosynthetic skin dressing.42 patients were managed conservatively with dressings or ointments.DiscussionIn this review over a three-year period (2015–2017), 90 cases of EC related burn injuries were reported, however, this is likely an underestimation of the problem.The suggested mechanism for EC related injuries is battery malfunction. ECs are powered by Lithium ion batteries which are susceptible to “thermal runaway” reactions, which result in device overheating with potential for subsequent explosion. We explain hypothesized triggers for these reactions and mechanisms of other injuries associated with ECs such as chemical burns and blast injury.ConclusionEC-associated burn injury results in combined thermal and chemical burns, which should be managed in tandem. Explosion injuries sustained whilst using the device may result in both facial trauma or inhalation injury and therefore should be reviewed with a high index of clinical suspicion.It is noted that there is no agreed standard for management for such burns by specialist bodies in the UK. We suggested a treatment algorithm to provide guidance for the burn injuries associated with ECs.     

Burn pain and dressing changes

The management of pain associated with trauma and burn injury presents a challenge to the pain practitioner. This is because the pain associated with injury and burns adds to the already activated stress response. Management is further complicated by hypovolemia, which may result in rapid decompensation if sympathetic activity is blunted by opioid or local anesthetic analgesia. Pain after burn injuries is due to stimulus of nociceptors in the skin, the accompanying inflammatory response, and nerve damage. As such, baseline pain management must include treatment of both nociceptive and neuropathic components. In addition to the baseline requirements, analgesic needs for painful procedures, such as dressing changes, must be addressed. Dressing change analgesia is a difficult problem because of the requirements of intense, but short-duration, analgesia. Ketamine, regional anesthesia, and alfentanil have been used successfully. Because injury and burns have multisystem effects, the approach to pain management must be multidisciplinary and include anesthesiologists, surgeons, critical care specialists, nurses, psychologists, and social workers. Copyright © 2002 by W.B. Saunders Company     

Ocular complications of thermal injury: a 3-year retrospective

BACKGROUND: Diagnosis and treatment of thermal ocular injuries are often delayed because facial burns are usually associated with life-threatening injuries requiring immediate intervention. The purpose of the present study is to review the diagnosis and management of ocular complications associated with thermal burns in a tertiary care burn unit. METHODS: In this retrospective study, the charts of patients admitted to the Loyola University Medical Center Burn Unit between January 1993 and January 1996 were reviewed. RESULTS: Of the 1,461 patients who were admitted to the burn unit during that period, 155 (10.6%) required ophthalmic consultation. Sixty-one patients (4.2%) had ocular injury, the most common type being periorbital burn and edema followed by corneal involvement. Thirty-one of the 61 patients (51%) received consultation on the day of admission. Six of the 61 patients (10%) required surgical intervention. There was no correlation between number of days to consultation and need for surgical intervention. Patients requiring surgery were more likely to have suffered third-degree burns. CONCLUSION: Because it is difficult to predict which patients suffering from thermal burns involving the eyes will require surgical intervention, ophthalmic consultation should be sought early.     

Burn unit management of toxic epidermal necrolysis.

Toxic epidermal necrolysis is the name given to a group of dermatologic disorders characterized by a separation of epidermis and dermis with a subsequent skin slough. The denuded areas have the appearance of a second-degree burn. The complications of infection, negative nitrogen balance, severe pain, and emotional instability are identical to those seen in the patient with major burns. There are difficulties in patient management and advantages in burn unit care. As with the major burn, care of the patient with skin loss from toxic epidermal necrolysis is extremely complex, requiring the expertise of a burn team along with that of the dermatologist.     

The enhanced Total Body Wrap—The new frontier in dressing care for burns

The management of extensive burns with their associated high fluid exudate following burn excision and skin grafting has always posed a challenge in burn wound care. The ideal dressing should protect the wound from physical damage and micro-organisms; be comfortable and durable; allow high humidity at the wound; and be able to allow maximal activity for wound healing without retarding or inhibiting any stage of the process.     

Epidemiology of burn injuries presenting to North Carolina emergency departments in 2006–2007

Approximately 600,000 burns present to Emergency Departments each year in the United States, yet there is little systematic or evidence-based training of Emergency Physicians in acute burn management. We retrospectively accessed the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) database to identify all thermal burns and electrical injuries with associated thermal burns presenting to 92% of North Carolina Emergency Departments over a 1-year period. Results: 10,501 patients met inclusion criteria, 0.3% of all state-wide reported ED visits. Ninety-two percent of burn visits were managed exclusively by Emergency Physicians without acute intervention by burn specialists, including 87% of first degree, 82% of second degree, and 53% of third degree injuries. Only 4.3% were admitted; 4.3% were transferred to another institution. Fifty-five percent were male; 33% were aged 25–44 and 33% presented on weekends. Conclusion: This is the first state-wide study of burn injury and identifies Emergency Physicians as the major providers of acute burn care. Ninety-two percent of 10,501 burn visits, including the majority of severe injuries, were managed exclusively by Emergency Physicians. This supports a need for improved, evidence-based training of Emergency Physicians in the acute management of burns of all types.     

Chemical burn to the skin: A systematic review of first aid impacts on clinical outcomes

Chemical burns can cause deep injury and subsequently significant scarring to the skin. The mechanism and pathophysiology of chemical burns is distinct to thermal burns, and recommended first aid approaches are consequently different. Twenty minutes of cool running water is an effective first aid measure to improve outcomes after thermal burn. For chemical burns to the skin, the recommendations are immediate water lavage for 60 min, removal of contaminated clothing if not stuck to the skin and then covering the wound with a sterile dressing. This review assesses the peer-reviewed literature to find the evidence behind the efficacy of cutaneous chemical burn first aid on short term outcomes such as length of hospital stay, depth of burn and longer-term outcomes such as scarring; in particular, the effect of immediate or early water lavage, and the effect of the duration of water lavage. Ocular chemical burns were not included in this review. The review suggests some evidence to support that the early application of cool water irrigation may reduce length of hospital stay and the extent of scarring. Community education should emphasize that water irrigation is recommended and that the earlier this happens, the better.     

Toxic epidermal necrolysis: 10 years experience of a burns centre in Hong Kong

Toxic epidermal necrolysis syndrome is characterized by extensive skin rash with blisters and exfoliation similar to that of major burns. Current evidence suggests that toxic epidermal necrolysis syndrome is most likely due to cell-mediated immune response triggered by certain drugs. Recognition of the clinical situation which is similar to major burn has resulted in general agreement that these patients are best treated in a burns unit, where critical support and meticulous wound care can be carried out by experienced personnel. This represents a major step forward in the management of this condition. The 10 year experience of managing seven patients with severe toxic epidermal necrolysis in a tertiary burns centre in Hong Kong is presented and the controversies over classification and management of the disease are also discussed.     

我国烧伤免疫的研究

The electric burn is a kind of special injury, in which the injured areas are not big, but deep tissues and organs are often injured, resulting in higher rates of mortality and amputation than thermal injury. In the process of management, besides the treatment for systemic and pathologic changes, wound repair is also emphasized for restoration of function. In the past 50 years, ten thound patients with electric burn were cured in our country, including hundreds of severe electric burn patients with extensive injury. Lots of operative regimes for electric burn were developed, and the scope of experimental research was broadening. As aresult, six monographs concerning electric burns were published. However, clinical management of severe electric burn to give a satisfactory result is still difficult, therefore further indepth research is necessary, especially in the field of the use of artificial skin, vessels, nerves, muscular tendon, etc. from gene and tissue engineering to improve quality of wound repair.     

Das Verbrennungstrauma – Teil 1

Severe burn injuries are rare and represent less than 1% of all medical emergencies. At the scene of the accident self-protection is important. The progress of thermal injury should be stopped, while cold water therapy is usually not indicated as the resulting hypothermia severely reduces the prognosis. A thorough body check reveals the burn size, depth and presence of co-injuries. Volume depletion is the main pathophysiological reason for burn shock. Early infusion therapy is of prognostic significance. Sufficient analgesia has to be established. Intubation is not generally indicated even with extensive burns, whereas early intubation can be life-saving in the case of circular thoracic burns, face burns and inhalation trauma. Local or systemic administration of corticosteroids is not indicated. Transfer to a specialized burn unit depends on burn size and depth. Emergency room management includes stabilization of vital functions, evaluation of co-injuries and initiation of the specific surgical and intensive care therapy.     

Management of the acutely burned ear

One hundred patients with burns of the ears were reviewed. Most had second-degree burns and did well. Loss of the external ear occurred in 15 patients, or 22 ears, due to the presence of very deep burn with full thickness injury. Chondritis developed in nine ears (5 per cent) with severe destruction of the ear in 8. Pseudomonas aeruginosa is an especially destructive organism to cartilage and was associated with all our cases of chondritis. Progression of deformity and development of infection can be minimized by avoidance of pressure, regular cleansing and application of topical antibiotics. Careful debridement and skin grafting of any third-degree burn areas are required and should be carried out as soon as possible.     

The deeply burned upper extremity: functional graft distribution concept with selective use of a synthetic dermal substitute (Integra) and split-thickness skin grafts

A 15-year-old boy sustained a severe inhalation injury and second/third degree burns following a flame burn involving the face, neck, upper thoracic regions, and upper extremities measuring 25% of his total body surface area. The right arm had a full-thickness burn, the left arm deep partial-thickness burns. Tangential excision and split-thickness skin grafting (STSG) were performed. Because of the full-thickness burns on the right arm, an epifascial excision was necessary on the left arm, sparing the venous tributaries. To reconstruct the epifascially excised extremity, a new concept was used. Split-thickness skin graftings were selectively distributed over the digits, and the remaining zones were covered with a synthetic dermal substitute (Integra). Unfortunately, the dressing changes and the definitive grafting of the synthetic dermal substitute had to be delayed until day 62 because of severe lung failure, acute respiratory distress syndrome (ARDS), the necessity for extracorporeal membrane oxygenation, multiple organ failure, and prolonged intensive care stay. Despite circulatory and ischemic complications, all grafts taken on both extremities after incorporation of the dermal substitute, both immediate and delayed, were complete. There was no infection or other complication. The functional range of motion of all involved joints and the skin surface quality and contour were remarkably good. It is emphasized that the considerations in this report should be considered as preliminary and that further investigations are required.     

Erhalt der oberen Extremität nach schwerstem Verbrennungstrauma unter Einsatz des Fixateur externe

Extensive thermal damage is one of the worst injuries possible.Destruction of large areas of the body surface leads not only to local damage with collapse of the skin barrier, but also to activation of all physiological cascade-systems with a consequent threat to life.The intensity of the trauma response depends on both the surface area destroyed and the depth of soft tissue destruction. In occasional cases an accident involving thermal damage can lead to fractures or joint instability as well as burns, and early stabilisation is then necessary.External fixation is an optimal stabilising procedure for wounds with no bacterial colonisation. In the case of fractures,however,preference should be given to early performance of the definitive internal procedure. In the present paper the use of external fixation in the upper extremity after a severe contact burn is reported and the possibilities of using the external fixator in burn trauma are critically reviewed.     

Burn prevention mechanisms and outcomes: pitfalls, failures and successes

Burns are responsible for significant mortality and morbidity worldwide and are among the most devastating of all injuries, with outcomes spanning the spectrum from physical impairments and disabilities to emotional and mental consequences. Management of burns and their sequelae even in well-equipped, modern burn units of advanced affluent societies remains demanding and extremely costly. Undoubtedly, in most low and middle income countries (LMICs) with limited resources and inaccessibility to sophisticated skills and technologies, the same standard of care is obviously not possible. Unfortunately, over 90% of fatal fire-related burns occur in developing or LMICs with South-East Asia alone accounting for over half of these fire-related deaths. If burn prevention is an essential part of any integrated burn management protocol anywhere, focusing on burn prevention in LMICs rather than treatment cannot be over-emphasized where it remains the major and probably the only available way of reducing the current state of morbidity and mortality. Like other injury mechanisms, the prevention of burns requires adequate knowledge of the epidemiological characteristics and associated risk factors, it is hence important to define clearly, the social, cultural and economic factors, which contribute to burn causation. While much has been accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs) such as the United States due to sustained research on the epidemiology and risk factors, the same cannot be said for many LMICs. Many health authorities, agencies, corporations and even medical personnel in LMICs consider injury prevention to have a much lower priority than disease prevention for understandable reasons. Consequently, burns prevention programmes fail to receive the government funding that they deserve. Prevention programmes need to be executed with patience, persistence, and precision, targeting high-risk groups. Depending on the population of the country, burns prevention could be a national programme. This can ensure sufficient funds are available and lead to proper coordination of district, regional, and tertiary care centres. It could also provide for compulsory reporting of all burn admissions to a central registry, and these data could be used to evaluate strategies and prevention programmes that should be directed at behavioural and environmental changes which can be easily adopted into lifestyle. Particularly in LMICs, the emphasis in burn prevention should be by advocating change from harmful cultural practices. This needs to be done with care and sensitivity. The present review is a summary of what has already been accomplished in terms of burn prevention highlighting some of the successes but above all the numerous pitfalls and failures. Recognizing these failures is the first step towards development of more effective burn prevention strategies particularly in LMICs in which burn injury remains endemic and associated with a high mortality rate. Burn prevention is not easy, but easy or not, we have no options; burns must be prevented.     

A review of the specialties that care for inpatient burns and smoke inhalation in the English counties of Lancashire and South Cumbria

Prevention is by far the best strategy to minimise the burden of burns and smoke inhalation injuries on public health. However, it is inevitable that some injuries will occur despite the best attempts to prevent them. We must, therefore, optimise treatment in order to restore individuals to the best possible condition. Previous experience has shown that a wide range of specialties, many of which are untrained in burn care medicine, are involved in the care of inpatient burns/smoke inhalation victims in the UK. In light of this, a local review of which specialties care for such injuries was conducted for the population of Lancashire and South Cumbria in the north-west of England. Using population-based health authority data from 1997 to 1999, all Hospital Episodes relating to a primary diagnosis of burns or smoke inhalation were ascertained. The results showed that 41% of all burns episodes were treated by specialties other than burns/plastics. The short lengths of stay in non-plastics/burns specialties suggest that relatively minor injuries are being admitted to these units. Analysis of smoke inhalation injuries showed admission to various different specialties. Admission to burn services ensures that key specialties are available for the care of complex burn injuries. These multidisciplinary teams include burn nurses, burn surgeons and burn anaesthetists/intensivists. From the data available, it was not possible to assess the appropriateness of admission of burns and smoke inhalation injuries to the various branches of medicine. In order to assess appropriateness, we need information on severity of injury and outcome of treatment in each specialty. Further research in this area is required since it is concerning that many burns/smoke inhalation injuries are being treated by specialties with no formal training in burn care medicine. This may have major implications for service planning alongside changes in referral patterns.