RECONSTRUCTION OF DEEP HEAD BURN WITH A FREE FLAP - A CASE REPORT.

Third degree burn trauma of the head and neck requires an interdisciplinary approach. After emergency care and hemodynamic stabilization of the patient the focus lies on the reconstruction of the damaged tissue. The options of reconstruction are influenced by the general condition of the patient and by the condition of the surrounding tissues. The deep defects of the head are dangerous for a high risk of wound infection and possible fatal complications. In particular cases the first methods of choice for closure of the defect may be ineffective and a free flap transfer should be considered. We present a case report of a 62-year-old woman who suffered third degree burn trauma of the head and neck leading to a deep defect of the forehead reaching behind the hairline. On the bottom there was an exposed bone with no healing tendency. Due to surrounding fragile scarred tissue we chose a free flap transfer using serratus anterior muscle as a method of closure. The flap was fully healed and provided good aesthetic and functional outcome.

Early surgical management in patients with burns.

Burns can be life threatening injuries with a significant risk of lifelong consequences. Severity of thermal injury is assessed using the combination of six essential factors (mechanism of injury, presence of inhalation trauma, extent of the burn area, depth of the burn, its location, patients age and co-morbidities) which also represent the determinants of referral to one of the three specialized burn centers in the Czech Republic. Early management consists of ABC Trauma Life Support (adequate oxygenation and ventilation, a venous access, parenteral fluid administration), pain relief, and sterile covering of the burn areas.

OUR EXPERIENCE WITH THE USE OF 40% BENZOIC ACID FOR NECRECTOMY IN DEEP BURNS.

INTRODUCTION: Chemical necrectomy of deep burns using 40% benzoic acid has been used extensively by the Department of Burns and Reconstructive Surgery at the University Hospital since its establishment in 1982. In spite of definite advantages for the patient and medical staff, hard data concerning benzoic acid absorption through skin necrosis and patient safety was missing. MATERIAL AND METHODS: We examined 22 burn patients in collaboration with the University Hospital Brno, Department of Clinical Biochemistry. The plasmatic levels of benzoic acid, hippuric acids and glycine, which is consumed during the metabolism of benzoic acid, were measured. Urine samples were collected to determine the total amount of hippuric acid that is excreted. We were able to determine the total amount of absorbed and excreted benzoic acid from these values. RESULTS: We consistently found that there was a rapid and short-term increase of plasmatic levels of benzoic acid (maximum 1.3 mmol/l). This value is about 5 times lower than the minimum toxic level of this acid (6.5 mmol/l). The same course has been observed in hippuric acid. The level of glycine dropped slightly, but was still within the normal range. DISCUSSION: Typical and atypical courses of the levels of both acids were discussed as well as the correlation of the dynamics of elimination with the extent of benzoic acid application in relationship with the clinical status of the patient. The effectiveness and safety of this method was evaluated. CONCLUSION: After summarizing the observations, it was demonstrated that chemical necrectomy using 40% benzoic acid is a selective method comparable with other types of sharp necrectomy. Chemical necrectomy is inexpensive, easy to perform and also reduces blood loss. Toxicity of absorbed benzoic acid is clinically negligible. Furthermore, benzoic acids antimycotic and antibacterial properties prevent the development of wound infection.

MICROMYCETES INFECTION IN PATIENTS WITH THERMAL TRAUMA.

GOAL: Determination of basic epidemiological parameters of burn patients with micromycetes infection. Identification of the most important micromycetes in burn patients. MATERIAL AND METHODS: Monocentre retrospective study enrolling all adult burn patients who were hospitalized between 2007 and 2015 and in whom micromycetes were isolated during hospitalization. ABSI index (Abbreviated Burn Severity Index) was used to evaluate severity of thermal trauma. Results were statistically analysed. RESULTS: There were 61 patients with thermal trauma identified in total during the period of observation, and there were yeast or fibrous fungi isolated. There were 37 males and 24 females (M:F ratio - 1.5:1) in this group. The average age of patients was 57.3 years (29 patients were aged up to 60 years, 32 patients were over the age of 60 years, inclusive). 6 patients died (lethality was 9.8%). The average extent of the burn area was 21.6% TBSA (median 14.0%). There were 90 strains of micromycetes cultured in total in these patients (79 yeasts, 11 fibrous fungi). Micromycetes were isolated from burn area in 30 patients, from the lower airways in 19 patients, from the urogenital area in 15 patients and from blood culture in 7 patients. Non-albicans Candida species were predominant among yeasts (60 strains); Candida albicans was isolated 16 times in total. Aspergillus fumigatus (4 isolations) and Fusarium species (2 isolations) were predominant species among fibrous fungi. CONCLUSION: We successfully identified the basic epidemiological parameters in burn patients with micromycetes infection, similarly to the most important yeasts and fibrous fungi causing infection in these patients.

Prevalence of infectious complications in burn patients requiring intensive care: data from a pan-European study.

UNLABELLED: The objective of this study was to determine the prevalence of infectious complications in burn patients requiring intensive care in a one-day multicenter study encompassing burn centers in various European countries. MATERIAL AND METHODS: The European Burns Association database identified 87 centers in Western and Eastern Europe, 27 of which agreed to cooperate. American Burn Association recommendations were used for diagnosis of various infectious complications in patients with thermal trauma. RESULTS: From those centers, we randomly assigned 134 patients (44 women) to the analysis. Mean age of the group was 40.39 ± 22.17(SD) years. Mean abbreviated burn severity index was 7.5±2.54, mean size of burned area was 30.49 ± 20.14% of total body surface area. Mean length of hospitalization to date was 24.32 ± 30.64 days. Infectious complications were observed in 92 patients (68.7%), 76 (56.7%) of whom met the criteria for infection of the burned area, 26 patients (19.4%) for bloodstream infection, 21 (15.7%) for pneumonia, and 13 (9.7%) for urinary system infection. Multifocal infections were found in 29 patients (21.6%). Gram-positive bacterial strains as potentially pathogenic microorganisms were identified in 67 patients (50.0%), Gram-negative bacterial strains in 73 (54.5%), and yeasts in 18 (13.4%) patients. Filamentous fungi were not isolated from any patient in the group. CONCLUSION: Cornerstone future standards in individual burn centers should be to monitor the occurrence of infectious complications in burn patients, prevent the spread of these complications, and report resistant pathogens. This work constitutes an important project in this area.

High voltage electrical injury: an 11-year single center epidemiological study.

The aim of our study was to retrospectively evaluate the epidemiological characteristics of patients with high voltage electrical injury from 1999 to 2009. The Clinic of Burns and Reconstructive Surgery, Faculty Hospital Brno is located in a region of 2,505,000 inhabitants. In total 13,911 patients (including both children and adults, and outpatients as well as hospitalized patients) were treated at our burn center during the period of study. Of these patients, 1,030 were hospitalized for burns treatment. For the purposes of this study, we have included only patients with high voltage electrical trauma, of which there were 58, 2 of whom were female. Basic epidemiological indicators were gathered on these patients, including age, gender, place of accident, extent of trauma, mortality and whether the injury was occupational or non-occupational. Electrical burns (caused by both low-voltage and high-voltage electric current) made up 1.10% of all burns treated in our burn center and high voltage electrical injuries represented 0.42% of all burn injuries. The average incidence of high voltage electrical trauma was 0.21 cases/100,000 inhabitants. The average age of the patients was 28.59 years. Nine patients died and the mortality was fixed at 15.52%. The average length of hospitalization was 53.43 days. The average extent of burnt area was 35.01% TBSA. In our study, we were able to define the basic epidemiological parameters in 58 patients with high voltage electrical trauma. We also have to highlight the still disappointingly high number of non-occupational electrical injuries affecting those in the lower age groups, especially children. However, preventive programmes for educating specific risk groups have shown positive results.

Le but de notre étude était d'évaluer rétrospectivement les caractéristiques épidémiologiques des patients présentant les lésions électriques causées par la haute tension de 1999 à 2009. La Clinique de « Burns and Reconstructive Surgery ¼, Faculty Hospital Brno, est située dans une région de 2.505.000 habitants. Au total, 13 911 patients (y compris les enfants et les adultes, et ambulatoires ainsi que les patients hospitalisés) ont été traités dans notre centre pendant la période d'étude. Parmi ces patients, 1.030 ont été hospitalisés pour le traitement des brûlures. Aux fins de cette étude, nous avons inclus seulement les patients avec un traumatisme électrique à haute tension, il y en avait 58, dont 2 étaient des femmes. Des indicateurs épidémiologiques de base ont été recueillies sur ces patients, dont l'âge, le sexe, le lieu de l'accident, l'ampleur du traumatisme, de la mortalité et si la blessure était liée ou non au travail. Les brûlures électriques (causée par une basse tension et le courant électrique à haute tension) représentaient 1,10% de toutes les brûlures traitées dans notre centre, et des blessures électriques à haute tension représenté 0,42% de toutes les brûlures. L'incidence moyenne de traumatisme électrique à haute tension est de 0,21 cas pour 100,000 habitants. L'âge moyen des patients était de 28,59 années. Neuf patients sont décédés et la mortalité a été fixée à 15,52%. La durée moyenne d'hospitalisation était de 53,43 jours. La moyenne surface corporelle brûlée était 35.01% de la SCT. Dans notre étude, nous avons pu définir les paramètres épidémiologiques de base chez 58 patients atteints de traumatismes électrique à haute tension. Nous devons également mettre en évidence le nombre toujours élevé de blessures électriques non-professionnelles affectant ceux dans les groupes d'âge inférieures, surtout les enfants. Toutefois, les programmes de prévention pour sensibiliser les groupes à risque spécifiques ont montré des résultats positifs.

Use of Xe-Derma(®), a novel biological cover, in a female patient with toxic epidermal necrolysis.

Toxic epidermal necrolysis is a rare condition involving the skin at the dermoepidermal junction, with possible inclusion of mucous membranes. The condition is associated with systemic toxicity and high mortality rates. Successful treatment requires optimization of local as well as systemic therapy. We report the case of a young woman who developed toxic epidermal necrolysis, possibly resulting from lamotrigine therapy. Local therapy included a combination of a biological cover and alginate together with a synthetic cover (Aquacel Ag®).

La nécrolyse épidermique toxique est une maladie rare touchant la peau à la jonction dermo-épidermique, avec inclusion possible des muqueuses. La condition est associée à une toxicité systémique et des taux de mortalité élevés. Le succès du traitement nécessite une optimisation de la thérapie locale ainsi que systémique. Nous rapportons le cas d'une jeune femme qui a développé une nécrolyse épidermique toxique, causée peut-être par un traitement par la lamotrigine. Le traitement local a compris une combinaison d'une couverture biologique et de l'alginate avec une couverture en matière synthétique (Aquacel Ag®).

The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997-2009.

UNLABELLED: The aim of this study was to determine the basic epidemiological characteristics of severely burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997-2009. METHODS: We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the use of mechanical ventilation and its duration, day and month of injury and the extent of burned area. RESULTS: In total 383 children (253 boys, 130 girls) aged 0-14 years, underwent intensive care for at least 48h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43±12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03±5.67 days in average. The average length of stay in ICU was 10.71±10.92 days and total length of hospital stay was an average of 21.55±14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). CONCLUSION: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care.

Epidemiology of ventilator-associated tracheobronchitis and vantilator-associated pneumonia in patients with inhalation injury at the Burn Centre in Brno (Czech Republic).

Aim. The aim of this work is to determine the incidence of ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP) and to define the define the most important respiratory pathogens in patients with inhalation injury. Introduction. Infectious complications in severely burned patients present serious problems. Patients with inhalation injuries are exposed to greater risk owing to the possible development of infectious complications in the lower respiratory tract. VAP is the predominant cause of death in these patients. This is due to the increasing resistance of strains of Gram-negative bacteria such as Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae. Design. Retrospective, monocentric. Setting. A five-bed burn intensive care unit. Material and methods. Between 2004 and 2009, 348 adult patients were hospitalized in the intensive care unit of the Department of Burns and Reconstructive Surgery, Brno University Hospital, Czech Republic. Of these, 127 (36.49%) were diagnosed by bronchoscopy as having inhalation injury. The prerequisite for inclusion in the cohort was an inhalation injury requiring artificial ventilation for at least 48 h. The lower airway microbiological condition was monitored regularly by sampling biological material for cultures (sputum, tracheobronchial aspirates, etc.). For the diagnosis of VAP and VAT we used the Centers for Disease Control and Prevention criteria and the Clinical Pulmonary Infection Score. Results. The average age of the 127 patients (31 women/96 men) included in the study was 38.4 yr (range, 21-69 yr) and the average total body surface area (TBSA) burned was 29.3% (range, 2-75%). The average length of hospital stay was 49.4 days (range, 4-150 days) and the duration of mechanical ventilation 8.7 days; 18 patients (14.2%) died. In patients with inhalation injury, 309 strains of bacteria were cultivated from the lower respiratory tract, of which 234 were Gram-negative. All of these bacterial strains were isolated in significant quantities for lower respiratory tract infection. The most common bacteria isolated from the lower respiratory tract was Klebsiella pneumoniae (78 times), followed by Pseudomonas aeruginosa (49x), and Acinetobacter baumannii (28x). VAT was diagnosed in 109 patients (85.8%) in the cohort. The incidence of VAT was calculated to be 98.8 per 1000 days of mechanical ventilation. VAP was diagnosed in 34 patients in the cohort (26.8%). The incidence of VAP was calculated as being 30.8 cases per 1,000 days of mechanical ventilation. In eight patients (23.5%), VAP was diagnosed within 5 days of initiation of mechanical ventilation (early onset) and in 26 patients (76.5%) after a longer period (late onset). The most common aetiological agent of VAT and VAP was Klebsiella pneumoniae (respectively 41.3% and 35.3%). Conclusion. In this study we were able to determine the incidence of VAP and VAT in patients with inhalation injury. In spite of the advances in diagnostics and therapy, inhalation injury is still burdened with disappointingly high morbidity and mortality rates. For this reason, the treatment of VAP remains a major challenge for all physicians caring for patients with inhalation injury.

[Changes in the bacterial spectrum in severe burn wounds]. / Zmena bakteriálního spektra na ranných plochách u tezce popálených pacientu.

STUDY OBJECTIVE: To determine the time axis for increase in Gram negative bacterial strains in burn wounds during hospitalization. STUDY TYPE: Retrospective. MATERIAL AND METHODS: Eighty-five patients hospitalized at the Clinic of burns and reconstructive surgery between 2006 and 2008 were enrolled in the study. The major criteria for enrolment were more than 15% of total body surface area (TBSA) burned, hospital stay of 1 month or more and age over 18 years. Specimens for microbiological examination were collected on days 2, 6, 10, 14 and 20 after admission. RESULTS: A total of 777 bacterial strains were isolated from the study patients, with 64.6% of these strains being Gram positive and 35.4% Gram negative. The most frequently isolated Gram positive pathogens were coagulase-negative Staphylococcus (260 strains) and Bacillus sp. (113 strains), while the most common Gram negative pathogens were Pseudomonas aeruginosa (81 strains), Escherichia coli (63 strains) and Acinetobacter calcoaceticus-baumannii complex (57 strains). CONCLUSION: The study provided data that supports the assumption of increase in Gram negative bacterial strains in burn wounds during hospitalization. Nevertheless, even on day 20 after admission, such strains did not predominate.

The importance of a multidisciplinary approach in the treatment of mutilating electrical injury: a case study.

Electrical burns are not ranked among the most frequent type of injuries, but they have the most devastating potential of all thermal injuries and often cause lifelong stigmatization. Those primarily affected are young males: work injuries predominate. An electrical burn is a specific nosological unit that has multiple acute and chronic abnormal manifestations. In this study we describe the case of a young man who suffered an electrical injury after contact with a high-voltage line (22,000 volts) while paragliding. This contact was followed by a 10 m fall. In our work we present the need for multidisciplinary cooperation along with the opportunities, problems and risks that accompany the treatment of this type of injury.

Unsuccessful therapy of combined mycotic infection in a severely burned patient: a case study.

Patients with burn trauma are always in danger of contracting an infection. Although invasive mycotic infections are not as frequent as bacterial infections, high mortality and in many cases difficult diagnostics pose a serious threat not only for neutropenic patients. In more extensive burns the status is further complicated by specifically compromised immunity. The most frequent species of micromycetes isolated in burn patients are Candida spp. and Aspergillus spp. Zygomycetes represents a relatively uncommon isolation worldwide (up to 2% of all fungi. We present a case study of a young patient with 82% TBSA (total body surface area) burns, where we isolated simultaneously 3 different types of micromycetes (Aspergillus fumigatus, Fusarium sp., Absidia sp.). Mycotic infection is understood primarily as a complication in neutropenic patients and, after prophylactic antibiotic and antimycotic administration, in extensive burn trauma patients. The case ended with the death of the patient due to severe sepsis caused by the multiresistant strain Pseudomonas aeruginosa.

Mutilating electrotrauma--case report.

The passage of electric current through a human body causes polarization changes in cell membranes, which can possibly lead to the death of these cells. At the same time, electric energy is transformed to thermal energy, primarily in high resistance tissues. We present a case report of a 22-year-old male who was hit by an electric current with a voltage of 22 kV when he was working on a high-voltage overhead line tower. Primary treatment which included fasciotomies was completed two hours after the injury. Fasciotomies and revisions of all muscle groups were completed on the left upper extremity and right shank. On the right upper extremity fasciotomies were completed on the forearm. Retinaculum flexorum was cut in the area of both wrists. Despite the complex therapy including higher doses of a low-molecular-weight heparin, ischemization of the whole left upper extremity and distal part of right shank and foot occurred. On the sixth day after the injury it was necessary to amputate the right lower extremity in shank and on the eighth day after injury to amputate the left upper extremity below the shoulder, and on the fourteenth day, due to progressive ischemic necrosis, it was necessary to complete exarticulation of the left shoulder. The 45th day after the injury our team of micro-surgeons closed the defect of soft tissues in the distal part of right forearm and radial part of right hand by transferred parascapular fasciocutaneous flap. The right median nerve appeared to be necrotic in the distal part of forearm even at the day of injury. Four months after the injury the 12 cm long defect of the right median nerve was bypassed by a graft from the suralis nerve. Outpatient care followed as well as physical and psychological rehabilitation. The support of the family was admirable. One and a half years after the injury reconstruction of the right thumb flexor tendon was completed. Two years after the injury function of the right hand in terms of grip function was satisfactory (patient was able to complete pinch grip and sign). Gait with the prosthesis was very good.

Hemocoagulation disorders in extensively burned patients: pilot study for scoring of the DIC.

GOAL OF THE STUDY: To apply results of the hemocoagulation parameters to the DIC (disseminated intravascular coagulation) score system. Compare parameters of the DIC score in patients with extensive burn trauma (hospitalized at the Intensive Care Unit, ICU) and patients with lesser extent of burn injury (hospitalized at the standard unit). To use these data within the evidence based medicine for the prediction of organ damage and multi-organ failure. TYPE OF STUDY: Prospective study. MATERIAL AND METHODS: We have included total of 36 patients in the group within four months. Twelve patients were hospitalized at the ICU, 24 patients were hospitalized at the intermedial care and standard unit. Repeatedly, we have taken blood from patients to evaluate the hemocoagulation parameters. In patients hospitalized at the ICU, the blood was taken from the central vein (prior to the drawn, the access was flushed with 100 ml of F1/1, the blood was taken from different access than from the one administering heparin), in patients hospitalized at the standard unit the blood was taken from a peripheral vein. The results were then put into the tables established according to the ISTH (International Society on Thrombosis and Hemostasis). Next, the DIC score was calculated to predict severity of hemocoagulation balance disorders in burn trauma, or occurrence of complications during the treatment. RESULTS: Part 1: We have evaluated 12 patients (4 females) hospitalized at the ICU. At the day of injury the overt DIC score reached 1.25 (0-3), fifth day after the injury the average value of overt DIC score was 1.83 (0-3), one day after the autotransplantation it was 2.08 (0-3) and at the day of discharge from the hospital 0. In the deceased patient the DIC score reached value of 2. Part 2: We evaluated 24 patients (10 females) hospitalized at the standard unit. The extent of their burn injury was 5.9% TBSA (0.5-12% TBSA), age 49.13 years (17-94 years). At the day of injury the overt DIC score reached 0.25 (0-2). Fifth day after the injury the average value of overt DIC score was 1.66 (0-2). Day after the autotransplantation it was 1.83 (0-3) and at the day of discharge 0.02 (0-2). CONCLUSION: During the treatment of the patients with various extent of burn injury, none of the patients' scores reached values that would mean occurrence of obvious "overt" DIC.

High voltage electrical injuries.

Between 1999 and 2005, a total of 41 patients were hospitalized at the Burn Centre of Brno University Hospital with high voltage electrical injuries, representing 6.06% of the total number of patients treated at the Burn Intensive Care Unit (ICU) for extensive burn trauma. The average age of patients with serious electrotraumas was 27.29 years. The youngest patient was 9 years old, the oldest 64 years. Lethality amounted to 17.07% of the total number of patients. The article clearly shows the sinister dimension (a frighteningly high number of cases) of high voltage electrical injuries suffered outside work context in the vicinity of railway tracks and affecting in particular the youngest age groups--children.

Unusual course of treatment of a patient diagnosed with Pemphigus Vulgaris (case report).

The case report is describing patient with an autoimmune disease, Pemphigus Vulgaris. This patient arrived to the general practitioner with Pemphigus Vulgaris after 20 days from the first manifestation of the disease. Despite intensive care, patient dies forty-seventh day after first clinical manifestation of the illness of candidemia. Candidiasis was diagnosed only in postmortem examination.

Reconstructive surgeries after extensive burns in children.

The authors' aim is to summarize and generalize the knowledge acquired in the course of the last eight years of work with children with extensive burns. Reconstructive surgeries show a certain specific feature consisting in the considerable extent of the scarred area often exceeding 50% of the body surface, and with the gradual increase in number of operations they are gaining importance.

Successful treatment of a critically burnt neonate (case-report).

In a health institution in 2000, a premature neonate suffered critical burns. In the submitted case-report the authors describe the successful treatment of this quite exceptional case. Indirectly, they thus also draw attention to the very positive role played by interdisciplinary collaboration under such unusual circumstances.

Cultured epidermal allografts: Quantitative evaluation of their healing effect in deep dermal burns.

This study summarizes the Brno Burn Centre experience with the application of cultured epidermal allografts (CEAl) in the treatment of deep dermal burns. In a prospective randomised trial on 30 patients with deep dermal burns CEAl obtained from young healthy and examined donors and fixed on tulle grass carrier (Grasolind) were compared with empty Grasolind as the lowest layer of dressing. All the other layers were identical.Both kinds of dressing were applied simultaneously on the same deep dermal burn wound between 6th and 10th day after burn. Six days later the non-healed wound areas were recorded through painting on cellophane membrane and scanned in the computer. The percentage of wound reduction was calculated and statistically evaluated.The reduction of the non-epithelialized wound area was 86.5% when covered through CEAl and only 71.2% when covered with tulle grass (Grasolind) only. This difference is statistically significant.In conclusion it can be stated that cultured epidermal allografts strongly stimulate reepithelialisation in deep dermal burns.