[Not Available]. / Afflux massif de brûlés : la doctrine française de triage en temps de paix.

Disaster situations involving mass burn casualties can occur at any time after a fire, a terrorist attack, an industrial explosion or a transport accident. The various burn societies in the world published recommendations on disaster burn-care planning. French burn society (Société Française d'Étude et de Traitement des Brûlures-SFETB) proposes triage of burned victims according to Total Burn Surface Area (TBSA), inhalation injury and associated traumatic injuries. This plan seeks to classify victims and to refer each burned patient to a bed suited to its needs (burn centre, surgical or medical ICU, Emergency room, surgical ward and triage). Emergency Medical Services play a pivotal role in this organisation: first care, advanced medical post, medical coordination, triage and transportation, additional equipment supply in proximal hospital. Burn disaster plan should be adapted to local medical resources.

[Not Available]. / Transport aérien longue distance des brûlés graves: revue de la littérature et application pratique.

The best treatment for victims of severe burns is provided in highly specialised burn centres. Due to the paucity of these centres, long distance aeromedical evacuation is often required. However, published data regarding such transfers are scarce. In this review, in order to help optimize patient management when air transportation is decided or even only considered, we propose simple principles derived from this limited literature and backed by the practical experience of the French military. We first describe how specific flight conditions may impact transportation of severe burn patients aboard aircraft. We then focus on the planning and organisation of these transfers discussing the risks associated with air transportation of such patients and their implications on indication, timing and modality of transport. Finally, provide an end-to-end view of the process from pre-flight equipment preparation, pre-boarding patient assessment and conditioning, to in-flight care.

Epidemiology of filamentous fungal infections in burned patients: A French retrospective study.

INTRODUCTION: Filamentous fungal infections (FFI) seem to become more frequent in burn patients, in whom they are usually accepted to cause severe. However published data regarding their incidence and consequences in that context remain scarce. The aim of this study was to evaluate the incidence of mould infections in our burn centre, and to review characteristics and outcomes of patients with such infections. METHODS: This retrospective single-centre study reviews all patients admitted in our centre with acute burns (2000-2011) and positive culture for moulds. Wound infections were defined as follows: fungal wound colonisations (FWC) for positive mycological cultures without signs of wound infection; fungal wound infections (FWI) for positive mycological cultures with local signs of wound infection; disseminated infection (DI) for FWI with a positive blood culture or a positive galactomannan (for aspergillosis) or severe sepsis or secondary organ localisation(s). RESULTS: Among 1849 patients, 31 patients presented a FFI. For 29 patients (93%), positive fungal samples were cutaneous: 20 Aspergillosis ASP (5 FWC, 8 FWI and 7 DI), 9 mucormycosis MMC (3 FWC and 6 FWI) and 3 fusariosis FUS (3 FWI). Two patients presented a catheter colonisation or a pulmonary colonisation (Aspergillus fumigatus). Incidence of FFI was 1.7%. Total body surface area burned, full-thickness burn surface area, Unit Burn Standard, Tobiasen score and SAPS2 (respectively 55% [40-73], 45% [30-63], 180 [129-259], 11 [8-12] and 50 [40-62]) were markedly higher than in burned patients without FFI hospitalised during the same time period. 30% of the patients with burn wound ASP (6/22) died. Mean length of stay was 111±67 days. CONCLUSION: FFI are essentially cutaneous, infrequent and occur in the most severe burned patients. ASP seems to be more serious than other FFI.

Sigmoid diverticulitis perforation in burns: case reports and review of the literature.

Burned patients are prone to develop severe intestinal complications because of decreased splanchnic circulation. We report three cases of sigmoid perforation in burn patients appearing late during hospitalization. The common aetiological factor was a state of septic shock treated with infusion of vasopressors. Two patients also received corticosteroids as treatment for acute respiratory distress syndrome. These cases underline the necessity to maintain adequate organ perfusion and to prevent intestinal ischaemia in severe burns.

Cell therapy of burns.

Severe burns remain a life-threatening local and general inflammatory condition often with serious sequelae, despite remarkable progress in their treatment over the past three decades. Cultured epidermal autografts, the first and still most up-to-date cell therapy for burns, plays a key role in that progress, but drawbacks to this need to be reduced by using cultured dermal-epidermal substitutes. This review focuses on what could be, in our view, the next major breakthrough in cell therapy of burns - use of mesenchymal stromal cells (MSCs). After summarizing current knowledge, including our own clinical experience with MSCs in the pioneering field of cell therapy of radiation-induced burns, we discuss the strong rationale supporting potential interest in MSCs in treatment of thermal burns, including limited but promising pre-clinical and clinical data in wound healing and acute inflammatory conditions other than burns. Practical options for future therapeutic applications of MSCs for burns treatment, are finally considered.

The influence of host fruit and temperature on the body size of adult Ceratitis capitata (Diptera: Tephritidae) under laboratory and field conditions.

The adult body size of the Mediterranean fruit fly, Ceratitis capitata (Wiedemann) (Diptera: Tephritidae), varies in natural conditions. Body size is an important fitness indicator in the Mediterranean fruit fly; larger individuals are more competitive at mating and have a greater dispersion capacity and fertility. Both temperature during larval development and host fruit quality have been cited as possible causes for this variation. We studied the influence of host fruit and temperature during larval development on adult body size (wing area) in the laboratory, and determined body size variation in field populations of the Mediterannean fruit fly in eastern Spain. Field flies measured had two origins: 1) flies periodically collected throughout the year in field traps from 32 citrus groves, during the period 2003-2007; and 2) flies evolved from different fruit species collected between June and December in 2003 and 2004. In the lab, wing area of male and female adults varied significantly with temperature during larval development, being larger at the lowest temperature. Adult size also was significantly different depending on the host fruit in which larvae developed. The size of the flies captured at the field, either from traps or from fruits, varied seasonally showing a gradual pattern of change along the year. The largest individuals were obtained during winter and early spring and the smallest during late summer. In field conditions, the size of the adult Mediterannean fruit fly seems apparently more related with air temperature than with host fruit. The implications of this adult size pattern on the biology of C. capitata and on the application of the sterile insect technique are discussed.

[Present and future of cell therapy in burns]. / Présent et futur de la thérapie cellulaire des brûlures.

Severe burned patients need definitive and efficient wound coverage. Outcome of massive burns has been improved by using cultured epithelial autografts (CEA). Despite fragility, percentages of success take, cost of treatment and long-term tendency to contracture, this surgical technique has been developed in few burn centres. First improvements were to combine CEA and dermis-like substitute. Cultured skin substitutes provide earlier skin closure and satisfying functional result. These methods have been used successfully in massive burns. Second improvement was to allow skin regeneration by using epidermal stem cells. Stem cells have capacity to differentiate into keratinocytes, to promote wound repair and to regenerate skin appendages. Human mesenchymal stem cells contribute to wound healing and were evaluated in cutaneous radiation syndrome. Skin regeneration and tissue engineering methods remain a complex challenge and offer the possibility of new treatment for injured and burned patients.

[Radiation burn "innovating therapeutic approach"]. / Brûlure par irradiation « approche thérapeutique innovante ¼.

Radiation burn is a determinist effect of localized irradiation. The lesion is in good correlation with absorbed dose. Radiation burn is different from thermal burn. The evolution is spatiotemporal unpredictable with successive inflammatory waves and recurrence of necrosis. The conventional surgical treatment is rarely efficient because each surgical operative act seems to stimulate the inflammatory waves and fibro-necrosis process. The lesion can escape to this conventional surgical treatment. The new therapeutic approach combines surgery and cellular therapy with local administration of autologous mesenchymal stem cells. From 5 years, cell therapy have been an adjuvant treatment of surgery. This association is a therapeutic innovation, it's now the recommendation for conservative surgery of this very serious radiation burn.

[Burns care following a nuclear incident]. / Soins Aux Brules Apres Un Accident Nucleaire.

Radiation injuries are usually caused by radioactive isotopes in industry. Detonations of nuclear reactors, the use of military nuclear weapons, and terrorist attacks represent a risk of mass burn casualties. Ionizing radiation creates thermal burns, acute radiation syndrome with pancytopenia, and a delayed cutaneous syndrome. After a latency period, skin symptoms appear and the depth of tissue damages increase with dose exposure. The usual burn resuscitation protocols have to be applied. Care of these victims also requires assessment of the level of radiation, plus decontamination by an experienced team. In nuclear disasters, the priority is to optimize the available resources and reserve treatment to patients with the highest probability of survival. After localized nuclear injury, assessment of burn depth and surgical techniques of skin coverage are the main difficulties in a burn centre. Training in medical facilities and burn centres is necessary in the preparation for management of the different types of burn injuries.

[Incidence and microbiology of infectious complications with the use of artificial skin Integra in burns]. / Incidence et microbiologie des complications infectieuses lors d'utilisation de la peau artificielle Integra chez le brûlé.

Integra dermal substitute is used as biomaterial after thermal injury. This artificial skin allows temporary coverage after burns excision, transformation of matrix in neo dermis and definitive engraftment. Infections are the most common complication of this technique. The objectives were to evaluate incidence of sepsis, to analyse microbiology and risk factors of developing Integra infections. Patients with acute burns and indications of Integra during five years were retrospectively enrolled. Demographic data, surgical procedures and microbiologic biopsies were collected. Fifty patients (40 + or - 15 years) were studied and 71 surgical procedures using Integra were performed. Burns were extended 45 + or - 21% total body surface area. Placement of Integra was made 15 + or - 11 days after burns and autografts 31 + or - 9 days after placement of Integra. Twenty-one patients had infected Integra (42% of population). A total of 23 Integra infected sites were observed (15 local and eight invasive). Diagnosis of infection was made after 13 + or - 5 days using quantitative cultures. Other sites of infection were respiratory tract (46 pneumonias) and others burned wounds (17 infections outside of Integra. Any risk factor was identified between burns who developed Integra infections and the others. Incidence of infected Integra was higher than in previous studies. Delayed application of Integra after burns could explain higher incidence of infection. Pseudomonas aeruginosa and Staphylococcus aureus were more frequently isolated than other pathogens. Standardized technique for wounds coverage with Integra is necessary to reduce incidence of infections and improve functional results in burns patients.

[Clinical and biological monitoring of nutritional status in severe burns]. / Surveillance clinique et biologique de l'état nutritionnel de brûlés graves.

AIM OF THE STUDY: Burn patients are subject to hypermetabolism and catabolic states. Aim was to evaluate our current practice in nutrition. METHODS: Twenty-one severely burned patients were prospectively included during three months period. Body weight was measured at least two times in a week during all stay in burn ICU. Biological markers of inflammation (C-reactive protein, CRP) and nutrition (prealbumin) were performed weekly. Protocol included early nasogastric feeding, tolerated gastric stasis less than 250 mL at four hours nasogastric aspirations, caloric target value of 40 Kcal/kg per day and measurement of total daily calorie intakes. RESULTS: Patient demographics showed a mean percent total body surface burn of 51.1+/-27 % (range 20-90), age of 38.7+/-13.1 years (range 18-67) and 57.3 % of smoke inhalation. All patients were ventilated and 19 patients survived. Length of stay was 75.7+/-47 days (range 22-184). Patients received only 58.9+/-10 % of calorie intakes recommended by French burn society. Loss of body mass was 15.2+/-9 kg (range 3-31) or 19.1+/-10 % of admission weight (range 5-37). Erosion of body mass was not correlated with burned surface (p=0.08), calorie intakes (p=0.26), smoke inhalation (p=0.46), lengths of stay (p=0.53), lengths of ventilation (p=0.08) or nutrition (p=0.12), days of antibiotic (p=0.72), number of dressing changes (p=0.6) or surgery (p=0.64). Biological parameters showed CRP decreasing and prealbumin improving values. CONCLUSION: New strategies of nutrition are necessary to improve outcome and reduce body mass loss in burns.

Evaluation of serum procalcitonin concentration in the ICU following severe burn.

The goal of the study was to analyse plasma procalcitonin (PCT) concentrations during infectious events of burns in ICU. Clinical and laboratory data were collected at admission and twice a week in burned patients admitted with a total body surface area (TBSA) >20%. Procalcitonin was determined using both a semi-quantitative detection (PCT-Q) and a quantitative immunoluminometric method (PCT-Lumi). A total of 359 time points in 25 consecutive patients with 40+/-17% (20-86%) TBSA burned, defined as a procalcitonin concentration associated with an inflammatory status according to society critical care medicine definition, were made. The principal site of infection was the respiratory tract (84% of patients required mechanical ventilation). PCT-Lumi values corresponded to the four semi-quantitative ranges of PCT-Q and statistically reflected the simultaneously observed inflammatory status (Kruskall-Wallis test). The area under the receiver operating characteristic curve for C-reactive protein (CRP) was higher than those for PCT and white blood cell (WBC) count, but this difference was not significant. The optimum PCT cut-off value was 0.534 ng/ml with sensitivity and specificity of 42.4% and 88.8%, respectively. However, PCT does not appear to be superior to C-reactive protein (CRP) and white blood count (WBC) as diagnosis marker of sepsis in burns. PCT is not sufficient to diagnose and to follow infection in burns admitted in ICU.

[Heparin-induced thrombocytopenia: report of four cases in severely burned patients]. / Thrombopénie induite par l'héparine de type II: description de quatre observations chez le brûlé grave.

Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin therapy caused by an antibody against heparin/Platelet Factor 4 (PF4) complex. HIT complicates about 2% of treatment with unfractionated heparin (UFH). The aim of the study was to determine the incidence of HIT in a burn center and to report four cases in severely burned patients. HIT was documented in 2.8% of burns treated with UFH administered for antithrombotic prophylaxis and in none of burns receiving low molecular weight heparin (LMWH). All HIT cases occurred after extensive deep burns (mean total body surface area or TBSA was 60+/-21%) and three cases had above 75% of burn. We suggest that systemic platelet activation after thermal injury and local production of PF4 in the burn wound could participate to development of HIT. The risk is a late diagnosis since thrombosis clinical detection under burned skin is difficult. HIT appears during the first week of UHF treatment at the same time as a unstable period of fluctuating platelets.

[Respiratory dysfunction in burned patients]. / Lésions respiratoires et brûlures.

INTRODUCTION: Smoke inhalation and respiratory complications are still the major causes of mortality in severely burned patients. STATE OF THE ART: The diagnosis is suspected clinically on the basis of history and physical examination and can be confirmed bronchoscopically. Respiratory failure in burned patients occurs through a number of associated mechanisms. Pneumonitis and adult respiratory distress syndrome (ARDS) are common early complications. New pulmonary treatments and advances in ventilation have reduced the incidence of both barotrauma and infectious complications. Tracheal stenosis can occur as a late complication of prolonged mechanical ventilation. PERSPECTIVES: Clinical and experimental studies have shown that damage to the mucosal barrier and the release of inflammatory mediators are the most important pathophysiological events following smoke inhalation. Manipulation of the inflammatory response following inhalation may be a treatment option in the distant future. CONCLUSION: Inhalation injury occurring in burned patients can produce severe respiratory and systemic complications.

[Venous thromboprophylaxis in burn patient]. / Prévention de la maladie thromboembolique veineuse chez le brûlé.

Few studies deal with thromboembolic complications in burn patients. The review of the literature and current practice in burn centres point out low, average and high-risk patients, according to the characteristics of the burns wounds. In case of average risk, low molecular weight heparin prophylaxis is suggested. In high risk patients, low molecular weight heparin therapy or continuous intravenous heparin are recommended. This prevention should be continued until the recovery of a normal mobility and complete resolution of inflammation.

[Inflammatory reaction and infection in severe burns]. / Réaction inflammatoire et infection chez le brûlé grave.

Major burn injury is a lesion where the inflammatory reaction is exported to the whole body. After a short time of hemodynamic changes, this inflammation is kept by necrotic tissues, persistence of an opened wound, and by the pulmonary and gut reactions. When infection starts, it becomes difficult to distinguish its symptoms among the inflammatory signals. The main point of the care of burn patient consists in trying to control this reaction and the immuno-depression it leads to: early excision and grafts, early enteral nutrition, perfect nursing care. There is no specific medical treatment of this state. The antibiotic use must be well weighed up. Infection is often the trigger of the multiple organ dysfunction which is the way the burn patient dies but is not mandatory.

Efficacy of continuous insufflation of oxygen combined with active cardiac compression-decompression during out-of-hospital cardiorespiratory arrest.

BACKGROUND: During experimental cardiac arrest, continuous insufflation of air or oxygen (CIO) through microcannulas inserted into the inner wall of a modified intubation tube and generating a permanent positive intrathoracic pressure, combined with external cardiac massage, has previously been shown to be as effective as intermittent positive pressure ventilation (IPPV). METHODS: After basic cardiorespiratory resuscitation, the adult patients who experienced nontraumatic, out-of-hospital cardiac arrest with asystole, were randomized to two groups: an IPPV group tracheally intubated with a standard tube and ventilated with standard IPPV and a CIO group for whom a modified tube was inserted, and in which CIO at a flow rate of 15 l/min replaced IPPV (the tube was left open to atmosphere). Both groups underwent active cardiac compression-decompression with a device. Resuscitation was continued for a maximum of 30 min. Blood gas analysis was performed as soon as stable spontaneous cardiac activity was restored, and a second blood gas analysis was performed at admission to the hospital. RESULTS: The two groups of patients (47 in the IPPV and 48 in the CIO group) were comparable. The percentages of patients who underwent successful resuscitation (stable cardiac activity; 21.3 in the IPPV group and 27.1% in the CIO group) and the time necessary for successful resuscitation (11.8 +/- 1.8 and 12.8 +/- 1.9 min) were also comparable. The blood gas analysis performed after resuscitation (8 patients in the IPPV and 10 in the CIO group) did not show significant differences. The arterial blood gases performed after admission to the hospital and ventilation using a transport ventilator (seven patients in the IPPV group and six in the CIO group) showed that the partial pressure of arterial carbon dioxide (PaCO2) was significantly lower in the CIO group (35.7 +/- 2.1 compared with 72.7 +/- 7.4 mmHg), whereas the pH and the partial pressure of arterial oxygen (PaO2) were significantly higher (all P < 0.05). CONCLUSIONS: Continuous insufflation of air or oxygen alone through a multichannel open tube was as effective as IPPV during out-of-hospital cardiac arrest. A significantly greater elimination of carbon dioxide and a better level of oxygenation in the group previously treated with CIO probably reflected better lung mechanics.