African Burn Research Articles

A profile of adult patients with major burns admitted to a Level 1 Trauma Centre and their functional outcomes at discharge: A retrospective review.

BackgroundPatients with major burns suffer with pain, which impacts their physical function during hospitalisation.ObjectivesTo describe the demographics, burn characteristics, clinical course, physical function, complications developed after major burns and to establish predictors of non-independent physical function at hospital discharge.MethodRecords of all consecutive adult burn admissions to a Level 1 Trauma Centre between 2015 and 2017 were screened retrospectively against our study criteria, using the Trauma Bank Data Registry. Anonymised data from included records were captured on specifically designed data extraction forms. Descriptive statistics were used to summarise findings. A regression analysis was undertaken to establish predictors of non-independent function at discharge.ResultsMales represented 87.7% (n = 64) of included records (n = 73). Median age was 38 (interquartile range [IQR]: 22). Thermal burns were most reported (n = 47, 64.4%), followed by median total body surface area (TBSA) 31% and head and arms were most affected (60.3% and 71.2%). Injury severity was high with median intensive care unit (ICU) length of stay (LOS) of 17 (IQR: 34) and hospital LOS 44 (IQR: 31) days. Wound debridement was mostly performed (n = 27, 36.9%) with limb oedema as a common complication (n = 15, 21.7%). Muscle strength and functional performance improved throughout LOS. None of the variables identified were predictors of non-independent function at hospital discharge.ConclusionAdults with major burns were predominantly male, in mid-life and sustained thermal injury with a high injury severity. Decreased range of motion (ROM) of affected areas, ‘fair’ muscle strength and independent function were recorded for most patients at hospital discharge.Clinical implicationsThese findings contribute to the limited body of evidence on the profile, clinical course and outcomes of South African adult burn patients.

South African Burn Association

South African Burn Association

Access to Operative Intervention Reduces Mortality in Adult Burn Patients in a Resource-Limited Setting in Sub-Saharan Africa.

Early excision and grafting remains the standard of care after burn injury. However, in a resource-limited setting, operative capacity often limits patient access to surgical intervention. This study sought to describe access to excision and grafting for adult burn patients in a sub-Saharan African burn unit and its relationship with burn-associated mortality. We analyzed patients recorded in the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi from 2011-2019. We examined patient characteristics, interventions, and outcomes for adults aged ≥16years. Modified Poisson regression modeling was used to identify risk factors for mortality. Five hundred and seventy-three patients were included. Median age was 30years (IQR 23-40) with a male preponderance (63%). Median percent total body surface area burned (%TBSA) was 15% (IQR 8-26) and 68% of burns were caused by flame. 27% (n = 154) had burn excision with skin grafting, with a median time to operation of 18days (IQR 9-38). When adjusted for age, %TBSA, and time to presentation, operative intervention conferred a survival benefit for patients with flame burns with a RR 0.16 (95% CI 0.06, 0.42). In a resource-limiting setting, access to the operating room is inadequate, and burn patients are not prioritized. While many scald burn patients may be managed with wound care alone, patients with flame burn require surgical intervention to improve clinical outcomes. Burn injury in this region continues to confer a high risk of mortality, and more investment in operative capacity is imperative.

South African Burn Association Letter From the President

South African Burn Association Letter From the President

Genetic analysis of carbapenemase-producing Gram-negative bacteria isolated from a university teaching hospital in Egypt

A total of 65 non-replicate Gram-negative bacterial strains were recovered from clinical specimens between April and September 2014 at a University Hospital in Egypt. This collection was screened by PCR for carbapenemase-encoding genes, 16S rRNA methylases, and colistin resistance genes (mcr-1–mcr-8). Twenty-two strains (22/65, 33.8%) were positive for carbapenemase-encoding genes [13 NDM-1-producers (four Escherichia coli, two Klebsiella pneumoniae, and seven Providencia stuartii), two E. coli co-carrying NDM-5 and OXA-181, and seven Pseudomonas aeruginosa (three VIM-2, four VIM-24) strains]. The 16S rRNA methylase RmtC was detected in 12 NDM-1-producers for the first time in Egypt; no mcr genes were detected. A self-transmissible A/C plasmid was found to carry blaNDM-1 in all NDM-1-producing strains. NDM-5 and OXA-181 were located on an untypeable and IncX3 plasmid, respectively. Additionally, Enterobacterial repetitive intergenic consensus (ERIC)-PCR revealed five clonally related P. stuartii isolates collected over a 1.5-month period. Thirteen carbapenemase-producing strains were isolated from burn patients who are at a high risk of developing infections and require special medical care. To our knowledge, this is the first report of NDM-1-producing-P. stuartii strains in an African burn unit, NDM-1- and RmtC-positive non-lactose fermenting E. coli globally, VIM-24-producing P. aeruginosa in Africa, and 16S RMTase rmtC-NDM-1-producers in Egypt. This work highlights the detection of different carbapenemase-producing bacterial strains within an Egyptian teaching hospital compromising the effectiveness of carbapenems and urgently asking the Egyptian medical authorities for implementation of antimicrobial surveillance plans and infection control policies to early detect and to effectively halt the rapid spread of these superbugs.

Letter from the South African Burn Association

Letter from the South African Burn Association

Development of the Pan African burn services directory

BackgroundInternational burn societies in many parts of the world have created electronic registries of burn centers in their region. No such directory exists for the continent of Africa. ObjectiveTo create the first electronic directory of burn care providers in Africa. MethodologyEmails were sent out to attendees of the Pan African Burn Congress and members of the Pan African Burn Society (PABS) asking if they would like to participate in the directory. Basic information about each burn site were obtained from respondents and compiled into the directory. An online interactive map was created and made available to the public. Results40 burn sites were identified across 14 different countries. The majority of burn sites are located in only 5 countries. The most common language spoken is English, followed by French, Amharic, and Afrikaans. ConclusionThis is the first known online directory of burn sites in Africa. Significant challenges exist identifying burn care providers in large portions of the continent.

Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit: methodological issues

Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit: methodological issues

Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit

Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit

Pre-burn malnutrition increases operative mortality in burn patients who undergo early excision and grafting in a sub-Saharan African burn unit

IntroductionIn the developed world, pre-existing malnutrition in the burn population influences operative outcomes. However, studies on pre-existing malnutrition and operative outcomes of burn patients in the developing world are lacking. We therefore sought to characterize the burn injury outcomes following operative intervention based on nutritional status. MethodsThis is a retrospective review of operative patients admitted to our burn unit from July 2011 to May 2016. Age-adjusted Z scores were calculated for height, weight, weight for height, and mid-upper arm circumference (MUAC). Following bivariate analysis, we constructed a fully adjusted logistic regression model of significant predictors of post-operative mortality, both overall and for specific age categories. ResultsOf the 1356 admitted patients, 393 received operative intervention (29%). Of those, 205 (52.2%) were male, and the median age was 6 years (3, 25), with 265 patients (67%) aged ≤16 years. The median TBSA was 15.4% (10%–25%) and open flames caused the majority of burns (64%), though in children under 5, scalds were the predominant cause of burn (52.2%). Overall mortality was 14.5% (57 patients) and ranged from 9.09% for patients aged 6–16, to 33.3% for adults ≥50years. Increased time from injury to operative intervention was protective (OR: 0.90, 95% CI: 0.83, 0.99). In post-operative patients with z-scores, increasing %TBSA burned (OR: 1.11, 95% CI: 1.05, 1.17) and increasing malnutrition (OR: 1.46, 95% CI: 1.03, 1.91) predicted death in the adjusted model. ConclusionPoor nutrition is an important risk factor for post-operative mortality in burned patients in resource-poor settings. Screening for malnutrition and designing effective interventions to optimize nutritional status may improve surgical outcomes in LMIC burn patients.

The effect of pre-existing malnutrition on pediatric burn mortality in a sub-Saharan African burn unit

IntroductionNutritional status predicts burn outcomes in the developed world, but its effect on burn mortality in the developing world has not been widely studied. In sub Saharan Africa, burn is primarily a disease of children, and the majority of children in sub-Saharan Africa are malnourished. We therefore sought to determine the prevalence and effect of malnutrition on burn mortality at our institution. MethodsThis is a retrospective review of children aged 0–5, with anthropomorphic measurements available, who were admitted to our burn unit from July 2011 to May 2016. Age-adjusted Z scores were calculated for height, weight, weight for height, and mid-upper arm circumference (MUAC). Following bivariate analysis, we used logistic regression to construct a fully adjusted model of predictors of mortality. ResultsOf the 1357 admitted patients, 839 (61.2%) were aged 0–5. Of those, 512 (62.9%) had one or more anthropomorphic measurements available, and were included in the analysis. 54% were male, and the median age was 28 months. The median TBSA was 15%, with a majority of burns caused by scalds (77%). Mortality was 16%. Average Z-score for any of the indicators of malnutrition was −1.45±1.66. TBSA (OR: 1.08, 95% CI: 1.06, 1.11), decreasing Z-score (OR: 1.19, 95% CI: 1.00, 1.41), and flame burn (OR: 2.51, 95% CI: 1.40, 4.49) were associated with an increase in mortality. ConclusionPreexisting malnutrition in burn patients in sub-Saharan Africa increases odds of mortality after controlling for significant covariates. Survival of burn patients in this region will not reach that of the developed world until a strategy of aggressive nutritional support is implemented in this population.

The effect of pre-existing malnutrition on pediatric burn mortality in a sub-Saharan African burn unit

The effect of pre-existing malnutrition on pediatric burn mortality in a sub-Saharan African burn unit

Modified first world mortality scores can be used in a regional South African burn service with resource limitations

IntroductionSurvival following a major burn is highly dependent on the availability of scare and expensive resources such as critical care services, modern dressings and access to operating theatres. Scoring systems, which predict mortality have been developed and can be used to identify patients in whom the outlay of these resources is futile. The aim of this study was to analyse the mortality at a regional South African burn service and to see if these scoring models developed in a resource rich environment were applicable to our setting. MethodsConsecutive admissions to the Edendale burn service, South Africa were collected from patient records over a 2-year period from July 2013 to June 2015. Demographic, burn details and final outcome (lived or died) were captured for statistical analysis. Each patient was scored using the Modified Baux, Coste et al., Belgian Outcome of Burn Injury (BOBI) and Abbreviated Burn Severity Index (ABSI) scores. Validation of models and inferential statistics were done to determine new breakpoints more applicable to our sample. ResultsA total of 748 patients were included in the sample, with a mortality rate of 7.1%. The mean Modified Baux score was 27 (range 1–134), with the new breakpoint of 40 predicting 74% of the mortalities compared to the 42% predicted by the old breakpoint of 75. The mean ABSI score was 4 (range 2–15), with a lower break point of 6 predicting 75% of deaths compared to 42% with the old breakpoint of 8.The mean Coste score for the sample was 12 (range 0–100). With a suggested break point of 85 (predicting 50% mortality), only 6% of mortalities were predicted. The new break point of 17 predicted 91% of deaths. The original break point for the BOBI score was 6 (range 0–7). This included 42% of deaths. With a new breakpoint of 1, 74% of deaths were predicted. DiscussionOur data has shown that in our environment a significant number of fatalities occur in patients with potentially salvageable burns, and the breakpoints for the mortality prediction scores such as, the Modified Baux score, Coste et al. score, BOBI and ABSI scores are much lower than high-income countries.However these mortality predictive scores can be used in a resource scarce South African setting to triage patients into risk categories by lowering the breakpoints. This may facilitate early and more aggressive management of high-risk burn patients, improving survival rates, as well as efficient and judicious use of critical care and other resources.

Burn surgeons in South Africa: A rare species.

The high burden of burn injuries in South Africa (SA) requires surgeons skilled in burn care. However, there are few dedicated burn surgeons and properly equipped units or centres. To quantify the involvement of surgeons in burn care in SA hospitals, identify factors that attract surgeons to pursue burn care as a career and deter them from doing so, and understand the challenges of hospitals treating burn patients around the country. This was a prospective, qualitative study. Questionnaires were handed out at the South African Burn Society Congress in September 2013 and a trade symposium in March 2014. One hundred questionnaires were handed out, and there was a 70% response rate. Twenty-six (39%) of the respondents had a specialist surgical qualification. Only half the units had registrars (48%) and interns (51%) on their staff. Only 30% of the respondents were dedicated to burn care alone, the majority being involved on a part-time basis. The most common factor respondents suggested was needed to recruit future burn care providers, cited by 76%, was better facilities and resources. Other factors included training and skills development (59%), subspecialist training (55%), development of a diploma in burn care (52%), development of research (52%) and healthcare worker psychological support (45%). We have demonstrated that current workforce resources for burn care are inadequate, the major deficit being lack of training and the resource-restricted environment. This survey provides basic information towards workforce planning, which can be used to inform the necessary strategic decisions.

Burn resuscitation on the African continent

A survey of members of the International Society of Burn Injuries (ISBI) and the American Burn Association (ABA) indicated that although there was difference in burn resuscitation protocols, they all fulfilled their functions. This study presents the findings of the same survey replicated in Africa, the only continent not included in the original survey.One hundred and eight responses were received. The mean annual number of admissions per unit was ninety-eight. Fluid resuscitation was usually initiated with total body surface area burns of either more than ten or more than fifteen percent. Twenty-six respondents made use of enteral resuscitation.The preferred resuscitation formula was the Parkland formula, and Ringer's Lactate was the favoured intravenous fluid. Despite satisfaction with the formula, many respondents believed that patients received volumes that differed from that predicted. Urine output was the principle guide to adequate resuscitation, with only twenty-one using the evolving clinical picture and thirty using invasive monitoring methods. Only fifty-one respondents replied to the question relating to the method of adjusting resuscitation. While colloids are not available in many parts of the African continent on account of cost, one might infer than African burn surgeons make better use of enteral resuscitation.

Pediatric burn care in sub-Saharan Africa

Burn injuries in Africa are considered to be a major health care problem. Sub-Saharan Africa has the highest number of pediatric burn admissions in the world. Burn care is complicated by numerous factors such as financial constraints, lack of resources, health care personnel and modern well equipped easily accessible health care facilities. Despite these numerous obstacles, burn care professionals on the continent of Africa have delivered a sterling service. A review of 70 articles published by authors on the African continent revealed information on topics ranging from the management of the HIV + patient, burn prevention strategies and new trends in African burn care.

The dilemma of treating major burns in South Africa

The major challenge facing South African burn surgeons is the current and future management of major burns. Survival is greatly dependent on adequate therapeutic measures. Various therapeutic measures can be instituted to overcome the shortage of donor skin, as we describe. Each of these methods has its specific role in the management of major burns. The use of very expensive and highly specialised techniques for individual patients cannot be justified when more accessible and cost-effective methods are available. To serve the greater population of burn victims, every effort should be made to use these available methods rather than channelling scarce financial resources into procedures that have a very limited role in South Africa.

Survey of Care and Evaluation of East African Burn Unit Feasibility

Weill Cornell Medical College in New York, partnered with Weill Bugando Medical College and Sekou Toure Regional Referral Hospital, in Mwanza, Tanzania, to consider the development of a burn unit there. This institutional partnership provided a unique opportunity to promote sustainable academic exchange and build burn care capacity in the East African region. A Weill Cornell burn surgeon and burn fellow collaborated with the Sekou Toure department of surgery to assess its current burn care capabilities and potential for burn unit development. All aspects of interdisciplinary burn care were reviewed and institutional infrastructure evaluated. Sekou Toure is a 375-bed regional referral center and teaching hospital of Weill Bugando Medical College. In 2010-2011, it admitted 5244 pediatric patients in total; 100 of these patients were burn-injured children (2% of admissions). There was no specific data kept on percentage of body surface burned, degree of burn, length of stay, or complications. No adult, operative, or outpatient burn data were available. There are two operating theaters. Patient's families perform wound care with nursing supervision. Rehabilitation therapists consult as needed. Meals are provided three times daily by a central kitchen. Public health outreach is possible through village-based communication networks. Infrastructure to support the development of a burn care unit exists at Sekou Toure, but needs increased clinical focus, human resource capacity building, and record-keeping to track accurate patient numbers. A multidisciplinary center could improve record-keeping and outcomes, encourage referrals, and facilitate outreach through villages.

Imaging and Resuscitation in Trauma

Injury is expected to become the second leading cause of death by 2020 [1]. The initial evaluation of a critically injured polytrauma patient is a challenging task and every minute can make the difference between life and death. It has been shown that mortality decreases as the time from injury to diagnosis and treatment is shortened [1]. Over the past few years, the assessment of trauma patients has evolved, due to the improved understanding of the mechanisms that contribute to morbidity and mortality in trauma, and this has led to the development of advanced trauma life support. Because hemorrhagic shock is the second leading cause of death after trauma, the optimal treatment for bleeding has become a major priority. In their paper, V. Jeger et al. “The role of thromboelastography in multiple trauma” describe thrombelastography (TEG) as a very useful tool in managing bleeding patients, and we suspect that this procedure will become a gold standard of resuscitation during the next decade. Since fluid resuscitation is one of the major tasks in the management and treatment of severely burned patients, the paper by M. Stander et al. “The emergency management and treatment of severe burns” is really significant, as it presents a simple guideline for the initial management of severe burns, as utilised by the South African Burn Society. But what would treatment be without imaging? Quick and cost-effective imaging has become one of the cornerstones of modern trauma management. R. Kaewlai et al. “Blunt cardiac injury in trauma patients with thoracic aortic injury” and P. D. Levy et al. “Micropower impulse radar: a novel technology for rapid, real-time detection of pneumothorax” present some very promising data on detecting injuries of the heart and lungs. Micropower impulse radar, for example, is a novel technology for the rapid detection of pneumothorax, with the power to simplify decision making in the prehospital sector as well as in the trauma bay and to reduce the burden of radiation for patients and staff. Since no technology is perfect and any 100% sensitivity and specificity margin for diagnosing injuries is a myth, we focus on the importance of the followup of trauma patients and raise the awareness for even rare but potentially life-threatening complications. Aristomenis K. Exadaktylos Marc A. de Moya Fiona Lecky Peter Driscoll Heinz Zimmermann Lee Alan Wallis Robert A. Novelline

The Emergency Management and Treatment of Severe Burns

Burn injuries continue to cause morbidity and mortality internationally. Despite international collaborations and preventative measures, there are still many cases reported in high- and low-income countries. The treatment of these patients is often protracted and requires extensive resources. The adequate resuscitation of these patients coupled with meticulous wound care can have a huge impact on their outcome. The authors present a simple guideline for the initial management of severe burns which is utilised by the South African Burn Society and is based on the guidelines of the American Burn Association and the Australian and New Zealand Burn Association.