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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 63-69

Burns and COVID-19: Is the synergy sinister?


Department of Plastic Surgery and Burns, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission11-Oct-2021
Date of Decision06-Dec-2021
Date of Acceptance05-Jan-2022
Date of Web Publication08-Jun-2022

Correspondence Address:
Dr. P Umar Farooq Baba
Department of Plastic Surgery and Burns, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_24_21

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  Abstract 


Background: A burn injury necessitates immediate emergency treatment that should be furnished securely to the victims. Appropriate precautions need to be undertaken to cut down the risk of exposure. A proper assessment and treatment commencement ought to be carried out before the viral infection has even been excluded as it is a race against time. The prognosis is determined by the established factors with viral infection acting as an ancillary addition. Burns are associated with many systemic disorders such as coagulopathy, sepsis, and respiratory distress which need to be differentiated from similar manifestations of the disease.
Materials and Methods: A retrospective study was conducted in our burn unit (analysing data from Burn Registry of the Department), comparing various parameters during the pandemic year with those of the previous year. The aim was to observe whether COVID-19 has any sinister impact on burn management and outcome or not.
Results: There was a 30.5% decrease in burn admissions with reduction in male burns (9%; M: F ratio decreased from 3:2 to 1:1) and delayed presentations (4%). The epidemiological parameters largely remained unaltered. The intensive care unit (ICU) admission rate and mortality remained the same. Our COVID positivity rate among burns was 5.3%.
Conclusion: We conclude that incidence of burn admissions decreased during the pandemic with increase in delayed presentations. The ICU admission rate and mortality increased by 9% rate (outcome) remained unchanged. Hence, COVID-19 did not at the end of the “first wave” put any sinister impact on burn increased, management as well as the outcome.

Keywords: Burn care professionals, burns, COVID-19, pandemic, telemedicine


How to cite this article:
Baba P U, Shah RA, Bhat HA, Gul A, Wani AH. Burns and COVID-19: Is the synergy sinister?. Indian J Burns 2021;29:63-9

How to cite this URL:
Baba P U, Shah RA, Bhat HA, Gul A, Wani AH. Burns and COVID-19: Is the synergy sinister?. Indian J Burns [serial online] 2021 [cited 2022 Jul 5];29:63-9. Available from: https://www.ijburns.com/text.asp?2021/29/1/63/346907




  Introduction Top


COVID-19 pandemic proved to be the largest medical challenge that health-care professionals are facing today.[1],[2] Acting responsibly, it is to be made certain that the imperative burn care carries on with the least pressure on the already threatened-to-collapse health-care system.[3] Hence, the goal should be to deliver optimum care while also ensuring a sound and secure working atmosphere for the management squad.[2],[4]

Burn as challenge during COVID-19

Burns is a critical public health problem, especially in developing nations, accompanied by immense morbidity and mortality.[5] That is why, in the midst of the current crisis, several burn units released blueprints of the plan of action for the care of these patients.[6] COVID-19 may be an antecedent, accompaniment, or successive inclusion to burn.[7],[8] Of first and foremost importance is the initiation of the treatment of extensive burns before the determination of COVID status, for they embody a race against the time. The consensus opinion of burn experts from many countries maintained the prognosticative importance of the existing burn scores with COVID positivity only as an ancillary risk factor.[9],[10],[11] Studies unfold that with proper precautions, high-quality burn care stays on without extra risk.[8] Although unvalidated, the combination of major burn and COVID-19 may be expected to complicate hospital course and outcome, over and above the expected seriousness of injury; so, further studies need to reach a valid conclusion.[11] Moreover, outpatient rehabilitation and scar treatments have been suspended temporarily.[12]


  Methods and Materials Top


This is a retrospective comparative study conducted in the Department of Plastic Surgery and Burns, SKIMS, Srinagar. A comparison of various burn patient parameters (demographic as well as disease specific) during the first pandemic year (year 2020) with those of the immediate previous year (year 2019) was done. The objective was to study the influence of the pandemic on various burn parameters, management as well as the outcome.


  Results Top


There was a 30.5% reduction in the burn admissions in our burn unit. There was a decrease in the number of male patients admitted with change in the gender ratio from 3:2 to 1:1. The intensive care unit (ICU) admission rate rose by 9%. However, the outcome (discharge /mortality rate) remained the same. The COVID-19 positivity rate (by RT-PCR) of burn patients was 5.3%; while 4% of our patients had delayed presentation [Table 1].
Table 1: Comparative Table Depicting Various Burn Patient Parameters During Pre-COVID year and COVID year

Click here to view



  Discussion Top


Pandemic witnessed an objective reduction in trauma that encompasses burns also.[13],[14] A 40% decrease in trauma admissions is reported.[3],[15] In accordance, our burn unit admissions were reduced by 30.5% [Table 1] compared to previous year figures. We detected a decrease in male burn patients with the sex ratio reduced to 1:1 from earlier 3:2 [Table 1]. However, the mortality rate, remained the same with just 9% rise in intensive care unit (ICU) admission; the reason being delayed presentation of some patients in a very sick condition requiring ICU management.

In contrast to some reports,[16] we observed no significant change in the burn pattern. There have been reports exhibiting a rise in scald burns, especially in children among Asian families, due to use of steam inhalation as a remedy for upper respiratory symptoms.[16] Although quite prevalent in our region, we did not find any such victim; nor did we encounter any sanitizer burn.

Concerning COVID testing, four (5.3%) of our burn patients showed positive results by reverse transcription polymerase chain reaction (RT-PCR); one of them was positive at the presentation, the rest turned positive during their hospital stay. Of these, a 45% burn child expired in the COVID-19 ward due to septicemia. The remaining 3 were discharged after proper treatment.

We observed three patients (4%)-one child and two adults-with major burns with late/delayed presentation to our facility. Research has suggested significant changes in presentation, including, late presentations during pandemic times due to scare of contracting deadly infection in hospitals.[17] All these were referred in a very sick condition (a paediatric patient intubated in septic shock, another adult female intubated with facial burn with inhalation, and 3rd one adult in sepsis with 40% burn). Among these the child expired, rest two were discharged after proper treatment.

Triage (right patient to right facility at right time)

Most burns can be managed well at local hospitals without need for referral to specialized centres.[18],[19] Minor burns <10% total body surface area (TBSA) can be handled conveniently at home. During the epidemic, telemedicine has emerged as a strong tool that provides every patient state-of-the-art burn care (acute evaluation and management).[20],[21],[22] On-going triage paradigms are simple enough to implement, ensuring that victims who need it the most receive the best possible care within given limited resources, thereby limiting under/over triage, maximizing resource utilization, and extending low budget burn expertise to far-off regions.[18],[23],[24],[25]

Emergency management

Burns is an acute condition that needs proper assessment and initiation of treatment ahead of investigations for the coronavirus.[11] However, in principle, all burn patients are taken as suspected COVID-19 cases.[26] Obtaining intravenous access and other emergency procedures such as endotracheal intubation, tracheostomy, fasciotomy/escharotomy, debridement, and wound care raise the infection risk.[11] Burn patients without any COVID suspicious symptoms are admitted as per the standard indications for burn admissions. While those admitted on a medical ground (COVID cases), who have sustained burns previously are managed as per the existing protocol with the optimum treatment of the wound in COVID designated areas.

Pain management

Pain management poses a challenge in burns and conventionally a multi-pronged approach attains optimum results. Rationally tackled pain results in better handling of apprehension and nervousness with superior burn cure and convalescence.[11] The control of pain in burns continues to be unaltered[6],[27] with no recommendation regarding the change in pharmacological treatment (opioids/nonsteroidal anti-inflammatory drugs [NSAIDs]).[28] However, in addition to respiratory depression and fever, caution demands that opioids, for instance, morphine, fentanyl, and so on might induce immunosuppression. Hence, theoretically, resultant immunosuppression may favour a more severe disease.[29] Earlier some concerning reports emerged indicating that in COVID-19 cases, the use of NSAIDs worsened the severity of their disease (ibuprofen increasing viral replication by interacting with angiotensin-converting enzyme 2). In the first instance, it seemed that we may lose one of the indispensable drugs in our armamentarium against pain in burns.[29],[30] Nonetheless, soon these reports were strongly refuted by the Societies of Regional Anesthesia and Pain Medicine in the USA and Europe.[6] Hence, we carried on with the medication on a routine basis.

Dressing changes

Specific focus is laid down on the utilization of supply materials and methodology, which minimize the need for dressing changes and ensure patient safety. To diminish the risk of infection during hospital visits, dressing changes at local health facility or a nearby clinic are justified, or even home dressing may a viable option.[12],[26],[31] The frequency too can be appropriately reduced according to the stage of healing and level of exudation.[26] It has been a fear that exudate or wound itself may harbor virus in positive patients.[32] Meanwhile, a pilot study from India revealed the absence of virus in the wounds of the patients positive for virus by nasal/throat swabs. Nevertheless, strict precautions still need to be followed.[33] Depending on wound condition, exposure/semi-exposure technique can be applied. Vacuum-assisted closure therapy and newer dressing types (e.g., foam-based) hold a promising role in this regard.[4],[26] The surgeon can consistently track the healing process by virtue of telemedicine.[21],[34]

Burn surgeries

To start with, burn surgeries were restricted to life or limb-saving procedures.[3],[6],[35] Studies suggest temporary suspension of all elective burn surgeries except those determining prognoses significantly or threatening life. Even for emergency surgery, severe COVID-19 is a relative while critical COVID-19 is an absolute contraindication. Nonoperative treatment, including rapid enzymatic debridement, has been propounded to circumvent the need for surgery and subsequent blood products that are expected to be in the short supply because of declining donation.[26]

Coagulopathy and venous thromboembolism prophylaxis

Notably, coagulopathy occurs both in burns and COVID-19 patients as both are deemed to be hypercoagulable states leading to serious complications. Studies indicate that in half of the admitted severe acute respiratory syndrome coronavirus 2” patients, D-dimer levels are raised making them vulnerable to pulmonary embolism. Hence, most physicians and professional societies recommend anticoagulation for all hospitalized COVID-19 patients.[36],[37] Consequently, COVID-19 burn patients must be closely monitored coupled with an incremental need for venous thromboembolism prophylaxis.[6] An increased prophylactic dose should be considered actively to ameliorate the deranged coagulation profile. Last but not least, there is a need for research to develop recommendations for treating these cases.[27],[36]

Interpreting “fever” and inhalation injury

Pyrexia is a frequent entity both in extensive thermal injuries and virus-infected patients. Accordingly, respiratory distress and fever in burn sepsis and inhalational burns need to be distinguished from that of COVID-19. Noteworthy is that respiratory distress/acute lung injury can occur in any critical patient, including extensive burns, and not just in COVID-19 or inhalation injuries.[38] Burn patients at greatest risk are those with risk factors such as diabetes, inhalational injury, and TBSA >20%. In contrast to rapid violent inflammatory response seen in bacterial infections; in coronavirus disease, it is a somewhat gradually progressive inflammatory response till the virus has been duplicated in a huge number of cells and is ready to be released suddenly causing “storm.” Such relative protracted course may be one differentiating feature.[38]

Ordinarily, fever in burn wounds is not associated with cough, saving when complicated by inhalation injuries. It is, therefore, a clinical challenge to differentiate and diagnose these. We need to proceed in a systematic way trying to differentiate. History may be an indispensable aid (like facial burns, burns in enclosed space, singed nasal hair, sooty sputum, wheeze-in inhalation burns: burn wound infection, extensive cutaneous burn, hypo/hyperthermia, gastrointestinal symptoms-in sepsis; travel history or contact with a positive patient, incubation period-in COVID disease). Furthermore, hematological investigations can be differentiating these (positive septic profile in septicemia, serial arterial blood gas, RT-PCR positivity, and other raised markers in COVID disease) and so forth.

Dismally, chest radiography in inhalation burns closely matches the initial findings of COVID-19.[3],[6],[9] The chest computed tomography (CT) findings in inhalation lung injury are peribronchial ground-glass opacities (GGOs) and/or patchy peribronchial consolidations.[39],[40] Similarly, the characteristic CT attributes in typical COVID pneumonia again include bilateral small GGO more in the lower lobes which quickly diffuse, forming a larger spherical GGO. The typical “fine grid sign” and “pleural parallel sign” may be evident.[41] Unfortunately, there is no proven test to date to solve such a challenging clinical issue.[3],[6],[9] Emergence of other distinctive signs such as pneumonia, air bronchogram, crazy pavement appearance, and air bubble signs during the ensuing course of the COVID disease may be of some aid to differentiate the two.[42] The clinical acumen with good aid from various investigations, in our experience, helps to differentiate the clinical entities followed by the proper institution of therapy.

Hand sanitizer burns

A few reports of chemical hand sanitizer burn to the eyes have been reported, especially in children.[43] Au SCL reported an acute escalation in such ocular injuries. He argues that unlike the previously reported 1 or at the most 2 cases annually, and those too exclusively in health-care workers (HCWs); during the pandemic, he noticed five ocular injuries within 3 months.[44] A JAMA ophthalmology paper mentions a sevenfold increase in sanitizer chemical ocular injuries in children in France. Another study narrated two children from India with sanitizer eye burns with almost complete regaining of function following optimum treatment.[45]

Similarly, anecdotal flame burns due to sanitizers have been reported in the past, those too confined again to HCWs.[46],[47] However, their overabundant use during the pandemic resulted in multiple such burn cases in the general population.[48] Worksites and other service locations are acknowledged as high-risk areas. The probable cause of ignition includes sparks/arcs from electrical gadgets, lighters, match sticks, and so on (best is to wait to let the sanitizer fully absorbs or evaporates).[49]

Psychological support

Practically psychological recovery in burns remains unresolved for long even after physical recovery.[50] This may be further hindered by the pandemic sponsored social restrictions which may result in delayed stress syndrome and depressive disorder in these individuals. Thermal injuries in COVID-19 cases may suffer from seclusion, apprehension, scare, and anxiety. Those who sustain burn trauma are suitable for social retreat associated with their cicatricial marks and corporeal image. They are the candidates for emotional support.[27] A biopsychosocial model can be used to address the emotional aspects and consequences of social isolation.[29] Telecommunication in the form of video calls/video chats through various social media platforms would certainly prove indispensable to diffuse the psychological stress without vulnerating safety.[6]

Role of telemedicine

To count on an optimistic angle of the pandemic, it caused the reincarnation of telemedicine and telecommunication both for academics and for patient consultation and follow-up. This method could be used to perform a preliminary evaluation as well as subsequent medical appraisals foreshortening the requisite for physical contact. Triaging burn patients through telemedicine is becoming increasingly important in linking providers/experts for concerted instructions and guidance on the prompt and proper treatment for better outcomes.[51] At the outset of the pandemic, practising guidelines for telemedicine were nonexistent in India. Furthermore, this ambiguity had been magnified by the decision of the Hon'ble Bombay High Court in 2018. However, given the on-going COVID-19 crisis, the Medical Council of India, in collaboration with Niti Aayog, recognised the need and issued the “Telemedicine Practice Guidelines” on March 25, 2020, thereby legalising telemedicine consultation in India.[52] It has been illustrated to brush up the validity of triage, allowing correct evaluation of burns and the need for transfer.[18] It is considered simple, reliable, cost-effective, user-friendly, highly sensitive, and specific with a diagnostic accuracy of nearly 90% when compared with clinical diagnoses confirmed in-person.[18],[53] Studies from various centers have advocated for its wider application for burn care especially in developing countries like India, and advancement into other forms of trauma and major disasters.[19],[51],[54] Telemedicine feasibility has been validated for acute care as well as follow-up of rehabilitating patients who live far away from the burn center.[53] Burn expert interactions and exchange of ideas regarding various cases and case scenarios are quite promising.[31] Based on this, the burn centers across the world form an impressive network to learn from one another. The exploitation of this medium with lasting benefits may last longer than the crisis itself.

Burn care professionals and infection transmission

Maintaining burn competency necessitates the preservation of the burn workforce.[31] They need to be recharged by timely leave from the work schedule. The predominant mode of transmission in burn care professionals (BCPs) is documented to be from patients.[8] Patients turning positive during their hospital course also indicates the likelihood of vice versa. Transmission from BCPs to BCPs, patient to BCPs, and BCPs to patients have been documented.[26] In our unit, 4 surgeons and 7 among nursing staff turned positive. These observations are consistent with those of Xiaoquan Lai et al.[53] and Sikkema et al.[55] who observed higher infection rates among nursing assistants/staff than in doctors. A higher risk is anticipated among BCPs owing to an intimate association in OR, burn ward, burn ICU and clinics.[26] Lack of ample space and reserved rooms to ensure proper isolation and social distancing among patients or BCPs is an issue in our setup. Infrastructure is established about four and a half decades back with no contemplation of managing a pandemic like this. Another vital issue is patient attendants in whom testing is not performed; they may serve as a reasonable transmitter, serving a link between the patient, staff, and social milieu. In addition, they may intentionally conceal the contact history because of the stigma attached to COVID-19. Minimizing the number of family caregivers usually, one caregiver is permitted to accompany each adult and two with a paediatric burn. The issue gets more complicated with the periodic replacement of such attendants.[3],[6],[26]


  Conclusion Top


Hence, the information gathered so far does not reflect any adverse impact of the pandemic on burns-not a sinister association. Overall, the outcome, cut, mortality rate, and other parameters remained unaltered. Although numbers did reduce along with a few largely delayed presentations, management largely remained the same. The limitation is that it is a small study and needs a larger study across multiple burn units to draw robust conclusions. Impressive to mention here is that the burn care was never lent a leave during the sudden onslaught of the pandemic. Our experience says that COVID has till now not cast any sinister effect on burn management as well as the outcome. The drive-out of the pandemic may be long and arduous, but taking stringent measures at every stage is crucial to reduce the risk of infection and cross-infection. Effective screening of patients and HCWs, proper segregation of negative and positive/suspect patients, and a low threshold for testing are essential to check the transmission of infection at large. Above all, pandemic taught us that despite restrictions, optimum burn care is attainable without any negative bearing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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