|Ahead of print
Management of SARS-Cov-2-positive major burns: The tribulations and dilemmas
Raman Sharma, Rajeev B Ahuja
Department of Burn, Plastic and Aesthetic Surgery, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||22-Nov-2020|
|Date of Acceptance||18-Mar-2021|
|Date of Web Publication||03-Feb-2022|
Department of Burn, Plastic and Aesthetic Surgery, Sir Ganga Ram Hospital, New Delhi - 110 060
Source of Support: None, Conflict of Interest: None
SARS-CoV-2 (COVID-19) pandemic is still ravaging territories and spreading like wildfire. Infection with this virus is already complicating many clinical and emergency situations by overlapping symptoms, development of newer protocols for disease management, by redefining prognostic indicators, and upscaling the level of protection required for health-care workers. The current report outlines the tribulations and dilemmas of managing an asymptomatic 35% total body surface area burn patient with concomitant SARS-CoV-2 infection, from its diagnosis till full wound healing. Countries with a large population and a high incidence of SARS-CoV-2 infection need to maintain a high index of suspicion for a concomitant SARS-CoV-2 infection because asymptomatic patients can present with burns and they can also be carriers. Further, there is a need to strategize the deployment of resources, workforce, and burn wound management and to adopt effective precautionary measures for better outcomes and safety of health-care workers.
Keywords: Burn injury, COVID-19, hand sanitizer burns, SARS-CoV-2
| Introduction|| |
SARS-CoV-2 pandemic is still setting new records daily in many countries. In India, it is now a serious health emergency and they are reporting more than 50,000 cases daily, with an overall case aggregate of >9 million. At present, there are more than 58 million cases worldwide. It is difficult to assign an end date to this catastrophic contagion. However, infection with this virus will complicate many clinical and emergency situations by overlapping symptoms, development of newer protocols for disease management, by redefining prognostic indicators, and upscaling the level of protection required for health-care workers. The majority of COVID-19 patients are asymptomatic and the case fatality rate is <4%. The asymptomatic patients can also present with burns and also act as carriers.
It was estimated earlier that annually >6 million people suffer from burn injuries in India., In the absence of a central burns registry, it is difficult to estimate the current incidence of burns in India but the numbers are still very high and burn units deal with the sickest of patients with most complex wounds. Thus, a COVID-19 infection in a burn patient can be very lethal to the patient and a potential source of the epidemic in the burn unit. The current literature was quick in outlining strategies and algorithms for the management of burn patients during this pandemic.,,,, They even cautioned on the long-term impact of social distancing norms on burn survivors, now mandated because of this pandemic. So far, literature records just two reports on burn injury with concomitant SARS-CoV-2 infection., It is fortunate that, till so far, no series of such cases have been reported from any country.
The current report outlines the tribulations and dilemmas of managing an extensive burn patient with concomitant SARS-CoV-2 infection, from its diagnosis till full wound healing. This clinical encounter is reported from a private multi-super specialty hospital without a dedicated burn unit or a burn intensive care unit, but having a team of burn experts.
| Case Report|| |
A 16-year-old boy was brought to the emergency 4 h after sustaining thermal burns. He got injured while trying to create the “blue flame” from a hand sanitizer. Burns were sustained in the closed space of the bathroom where the experiment was being carried out in privacy. The daredevil act was inspired by a YouTube video (https://www.youtube.com/watch? v = gdTtkfrSR8M). Accidently, his T-shirt caught fire, and before any help could reach him, he had sustained 35% total body surface area burns; to both upper limbs, trunk, face, and neck. There was no contact history for SARS-CoV-2 or history of travel. The patient was asymptomatic for SARS-CoV-2 infection. At admission, he complained of hoarseness of voice and severe pain in the burnt areas. There was no respiratory distress. Burns were mostly deep dermal and only partly superficial. Fluid resuscitation was given as per the Parkland's formula. Along with routine blood investigations, a rapid antigen test for COVID-19 rapid antigen testing (RAT) and chest X-ray were carried out. His wounds were dressed with a nanosilver colloidal gel. Investigation results at admission were as follows: RAT was negative, arterial blood gas analysis was normal, there was hemoconcentration, total leukocytic count (TLC) was 35.67 thousand/μl, chest X-ray was normal, and pulse oximeter showed oxygenation between 96% and 97%. The patient was started on hydrocortisone 100 mg intravenous, once a day and nasal oxygen because of hoarseness of voice. No bronchoscopy was carried out as the pulmonologist did not feel the necessity. The patient parameters were stable for the next 36 h, however, on day 3, he started to show signs of hypoxia. Pulse oximeter showed oxygen saturation between 85% and 90% during sleep and 92% and 94% when awake, although there was no respiratory distress. The patient developed crepitations in lungs, bilaterally, but there was no evidence of fluid overload and urine output was normal. On day 4 as the crepts continued, he was given a bolus of 40 mg furosemide intravenous but there was no change in lung symptoms. He also developed a fever spike of 102°F which was controlled by injection paracetamol. These developments raised the suspicion of a concomitant SARS-CoV-2 infection. Results of further investigations at this stage were as follows: reverse transcription polymerase chain reaction (RT-PCR) was positive for COVID-19. High-resolution computed tomography (HRCT) revealed large areas of consolidation involving both lower lobes, more marked on the left side and bilaterally patchy areas of consolidation [Figure 1]. All inflammatory markers (procalcitonin – 6.54 ng/ml, C-reactive protein – 200.33 mg/l, interleukin-6 – 174.17 pg/ml, and serum ferritin – 927.18 ng/ml) were raised. Hemoglobin was 12.3 g/dl, TLC was 14.31 thousand/μl, and D-dimer was 1.51 μg/ml.
|Figure 1: High-resolution computed tomography of chest showing areas of consolidation in both lower lobes; more marked on the left side with bilateral patchy areas of consolidation|
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The patient was shifted to the dedicated COVID-19 unit. His fever spikes continued for the next 5 to 6 days with 1–2 spikes each day. Further management included intravenous antibiotics (imipenem and amikacin), oxygen support (5 liters per min), enoxaparin (60 mg subcutaneous daily), hydrocortisone (100 mg intravenous daily), nebulization with salbutamol, and chest physiotherapy. He continued to have fever spikes for the next 6 days (day 10) and the crepts also persisted for the same duration. Serum procalcitonin was still high at 1.71 ng/ml on day 10 so amikacin was replaced with colistin and antifungal (fluconazole) was added to the treatment. After day 10, oxygen support was tapered to 2 liters per min before weaning off on day 15, burn wounds continued to be managed by daily dressings for the next 10 days (day 15) and thereafter on alternate days till discharge. Repeat RT-PCR on day 10 was again positive for COVID-19, but the test carried out on day 15 was negative. The patient's condition continued to improve and he was discharged on day 17. At discharge, all laboratory values were normal and almost 60% burn wounds had healed. The patient was discharged on oral antibiotics, analgesics, bronchodilator, and multivitamin. The patient's close contacts were also tested for the COVID-19 on day 4 after the patient's positive report. All family members including mother, father, and brother tested positive with RT-PCR test. However, they were asymptomatic and were managed in home isolation with teleconsultation only. One resident doctor dressing the patient daily in the initial 3 days of admission developed mild sore throat and tested positive for SARS-CoV-2 infection. She was quarantined for 2 weeks and she remained asymptomatic.
After 3 weeks of serial follow-up, the burn wounds have almost healed 98% and the patient has a normal active and passive range of finger, wrist, elbow shoulder, and neck movements. A small raw area (6 cm × 5 cm) on the medial side of left upper arm is posted for stands for Split thickness Skin Grafting (SSG).
| Discussion|| |
A large number of burn patients in the developing world, and perhaps in an emergent situation in the developed world, have to be managed in surgical units bereft of facilities to pursue elaborate protocols laid out to manage major burn injuries associated with SARS-CoV-2 infliction. Of additional concern in such health-care facilities in India are government directives dedicating the majority of public/private hospital beds for COVID-19 patients. This directive necessitates redistribution of hospital beds, deputing resident doctors and other staff to general COVID-19 care, leading to staff shortages for other patients' care. On the flip side, it provided the necessary “hands-on” training in newer protocols and management drills. In most such facilities, there is no possibility of segregation of any patient in the emergency ward until the COVID-19 status is known. Confirmed and suspected cases are isolated in red areas and rest are designated in the green zone. There is another major concern in private hospitals about the affordability of costs, especially if the patient has no insurance cover or the cover limit is low.
At our institution for all non-COVID-19 burn admissions, a RAT is undertaken before transferring the patient to an appropriate segregation room/facility, as per guidelines recommended by Centers for Disease Control and Prevention (USA). Of course, all resuscitation and emergency treatment are provided in the emergency room itself till the COVID-19 report is received. It has been recommended previously that burn admissions should be triaged and treated in a segregated area as suspected COVID-19-positive patients till a negative RT-PCR report or a normal HRCT scan report is available. This does seem an ideal practice but the RT-PCR test often takes 12–24 h to report, and HRCT as a screening tool is not practical in the majority of the institutions if the patient load of the hospital is large and many patients of different specialties are waiting in the emergency room for admission. As previously mentioned, we too believe that the presence of a negative COVID-19 test or absence of clinical symptoms of COVID-19 should not be taken at face value. A high index of suspicion should be maintained, and therefore, our protocol currently is to do HRCT and RT-PCR test on evidence of any suspicion of SARS-CoV-2 infection. HRCT has higher accuracy in establishing the diagnosis of lung involvement in SARS-CoV-2 infection, even if it fails to identify the specific viral etiology. Test results are also available very quickly. Li and Xia in their study found features of consolidation and ground-glass appearance in 49 out of 51 RT-PCR confirmed cases of COVID-19.
A crucial takeaway from this case is that we maintained a high degree of suspicion for SARS-CoV-2 infection. The unusual presence of lung crepitations, desaturation without much evidence of inhalation injury, fever spikes unexplained by the burn wound condition, and raised inflammatory markers prompted us to conduct the RT-PCR and HRCT on day 3 to confirm the source of infection.
It is conjectured by us that because the patient was administered nasal oxygen and hydrocortisone since admission, because of suspected mild inhalation injury, it could have contributed to containing the onslaught of SARS-CoV-2 infection in our patient. No antiviral drugs were necessary.
The burn wounds were managed by dressings only, and no excisional surgery was contemplated because of severe bilateral lung consolidation and continuing desaturation episodes. In more favorable general condition of such patients, it may be feasible to excise the burn wounds and skin graft them to expedite healing, as is suggested by Diez et al.
We observed that even though the doctors attending were properly masked and gowned, they were without full hazmat suits during the initial 3 days in the non-COVID facility. The dressing each day took almost 1 h. This prolonged exposure to the patient and the fact that the patient also wore no mask contributed to the risk of infection among the health-care workers attending on the patient.
We also feel that video such as https://www.youtube.com/watch? v=gdTtkfrSR8M should be removed from the World Wide Web because they instigate the youngsters to replicate such risky experiments, and many burn injuries resulting from such daredevil acts may be going unreported.
Protocols are still evolving and the standard of care is different in different parts of the world, between the developing countries and the developed world. India being a burn endemic country is undoubtedly going to witness many more burn cases with SARS-CoV-2 infection. This is also applicable to other developing countries with large population and a high incidence of SARS-CoV-2 infection. Suitable deployment of resources and workforce, adopting appropriate precautionary measures, maintaining a high index of suspicion for SARS-CoV-2 infection, and strategizing the burn wound management are going to be crucial to obtain better outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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