Are we bound to our scores? a 74-year-old patient with an abbreviated burn severity index of 14

Summary

We report a case of a 74-year-old female patient who was involved in a car accident. The patient suffered deep dermal and full thickness burns and the probability of survival calculated with the Abbreviated Burn Severity Index (ABSI) was extremely low. The patient showed sufficient cardiorespiratory and renal function for the entire treatment period. An epifascial necrosectomy of all four limbs was performed on day three after admission. Wound coverage was performed using the MEEK technique and split skin grafts. The patient was bedded in a FluidAir bed, which enabled the burn wounds on the back to dry and heal in large part. After four surgical procedures and four months of treatment at the burn ICU, the patient was sufficiently mobilized for transfer to a hospital in her home region. The aim of the following case report is to demonstrate that burn patients with very low chances of survival can be treated successfully.

Introduction

We report an exceptional case of a 74-year-old female patient who was involved in a tragic car accident. The patient suffered deep dermal and full thickness burns affecting the face, both upper and lower limbs, the back, neck and buttocks. The Total Body Surface Area (TBSA) was estimated at 70% and was determined by the Wallace Rule of Nines (Fig. 1A-F). In addition, a stable fracture with no dislocation of C6 and an inhalation injury were diagnosed. The patient’s only previously known condition was arterial hypertension. Immediately after the accident, the patient was transported by helicopter to the Vienna General Hospital´s Burn ICU. An Abbreviated Burn Severity Index (ABSI) of 14 was calculated, and the probability of survival was extremely low (less than 10%).¹ However, after an interdisciplinary discussion, the treating team decided to initiate a curative therapy.

Fig. 1. Burn injury on day of admission.

Case report

On the admission day, an escharotomy of all four extremities and a tracheotomy were performed. For precise hemodynamic monitoring, a Pulse Contour Cardiac Output (PiCCO) catheter was inserted, and thermodilution showed the following values: cardiac index (CI) of 3.2 L/min/m2, global end-diastolic volume (GEDV) of 690 ml/m2 and extravascular lung water (EVLW) of 9 ml/m2. During the treatment course, the patient showed sufficient renal and cardiorespiratory function. Maintaining sufficient body temperature presented a major challenge during the early therapy process. Maximal laminar airflow was necessary for several weeks, with short-term support of an intravenous thermocatheter (Thermogard XP).

Subsequently, the team was able to perform the first reconstructive surgery on day three after admission. Due to the depth and extent of the burn injury, an epifascial necrosectomy of all four limbs had to be performed. Wound coverage was performed using the MEEK technique (1:9) (extremities) and split skin grafts (back of the hands and elbows). The patient was bedded in a FluidAir bed, which enabled the burn wounds on the back to dry and heal in large part without an operation (Fig. 1E, Fig. 2C). Additionally, the facial burns were treated with Acticoat 7 and healed conservatively (Fig. 1F, Fig. 2E, 2F). A further operation was necessary on day 24 to treat remaining defects on the upper extremities. After two months of treatment, the wounds showed sufficient healing and the patient was already mobilized (Fig. 2A-F). However, on day 66, a fourth operation was necessary on both lower legs to treat exposed bone on the anterior edge of the tibial plateau by intramedullary drilling (Fig. 3). The exposed bone was fully covered by granulation tissue on day 132 (Fig. 3).

Fig. 2. Results after 97 days of treatment.

Fig. 3. Exposed bone on the anterior edge of the tibia.

It is commonly known that a prolonged ICU stay is associated with severe complications such as blood stream infections.^2,3 On day 86, Stenotrophomonas maltophilia was detected in wound swabs, bronchial secretion and blood culture. This blood stream infection was treated successfully with Gentamicin for 12 days. However, the systemic infection prolonged mobilization and decelerated the therapeutic progress. The FluidAir bed therapy was terminated on day 80 after admission. At the same time, the patient was successfully decannulated, and the wound left from the tracheostomy healed within two weeks. The long FluidAir bed therapy and the patient’s advanced age were additional reasons for the prolonged therapy process and the protracted mobilization. However, we do believe that the benefits outweighed the drawbacks. The most important benefit of air-fluidized therapy is the reduction of sheer stress and restoration of a dry wound and skin microenvironment. This minimizes bacterial infection, accelerates wound healing and reduces pressure ulcers.⁴

The patient received physiotherapy, logotherapy and ergotherapy on a daily basis. In addition, she received intensive psychological support. After four months of treatment at the burn ICU, the wounds were almost completely healed and the patient was sufficiently mobilized for transfer to a hospital in her home region. At the time of discharge, the patient still received pain therapy with Metamizole and Piritramide three times a day.

Discussion

In the literature, the survival chances of elderly burn patients with a high TBSA are discussed pessimistically.3,5 For instance, Hörbrand et al. concluded that advanced age and a greater TBSA are negative prognostic factors for survival in burn victims.2 However, survival after burn trauma is not only determined by age and TBSA. Germann et al. concordantly found a strong correlation of higher age, smoking, alcohol abuse and pre-existent cardiac and neurologic conditions with increased mortality in burn patients.6 Despite her severe injuries and advanced age, the absence of the majority of the risk factors mentioned above possibly favoured the recovery of our patient. In the case described above we had ideal treatment conditions. On the day of admission, the patient was the only new patient admitted to our burn ICU. The treating team was able to fully concentrate on her treatment. In the case of a mass accident, the situation and outcome might have been different. However, our burn team can maintain the standard of care even when multiple burn patients are admitted at the same time. Our department has a 6-bed burn ICU and if we have to treat more than 6 burn patients requiring intensive care at the same time, we are able to initiate the treatment in other ICUs, the emergency room, and the department of trauma surgery of the General Hospital of Vienna. In the case of a great number of burn victims, the surrounding hospitals would be obliged to also treat burn patients and transfer them to our burn ICU as soon as we had an open position. Treating burns is extremely expensive and time-consuming. The treatment of burn victims with poor survival scores in low and middle-income countries is different to the treatment provided in our institution. In particular, in war zones physicians have to prioritize patients with a good chance of survival to guarantee resource efficiency.7-9 Due to a lack of resources, the abovementioned patient in a low income country or combat zone might have received palliative treatment with no chance of survival.⁷ By means of this case report, we aim to demonstrate that burn patients with very low chances for survival can be treated successfully. However, ideal working conditions are mandatory for successful treatment. The ABSI score alone is clearly no longer a suitable tool to decide on curative versus palliative treatment in severely burned patients.