|Year : 2020 | Volume
| Issue : 1 | Page : 108-112
Major COVID-19-positive burns treated successfully
Vijay Y Bhatia1, Kena M Patel1, Sruja D Narola1, Ranjit R Zapadiya1, Ami P Parikh2
1 Department of Burns and Plastic Surgery, SVP Institute of Medical Sciences and Research, Ahmedabad, Gujarat, India
2 Department of General Medicine, SVP Institute of Medical Sciences and Research, Ahmedabad, Gujarat, India
|Date of Submission||05-Aug-2020|
|Date of Decision||08-Oct-2020|
|Date of Acceptance||24-Nov-2020|
|Date of Web Publication||21-May-2021|
Dr. Vijay Y Bhatia
23, Armaan Bunglows, Near Sindhu Bhavan, Thaltej, Ahmedabad - 380 059, Gujarat
Source of Support: None, Conflict of Interest: None
Extensive burns are severe form of trauma causing a great threat to life. Approximately 300,000 deaths is attributed to burns annually, majority (>95%) of which occur in developing countries. Survival rate of patients decreases as the rate of burn increases. Coronavirus disease (COVID-19) pandemic has affected all the communities worldwide. It has strong infectivity and high transmission rate. When treating corona-virus-infected burns patients, prevention of cross infection to health workers becomes of utmost importance. Here, authors present a case of extensive burns along with COVID-19 infection, the precautions taken to prevent infection among health workers and protocols followed for management. The patient was treated over a span of 75 days where the patient was cured of COVID-19 in 21 days and underwent two surgeries with homograft and autograft application. Multidisciplinary approach with strict protocols of safety and vigilant monitoring is key to successful management.
Keywords: Burns, corona virus disease markers, coronavirus disease-19, homograft-autograft, protocol
|How to cite this article:|
Bhatia VY, Patel KM, Narola SD, Zapadiya RR, Parikh AP. Major COVID-19-positive burns treated successfully. Indian J Burns 2020;28:108-12
|How to cite this URL:|
Bhatia VY, Patel KM, Narola SD, Zapadiya RR, Parikh AP. Major COVID-19-positive burns treated successfully. Indian J Burns [serial online] 2020 [cited 2022 Jan 28];28:108-12. Available from: https://www.ijburns.com/text.asp?2020/28/1/108/316572
| Introduction|| |
Treatment of extensive burns is a challenge as burns involves all organs at all level and has a higher rate of complications and mortality. Coronavirus disease (COVID-19) pandemic is a major health concern worldwide, caused by SARS-CoV2 virus. When an individual is affected by COVID-19 and burns both simultaneously, management of such a patient requires a multidisciplinary approach. Changing protocols for the treatment of COVID-19 infected burns patient poses a greater challenge for treating professionals.
In this case report, authors present a rare case of extensive burns along with COVID-19 infection, the precautions taken to prevent infection among health workers and protocols followed for management. The patient was treated over a span of 75 days where the patient was cured of COVID-19 in 21 days and underwent two surgeries with homograft and autograft application.
| Case Report|| |
A 23-year-old female presented to our dedicated COVID-19 care center with flame burns and COVID-19 infection. She was referred to us after testing COVID-19 positive at another hospital. On examination, she had sustained 71% burns (30% second degree superficial; 41% deep burns) involving head, neck, bilateral upper-limb, bilateral lower limbs, anterior and posterior trunk [Figure 1]. As per protocol, after central line insertion, fluids were started, monitoring the urine output and investigated with chest X-ray, electrocardiogram, routine blood tests, coagulation profile, COVID-19 markers such as C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, Troponin I, and procalcitonin. Chest X-ray showed bilateral lower zone haziness. Initial blood analysis showed elevated total count with neutrophilia, lymphopenia, and normal platelet count with elevated COVID-19 markers. Swab culture showed heavy presence of Proteus mirabilis and Acinetobacter baumannii sensitive to various antibiotics. Antibiotics were given according to sensitivity. Superficial burns were dressed with paraffin gauze and eschar covered deep burns with silver sulphadiazine. Patient required intermittent oxygen support at 4 L/min for initial 10 days. Chest physiotherapy with nebulization was given regularly. During her stay COVID-19 markers, were repeated biweekly as per hospital protocol which normalized over the course of 1 month. Her routine blood investigations were repeated on every alternate day and swab sensitivity was done weekly. Antibiotics were changed according to the sensitivity. She was started on high protein diet with multivitamin and micronutrient supplements. The patient became COVID-19 negative after 21 days of treatment; reverse transcriptase-polymerase chain reaction swab test was used. She had altered coagulation profile for which injection Vitamin K was given for 3 days. Blood and albumin transfusions were given depending on the investigations. Post eschar separation, raw areas were dressed with normal saline [Figure 2]. After 28 days, she was operated for homograft (cadaveric) and autograft application [Figure 3]. With subsequent dressings approximately 80% of the raw areas were covered. The patient underwent second surgery 14 days after first surgery where autograft was applied to the remaining 20% of raw area [Figure 4]. All procedures and dressings were done in the operation theater (OT) following the National Clinical Management Guidelines for COVID-19.
|Figure 1: Seventy-one percent mixed superficial and deep burns at the time of presentation|
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|Figure 2: Healed superficial burns with subsequent post burn-raw area formation|
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|Figure 3: Intraoperative pictures showing homograft-autograft application|
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| Discussion|| |
COVID-19 has high infectivity with droplet transmission being the main mode, chance of infection further increases in case of close contact. According to the WHO guidelines for treatment of such patients, health workers should take tertiary protection which includes hand hygiene, personal protective equipment (PPE), respiratory hygiene, needle-stick preventions, cleaning of medical supplies, and treatment of medical waste. Related literature also suggests that aerosol generating procedures like intubation can increase the risk of SARS-COV transmission.
As a precautionary measure, all dressings were done in OT which was adequately ventilated and fumigated before and after each dressing. The patient was shifted to the theater after all preparations to minimize contact duration. All heath workers wore PPE kits which included a full sleeve gown, foot and head cover, face shield, eye protection along with N95 mask. The patient also wore a N95 mask. Only necessary medical and paramedical staff was allowed in the OT. To prevent contact with any spray of bodily secretions from the patient, health workers wore face shields during all the procedures such as blood collection, central line insertion, intubation, dressings, surgical procedures, emptying the urine bag as well as during any conversation with the patients. All these form the high risk points for exposure to infections hence utmost importance was given to the safety of the health workers and all the national guidelines for COVID-19 were followed.
COVID-19 infection results in an inflammatory state which may cause cytokine storm or macrophage activation syndrome resulting in acute consumptive coagulopathy leading to disseminated intravascular coagulation-this forms basis for anticytokine therapy given in cases of severe COVID-19 infections. The respiratory involvement causes acute respiratory distress syndrome (ARDS) and pneumonitis. In case of extensive burns, there is increased capillary permeability leading to loss of proteins and fluid from intracellular to extracellular compartment resulting in hypovolemia causing decreased cardiac output, peripheral vasoconstriction, cardiac depression, hypoxia, metabolic acidosis and ARDS. In burn shock, platelets are activated precipitating consumption coagulopathy. When both these conditions present together, the chances of complications increases.
Complete blood count, cytokines, liver enzymes, CRP, LDH, procalcitonin, ferritin, cardiac troponin, and coagulation profile are the blood parameters used as COVID-19 markers for assessing the severity and fatality of the disease. They help in risk stratification and rational triaging. Apart from clinical management, we followed a strict protocol for investigating the COVID-19 markers biweekly which helped to monitor the progression of the disease.
In patients with extensive burns, barrier function of the skin is lost resulting in exudate formation. Until the raw area is prepared for grafting, regular change of dressing is required. Superficial burns epithelize while deep burns requires wound coverage in the form of skin graft or temporary bioactive skin substitutes to prevent the electrolytes, protein and fluid loss. In developing countries, homograft is widely used for skin coverage. Here, due to paucity of the patient's autologous donor sites, widely meshed homograft was used along with allograft, facilitating the process of “creeping substitution” and early epithelization.
| Conclusion|| |
COVID-19 being a new disease with evolving guidelines, multidisciplinary approach with strict protocols of safety and vigilant monitoring are key to successful management. Providing dynamic environment that aids in epithelization of superficial burns and early coverage of post burn raw areas in the form of homograft-autograft combination plays an important role in survival of such patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient 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.
| References|| |
Zaim S, Chong JH, Sankaranarayanan V, Harky A. COVID-19 and multiorgan response. Curr Probl Cardiol 2020;45:100618.
Ministry of Health and Family Welfare. 2020. Clinical Management Protocol: COVID-19, (Version 3) 13 July.
Huang Z, Zhuang D, Xiong B, Deng DX, Li H, Lai W. Occupational exposure to SARS-CoV-2 in burns treatment during the COVID-19 epidemic: Specific diagnosis and treatment protocol. Biomed Pharmacother. 2020 Jul;127:110176. doi: 10.1016/j.biopha.2020.110176. Epub 2020 Apr 23. PMID: 32353825; PMCID: PMC7177133.
World Health Organization. Infection Prevention and Control During Health Care When Novel Coronavirus (nCoV) Infection Is Suspected (Interim Guidance). World Health Organization; 2020.
Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814-20.
McGonagle D, O'Donnell JS, Sharif K, Emery P, Bridgewood C. Immune mechanisms of pulmonary intravascular coagulopathy in COVID-19 pneumonia. Lancet Rheumatol 2020;2:e437-e445.
Nielson CB, Duethman NC, Howard JM, Moncure M, Wood JG. Burns: Pathophysiology of systemic complications and current management. J Burn Care Res 2017;38:e469-81.
Velavan TP, Meyer CG. Mild versus severe COVID-19: Laboratory markers. Int J Infect Dis 2020;95:304-7.
Calota DR, Nitescu C, Florescu IP, Lascar I. Surgical management of extensive burns treatment using allografts. J Med Life 2012;5:486-90.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]