TREATMENT OF SEVERE BURNS AFTER THE EXPLOSION INCIDENT IN BRAZZAVILLE/REP. OF CONGO ON THE 4TH OF MARCH 2012


TREATMENT OF SEVERE BURNS AFTER THE EXPLOSION INCIDENT IN BRAZZAVILLE/REP. OF CONGO ON THE 4TH OF MARCH 2012

OBJECTIVE:
This article will present an overview of the situation at hand and also provide a case report of the treatment of a severely burned patient under disaster situations like those reported by L. C. Cancio and B. Pruitt [1].

MATERIALS AND METHOD:
On March 4th 2012 an explosion in an Army Ammunitions Depot led to 246 casualties and more than 1945 injured. The Depot it self was situated right within the city-limits of Brazzaville, a one million inhabitant’s city. On the morning of the 4th at 8.00 the city was shaken by a gigantic explosion. The shockwave of the explosion was even felt in the city of Kinshasa, on the other side of the Congo river, a distance no less than 20 km away from the initial impact site. In the fi rst hour after the main explosion several minor explosions were felt and reported.

RESULTS:
A common psychological refl ex to the explosion was fear of another civil war. These secondary explosions occurred due to the ongoing explosion of bullets and grenades and aggravated the emergency at hand. Among the victims were fi rst responders, fi re and police brigades.

CONCLUSION:
Among the various blast injuries severe burns and open fractures were among the dominant injury patterns. Treatment of burn patients with Suprathel®, a special biological skin dressing material, was performed.

KEY WORDS:
Disaster, explosion, blast injuries, burns, open fractures.


Autoři: Bernd-Dieter Domres 1;  Philipp Fischer 2;  Rashidhamed Al Badi 1;  Norman Hecker 1,3
Působiště autorů: Německý Institut urgentní medicíny a medicíny katastrof 1;  Univerzitní nemocnice Bonn, Oddělení ortopedie a traumatologie 2;  Univerzitní nemocnice Aachen, Anesteziologické oddělení 3
Vyšlo v časopise: Úraz chir. 23., 2015, č.4

Souhrn

CÍL:
Tento článek přináší přehled o situaci v místě události a dále představuje kazuistiku léčby pacienta se závažnými popáleninami v podmínkách katastrofy, které již byly popsány autory L. C. Cancio a B. Pruitt [1].

MATERIÁL A METODY:
Dne 4. března 2012 došlo k výbuchu v armádním muničním skladu, který měl za následek 246 obětí na životech a více než 1945 zraněných. Muniční sklad byl umístěn přímo v milionovém městě Brazzaville. V osm hodin ráno toho dne se město otřáslo masivní explozí. Tlaková vlna způsobená výbuchem byla zaznamenána dokonce až ve městě Kinshasa na druhém břehu řeky Kongo, ve vzdálenosti 20 kilometrů od místa výbuchu. V průběhu první hodiny po hlavním výbuchu bylo zaznamenáno rovněž několik dalších menších explozí.

VÝSLEDKY:
Běžnou psychologickou reakcí na výbuch byla obava z vypuknutí další občanské války. Sekundární výbuchy, způsobené pokračující explozí střeliva a granátů, ztěžovaly poskytování urgentní péče na místě neštěstí. Mezi oběťmi byli rovněž osoby, které na událost zareagovaly jako první, hasiči a policisté.

ZÁVĚR:
Mezi různými typy poranění způsobenými výbuchy dominovala závažná popáleninová traumata a otevřené zlomeniny. Léčba pacientů s popáleninami byla provedena pomocí přípravku Suprathel®, speciálního biologického materiálu pro překrytí postižené kůže.

KLÍČOVÁ SLOVA:
Katastrofa, exploze, poranění způsobené výbuchy, popáleniny, otevřené zlomeniny.

Scenario of the Explosion

Disaster After the major explosion on Sunday morning 4th of March several smaller thus minor explosions were reported. The immediate threat of ongoing explosions was roughly under control by the 6th of March. Army, police and fire brigades had evacuated the affected area and all patients that were still alive had been transported to a hospital. However, the explosion had scattered many warfare agents, such as grenades and ammunitions, in a wide-spread circle (first estimate 4 km radius) around the former depot. Until the morning of the 7th of March 1945 Patients had been Pic. 1: Destroyed house after the explosion disaster counted in the city`s Hospitals.

Pic. 1: Destroyed house after the explosion disaster counted in the city`s Hospitals.
Photo <sup>©</sup>REUTERS /Stringer, courtesy Trust.org - AlertNet
Pic. 1: Destroyed house after the explosion disaster counted in the city`s Hospitals. Photo <sup>©</sup>REUTERS /Stringer, courtesy Trust.org - AlertNet

Clinical Treatment Capacities in Brazzaville

The city itself only holds limited resources for the treatment of major blast injuries and burns or complicated fractures. There are 5 Hospitals in Brazzaville/Congo. The CHUB (Centre Hospitalier et Universitaire de Brazzaville, 600 beds), the HCA (Hopital Central des Armées, 600 beds), the HBM (Hopital de Base de Makelekele, 200 beds), the HBT (Hopital de Base de Talangai a level 2 Hospital serving for 300000 inhabitants which was destroyed during the explosions) and HBB (Hopital de Base de Bacongo, 200 beds), and HML (Hopial Municipal Leyono, 100 beds).

Pic. 2: Mesh graft tool, dermatome, Suprathel
(Photo: B. Domres)
Pic. 2: Mesh graft tool, dermatome, Suprathel (Photo: B. Domres)

The initial rescue procedures were critically limited at first, and numerous first responders suffered from injuries because of the secondary explosions. An immediate transport of injured was not possible, because the military and the police restricted the entrance to danger zone.

When access to the area was issued by the official authorities the 1945 Patients were transported from the scene and distributed among the above mentioned clinics. 14 primary health care posts were established or used during the intermission.

87 patients died on arrival in the Hospitals. Damage Control Operations were performed in 16 % of the total patient population. By day 4 after the incident 92 Patients had been operated. 293 were waiting on an operation. 56 patients were secondarily transferred from level 2/3 hospitals to level 1 hospitals. Our assessment in the hospitals on day 4 after the disaster revealed a delay over 300 operations in burn injuries, fractures of the upper and lower limbs, as well as “second look“ operations for patients with amputated extremities. Roughly 70 % of the surveyed injuries were upper and lower limb fractures and wounds. There were minimal resources of care available, such as external fixators, monitoring or ICU beds. Blood banks were critical overwhelmed from the incident and had a shortage of blood.

Pic. 3: Right arm after necrectomy and with prior performed fasciotomy
(Photo: N. Hecker)
Pic. 3: Right arm after necrectomy and with prior performed fasciotomy (Photo: N. Hecker)

The Humedica Medical Team

Quickly after the disastrous events in Brazzaville a team of medical professionals of the HUMEDICA humanitarian relief organization was dispatched to the scene. Congolese officials had called for international support and thus the mission was sponsored by the German Foreign Ministry. The team itself consisted of 4 medical doctors, a nurse and a coordinator.

Pic. 4: Surgical treatment of the facial area with Suprathel mask
(Photo: B. Domres, N. Hecker)
Pic. 4: Surgical treatment of the facial area with Suprathel mask (Photo: B. Domres, N. Hecker)

The Equipment

Medical Kit External Fixator Kit Burn Treatment Kit (including a dermatome and mesh graft tool and in addition Suprathel®, a polylactid biological dressing material and Sulfathiazine ointment). On March the 6th the team landed in Brazzaville and immediately started action. At that time more than 300 injured were waiting for their surgical treatment.

Pic. 5: Condition of the facial area after Suprathel mask treatment for 12 days, patient is prepared ready for skin grafting (Photo: N. Hecker)
Pic. 5: Condition of the facial area after Suprathel mask treatment for 12 days, patient is prepared ready for skin grafting (Photo: N. Hecker)

Triage of Treatment:

Priority of treatment of the burn patients was given to:

  • Total body surface burned over 20 %
  • Depth of burns II b° and III rd °
  • Burns of face and hands

Case Report:

52 year old Patient, II°-III° burns of the face (5% TBS), II° burns of the right thorax (5% TBS) and the whole right arm with smaller portions of the right dorsal shoulder (10 % TBS). Total up to 20 % TBS.

The HUMEDICA team took charge of the treatment of the patient on day 4 after the explosion. The present state of the patient was miserable. He had received a damage control surgery of the right arm, where a fasciotomy was done on day 2 after the explosion. The patient was unable to speak or see, however he responded by moving his head. The lashes were charred, the eyes covered by smut, blood and wound material. The patient received intravenous fluids and broadband antibiotics (Amoxicillin and Metronidazole).

Pic. 6: Final outcome two years after the trauma (Photo: B. Domres)
Pic. 6: Final outcome two years after the trauma (Photo: B. Domres)

Suprathel

Suprathel is an innovative resorbable wound covering for the treatment of burns, donor sites and post-trauma skin defects [3]. It is a skin substitute that sticks directly to the wound and automatically lets go again after complete epithelialisation. It does not require any change of dressing, which means that uninterrupted wound-healing is possible.

The indications of using Suprathel are:

  • Burns
    • Burns, mixed superficial and deep 2nd-degree
    • Deep 2nd-degree burns
    • Burns, mixed 2nd-degree and minor 3rd-degree defects
  • Split skin donor sites
  • Post-trauma skin defects

Benefits and characteristics

Significantly less pain

Clinical studies confirm a significant reduction of pain through the use f Suprathel®

Uninterrupted wound-healing

  • Does not have to be replaced, so the would can be left to heal without interruption
  • Is permeable to wound fluid, oxygen and water vapour
  • Is completely resorbable

Excellent patient comfort

  • Suprathel® is less inconvenient for the patient, because it does not need any painful change of dressing
  • Less pain, reduction of analgesic therapy is therefore possible
  • Remains elastic and flexible and does not dry out
  • Remains elastic and flexible and does not dry out
  • Patients can begin remobilization faster
  • Children can move around easily and painlessly

Easy to apply

  • Suprathel® sticks directly to the wound, fixation is not necessary
  • Is flexible in use, even on anatomically difficult places such as the hands, face, etc.

Reduction of treatment time

  • Stays on the wound until complete wound-closure, so fewer secondary changes of dressing are necessary
  • Is transparent, so the wound bed can be inspected

Acid antibacterial effect.

Four our patient the first mask was removed due to unknown reason during the night after the initial application. The application was renewed the next morning. Due to the strong withdrawal of the material in the next 3 days the mask was renewed during a second necrectomy of chest and arm.

The same was observed another 3 days later and the procedure was repeated. However, The withdrawal were less than the first time. The facial wound area had already significantly improved in between application 2 and 3. Since we could not guarantee the optimal storage temperature for prolonged periods out of our resort, the material lost elasticity and the initially seen good contact between surface and material.

The facial area presented clean and generous granulation after necrectomy of III° burns and the treatment with the facial Suprathel mask.

At the end of the mission of the HUMEDICA-Team, the patient was vitally stable, able to clearly visually identify individuals and describe objects within his perimeter of sight. Vocalize full sentences and interact in basic conversation.

After the treatment with skin grafts the Patient`s treatment successfully finalized as the following photo shows.

Prof. Dr. Dr. Bernd Domres

bddomres@yahoo.de


Zdroje

1. CANCIO, LC, PRUITT, B. Management of mass casualty burn disasters. International Journal of Disaster Medicine. 2005, 000, 1–16.

2. KECK, M., SELIG, HF, LUMENTA, DB. et al. The use of Suprathel® in deep dermal burns: First results of a prospective study. J Burns. 2012, 38, 388–395.

3. UHLIG, C. Suprathel®- An Innovative, Resorbable Skin Substitute for the Treatment of Burn Victims. Burns. 2007, 33, 221–229.

Štítky
Chirurgie všeobecná Traumatologie Urgentní medicína

Článek vyšel v časopise

Úrazová chirurgie

Číslo 4

2015 Číslo 4

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