Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting. Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses. Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively. In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.

Low-cost and efficient culture environments comparable to standard techniques would undoubtedly improve burn outcomes in underresourced settings. The aim of this case series was to report on the cultured epithelial autografting (CEA) graft-take using a modified composite culture technique. Cultured epithelial autografting transplants, following emergency ethical approval, occurred for patients with burns (n = 25) with low survival prognosis and/or exhausted donor sites. Keratinocytes were retrieved from skin biopsies, seeded centrally on routinely used dressing gauze, and incubated at 37 °C in pediatric incubators. Fresh autogenous plasma was applied daily and hydrogel every third or fourth day. After confluence, the CEA was transplanted onto debrided wound beds. Xenografts were used for temporary cover during the culture period. Final graft take assessment (21 days) was assessed and calculated as a graft take percentage for total CEA area transplanted. Central indices were described as mean (95% confidence interval [CI]) and frequency (%) for age, total body surface area, abbreviated burn severity index scores, survival prognosis, and graft take. Eleven patients survived with a mean age of 36.1 years (95% CI: 25.8-46.4), 45.0% total body surface area burns (95% CI: 35.1-54.9), 9.7 abbreviated burn severity index scores (95% CI: 8.6-10.8), and 79.5% graft take (95% CI: 62.9-96.0). Reduced graft take (61.2%) was observed in patients with perineum burns and increased graft take (97%) in uncomplicated burns. The average CEA graft take was 79.5% using a low-cost culture technique and was comparable to the largest case series in the literature. The survival of the major burn cases was highly favorable considering injury severity, expected outcomes without CEA and the observed challenges.

Cultured epithelial autograft applications are limited by the associated cost and time constraints in resource-limited settings. A modified composite technique using the patients’ own tissue and Cutimed Sorbact dressing was employed as a life-saving emergency measure. Since the non-Caucasian population was more commonly treated at the center, it was important to report the first Caucasian patient outcome, as the graft-take outcome for all populations was unknown. A 54-year-old male with extensive flame burns and a low chance of survival was admitted to the Tygerberg Burn Center. He received traditional skin grafts and cultured epithelial cells, after the 2 week-culture period using the current technique. Short- (⩽2 weeks) and long-term graft take (⩽8 years) was inspected. Good graft take and complete epithelialization was observed during short-term inspection with partially healed areas initially attributed to extensive burn depth and dressing removal. Long-term follow-up indicated a near normal tissue appearance and excellent pliability.

Burn depth is a difficult topic to teach for several reasons. Depth is dynamic, and can change over time. This change in depth over time is called burn-depth conversion. Several factors affect this conversion, adding to the complexity of depth assessment. As the dermis is white, a piece of white bread will be used in this analogy. Just as white bread is soft, floppy and moist with some stretch before going into the toaster, so is the skin soft, stretchable and moist in the dermis. Once the white bread begins toasting, the following colour changes occur: light yellow, light brown, dark brown and then black. The white dermis of the skin goes through similar colour changes when burned. Toasted white bread also loses more of its moistness and elasticity as it is increasingly toasted. The same happens in the skin. It loses its elasticity and moistness, and so a full-thickness burn (eschar) has to be cut open (-otomy; escharotomy) to accommodate stretch from swelling, or to allow mobility of joints or functional structures, or the chest wall. To understand the colour changes in the dermis, the vascular plexus in the superficial dermis must be considered. The blood colour is red in the superficial dermis, and mixed with the white of the dermis, it will appear pink. Capillary refill time will be rapid in superficial partial-thickness areas, and this is considered an important clinical test to increase the accuracy of depth assessment. As the burn goes deeper than the vascular plexus, the normal whiter/paler colour of the dermis will appear. Changes will then be reflected by the toast analogy: yellow, then brown, then black. As burn depth is difficult for students to learn and grasp, the toast analogy may help in the teaching of the topic. Understanding the dynamic nature of burn depth is important, as is understanding the importance of, and being able to use, the diagnostic clinical tests for burn depth, such as the capillary refill test, to increase the accuracy of the assessment.

Resource-limited burn centers are usually devoid of cultured epithelial autografts (CEA) owing largely to prohibitive costs. A modified CEA technique at our burn center incorporated cost-effective, routinely-used dressings with favorable outcomes. One unknown concern was the immunosuppressive effect that extensive burns and potentially human immunodeficiency virus (HIV) infection may have on graft take. This case study reports on the graft take outcomes of the first CEA transplanted in an HIV-positive patient with extensive burns in South Africa, using this technique. Graft take was determined after 21 days at 80% and a long-term follow-up of 8 years indicated good pigmentation return and skin pliability. Delayed diagnosis of pyoderma gangrenosum caused partial graft loss; however, successful regrafting occurred after pyoderma gangrenosum treatment and eradication. The case was considered clinically successful. HIV may not directly affect graft take, but may result in immunosuppressive conditions that delay graft take success.

This study aimed to compare factors contributing to a positive outcome of adult burn injury patients managed at two primary and one tertiary level Western Cape hospitals. These patients from the primary hospitals (PLHs) met the referral criteria for specialised care at the Tygerberg Hospital burns unit (TBU) but were not accepted or were accepted late. A total of 1034 adult burn injury patients seen at two primary level ("A" and "B") hospitals and the TBU between 2016 and 2019 were retrospectively analysed. One hundred and eleven (111) primary level patients ("A" 71, "B" 40) met the criteria for referral to the TBU. The outcomes and factors contributing to positive outcome of these patients were compared with the 859 patients treated at the TBU during the same period. Patients treated at the TBU showed longer theatre waiting times, more operations, and higher complication and death rates than their primary level counterparts. The PLHs showed no factors significantly contributing to hospital discharge. At TBU, pregnancy status, younger age, hot water burns, lower abbreviated burns severity index (ABSI) score, and longer time to theatre were associated with hospital discharge. A shortage of beds was the main reason for denial of admission to the TBU. The PLHs showed good outcomes in managing severe burn injuries, although no significant contributors to a positive outcome were identified. Patient- and facility-related factors contributed to positive outcomes at the TBU. Upgrading both the Western Cape's primary level capabilities and the TBU's accessibility and efficiency are necessary to improve burns services.