Following the fatal fire that occurred on New Year’s Eve in a bar in Crans-Montana, Switzerland, several French hospitals agreed to treat injured patients.

Among them was the Burn Treatment Center at Hôpital Saint-Louis in Paris, France, part of the Assistance Publique-Hôpitaux de Paris, where the medical director, François Dépret, MD, PhD, anesthesiologist-intensivist in AP-HP’s Department of Anesthesiology and Critical Care and Burn Unit at Hôpital Saint-Louis, detailed the complex care of patients with severe burns to Medscape France.

Since January 1, the transfer of severely burned patients and their distribution in French hospitals were coordinated by the operational center for regulation and response to health and social emergencies of the health crisis center (CORRUSS) in close collaboration with a physician specializing in severe burns and Regional Health Agencies, while ensuring that a coherent healthcare offer was maintained throughout France.

Hospitals receiving patients included the Burn Treatment Center at Hôpital Saint-Louis; the Centre des brûlés de Lyon Pierre Colson at Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France, which currently treats five patients; and Hôpital Mercy, part of the CHR Metz-Thionville, in Ars-Laquenexy, France.

As of January 8, a total of 20 patient transfers to French hospitals had occurred, according to figures provided to Medscape France by the Ministry of Health. In these highly specialized units, patients are managed by multidisciplinary teams for variable but generally prolonged periods.

Defining Severe Burns

“We define severe burns as involving at least 20% of the total body surface area. A burn is considered critical when a third-degree injury affects more than 5% of the body surface area,” said Dépret.

Additional risk factors include smoke inhalation, which can be life-threatening, high-voltage electrical burns, and deep burns in areas with high functional risk, such as the hands, face, feet, and perineum.

“Care for these patients is multidisciplinary,” Dépret said. “In our unit, we have about 15 anesthesiologist-intensivists, five plastic surgeons, several dozen nurses and nursing assistants, a psychologist, physical therapists, and a nutritionist.”

Dressings must be changed every 48 hours, a process that requires extensive expertise, staffing, and time. “Changing a single dressing can take up to 2 hours and requires three to four nurses and nursing assistants,” he explained. “Training a burn unit nurse takes about 1-1.5 years before full autonomy is achieved. They were highly qualified professionals. If someone is absent, you cannot simply replace them with staff from another ward.”

Surgery and Rehabilitation

However, deep burns often require surgical grafting. “The surgeon removes third-degree burned skin, harvests a very superficial layer of skin from an unburned area, then expands it to increase surface area,” Dépret said. “It forms a mesh-like structure that is placed over an excised area. Skin cells then gradually fill in the gaps.”

Multiple grafting procedures may be required during hospitalization. These interventions have prolonged systemic effects, followed by a rehabilitation phase that requires specialized physicians, occupational therapists, and physical therapists. Psychological support is also offered to patients, their families, and healthcare staff.

The length of hospital stay varies widely and may extend to several months post-injury. “A rough estimate is about 1 day of hospitalization per percentage point of burned skin,” Dépret said. “That translates to roughly 2 months for a patient with 60% total body surface area burned.”

Early complications depend on the phase of care provided. “The initial complication is hypovolemic shock because burn patients lose large amounts of fluid very quickly,” he said. “Fluid resuscitation is required for 24-48 hours.”

Smoke inhalation, as seen in the Crans-Montana fire, carries a risk for airway burns and respiratory failure. “Patients may require oxygen or even intubation,” he added.

Toxic Exposures and Infection Risk

Patients with burns may also experience toxic exposure due to smoke inhalation. Management includes removal of exposure and oxygen therapy. High-flow oxygen is required in cases of carbon monoxide poisoning.

“In cases of cyanide derivative poisoning, we administer an antidote, vitamin B₁₂,” Dépret said. “We do not truly know how effective it is because randomized clinical trials in large patient populations are not feasible given the emergency setting and the rarity of these events.”

Complications are primarily infectious. “Skin is our barrier to the external environment,” he said. “Without this, bacteria and fungi have direct access. Infection remains the leading cause of death.”

In the case of patients injured in the Crans-Montana fire, young age represents a favorable prognostic factor.

“The abbreviated burn severity index score helps estimate survival probability,” Dépret said. “Two major favorable factors are age and burned surface area. With the same burn size, a man aged 0-20 years with 40%-50% total body surface area burned has an 80%-90% chance of survival compared with 50%-70% in a man aged 60-80 years.”

Smoke inhalation and preexisting conditions also influence prognosis.

Over the past 20 years, advances in intensive care have improved the outcomes of patients with severe burn injuries. “Ultimately, what saves lives is covering the burns, grafting, and achieving healing,” Dépret said. “There has been no major revolution in this area in recent years.”

Future progress may depend on the ability to culture skin from small patient samples to produce sufficient graft material without rejection. “The most extensively burned patients, with little healthy skin available, are the hardest to save,” he added. “After skin harvesting, we must wait for the donor sites to heal before grafting again. Patients lose weight and develop infections due to burn injuries. It is a race against time.”

Currently, cell culture techniques are not sufficiently advanced for routine clinical use.

This story was translated from Medscape’s French edition.