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Non intentional burns in children: Analyzing prevention and acute treatment in a highly developed country
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Non intentional burns in children: Analyzing prevention and acute treatment in a highly developed country Theres Moehrlen a, Markus A. Landolt b,c , Martin Meuli a, Ueli Moehrlen a, * a
Department of Pediatric Surgery, University Children’s Hospital Zurich, Switzerland Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Switzerland c Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland b
article info
abstract
Article history:
The objective of this study was to evaluate where and when pediatric burn injuries occurred.
Accepted 28 May 2019
Furthermore the quality of first aid treatment, ratio of skin grafting and length of hospital
Available online xxx
stay were evaluated. The patient records of 749 children with acute burns admitted to the University Children’s
Keywords: Burn
Hospital of Zurich, Switzerland, were retrospectively reviewed over an 11-year period. Burn injuries in children with an immigrant background were overrepresented in our study population, whereby the proportion of immigrants decreased with rising age.
Scald Pediatric Children Treatment Prevention Epidemiology First aid
Sixty-five percent of all patients received some form of first aid. Of those 4.5% did not comply with the current guidelines. Furthermore initial assessment of total body surface area (TBSA) by the first line physician was overestimated in 76% of cases. Flame injuries occurred mainly in summertime in outdoor settings and needed significant more often skin grafts than scalds, which mainly occurred indoors and in wintertime. As a result, patients with flame injuries had to stay significantly longer in hospital (flames: 21 days (range: 1 259 days; median: 30; interquartile range (IQR): 30) versus scalds: 7 days (range: 1 130 days; median: 7; IQR: 12); p < 0.001). Furthermore high voltage injuries often resulted in lower-leg amputations (n = 3; 43%). Based on these facts, targets for the improvement of a prevention campaign and the treatment for burned children were named. © 2019 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are some of the most devastating injuries and recipients may carry the sequelae for the rest of their lives [1]. Burns occur in all age groups, and may range in severity from very minor,
undergoing no treatment, to extremely severe resulting in death [2]. Certainly, the best way to cope with the problem is prevention by public awareness and attempts to minimize the risk factors. Prevention is, of course, much more rewarding than treatment and requires exploration of the epidemiological features of the injury in a given population [1].
* Corresponding author at: Department of Pediatric Surgery, University Children’s Hospital Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland. E-mail address: [email protected] (U. Moehrlen). https://doi.org/10.1016/j.burns.2019.05.018 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.
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Various epidemiological studies on pediatric burns have been performed [3 13]. The results of these studies vary depending on cultural and environmental factors. However epidemiological studies on childhood burns in Switzerland and the whole German-speaking part of Europe are rare. In 2017, an 11-year study was published on the frequency, mortality and mode of injury leading to admission in the largest Swiss Pediatric Burn Center of the University Children’s Hospital Zurich [8]. This study corroborates the age and gender-specific pattern for burn injuries and recommends that a prevention campaign to avoid contact burns and scalds should be targeted at parents and caregivers of infants and toddlers, a campaign for flame burns and high voltage burns should be directly addressed to older boys and teenagers. The primary aim of this study was to describe patient ethnicity, location and time (time of the day, season) of burn injuries. The secondary aim was to assess the quality of the first aid treatment, the initial assessment of TBSA and the rate of skin grafting and length of hospital stay (LOS). Based on these facts, targets for the improvement of treatment for burned children were analysed.
2.
Methods
The University Children’s Hospital Zurich is the only referral center in Switzerland, according to the American Burn Association guidelines (ABA), for pediatric burn injuries exclusively. Our center fulfils two main functions, namely serving as a regional burn center (approximately 1.2 million inhabitants) as well as a national burn center for the Italian and German-speaking parts of Switzerland (approximately 6 million inhabitants). The admission criteria for our burn unit are listed in Table 1. For the purpose of this study, all medical records of acute burn patients admitted to the University Children’s Hospital of Zurich between January 1998 and December 2008 were reviewed retrospectively. Readmissions were excluded. Other characteristics of this study population have been analyzed in another study [8]. The study was approved by the Ethic Committee of the University Children’s Hospital of Zurich. A total of 765 patients with acute burn injuries were admitted to our unit in the observed time period. From this
Table 1 – Admission criteria of our unit. Extent of burn
Depth Localization Case history
Baby with total body surface area (TBSA) >5% Child with TBSA >10% Deep second degree burn All third degree burns Always: face, genitals, circumferential burns Depending on extent: hand, feet, joint Suspected inhalation injury High-voltage injuries (1000 V) Suspected child-abuse Difficult linguistic communication Complicated social circumstances
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group of eligible individuals, 749 (97.9%) were included in this analysis (Fig. 1). Pertinent information of patient ethnicity, time, supervision and location of accident were recorded. First aid treatment, initial assessment of TBSA, rate of skin grafting and LOS were also retrieved from the patient records. Data were analyzed using SPSS (version 19.0 for Windows). Depending on the distribution of the data, Mann Whitney U-tests or Kruskal Wallis tests were used to assess group differences with regards to continuous variables. A p-value of p < 0.05 was considered significant. In case of multiple tests, Bonferroni correction was performed.
3.
Results
3.1.
Patient ethnicity
Patients admitted to our unit had nationalities from 49 different countries. More than half of the children were Swiss. Table 2 shows that the percentage of children from Switzerland increased with age from 50.5% among the 0 4 years-old to 71.3% among those over 9 years old. Most children with an immigrant background were from Balkan nations (n = 131; 17.5%), with the next largest group of patients from Germany (n = 43; 5.7%). Overall, 271 patients (36.2%) were children with an immigrant background but with permanent residence in Switzerland and 41 patients (5.6%) were children with an immigrant background residing outside Switzerland, predominantly in Germany (n = 20; 48.8%) and United Arab Emirates (n = 7; 17.1%).
3.2.
Location of accident
Most of the accidents occurred indoors (Table 4). The place of indoor-injury occurrence was unknown for a large number of cases (n = 234; 42.9%). Of those where place of accident was specified, the kitchen was the most common. Two accidents (0.6%) occurred in maternity clinics. Both of these injuries occurred while a hospital employee was warming the baby’s heel for taking a blood sample. Table 3 shows that most outdoor injuries occurred in forests (n = 25; 37.9%). Of these children 8 (32%) were attending a youth group at the time of the accident. The majority of flame injuries (n = 101; 61.6%) occurred in an outdoor setting. In contrast, scald (n = 426; 88.4%) and contact injuries (n = 55; 72.4%) occurred significant more often indoors (Table 4). Children who suffered burns in outdoor settings were significantly older and sustained a higher TBSA than children who were injured indoors (Table 3).
3.3.
Time of the day (TOD)
Information about TOD was obtained in 438 of 749 cases (58.5%). Of these cases, burns occurred most frequently in the early evening (n = 203; 46.4%) between 7 p.m. and 9 p.m. (Fig. 3). In the scald group a double-peak pattern is observable, namely between 10 a.m. and 12 a.m. and between 7 p. m. and 9 p.m. One hundred and seventy-nine scald injuries
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Fig. 1 – Flow diagram of participants.
Table 2 – Patient ethnicity.
Switzerland Immigrants/visitors Balkan nationa Germanyb Portugal Sri Lanka Italyb India United Arab Emirates Franceb Austriab Iraq Others Unknown Total a b
Total n (%)
0 4 year
5 9 year
>9 year
421 (56.2) 312 (41.7) 131 (17.5) 43 (5.7) 21 (2.8) 21 (2.8) 18 (2.4) 7 (0.9) 7 (0.9) 5 (0.7) 4 (0.5) 4 (0.5) 51 (6.8) 16 (2.1) 749 (100)
261 (50.5) 245 (47.4) 102 (19.7) 31 (6.0) 16 (3.1) 18 (3.5) 12 (2.3) 7 (1.4) 5 (1.0) 3 (0.6) 4 (0.8) 4 (0.8) 43 (8.3) 11 (2.1) 517 (100)
73 (66.4) 33 (30.0) 16 (14.5) 3 (2.7) 4 (3.6) 2 (1.8) 3 (2.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (4.5) 4 (3.6) 110 (100)
87 (71.3) 34 (27.9) 13 (10.7) 9 (7.4) 1 (0.8) 1 (0.8) 3 (2.5) 0 (0.0) 2 (1.6) 2 (1.6) 0 (0.0) 0 (0.0) 3 (2.5) 1 (0.8) 122 (100)
Albania, Bosnia, Kosovo, Macedonia or Turkey. Neighboring country of Switzerland.
(60.9% of all scalds) occurred in these two time frames, with a peak time at 6 p.m. (n = 38; 12.9% of all scalds). Most of the flame injuries (n = 40; 38.5% of all flames) occurred between 6 p.m. and 9 p.m. with a peak time of 6 p.m. (n = 12; 11.5%).
3.4.
Monthly variations
Fig. 2 shows that the majority of scalds (n = 262; 54.4%) occurred in winter months (September February) with a peak in January (n = 53; 11%). In contrast, the majority of flame injuries (n = 108; 65.9%) occurred in summer months (March August) with peaks in May and August (n = 26, 15.9% and n = 24; 14.6%, respectively). In addition, the contact burn inpatient census was highest in June (n = 13; 17%). Furthermore, of the 15 accidents involving fireworks in August, 8 (53.3%) occurred on 1st August (n = 5; 62.5%), or 2nd August (n = 3; 37.5%).
3.5.
Supervision
In 82.5% of cases, the parents were responsible for supervising the children when the accident occurred. In 24 cases (4.3%) other children were present and in 18 cases (3.2%) the grandparents were present at the time of the accident. Overall, 15 children (2%) were sitting on somebody’s lap and 10 children (1.3%) were seated in a child safety seat when the accident occurred.
3.6.
First aid
About two third of all patients received some form of first aid by parents or guardians before attending a physician (Table 3). Of those patients, cold water applied to the burn was the most common treatment. In almost half of the cases, the length of cooling with water was longer than 15 min.
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Table 3 – First aid measures. Number
Percentage (%)
Some form of first aid Compliance with current references Cold water Lengths of cooling <5 min 5 min 10 min 15 min Unknown Burn ointment Additional analgesia
485 463 439
64.8 95.5a 90.5a
20 53 57 120 189 24 1
8.0b 21.2b 22.8b 48.0b 43.1c 5.0a 0.2a
No compliance with current references Toothpast Youghurt/curds Others (e.g. butter, white egg) No first aid No information Total
22 11 5 6 96 168 749
4.5a 2.3a 1.0 1.2a 12.8 22.4 100
a b c
Fig. 2 – Seasonal variation and cause of burn.
Percentage of all patients who received first aid. Percentage of all patient where the lengths of cooling is known. Percentage of all patients who received cooling.
Out of the 485 children (64.8%) who received some form of first aid treatment, 22 patients (4.5%) received first aid treatment that did not comply with current guidelines (Table 2). In 11 of these cases (50%), toothpaste was applied to the burn. Six of these patients (54.5%) had Albanian as native language. The other 5 patients (45.5%) had Arabic, Italian,
Serbian, Spanish and Tamil as their native languages. One child had been given oral analgesia by their parents/guardians before visiting a physician.
3.7.
Initial assessment of total body surface area (TBSA)
The vast majority of patients sustained burns of 10% TBSA or less (Table 5).
Table 4 – Place of accident.
a
Indoor Place of accident is specified Kitchen Living/dining room Bathroom Bedroom School/playgroup Restaurant Maternity clinic Other Place of accident is not specified Outdoora Place of accident is specified Forest Garden/balcony Street/playground Body of water Railway Others Place of accident is not specified Unknown Total a
Total n (%)
Scalda n (%)
Flamesa n (%)
Contacta n (%)
Electrics n (%)
Chemical n (%)
545 (72.8) 31 (57.1) 160 (51.4) 64 (20.6) 33 (10.6) 23 (7.4) 11 (3.6) 5 (1.6) 2 (0.6) 13 (4.2) 234 (42.9) 135 (18) 66 (48.9) 25 (37.9) 15 (22.7) 9 (21.2) 5 (7.6) 5 (7.6) 7 (10.6) 69 (51.1) 69 (9.2) 749 (100)
426 (88.4) 228 (47.3) 132 (57.9) 43 (189) 30 (13.2) 14 (6.1) 2 (0.9) 3 (1.3) 1 (0.4) 3 (1.3) 198 (46.5) 8 (1.6) 6 (75.0) 3 (37.5) 0 (0.0) 1 (16.7) 1 (16.7) 0 (0.0) 1 (16.7) 2 (25.0) 48 (10) 482 (64.4)
47 (28.7) 39 (83.0) 6 (15.4) 15 (38.5) 1 (2.6) 3 (7.7) 5 (12.8) 0 (0.0) 0 (0.0) 9 (23.1) 8 (17.0) 101 (61.6) 43 (42.6) 20 (46.5) 12 (27.9) 3 (7.0) 3 (7.0) 5 (11.6) 0 (0.0) 58 (57.4) 16 (9.8) 164 (21.9)
55 (72.4) 39 (70.9) 22 (56.4) 6 (15.4) 0 (0.0) 4 (10.3) 4 (10.3) 1 (2.6) 1 (2.6) 1 (2.6) 16 (29.1) 16 (21.1) 9 (56.3) 2 (22.2) 3 (33.3) 3 (33.3) 1 (11.1) 0 (0.0) 0 (0.0) 7 (43.7) 5 (6.6) 7 (10.1)
15 (60.0) 4 (26.7) 0 (0.0) 0 (0.0) 1 (25.0) 2 (50.0) 0 (0.0) 1 (25.0) 0 (0.0) 0 (0.0) 11 (73.3) 10 (40.0) 8 (80.0) 0 (0.0) 0 (0.0) 2 (25.0) 0 (0.0) 5 (62.5) 1 (12.5) 2 (20.0) 0 (0.0) 25 (3.3)
2 (100) 1 (50.0) 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.3)
Outdoor vs indoor: flames vs contacts: OR = 7387; 95%CI: 3,835 14,228; p < 0.001. Outdoor vs indoor: flames vs scalds: OR = 11,443; 95%CI: 52,437 249,718; p < 0.001.
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The initial assessment of TBSA by the first line physician (outside the Children’s Hospital) was often overestimated (Table 6).
3.8.
Hospitalization
The majority of children presented their burn injury to a physician within 24 h of the accident (n = 734; 98%). Children, who presented their burns later than 24 h after their accident, had a median affected TBSA of 1% (1 7%). Most children were admitted to our unit on the day of accident (Table 5). Half of these patients (n = 309; 50.5%) were referred directly to the Children’s Hospital, 262 patients (42.8%) by other hospitals, 52 patients (8.5%) by a general practitioner and in 9 children (1.5%) the authority for first line therapy is unknown. Table 4 shows that mean TBSA in patients who were initially admitted to a hospital was significantly higher than in
Fig. 3 – Time variation and cause of burn.
Table 5 – Distribution of age and TBSA.
Age Sex Male Female Place of injury Indoor Outdoor Unknown TBSA Sex Male Female Place of injury Indoor Outdoor Unknown Burn etiologya Flames Scalds Contacts Electrics High-voltageb Low-voltageb Admission Initially inpatient Initially outpatient Admitted to our unit on day of accident Initially admitted to other hospitals Intensive care Yes No Skin grafts Yes No Unknown a b
n (%)
Median
Range
749 (100) 479 (64) 270 (36)
2 year 2 month 2,4 year 2 year
3 day 15 years 10 months 3 day 15 years 10 months 10 days 15 years 10 months
545 (72.8) 135 (18) 69 (9.2)
1 year 8 months 10 years 10 months
3 day 15 years 10 months 9 month 15 years 9 month
749 (100) 479 (64) 270 (36)
5% 5% 5%
1 90% 1 90% 1 80%
545 (72.8) 135 (18) 69 (9.2)
5,0 6,5
1 80% 1 90%
164 (21.9) 482 (64.4) 76 (10.1) 25 (3.3) 7 (28) 18 (72)
7,5% 6% 1% 1% 405% <1%
1 90% 1 70% 1 41% 1 70% 3 70% <1 1%
658 (87.9) 91 (12.1) 612 (93) 46 (7)
6% 2% 6% 9%
1 1 1 1
67 (8.9) 682 (91.1)
17% 5%
1 90% 1 41%
259 (34.6) 485 (64.8) 5 (0.6)
8% 5%
1 90% 1 55%
p-Value 0.014
<0.001
0.61
0.02
a
<0.001b
<0.001 90% 12% 90% 55%
<0.001 <0.001
<0.001
Burn etiology: flame vs scalds; flames vs contacts; flames vs electrics; scalds vs contacts; scalds vs electrics p < 0.001; contacts vs electrics p = 0.578. Electrics: high-voltage vs low voltage p < 0.001.
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Table 6 – Initial assessment of total body surface area (TBSA).
Overestimation <5% TBSA 5 9.9% TBSA 10 19.9% TBSA 20 25% TBSA Correct estimation Underestimation <5% TBSA 5 10% TBSA Total
Number
Percentage (%)
147 61 45 34 7 30 15 10 5 192
76.6 41.5 30.6 23.1 4.8 15.6 7.8 66.7 33.3 100
patients who were initially treated as an outpatient. Furthermore, the mean TBSA was significant higher in patients who were initially treated in other hospitals. A total of 297 patients (39.7%) were self-referred to the Children’s Hospital, 251 children (33.5%) were admitted by ambulance, 107 patients (14.3%) by rescue helicopter and for 94 children (12.5%), the mode of transport to the Hospital was unknown. Sixty-seven patients (8.9%) underwent treatment in the intensive care unit. The median TBSA of these patients was significantly higher than in patients who did not undergo treatment in the intensive care unit (Table 5).
3.9.
Skin grafting
One third of all patients underwent skin grafting (Table 5). In 4 of these patients (1.6%) a conservative therapy was initially attempted, unsuccessfully, undergoing hospitalization for skin grafting. Of the 259 patients with skin grafts, 250 patients (96.5%) underwent split-thickness skin transplantation and 9 patients (3.5%) underwent full-thickness skin grafting. Six of these patients (66.7%) sustained contact injuries and 3 of these patients (33.3%) sustained low-voltage burns (<1000 V). In all 9 patients (100%) who underwent full-thickness skin grafting, the affected TBSA was 1% or less. Of the total 7 patients who sustained high-voltage injuries (1000 V), 3 patients (42.9%) underwent skin grafting, 3 patients (42.9%) underwent lowerleg amputation and one patient was transferred abroad before surgical intervention. Only one patient with a low-voltage injury underwent an amputation (distal phalanx of the thumb). One hundred and five patients (42% of the patients who underwent split-thickness skin grafting) had injuries with coverage on multiple areas of the body. Before split-thickness skin transplantation, cadaveric donor skin was applied to the wound in 54 patients (21.6%). In the majority of the cases, skin was taken from either the scalp (n = 230; 96.2%) or leg (n = 32; 13.4). Patients who underwent skin grafting had a significant higher mean TBSA than patients who did not undergo skin grafting (Table 5). The rate for skin grafting was highest in flame injuries, followed by contact and scald injuries (Fig. 4).
3.10.
Length of hospital stay (LOS)
Thirteen patients were excluded from LOS. Five of these patients were transferred to other hospitals before recovery.
Fig. 4 – Etiology and need of skin grafting.
Four patients received skin grafts following rehospitalisation. Three patients died in the hospital and one patient received skin grafts in another hospital before being transfer to the University Children’s Hospital of Zurich. The median LOS was 8 days (range: 1 259 days; IQR: 17) and did not vary during the study period, in either patients who received skin grafts or those that received conservative therapies (Table 7). LOS increased with increasing TBSA. Furthermore, victims of flame injuries and patients who underwent skin grafting with longer hospital stays. During the 11-year study period, 12 patients were hospitalized in our unit for longer than 3 months.
4.
Discussion
In this study, we described patient ethnicity and supervision, location, TOD and season of burn injuries. Additionally we assessed the quality of the first aid treatment, the initial assessment of TBSA, rate of skin grafting and LOS. Based on these facts, targets for the improvement of a prevention campaign and the treatment for burned children were named.
4.1.
Patient ethnicity
More than one third of all patients in our sample had an immigrant background, but permanent residence in Switzerland. This is surprising as the percentage of immigrants in Switzerland during the whole study period varied between 18 21% [14]. Thus, Swiss children were significantly less affected by burns than children with other nationalities. Our findings are in agreement with those of Johann [15] who demonstrated that scalds and burn injuries in infants and toddlers with an immigrant background are six-fold higher than those of the same age of German nationality. In our study 6.7% of foreign children came from Sri Lanka, an ethnic group comprising 0.8 2.1% [16] of the Swiss population during the 11-year study period, showing that children from Sri Lanka were significantly overrepresented in this study (p < 0.001).
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Table 7 – Length of hospital stay. n (%)
Mean (day)
Median (day)
Range (day)
IQR
Sex Male Female Total
470 (63.9) 266 (36.1) 736 (100)
16 13 15
9 8 8
1 249 1 259 1 259
18 15 17
Agegroup <1 year 1 4 year 5 9 year 10 14 year >14 year Total
74 (10.1) 437 (59.4) 106 (14.4) 102 (13.9) 17 (2.3) 736 (100)
12 12 25 21 27 15
7 7 11 17 10 8
1 1 1 1 1 1
10 13 27 23 23 17
TBSA <10% 10 19% 20 29% 30 39% 40 49% 50 100% Total
555 (75.7) 133 (18.1) 23 (3.1) 7 (1.0) 5 (0.7) 10 (1.4) 733 (100)
9 25 32 64 73 45
6 21 30 76 85 118
1 78 2 203 11 57 32 88 24 113 67 259
10 21 12 46 65 163
Burn etiologya Scalds Flames Contacts Electricalb High-voltage Low-voltage Chemical injuries Total
478 (64.9) 159 (21.6) 74 (10.1) 23 (3.1) 5 (21.7) 18 (78.3) 2 (0.3) 736 (100)
11 29 8 19 73 4 5 15
7 21 5 1 54 1 5 8
1 130 1 259 1 31 1 142 23 142 1 36 2 8 1 259
12 30 11 22 90 0 N/A 17
Skin graftsc Yes No Total
245 (33.3) 491 (66.7) 736 (100)
33 6 15
25 5 8
3 259 1 54 1 259
17 7 17
a b c
113 259 238 104 249 259
Flames vs. scalds and contacts p < 0.001 scalds vs. contacts p = 0.03. High voltage injuries vs. low voltage injuries p < 0.001. Skin grafting vs. conservative therapy p < 0.001.
Therefore a prevention campaign directed directly to this ethnic group might reduce incidence of injury. During the study period, 5.6% of all patients had permanent residence abroad. Most of these children lived in Germany at the time of accident. This is due to an agreement between the Children’s Hospital and Germany that the Burn Unit of the Children’s Hospital provides treatment for severe burns from the southern part of Germany if local hospitals do not have the capacity for treatment. The second most common patient group with residence abroad was from the United Arab Emirates. This is due to a special collaboration of our unit with hospitals in that region.
4.2.
Location of accident
In agreement with prior studies we found that three out of four accidents occurred indoors [10,17 19]. Many studies specify that the kitchen is the most dangerous room in the house [6,10,17,20]. In the current study approximately half of all indoor accidents occurred in the kitchen, a result which is
comparable with a study from France [21]. In contrast, studies from Czech Republic (70%) [17], Ireland (70%) [20] and Australia (65%) [6] showed much higher percentages of kitchen accidents. Scald and contact injuries occurring in the kitchen have been associated with drink and food preparation or food consumption. This finding has been corroborated in several studies [5,11,18,20]. Most of these accidents could be prevented if parents were better educated and more aware of potentially dangerous situations when preparing and consuming food and drinks. Shah et al. [12] and Bradshaw et al. [22] recommend defining the kitchen as a “no zone area for children” to minimize injuries. This recommendation is also supported by a Danish study [23] that found 27% of all indoor accidents occurred in the kitchen. This result is lower than the incidence reported in other studies [1,6,17,20,21]. The authors explain the lower incidence of kitchen accidents as being due to the fact that small children are generally outside the kitchen during cooking, resulting in a higher occurrence of injuries in the living/dining room. In our consideration, banishing children
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from the kitchen is only effective if the safety of the child outside the kitchen can be guaranteed. Consequently, infant and toddlers should be in a playpen or supervised by another responsible person so that the child is not exposed to other dangers outside the kitchen. It is alarming that more than 3% of all children in our study were sitting on somebody’s lap or were seated in a child safety seat when the accident occurred. The authors of a Finish study [3] describe children on someone’s lap were commonly scalded by pulling coffee cups or pots over themselves. Quite often these children were sitting on their parent’s lap. This finding underlines the need to educate parents that perceived safe areas also carry a risk of burns if dangerous objects are within reach of the child.
4.3.
Time and monthly variations
According to the literature, the time between 4 p.m. and 7 p.m. is the most dangerous time in relation to burn accidents [6,13,22,24] and is associated with meal preparation and consumption and children’s bath-times. In our current study the period between 6 p.m. and 9 p.m. was identified as the most hazardous time of day and is consistent with findings of another Swiss study [18]. While there is no explanation for this discrepancy in the time of injury between Swiss and international studies, we suggest that the difference in timing of these activities across cultures. In other words, the same incidents occur, but later in the day in Switzerland. But it has to be taken into account that this two-hour time-delay in accident occurrence in the Swiss studies is also directly linked with meal preparation and consumption and children’s bathtimes. Similar to a Danish study [23] we observed a second peak in scald injuries between 10 a.m. and 1 p.m., coinciding with lunch preparation and a smaller third peak between 7 a. m. and 8 a.m., coinciding with breakfast preparation and consumption. This third peak was not observed in the Danish study. During the study period scald injuries occurred predominantly in wintertime. This can be linked to higher consumption of hot drinks and the inhalation therapy with hot liquid in this cold season. In contrast, contact injuries and flame injuries occurred more frequently in summertime, coinciding with open air barbecues. As expected, more than half of all accidents caused by fireworks occurred in August, specifically on 1st August (62.5%) or 2nd August (37.5%). This is explained by the Swiss national holiday on first of August. Traditionally, many residents light fireworks on these days. These fireworks are readily accessible and may be legally purchased.
4.4.
Supervision
Eighty-two percent of all children were supervised by at least one parent, when the accident occurred. But it should be considered that at the time of accident the child was not necessarily under the direct supervision of one or both parents. A Dutch study confirms this result [5]. The authors of the Dutch study mentioned further that in cases where somebody was present, 41% said their attention had been distracted for a moment. The most common reason for leaving the child alone was another child demanding attention, the
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telephone or door bell, or the child went, unnoticed, into another room. In 3.4% of all accidents the child was under professional care (e.g. school or kindergarten). This result moderately exceeds the observation of another Swiss study at CHUV [18] in which 2% of burned children were under professional care at the time of accident.
4.5.
First aid
Early cooling of burns prevents a significant number of superficial burns from progressing to deep burns [25]. Studies from Ireland [20], Australia [6] and Denmark [23] demonstrate that cold water was applied in 87 90% of cases immediately after the accident. In contrast, we found less frequent use of cold water in our sample (n = 439; 61.8%) and where applied, for a shorter duration (<10 min). While interpreting this result it should be considered that information on length of cooling was obtained from parents in the emergency room shortly after the accident. It is conceivable that the length of cooling for some patients was shorter than recorded, because in emergency situations, most parents tend to overestimate, rather than underestimate the length of cooling [26]. In Switzerland it is obligatory to attend a first aid teaching lesson to receive a driving license. In these lessons the importance of cooling after burn injuries has to be addressed in a more explicit and understandable way to be more effective. In 3% of all cases, first aid did not comply with current standards (e.g., in 2.3% of cases tooth paste was applied to the wounds). Our result is similar to a previous British study [7] where it was observed that in 4% of all cases tooth paste application was involved in first aid treatment. All these patients came from Asia. In the current study, it was also seen that no patients with German as a native language applied toothpaste to the injury. It can thus be concluded that correct first aid teaching should be specified to people from different cultural backgrounds. This is supported by an Indian study [9], where wrongly ink or honey was applied to wounds.
4.6.
Initial assessment of TBSA
In our study the affected TBSA was overestimated in the majority of cases (77%) during initial medical assessment. This result is in line with a study from the United Kingdom [27]. The authors of that study note that estimation of burn size in pediatric burns is challenging and therefore the benefits of early transfer to a specialist service center cannot be overemphasized. Furthermore the authors highlighted that training and education is essential for clinicians in emergency departments.
4.7.
Hospitalization
The majority of all children with burns presented to a physician within 24 h of the accident. Prior to admission, more than half of all patients were treated outside the Children’s Hospital of Zurich. This is because the Swiss health care system promotes the idea that patients should first go to a primary care center facility close to where they are living. Only those patients with severe injuries are transferred to a tertiary
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hospital such as the Children’s Hospital of Zurich. The results of the current study show that patients who were transferred from another hospital had a significant higher mean TBSA than patients who were admitted initially to the Children’s Hospital of Zurich. This result indicates that regional hospitals in Switzerland fulfill their mandatory service.
4.8.
Skin grafting
We found that patients undergoing skin grafting had a significantly higher mean TBSA than those not undergoing grafting and this finding is consistent with prior studies [1,28]. Although high-voltage injuries (1000 V) are rare [8], they benefit from special attention and may result in serious injuries with many complications [29,30]. In the current study, patients with a high-voltage injury had higher affected TBSAs, higher incidences of grafts and longer hospital stays than patients with low-voltage injuries (<1000 V). This finding is similar to other studies [29,31 34]. The amputation rate for high-voltage injuries of 43% in our study is comparable with previous reports of 11 49.4% [35].
4.9.
Length of hospital stay (LOS)
The overall median LOS was 8 days (1 259 days) and is shorter than in comparable studies from Canada [19] (16 days; 1 267 days), Czech Republic [24] (158 days; 2 165 days) und Egypt [13] (20 days; 1 70 days). One Canadian study had a comparable LOS range to our study. In an Austrian study the LOS in acute burn patients was reduced by 71% over the 25-year study period [10]. In our study no time-related change was observed. Typically, scalds and contact burns caused smaller injuries, whereas fire and high-voltage electricity injuries affected extensive parts of the body [8]. Due to the fact that the LOS increased correspondingly with higher TBSA burned, flame injuries and high-voltage injuries led in longer hospital stays than scalds and contact injuries. These findings are in line with other studies [1,10,17,36]. Furthermore a Czech study [17] showed that boys had to stay longer in hospital than girls. In our sample we found no gender-difference in the length of hospital stay. Additionally, patients with flame injuries underwent skin grafting more often than other patients. Consequently, those showed to longest hospitals stays.
5.
Conclusion
First, to reduce the incident of burn injuries in children and secondary to improve the treatment of burned children, the following points should be considered: Prevention campaign in different languages: Children from immigrant backgrounds are overrepresented in our study population. Infants and toddlers from Sri Lanka are at particularly high risk. A prevention campaign directed at this ethnic group may reduce incidence of injuries. A prevention campaign on flame injuries appears to be appropriate especially in summer month, in contrast a campaign on scalds in winter month.
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Awareness of potential dangerous situations, such as sitting on somebody’s lap when they are drinking hot beverages and child safety seats and playpens are only as secure as the surrounding environment. Directly in the selling of fireworks it is important to draw the buyer’s attention to possible danger, because the vast majority of accidents with fireworks occurred shortly after the purchase. First aid: A teaching campaign about first aid measures focusing on immediate and optimal cooling time for burns should be announced to the general population. Due to the fact that only parents with foreign native-languages (especially Albanian) applied toothpaste to wounds, such a campaign should be run preferably in different languages. First line physicians should bear in mind that the initial medical assessment of the affected surface is mostly overestimated. Due to the frequent skin transplantations in children with flame injuries and the high amputation rate after high voltage accidents, these accident scenarios have an increased impact on the functional and cosmetic result. These facts should also be mentioned prevention campaigns.
Conflict of interest All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence their work. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. REFERENCES
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Non intentional burns in children: Analyzing prevention and acute treatment in a highly developed country Theres Moehrlen a, Markus A. Landolt b,c , Martin Meuli a, Ueli Moehrlen a, * a
Department of Pediatric Surgery, University Children’s Hospital Zurich, Switzerland Department of Psychosomatics and Psychiatry, University Children’s Hospital Zurich, Switzerland c Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland b
article info
abstract
Article history:
The objective of this study was to evaluate where and when pediatric burn injuries occurred.
Accepted 28 May 2019
Furthermore the quality of first aid treatment, ratio of skin grafting and length of hospital
Available online xxx
stay were evaluated. The patient records of 749 children with acute burns admitted to the University Children’s
Keywords: Burn
Hospital of Zurich, Switzerland, were retrospectively reviewed over an 11-year period. Burn injuries in children with an immigrant background were overrepresented in our study population, whereby the proportion of immigrants decreased with rising age.
Scald Pediatric Children Treatment Prevention Epidemiology First aid
Sixty-five percent of all patients received some form of first aid. Of those 4.5% did not comply with the current guidelines. Furthermore initial assessment of total body surface area (TBSA) by the first line physician was overestimated in 76% of cases. Flame injuries occurred mainly in summertime in outdoor settings and needed significant more often skin grafts than scalds, which mainly occurred indoors and in wintertime. As a result, patients with flame injuries had to stay significantly longer in hospital (flames: 21 days (range: 1 259 days; median: 30; interquartile range (IQR): 30) versus scalds: 7 days (range: 1 130 days; median: 7; IQR: 12); p < 0.001). Furthermore high voltage injuries often resulted in lower-leg amputations (n = 3; 43%). Based on these facts, targets for the improvement of a prevention campaign and the treatment for burned children were named. © 2019 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are some of the most devastating injuries and recipients may carry the sequelae for the rest of their lives [1]. Burns occur in all age groups, and may range in severity from very minor,
undergoing no treatment, to extremely severe resulting in death [2]. Certainly, the best way to cope with the problem is prevention by public awareness and attempts to minimize the risk factors. Prevention is, of course, much more rewarding than treatment and requires exploration of the epidemiological features of the injury in a given population [1].
* Corresponding author at: Department of Pediatric Surgery, University Children’s Hospital Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland. E-mail address: [email protected] (U. Moehrlen). https://doi.org/10.1016/j.burns.2019.05.018 0305-4179/© 2019 Elsevier Ltd and ISBI. All rights reserved.
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Various epidemiological studies on pediatric burns have been performed [3 13]. The results of these studies vary depending on cultural and environmental factors. However epidemiological studies on childhood burns in Switzerland and the whole German-speaking part of Europe are rare. In 2017, an 11-year study was published on the frequency, mortality and mode of injury leading to admission in the largest Swiss Pediatric Burn Center of the University Children’s Hospital Zurich [8]. This study corroborates the age and gender-specific pattern for burn injuries and recommends that a prevention campaign to avoid contact burns and scalds should be targeted at parents and caregivers of infants and toddlers, a campaign for flame burns and high voltage burns should be directly addressed to older boys and teenagers. The primary aim of this study was to describe patient ethnicity, location and time (time of the day, season) of burn injuries. The secondary aim was to assess the quality of the first aid treatment, the initial assessment of TBSA and the rate of skin grafting and length of hospital stay (LOS). Based on these facts, targets for the improvement of treatment for burned children were analysed.
2.
Methods
The University Children’s Hospital Zurich is the only referral center in Switzerland, according to the American Burn Association guidelines (ABA), for pediatric burn injuries exclusively. Our center fulfils two main functions, namely serving as a regional burn center (approximately 1.2 million inhabitants) as well as a national burn center for the Italian and German-speaking parts of Switzerland (approximately 6 million inhabitants). The admission criteria for our burn unit are listed in Table 1. For the purpose of this study, all medical records of acute burn patients admitted to the University Children’s Hospital of Zurich between January 1998 and December 2008 were reviewed retrospectively. Readmissions were excluded. Other characteristics of this study population have been analyzed in another study [8]. The study was approved by the Ethic Committee of the University Children’s Hospital of Zurich. A total of 765 patients with acute burn injuries were admitted to our unit in the observed time period. From this
Table 1 – Admission criteria of our unit. Extent of burn
Depth Localization Case history
Baby with total body surface area (TBSA) >5% Child with TBSA >10% Deep second degree burn All third degree burns Always: face, genitals, circumferential burns Depending on extent: hand, feet, joint Suspected inhalation injury High-voltage injuries (1000 V) Suspected child-abuse Difficult linguistic communication Complicated social circumstances
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group of eligible individuals, 749 (97.9%) were included in this analysis (Fig. 1). Pertinent information of patient ethnicity, time, supervision and location of accident were recorded. First aid treatment, initial assessment of TBSA, rate of skin grafting and LOS were also retrieved from the patient records. Data were analyzed using SPSS (version 19.0 for Windows). Depending on the distribution of the data, Mann Whitney U-tests or Kruskal Wallis tests were used to assess group differences with regards to continuous variables. A p-value of p < 0.05 was considered significant. In case of multiple tests, Bonferroni correction was performed.
3.
Results
3.1.
Patient ethnicity
Patients admitted to our unit had nationalities from 49 different countries. More than half of the children were Swiss. Table 2 shows that the percentage of children from Switzerland increased with age from 50.5% among the 0 4 years-old to 71.3% among those over 9 years old. Most children with an immigrant background were from Balkan nations (n = 131; 17.5%), with the next largest group of patients from Germany (n = 43; 5.7%). Overall, 271 patients (36.2%) were children with an immigrant background but with permanent residence in Switzerland and 41 patients (5.6%) were children with an immigrant background residing outside Switzerland, predominantly in Germany (n = 20; 48.8%) and United Arab Emirates (n = 7; 17.1%).
3.2.
Location of accident
Most of the accidents occurred indoors (Table 4). The place of indoor-injury occurrence was unknown for a large number of cases (n = 234; 42.9%). Of those where place of accident was specified, the kitchen was the most common. Two accidents (0.6%) occurred in maternity clinics. Both of these injuries occurred while a hospital employee was warming the baby’s heel for taking a blood sample. Table 3 shows that most outdoor injuries occurred in forests (n = 25; 37.9%). Of these children 8 (32%) were attending a youth group at the time of the accident. The majority of flame injuries (n = 101; 61.6%) occurred in an outdoor setting. In contrast, scald (n = 426; 88.4%) and contact injuries (n = 55; 72.4%) occurred significant more often indoors (Table 4). Children who suffered burns in outdoor settings were significantly older and sustained a higher TBSA than children who were injured indoors (Table 3).
3.3.
Time of the day (TOD)
Information about TOD was obtained in 438 of 749 cases (58.5%). Of these cases, burns occurred most frequently in the early evening (n = 203; 46.4%) between 7 p.m. and 9 p.m. (Fig. 3). In the scald group a double-peak pattern is observable, namely between 10 a.m. and 12 a.m. and between 7 p. m. and 9 p.m. One hundred and seventy-nine scald injuries
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Fig. 1 – Flow diagram of participants.
Table 2 – Patient ethnicity.
Switzerland Immigrants/visitors Balkan nationa Germanyb Portugal Sri Lanka Italyb India United Arab Emirates Franceb Austriab Iraq Others Unknown Total a b
Total n (%)
0 4 year
5 9 year
>9 year
421 (56.2) 312 (41.7) 131 (17.5) 43 (5.7) 21 (2.8) 21 (2.8) 18 (2.4) 7 (0.9) 7 (0.9) 5 (0.7) 4 (0.5) 4 (0.5) 51 (6.8) 16 (2.1) 749 (100)
261 (50.5) 245 (47.4) 102 (19.7) 31 (6.0) 16 (3.1) 18 (3.5) 12 (2.3) 7 (1.4) 5 (1.0) 3 (0.6) 4 (0.8) 4 (0.8) 43 (8.3) 11 (2.1) 517 (100)
73 (66.4) 33 (30.0) 16 (14.5) 3 (2.7) 4 (3.6) 2 (1.8) 3 (2.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 5 (4.5) 4 (3.6) 110 (100)
87 (71.3) 34 (27.9) 13 (10.7) 9 (7.4) 1 (0.8) 1 (0.8) 3 (2.5) 0 (0.0) 2 (1.6) 2 (1.6) 0 (0.0) 0 (0.0) 3 (2.5) 1 (0.8) 122 (100)
Albania, Bosnia, Kosovo, Macedonia or Turkey. Neighboring country of Switzerland.
(60.9% of all scalds) occurred in these two time frames, with a peak time at 6 p.m. (n = 38; 12.9% of all scalds). Most of the flame injuries (n = 40; 38.5% of all flames) occurred between 6 p.m. and 9 p.m. with a peak time of 6 p.m. (n = 12; 11.5%).
3.4.
Monthly variations
Fig. 2 shows that the majority of scalds (n = 262; 54.4%) occurred in winter months (September February) with a peak in January (n = 53; 11%). In contrast, the majority of flame injuries (n = 108; 65.9%) occurred in summer months (March August) with peaks in May and August (n = 26, 15.9% and n = 24; 14.6%, respectively). In addition, the contact burn inpatient census was highest in June (n = 13; 17%). Furthermore, of the 15 accidents involving fireworks in August, 8 (53.3%) occurred on 1st August (n = 5; 62.5%), or 2nd August (n = 3; 37.5%).
3.5.
Supervision
In 82.5% of cases, the parents were responsible for supervising the children when the accident occurred. In 24 cases (4.3%) other children were present and in 18 cases (3.2%) the grandparents were present at the time of the accident. Overall, 15 children (2%) were sitting on somebody’s lap and 10 children (1.3%) were seated in a child safety seat when the accident occurred.
3.6.
First aid
About two third of all patients received some form of first aid by parents or guardians before attending a physician (Table 3). Of those patients, cold water applied to the burn was the most common treatment. In almost half of the cases, the length of cooling with water was longer than 15 min.
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Table 3 – First aid measures. Number
Percentage (%)
Some form of first aid Compliance with current references Cold water Lengths of cooling <5 min 5 min 10 min 15 min Unknown Burn ointment Additional analgesia
485 463 439
64.8 95.5a 90.5a
20 53 57 120 189 24 1
8.0b 21.2b 22.8b 48.0b 43.1c 5.0a 0.2a
No compliance with current references Toothpast Youghurt/curds Others (e.g. butter, white egg) No first aid No information Total
22 11 5 6 96 168 749
4.5a 2.3a 1.0 1.2a 12.8 22.4 100
a b c
Fig. 2 – Seasonal variation and cause of burn.
Percentage of all patients who received first aid. Percentage of all patient where the lengths of cooling is known. Percentage of all patients who received cooling.
Out of the 485 children (64.8%) who received some form of first aid treatment, 22 patients (4.5%) received first aid treatment that did not comply with current guidelines (Table 2). In 11 of these cases (50%), toothpaste was applied to the burn. Six of these patients (54.5%) had Albanian as native language. The other 5 patients (45.5%) had Arabic, Italian,
Serbian, Spanish and Tamil as their native languages. One child had been given oral analgesia by their parents/guardians before visiting a physician.
3.7.
Initial assessment of total body surface area (TBSA)
The vast majority of patients sustained burns of 10% TBSA or less (Table 5).
Table 4 – Place of accident.
a
Indoor Place of accident is specified Kitchen Living/dining room Bathroom Bedroom School/playgroup Restaurant Maternity clinic Other Place of accident is not specified Outdoora Place of accident is specified Forest Garden/balcony Street/playground Body of water Railway Others Place of accident is not specified Unknown Total a
Total n (%)
Scalda n (%)
Flamesa n (%)
Contacta n (%)
Electrics n (%)
Chemical n (%)
545 (72.8) 31 (57.1) 160 (51.4) 64 (20.6) 33 (10.6) 23 (7.4) 11 (3.6) 5 (1.6) 2 (0.6) 13 (4.2) 234 (42.9) 135 (18) 66 (48.9) 25 (37.9) 15 (22.7) 9 (21.2) 5 (7.6) 5 (7.6) 7 (10.6) 69 (51.1) 69 (9.2) 749 (100)
426 (88.4) 228 (47.3) 132 (57.9) 43 (189) 30 (13.2) 14 (6.1) 2 (0.9) 3 (1.3) 1 (0.4) 3 (1.3) 198 (46.5) 8 (1.6) 6 (75.0) 3 (37.5) 0 (0.0) 1 (16.7) 1 (16.7) 0 (0.0) 1 (16.7) 2 (25.0) 48 (10) 482 (64.4)
47 (28.7) 39 (83.0) 6 (15.4) 15 (38.5) 1 (2.6) 3 (7.7) 5 (12.8) 0 (0.0) 0 (0.0) 9 (23.1) 8 (17.0) 101 (61.6) 43 (42.6) 20 (46.5) 12 (27.9) 3 (7.0) 3 (7.0) 5 (11.6) 0 (0.0) 58 (57.4) 16 (9.8) 164 (21.9)
55 (72.4) 39 (70.9) 22 (56.4) 6 (15.4) 0 (0.0) 4 (10.3) 4 (10.3) 1 (2.6) 1 (2.6) 1 (2.6) 16 (29.1) 16 (21.1) 9 (56.3) 2 (22.2) 3 (33.3) 3 (33.3) 1 (11.1) 0 (0.0) 0 (0.0) 7 (43.7) 5 (6.6) 7 (10.1)
15 (60.0) 4 (26.7) 0 (0.0) 0 (0.0) 1 (25.0) 2 (50.0) 0 (0.0) 1 (25.0) 0 (0.0) 0 (0.0) 11 (73.3) 10 (40.0) 8 (80.0) 0 (0.0) 0 (0.0) 2 (25.0) 0 (0.0) 5 (62.5) 1 (12.5) 2 (20.0) 0 (0.0) 25 (3.3)
2 (100) 1 (50.0) 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.3)
Outdoor vs indoor: flames vs contacts: OR = 7387; 95%CI: 3,835 14,228; p < 0.001. Outdoor vs indoor: flames vs scalds: OR = 11,443; 95%CI: 52,437 249,718; p < 0.001.
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The initial assessment of TBSA by the first line physician (outside the Children’s Hospital) was often overestimated (Table 6).
3.8.
Hospitalization
The majority of children presented their burn injury to a physician within 24 h of the accident (n = 734; 98%). Children, who presented their burns later than 24 h after their accident, had a median affected TBSA of 1% (1 7%). Most children were admitted to our unit on the day of accident (Table 5). Half of these patients (n = 309; 50.5%) were referred directly to the Children’s Hospital, 262 patients (42.8%) by other hospitals, 52 patients (8.5%) by a general practitioner and in 9 children (1.5%) the authority for first line therapy is unknown. Table 4 shows that mean TBSA in patients who were initially admitted to a hospital was significantly higher than in
Fig. 3 – Time variation and cause of burn.
Table 5 – Distribution of age and TBSA.
Age Sex Male Female Place of injury Indoor Outdoor Unknown TBSA Sex Male Female Place of injury Indoor Outdoor Unknown Burn etiologya Flames Scalds Contacts Electrics High-voltageb Low-voltageb Admission Initially inpatient Initially outpatient Admitted to our unit on day of accident Initially admitted to other hospitals Intensive care Yes No Skin grafts Yes No Unknown a b
n (%)
Median
Range
749 (100) 479 (64) 270 (36)
2 year 2 month 2,4 year 2 year
3 day 15 years 10 months 3 day 15 years 10 months 10 days 15 years 10 months
545 (72.8) 135 (18) 69 (9.2)
1 year 8 months 10 years 10 months
3 day 15 years 10 months 9 month 15 years 9 month
749 (100) 479 (64) 270 (36)
5% 5% 5%
1 90% 1 90% 1 80%
545 (72.8) 135 (18) 69 (9.2)
5,0 6,5
1 80% 1 90%
164 (21.9) 482 (64.4) 76 (10.1) 25 (3.3) 7 (28) 18 (72)
7,5% 6% 1% 1% 405% <1%
1 90% 1 70% 1 41% 1 70% 3 70% <1 1%
658 (87.9) 91 (12.1) 612 (93) 46 (7)
6% 2% 6% 9%
1 1 1 1
67 (8.9) 682 (91.1)
17% 5%
1 90% 1 41%
259 (34.6) 485 (64.8) 5 (0.6)
8% 5%
1 90% 1 55%
p-Value 0.014
<0.001
0.61
0.02
a
<0.001b
<0.001 90% 12% 90% 55%
<0.001 <0.001
<0.001
Burn etiology: flame vs scalds; flames vs contacts; flames vs electrics; scalds vs contacts; scalds vs electrics p < 0.001; contacts vs electrics p = 0.578. Electrics: high-voltage vs low voltage p < 0.001.
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Table 6 – Initial assessment of total body surface area (TBSA).
Overestimation <5% TBSA 5 9.9% TBSA 10 19.9% TBSA 20 25% TBSA Correct estimation Underestimation <5% TBSA 5 10% TBSA Total
Number
Percentage (%)
147 61 45 34 7 30 15 10 5 192
76.6 41.5 30.6 23.1 4.8 15.6 7.8 66.7 33.3 100
patients who were initially treated as an outpatient. Furthermore, the mean TBSA was significant higher in patients who were initially treated in other hospitals. A total of 297 patients (39.7%) were self-referred to the Children’s Hospital, 251 children (33.5%) were admitted by ambulance, 107 patients (14.3%) by rescue helicopter and for 94 children (12.5%), the mode of transport to the Hospital was unknown. Sixty-seven patients (8.9%) underwent treatment in the intensive care unit. The median TBSA of these patients was significantly higher than in patients who did not undergo treatment in the intensive care unit (Table 5).
3.9.
Skin grafting
One third of all patients underwent skin grafting (Table 5). In 4 of these patients (1.6%) a conservative therapy was initially attempted, unsuccessfully, undergoing hospitalization for skin grafting. Of the 259 patients with skin grafts, 250 patients (96.5%) underwent split-thickness skin transplantation and 9 patients (3.5%) underwent full-thickness skin grafting. Six of these patients (66.7%) sustained contact injuries and 3 of these patients (33.3%) sustained low-voltage burns (<1000 V). In all 9 patients (100%) who underwent full-thickness skin grafting, the affected TBSA was 1% or less. Of the total 7 patients who sustained high-voltage injuries (1000 V), 3 patients (42.9%) underwent skin grafting, 3 patients (42.9%) underwent lowerleg amputation and one patient was transferred abroad before surgical intervention. Only one patient with a low-voltage injury underwent an amputation (distal phalanx of the thumb). One hundred and five patients (42% of the patients who underwent split-thickness skin grafting) had injuries with coverage on multiple areas of the body. Before split-thickness skin transplantation, cadaveric donor skin was applied to the wound in 54 patients (21.6%). In the majority of the cases, skin was taken from either the scalp (n = 230; 96.2%) or leg (n = 32; 13.4). Patients who underwent skin grafting had a significant higher mean TBSA than patients who did not undergo skin grafting (Table 5). The rate for skin grafting was highest in flame injuries, followed by contact and scald injuries (Fig. 4).
3.10.
Length of hospital stay (LOS)
Thirteen patients were excluded from LOS. Five of these patients were transferred to other hospitals before recovery.
Fig. 4 – Etiology and need of skin grafting.
Four patients received skin grafts following rehospitalisation. Three patients died in the hospital and one patient received skin grafts in another hospital before being transfer to the University Children’s Hospital of Zurich. The median LOS was 8 days (range: 1 259 days; IQR: 17) and did not vary during the study period, in either patients who received skin grafts or those that received conservative therapies (Table 7). LOS increased with increasing TBSA. Furthermore, victims of flame injuries and patients who underwent skin grafting with longer hospital stays. During the 11-year study period, 12 patients were hospitalized in our unit for longer than 3 months.
4.
Discussion
In this study, we described patient ethnicity and supervision, location, TOD and season of burn injuries. Additionally we assessed the quality of the first aid treatment, the initial assessment of TBSA, rate of skin grafting and LOS. Based on these facts, targets for the improvement of a prevention campaign and the treatment for burned children were named.
4.1.
Patient ethnicity
More than one third of all patients in our sample had an immigrant background, but permanent residence in Switzerland. This is surprising as the percentage of immigrants in Switzerland during the whole study period varied between 18 21% [14]. Thus, Swiss children were significantly less affected by burns than children with other nationalities. Our findings are in agreement with those of Johann [15] who demonstrated that scalds and burn injuries in infants and toddlers with an immigrant background are six-fold higher than those of the same age of German nationality. In our study 6.7% of foreign children came from Sri Lanka, an ethnic group comprising 0.8 2.1% [16] of the Swiss population during the 11-year study period, showing that children from Sri Lanka were significantly overrepresented in this study (p < 0.001).
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Table 7 – Length of hospital stay. n (%)
Mean (day)
Median (day)
Range (day)
IQR
Sex Male Female Total
470 (63.9) 266 (36.1) 736 (100)
16 13 15
9 8 8
1 249 1 259 1 259
18 15 17
Agegroup <1 year 1 4 year 5 9 year 10 14 year >14 year Total
74 (10.1) 437 (59.4) 106 (14.4) 102 (13.9) 17 (2.3) 736 (100)
12 12 25 21 27 15
7 7 11 17 10 8
1 1 1 1 1 1
10 13 27 23 23 17
TBSA <10% 10 19% 20 29% 30 39% 40 49% 50 100% Total
555 (75.7) 133 (18.1) 23 (3.1) 7 (1.0) 5 (0.7) 10 (1.4) 733 (100)
9 25 32 64 73 45
6 21 30 76 85 118
1 78 2 203 11 57 32 88 24 113 67 259
10 21 12 46 65 163
Burn etiologya Scalds Flames Contacts Electricalb High-voltage Low-voltage Chemical injuries Total
478 (64.9) 159 (21.6) 74 (10.1) 23 (3.1) 5 (21.7) 18 (78.3) 2 (0.3) 736 (100)
11 29 8 19 73 4 5 15
7 21 5 1 54 1 5 8
1 130 1 259 1 31 1 142 23 142 1 36 2 8 1 259
12 30 11 22 90 0 N/A 17
Skin graftsc Yes No Total
245 (33.3) 491 (66.7) 736 (100)
33 6 15
25 5 8
3 259 1 54 1 259
17 7 17
a b c
113 259 238 104 249 259
Flames vs. scalds and contacts p < 0.001 scalds vs. contacts p = 0.03. High voltage injuries vs. low voltage injuries p < 0.001. Skin grafting vs. conservative therapy p < 0.001.
Therefore a prevention campaign directed directly to this ethnic group might reduce incidence of injury. During the study period, 5.6% of all patients had permanent residence abroad. Most of these children lived in Germany at the time of accident. This is due to an agreement between the Children’s Hospital and Germany that the Burn Unit of the Children’s Hospital provides treatment for severe burns from the southern part of Germany if local hospitals do not have the capacity for treatment. The second most common patient group with residence abroad was from the United Arab Emirates. This is due to a special collaboration of our unit with hospitals in that region.
4.2.
Location of accident
In agreement with prior studies we found that three out of four accidents occurred indoors [10,17 19]. Many studies specify that the kitchen is the most dangerous room in the house [6,10,17,20]. In the current study approximately half of all indoor accidents occurred in the kitchen, a result which is
comparable with a study from France [21]. In contrast, studies from Czech Republic (70%) [17], Ireland (70%) [20] and Australia (65%) [6] showed much higher percentages of kitchen accidents. Scald and contact injuries occurring in the kitchen have been associated with drink and food preparation or food consumption. This finding has been corroborated in several studies [5,11,18,20]. Most of these accidents could be prevented if parents were better educated and more aware of potentially dangerous situations when preparing and consuming food and drinks. Shah et al. [12] and Bradshaw et al. [22] recommend defining the kitchen as a “no zone area for children” to minimize injuries. This recommendation is also supported by a Danish study [23] that found 27% of all indoor accidents occurred in the kitchen. This result is lower than the incidence reported in other studies [1,6,17,20,21]. The authors explain the lower incidence of kitchen accidents as being due to the fact that small children are generally outside the kitchen during cooking, resulting in a higher occurrence of injuries in the living/dining room. In our consideration, banishing children
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from the kitchen is only effective if the safety of the child outside the kitchen can be guaranteed. Consequently, infant and toddlers should be in a playpen or supervised by another responsible person so that the child is not exposed to other dangers outside the kitchen. It is alarming that more than 3% of all children in our study were sitting on somebody’s lap or were seated in a child safety seat when the accident occurred. The authors of a Finish study [3] describe children on someone’s lap were commonly scalded by pulling coffee cups or pots over themselves. Quite often these children were sitting on their parent’s lap. This finding underlines the need to educate parents that perceived safe areas also carry a risk of burns if dangerous objects are within reach of the child.
4.3.
Time and monthly variations
According to the literature, the time between 4 p.m. and 7 p.m. is the most dangerous time in relation to burn accidents [6,13,22,24] and is associated with meal preparation and consumption and children’s bath-times. In our current study the period between 6 p.m. and 9 p.m. was identified as the most hazardous time of day and is consistent with findings of another Swiss study [18]. While there is no explanation for this discrepancy in the time of injury between Swiss and international studies, we suggest that the difference in timing of these activities across cultures. In other words, the same incidents occur, but later in the day in Switzerland. But it has to be taken into account that this two-hour time-delay in accident occurrence in the Swiss studies is also directly linked with meal preparation and consumption and children’s bathtimes. Similar to a Danish study [23] we observed a second peak in scald injuries between 10 a.m. and 1 p.m., coinciding with lunch preparation and a smaller third peak between 7 a. m. and 8 a.m., coinciding with breakfast preparation and consumption. This third peak was not observed in the Danish study. During the study period scald injuries occurred predominantly in wintertime. This can be linked to higher consumption of hot drinks and the inhalation therapy with hot liquid in this cold season. In contrast, contact injuries and flame injuries occurred more frequently in summertime, coinciding with open air barbecues. As expected, more than half of all accidents caused by fireworks occurred in August, specifically on 1st August (62.5%) or 2nd August (37.5%). This is explained by the Swiss national holiday on first of August. Traditionally, many residents light fireworks on these days. These fireworks are readily accessible and may be legally purchased.
4.4.
Supervision
Eighty-two percent of all children were supervised by at least one parent, when the accident occurred. But it should be considered that at the time of accident the child was not necessarily under the direct supervision of one or both parents. A Dutch study confirms this result [5]. The authors of the Dutch study mentioned further that in cases where somebody was present, 41% said their attention had been distracted for a moment. The most common reason for leaving the child alone was another child demanding attention, the
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telephone or door bell, or the child went, unnoticed, into another room. In 3.4% of all accidents the child was under professional care (e.g. school or kindergarten). This result moderately exceeds the observation of another Swiss study at CHUV [18] in which 2% of burned children were under professional care at the time of accident.
4.5.
First aid
Early cooling of burns prevents a significant number of superficial burns from progressing to deep burns [25]. Studies from Ireland [20], Australia [6] and Denmark [23] demonstrate that cold water was applied in 87 90% of cases immediately after the accident. In contrast, we found less frequent use of cold water in our sample (n = 439; 61.8%) and where applied, for a shorter duration (<10 min). While interpreting this result it should be considered that information on length of cooling was obtained from parents in the emergency room shortly after the accident. It is conceivable that the length of cooling for some patients was shorter than recorded, because in emergency situations, most parents tend to overestimate, rather than underestimate the length of cooling [26]. In Switzerland it is obligatory to attend a first aid teaching lesson to receive a driving license. In these lessons the importance of cooling after burn injuries has to be addressed in a more explicit and understandable way to be more effective. In 3% of all cases, first aid did not comply with current standards (e.g., in 2.3% of cases tooth paste was applied to the wounds). Our result is similar to a previous British study [7] where it was observed that in 4% of all cases tooth paste application was involved in first aid treatment. All these patients came from Asia. In the current study, it was also seen that no patients with German as a native language applied toothpaste to the injury. It can thus be concluded that correct first aid teaching should be specified to people from different cultural backgrounds. This is supported by an Indian study [9], where wrongly ink or honey was applied to wounds.
4.6.
Initial assessment of TBSA
In our study the affected TBSA was overestimated in the majority of cases (77%) during initial medical assessment. This result is in line with a study from the United Kingdom [27]. The authors of that study note that estimation of burn size in pediatric burns is challenging and therefore the benefits of early transfer to a specialist service center cannot be overemphasized. Furthermore the authors highlighted that training and education is essential for clinicians in emergency departments.
4.7.
Hospitalization
The majority of all children with burns presented to a physician within 24 h of the accident. Prior to admission, more than half of all patients were treated outside the Children’s Hospital of Zurich. This is because the Swiss health care system promotes the idea that patients should first go to a primary care center facility close to where they are living. Only those patients with severe injuries are transferred to a tertiary
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hospital such as the Children’s Hospital of Zurich. The results of the current study show that patients who were transferred from another hospital had a significant higher mean TBSA than patients who were admitted initially to the Children’s Hospital of Zurich. This result indicates that regional hospitals in Switzerland fulfill their mandatory service.
4.8.
Skin grafting
We found that patients undergoing skin grafting had a significantly higher mean TBSA than those not undergoing grafting and this finding is consistent with prior studies [1,28]. Although high-voltage injuries (1000 V) are rare [8], they benefit from special attention and may result in serious injuries with many complications [29,30]. In the current study, patients with a high-voltage injury had higher affected TBSAs, higher incidences of grafts and longer hospital stays than patients with low-voltage injuries (<1000 V). This finding is similar to other studies [29,31 34]. The amputation rate for high-voltage injuries of 43% in our study is comparable with previous reports of 11 49.4% [35].
4.9.
Length of hospital stay (LOS)
The overall median LOS was 8 days (1 259 days) and is shorter than in comparable studies from Canada [19] (16 days; 1 267 days), Czech Republic [24] (158 days; 2 165 days) und Egypt [13] (20 days; 1 70 days). One Canadian study had a comparable LOS range to our study. In an Austrian study the LOS in acute burn patients was reduced by 71% over the 25-year study period [10]. In our study no time-related change was observed. Typically, scalds and contact burns caused smaller injuries, whereas fire and high-voltage electricity injuries affected extensive parts of the body [8]. Due to the fact that the LOS increased correspondingly with higher TBSA burned, flame injuries and high-voltage injuries led in longer hospital stays than scalds and contact injuries. These findings are in line with other studies [1,10,17,36]. Furthermore a Czech study [17] showed that boys had to stay longer in hospital than girls. In our sample we found no gender-difference in the length of hospital stay. Additionally, patients with flame injuries underwent skin grafting more often than other patients. Consequently, those showed to longest hospitals stays.
5.
Conclusion
First, to reduce the incident of burn injuries in children and secondary to improve the treatment of burned children, the following points should be considered: Prevention campaign in different languages: Children from immigrant backgrounds are overrepresented in our study population. Infants and toddlers from Sri Lanka are at particularly high risk. A prevention campaign directed at this ethnic group may reduce incidence of injuries. A prevention campaign on flame injuries appears to be appropriate especially in summer month, in contrast a campaign on scalds in winter month.
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Awareness of potential dangerous situations, such as sitting on somebody’s lap when they are drinking hot beverages and child safety seats and playpens are only as secure as the surrounding environment. Directly in the selling of fireworks it is important to draw the buyer’s attention to possible danger, because the vast majority of accidents with fireworks occurred shortly after the purchase. First aid: A teaching campaign about first aid measures focusing on immediate and optimal cooling time for burns should be announced to the general population. Due to the fact that only parents with foreign native-languages (especially Albanian) applied toothpaste to wounds, such a campaign should be run preferably in different languages. First line physicians should bear in mind that the initial medical assessment of the affected surface is mostly overestimated. Due to the frequent skin transplantations in children with flame injuries and the high amputation rate after high voltage accidents, these accident scenarios have an increased impact on the functional and cosmetic result. These facts should also be mentioned prevention campaigns.
Conflict of interest All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence their work. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. REFERENCES
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