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The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997–2009
burns 38 (2012) 776–782
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997–2009 B. Lipovy´ a,b,*, P. Brychta a,b, N. Gregorova´ a, Z. Jelı´nkova´ a,b, H. Rˇihova´ a, I. Sucha´nek a, Y. Kaloudova´ a, R. Mager a, H. Krupicova´ a, A. Martincova´ a a b
Department of Burns and Reconstructive Surgery, Faculty Hospital Brno, Czech Republic Faculty of Medicine, Masaryk University Brno, Czech Republic
article info
abstract
Article history:
The aim of this study was to determine the basic epidemiological characteristics of severely
Accepted 22 December 2011
burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997–2009.
Keywords:
Methods: We collected and evaluated epidemiological data such as age, sex, burn etiology,
Pediatric burn
length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic
Intensive care
strategies, the use of mechanical ventilation and its duration, day and month of injury and
Epidemiology
the extent of burned area. Results: In total 383 children (253 boys, 130 girls) aged 0–14 years, underwent intensive care for at least 48 h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43 12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03 5.67 days in average. The average length of stay in ICU was 10.71 10.92 days and total length of hospital stay was an average of 21.55 14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). Conclusion: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
The second half of the 20th century saw significant improvement in the care of severely burned pediatric patients resulting in the dramatic increase in the chance of survival from severe thermal trauma [1]. In 1949 there was 50% mortality in children
aged 0–14 years with 49% TBSA burns [2]. At the end of the 1990s, we find in the same age category 50% mortality in patients with 98% TBSA burns [3]. The reduction of mortality in burned children during this period was influenced by the application of the new formula for fluid resuscitation, improvement of mechanical ventilation, early surgical necrectomy and skin grafting, microbiological control and better nutritional support
* Corresponding author at: Department of Burns and Reconstructive Surgery, Faculty Hospital Brno, Czech Republic. Tel.: +420 532233004. E-mail address: [email protected] (B. Lipovy´). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.021
burns 38 (2012) 776–782
[4–6]. But the most important factor in decreasing mortality of severely burned patients was the establishment of specialized centers and centralization of burn care. Severe burn trauma places huge demands on the patient and his surroundings and creates a lifelong stigma both physically and mentally. Despite a number of more or less successful preventive programs, pediatric burns are still a very common type of injury. Exploratory behavior of children in the age group 1–3 years leads to the fact that patients in this age group have the highest risk for burns. Burn trauma is, after traffic accidents and drowning, the third most common cause of childhood death. Burn trauma requires the longest hospital stay for all admissions due to injuries [7]. Separate epidemiology of pediatric burns requiring intensive care has, to this point, not been extensively published in the Czech Republic. The aim of our study is to establish basic epidemiological characteristics of children requiring intensive care for burn trauma. The definition of severe burn trauma is very in childhood is very complex. While simply respecting the extent of burnt areas in children under 2 years is severe burn trauma defined as the extent of burns over 5%TBSA, in children under 10 years over 10% TBSA and in children under 15 years over 15%TBSA. This definition does not respect the presence of inhalation injury and possibly the for artificial lung ventilation. These patients require intensive care as well. Burn care in the Czech Republic is concentrated in three centers; Prague, Brno and Ostrava. These centers provided comprehensive care for all stages of thermal trauma in both pediatric and adult patients. Burn care in the Czech Republic has a long tradition, going back to 1952 with the founding of the first burn center in Prague. The Department of Burns and Reconstructive Surgery Teaching Hospital Brno is the youngest burn center and was established in 1979. This department consists of an intensive care unit with 5 critical care beds for children and adults; the standard children’s department has 9 beds and 16 standard beds for adults.
2.
Materials and methods
This is a 13 years retrospective monocentric study. The study includes all children hospitalized for burns in pediatric burn
777
intensive care unit from the period January 1, 1997 to December 31, 2009. Patients were age 0–14 years. We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the need for mechanical ventilation and its duration, day and month of injury and the extent of burned area. The extent of burned area was evaluated by Lund–Browder charts [8]. The main reasons for hospitalization in the intensive care unit were the extent and depth of the burned area, burn location, or presence of inhalation injury with the need of mechanical ventilation. On December 31, 2009 The Czech Republic had 10,506,813 citizens. Of these, 1,258,900 were children aged 0–14 years. On this date, the number of children aged 0–14 years in the tributary area of the Clinic of Burns and Reconstructive Surgery Teaching Hospital in Brno was 266,748.
3.
Results
From January 1, 1997 through December 31, 2009 a total of 1245 burn patients were admitted to the ICU Department of Burns and Reconstructive Surgery Faculty Hospital Brno. The number of pediatric patients was 383 (30.76%). The total number of admitted children and patients requiring intensive care for each year of the study is shown in Fig. 1. The 383 ICU pediatric patients consisted of 253 boys (66.06%) and 130 girls (33.94%). The male to female ratio for patients hospitalized in the children’s ICU was 1.95:1. Most of the children suffered burns indoors, with only 55 children being burned outdoors. Indoor/outdoor ratio was 5.96:1. We admitted 322 children under 6 years requiring intensive care. The number of ICU pediatric patients in the study and the gender ratio in different age groups is shown in Table 1. The average extent of burns in the group was 16.43 12.86% TBSA. The average extent of burned area for each year of the period is shown in Fig. 2. The most typical extent of burns in children hospitalized for burn trauma in the intensive care unit of our clinic was between 10 and 19% TBSA. 177 children in our study fit into this category (46.21%). During the reporting period 16 children were hospitalized with burns
Fig. 1 – Ratio of total/pediatric patient admitted to the ICU in years 1997–2009.
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burns 38 (2012) 776–782
Table 1 – The number and the gender ratio of ICU pediatric patients in different age groups.
Total Male Female M:F ratio
0–6 year
7–14 year
0–14 year
322 200 122 1.64:1
61 53 8 6.63:1
383 253 130 1.95:1
over 50% TBSA. Distribution of patients by extent of burned area is shown in Fig. 3. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in the group was 312 (81.46%). A total of 11 children under 14 years suffered high-voltage electrical injury. All children with electrical injury were in the age group of 7–14 years (see Fig. 4). The most typical burn location for children in the study was the trunk, followed by burns on the head and neck (Table 2). The most frequent time for child burn was between 8– 10 a.m. and 4–8 p.m. Fig. 5 shows the relationship between the time of day and the incident of child burn. Figs. 6 and 7 show the numbers of patients spread over the months of the year and days of the week.
Table 2 – Anatomical site of injury (%). Frequency (n)
Percentage (%)
165 234 123 69 42
43 61 32 18 11
Head and neck Trunk Upperextremities Lowerextremities Buttock and genitalia
The number of patients requiring mechanical ventilation is a very important epidemiological parameter especially in severely burned pediatric patients. Of all the patients in the study, 96 children underwent mechanical ventilation (25.07%). The average duration of mechanical ventilation in these patients was 8.03 5.67 days, as shown in Fig. 8. The average time spent in the intensive care unit was 10.71 10.92 days and mean total length of hospital stay was 21.55 14.55 days. Proportional representation of the number of days in ICU and total hospitalization time is shown in Fig. 9. The duration of intensive care treatment in relation to the percentage of TBSA in the period was 0.65 days per 1%TBSA. The total length of hospital stay per 1% of burned surface was fixed at 1.31 days per 1% TBSA. During the reporting period 3 children died (0.78%)
Fig. 2 – The average extent of burned area for each year of the study.
Fig. 3 – Distribution of patients by extent of burned area.
burns 38 (2012) 776–782
Fig. 4 – Etiological agents in pediatric patients admitted in our ICU 1997–2009.
Total of 184 patients (48.04%) underwent surgical therapy due to the depth of the burns. The most common procedure was excision and subsequent skin grafting. Conservative treatment was sufficient for 199 (51.96%) patients. General anesthesia was administered to each patient in the group an average of 6.23 5.99 times.
4.
Discussion
The number of children under 14 years in 1997 in the Czech Republic was 1,795,000, but in 2009 it was only 1,258,900. A similar situation (decrease number of children) was also found in the tributary area of the burn center in Brno. In spite of this
779
period of absolute decrease in the number of children, they still represent an important and specific group of patients in intensive care. The total number of admitted children for thermal trauma during this period increased mainly due to the centralization of care. The situation is different for patients requiring intensive care, where the number of admitted children decreasing, in contrast to the number of children admitted for minor burns [9]. The most common age group for hospitalization for thermal trauma were children ages 1–3 years, with the dominant etiology of burns in this age being scalding. Total number of scalded pediatric patients in our sample was 312 (81.46%). Akita et al. also identified scalding as the most frequent cause of burns in children – 68% of patients [10]. Similar results were achieved by Sharma et al. [11] and Torabian et al. [12] who accounted scalding for 67% and 71.7% respectively of all causes of burns in pediatric patients. Chen et al. in their retrospective study, which was performed on 735 pediatric burns, also adverted to the high number of scalded children. In their study group it was 92% of pediatric burns [13]. High-voltage electrical injury was detected as the mechanism of burn in 11 children of our group; all were 7–14 year old boys. None of the boys with high-voltage injuries died. Overall male to female ratio in our study was set at 1.95:1. A similar gender ratio was also reached in the study by Morrow et al. [14]. In almost all epidemiologic studies of gender ratio, boys predominate about 2:1. Maghsoudi et al. [15] found in their study a male to female ratio of 1.6:1. On the contrary, Jia et al. established gender ratio 4.42:1, but their study group was small [16]. The average extent of burns in our sample ranged from 10 to 19% TBSA. We treated in total 177 children (46.21%), who suffered this extent of burns. Papp et al. [17] also recorded this extent as the most common pediatric patients requiring intensive care. The most frequent anatomical burn sites in our study were the chest (61%) and head (43%). This location corresponds to the most frequent cause of injury – scalding. Upper and lower limbs are frequently affected in the event of flame burns or electrical injury in
Fig. 5 – Distribution of pediatric burns by the time of day.
780
burns 38 (2012) 776–782
Fig. 6 – Distribution of pediatric burns by the month.
older children. Children in our study underwent mechanical ventilation mostly due to location of burns, not because of inhalation injury, but because of the risk of development of edema in the case of head and neck burns. This situation can lead to suffocation with the development of acute respiratory insufficiency. From the perspective of the time of the year for burn trauma, we observed a slight dominance in autumn burns (27.15%), with the least number of pediatric burns occurring in the summer (24.02%). Opposite results were reached in the study by Tarim et al. [18] They described the most common time for burns to be summer with autumn as the least frequent (42% and 16% respectively). Carroll et al. [19] reported that burns occur most frequently in the summertime, whereas Chien et al. [20] and Dedovic et al. [21] found that spring is the most common season. We identified the two most dangerous time periods for pediatric burns as 8:00–9:59 a.m. (17.76%) and 4:00–5:59 p.m. (22.45%). Most epidemiological studies report the highest risk time between 4:00 p.m. and 8:00 p.m. As in our findings, the
Lin et al. [22] study of 157 pediatric patients highlighted two dominant time periods with the first between 11:00 a.m. and 1:00 p.m. (19.7% of burned children), and the second between 5:00 p.m. and 8:00 p.m. (35.0%). The average hospital stay for patients in the study was 21.55 days and an ICU average of 10.71 days. When adjusted for the percentage of burned surface the total length of hospital stay was 1.31 days per 1% TBSA and a length of ICU stay 0.65 days per 1%TBSA. Papp et al. [17] in his study consisting of 45 pediatric burn patients of 0–16 years hospitalized in two burn centers in Finland, reported the average length of stay related to the percentage of burned area at 0.88 days and length of stay in ICU at 0.29 days. In total 3 patients from our study died. Sepsis was identified as the cause of death in all of those patients. Mortality ratio is 0.78%, which is lower in comparison with the work of Sharma et al. [11] where the mortality ratio was reported 1.3%. Xin et al. [23] in their work counted 1.1% mortality in the group of 1494 burned children; sepsis was represented as the major cause of mortality in 82.4%. But in Light’s [24] or Shou’s [25] work, the
Fig. 7 – Distribution of pediatric burns by the day of the week.
burns 38 (2012) 776–782
781
Fig. 8 – Distribution of average duration of mechanical ventilation each year of the study.
Fig. 9 – Average duration of ICU stay/total hospital stay.
mortality ranges around 10% (10.1% respectively 9.08%). Both of these analyzes are from developing countries.
5.
Conclusion
In our report we identify the basic epidemiological characteristics of burned children requiring intensive care. The results of this epidemiological study show the need for future preventive actions focusing on the domestic environment to prevent scalding, which dominates actually all epidemiological indicators. This requires greater involvement of both parents and children, but also general practitioners. Intensive care for pediatric burn patients requires a specific approach and still represents a major challenge for medical staff.
Conflict of interest statement I declare that the article is not part of any conflict of interest.
references
[1] Herndon DN. Total burn care, 3rd ed., Philadelphia: Saunders Elsevier; 2007. p. 485. [2] Bull JP, Fisher AJ. A study in mortality in a burn unit: standards for the evaluation for alternative methods of treatment. Ann Surg 1949;130:160–73. [3] Herndon DN, Gore DC, Cole M, Desai MH, Linares H, Abston S, et al. Determinants of mortality in pediatric patients with greater then 70% full thickness total body surface area treated by early excision and rafting. J Trauma 1987;27: 208–12. [4] Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil 1995;16(3 Pt 1):219–32. [5] Sheridan R. Specific therapies for inhalation injury. Crit Care Med 2002;30:718–9. [6] Sheridan RL, Weber JM, Schnitzer JJ, Schulz JT, Ryan CM, Tompkins RG. Young age is not a predictor of mortality in burns. Pediatr Crit Care Med 2001;2:223–4.
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[7] National Center for Health Statistics. Hospitalizations for injury, United States 1996, vol. 318. Centers for Disease Control and Prevention; 1996. p. 1–10. [8] Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944;79:352–8. [9] Lipovy B, Suchanek I, Rihova H, Kaloudova Y, Mager R, Krupicova H. Epidemiology of Children’s Burn Trauma in South Moravia: a comparative study after 15 years. Cˇes-slov Pediat 2010;65(1):3–9. [10] Akita S, Nakagawa H, Tanaka K, Hirano A. Analysis of pediatric burns in Nagasaki University from 1983 to 2002. Burns 2005;31(December (8)):1041–4. [11] Sharma PN, Bang RL, Al-Fadhli AN, Sharma P, Bang S, Ghoneim IE. Pediatric burns in Kuwait: incidence, causes and mortality. Burns 2006;32(February (1)):104–11. [12] Torabian S, Saba MS. Epidemiology of pediatric burn injuries in Hamadan, Iran. Burns 2009;35(December (8)):1147–51. [13] Chen WD, Yin SL. Etiology of 735 pediatric burns. Guangzhou Yi Yao 2002;33(2):44–6 [in Chinese]. [14] Morrow SE, Smith DL, Cairns BA, Howell PD, Nakayama DK, Peterson HD. Etiology and outcome of pediatric burns. J Pediatr Surg 1996;31(March (3)):329–33. [15] Maghsoudi H, Samnia N. Etiology and outcome of pediatric burns in Tabriz, Iran. Burns 2005;31(September (6)):721–5. [16] Jia XC, Zhang JM, Ma W. Clinical analysis on 385 pediatric burns and preventative strategy. Yi Xue Lin Chuang Yan Jiu 2002;19(1):58 [in Chinese].
[17] Papp A, Rytko¨nen T, Koljonen V, Vuola J. Paediatric ICU burns in Finland 1994–2004. Burns 2008;34(May (3)): 339–44. [18] Tarim A, Nursal TZ, Yildirim S, Noyan T, Moray G, Haberal M. Epidemiology of pediatric burn injuries in southern Turkey. J Burn Care Rehabil 2005;26(July–August (4)):327–30. [19] Carroll SM, Gough M, Eadie PA, McHugh M, Edwards G, Lawlor D. A 3-year epidemiological review of burn unit admissions in Dublin, Ireland (1988–1991). Burns 1995;21(5):379–82. [20] Chien WC, Pai L, Lin CC, Chen HC. Epidemiology of hospitalized burns patients in Taiwan. Burns 2003;29(6):582–8. [21] Dedovic Z, Brychta P, Koupilova I, Suchanek I. Epidemiology of childhood burns at the Burn Center in Brno, Czech Republic. Burns 1996;22(2):125–9. [22] Lin TM, Wang KH, Lai CS, Lin SD. Epidemiology of pediatric burn in southern Taiwan. Burns 2005;31(March (2)):182–7. [23] Xin W, Yin Z, Qin Z, Jian L, Tanuseputro P, Gomez M, et al. Characteristics of 1494 pediatric burn patients in Shanghai. Burns 2006;32(August (5)):613–8. [24] Light TD, Latenser BA, Heinle JA, Stolpen MS, Quinn KA, Ravindran V, et al. Demographics of pediatric burns in Vellore, India. J Burn Care Res 2009;30(January–February (1)):50–4. [25] Shou JB. Clinical analysis on 628 pediatric burns and preventative strategy. Guangxi Yi Xue 2005;27(4):587–8 [in Chinese].
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
The epidemiology of pediatric burns undergoing intensive care in Burn Centre Brno, Czech Republic, 1997–2009 B. Lipovy´ a,b,*, P. Brychta a,b, N. Gregorova´ a, Z. Jelı´nkova´ a,b, H. Rˇihova´ a, I. Sucha´nek a, Y. Kaloudova´ a, R. Mager a, H. Krupicova´ a, A. Martincova´ a a b
Department of Burns and Reconstructive Surgery, Faculty Hospital Brno, Czech Republic Faculty of Medicine, Masaryk University Brno, Czech Republic
article info
abstract
Article history:
The aim of this study was to determine the basic epidemiological characteristics of severely
Accepted 22 December 2011
burned children who were admitted to the intensive care unit (ICU), Department of Burns and Reconstructive Surgery Faculty Hospital Brno, Czech Republic in the years 1997–2009.
Keywords:
Methods: We collected and evaluated epidemiological data such as age, sex, burn etiology,
Pediatric burn
length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic
Intensive care
strategies, the use of mechanical ventilation and its duration, day and month of injury and
Epidemiology
the extent of burned area. Results: In total 383 children (253 boys, 130 girls) aged 0–14 years, underwent intensive care for at least 48 h. Male to female ratio was 1.95:1. The average range of burn area in the group was 16.43 12.86% TBSA (total body surface area). During the reporting period, 16 children were admitted with burns over 50% TBSA. 328 children suffered burns indoors, with 55 children being burned outdoors. Indoor/outdoor ratio was set at 5.96:1. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in this group was 312 (81.46%). Mechanical ventilation was used in 96 cases (25.07% of all the admitted patients). The duration of mechanical ventilation in these patients was 8.03 5.67 days in average. The average length of stay in ICU was 10.71 10.92 days and total length of hospital stay was an average of 21.55 14.55 days. A total of 184 patients (48.04%) were treated surgically and therefore required necrectomy and skin grafting. The other 199 (51.96%) patients were treated conservatively. During the reporting period 3 children died (0.78%). Conclusion: In our report we identify basic epidemiological data defined in the aim of this study for burned children requiring intensive care. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
The second half of the 20th century saw significant improvement in the care of severely burned pediatric patients resulting in the dramatic increase in the chance of survival from severe thermal trauma [1]. In 1949 there was 50% mortality in children
aged 0–14 years with 49% TBSA burns [2]. At the end of the 1990s, we find in the same age category 50% mortality in patients with 98% TBSA burns [3]. The reduction of mortality in burned children during this period was influenced by the application of the new formula for fluid resuscitation, improvement of mechanical ventilation, early surgical necrectomy and skin grafting, microbiological control and better nutritional support
* Corresponding author at: Department of Burns and Reconstructive Surgery, Faculty Hospital Brno, Czech Republic. Tel.: +420 532233004. E-mail address: [email protected] (B. Lipovy´). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.021
burns 38 (2012) 776–782
[4–6]. But the most important factor in decreasing mortality of severely burned patients was the establishment of specialized centers and centralization of burn care. Severe burn trauma places huge demands on the patient and his surroundings and creates a lifelong stigma both physically and mentally. Despite a number of more or less successful preventive programs, pediatric burns are still a very common type of injury. Exploratory behavior of children in the age group 1–3 years leads to the fact that patients in this age group have the highest risk for burns. Burn trauma is, after traffic accidents and drowning, the third most common cause of childhood death. Burn trauma requires the longest hospital stay for all admissions due to injuries [7]. Separate epidemiology of pediatric burns requiring intensive care has, to this point, not been extensively published in the Czech Republic. The aim of our study is to establish basic epidemiological characteristics of children requiring intensive care for burn trauma. The definition of severe burn trauma is very in childhood is very complex. While simply respecting the extent of burnt areas in children under 2 years is severe burn trauma defined as the extent of burns over 5%TBSA, in children under 10 years over 10% TBSA and in children under 15 years over 15%TBSA. This definition does not respect the presence of inhalation injury and possibly the for artificial lung ventilation. These patients require intensive care as well. Burn care in the Czech Republic is concentrated in three centers; Prague, Brno and Ostrava. These centers provided comprehensive care for all stages of thermal trauma in both pediatric and adult patients. Burn care in the Czech Republic has a long tradition, going back to 1952 with the founding of the first burn center in Prague. The Department of Burns and Reconstructive Surgery Teaching Hospital Brno is the youngest burn center and was established in 1979. This department consists of an intensive care unit with 5 critical care beds for children and adults; the standard children’s department has 9 beds and 16 standard beds for adults.
2.
Materials and methods
This is a 13 years retrospective monocentric study. The study includes all children hospitalized for burns in pediatric burn
777
intensive care unit from the period January 1, 1997 to December 31, 2009. Patients were age 0–14 years. We collected and evaluated epidemiological data such as age, sex, burn etiology, length of hospitalization, duration of the ICU stay, surgical or conservative therapeutic strategies, the need for mechanical ventilation and its duration, day and month of injury and the extent of burned area. The extent of burned area was evaluated by Lund–Browder charts [8]. The main reasons for hospitalization in the intensive care unit were the extent and depth of the burned area, burn location, or presence of inhalation injury with the need of mechanical ventilation. On December 31, 2009 The Czech Republic had 10,506,813 citizens. Of these, 1,258,900 were children aged 0–14 years. On this date, the number of children aged 0–14 years in the tributary area of the Clinic of Burns and Reconstructive Surgery Teaching Hospital in Brno was 266,748.
3.
Results
From January 1, 1997 through December 31, 2009 a total of 1245 burn patients were admitted to the ICU Department of Burns and Reconstructive Surgery Faculty Hospital Brno. The number of pediatric patients was 383 (30.76%). The total number of admitted children and patients requiring intensive care for each year of the study is shown in Fig. 1. The 383 ICU pediatric patients consisted of 253 boys (66.06%) and 130 girls (33.94%). The male to female ratio for patients hospitalized in the children’s ICU was 1.95:1. Most of the children suffered burns indoors, with only 55 children being burned outdoors. Indoor/outdoor ratio was 5.96:1. We admitted 322 children under 6 years requiring intensive care. The number of ICU pediatric patients in the study and the gender ratio in different age groups is shown in Table 1. The average extent of burns in the group was 16.43 12.86% TBSA. The average extent of burned area for each year of the period is shown in Fig. 2. The most typical extent of burns in children hospitalized for burn trauma in the intensive care unit of our clinic was between 10 and 19% TBSA. 177 children in our study fit into this category (46.21%). During the reporting period 16 children were hospitalized with burns
Fig. 1 – Ratio of total/pediatric patient admitted to the ICU in years 1997–2009.
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burns 38 (2012) 776–782
Table 1 – The number and the gender ratio of ICU pediatric patients in different age groups.
Total Male Female M:F ratio
0–6 year
7–14 year
0–14 year
322 200 122 1.64:1
61 53 8 6.63:1
383 253 130 1.95:1
over 50% TBSA. Distribution of patients by extent of burned area is shown in Fig. 3. The most frequent etiological agent was scalding (hot water, soup, coffee, oil, tea). The total number of scalded children in the group was 312 (81.46%). A total of 11 children under 14 years suffered high-voltage electrical injury. All children with electrical injury were in the age group of 7–14 years (see Fig. 4). The most typical burn location for children in the study was the trunk, followed by burns on the head and neck (Table 2). The most frequent time for child burn was between 8– 10 a.m. and 4–8 p.m. Fig. 5 shows the relationship between the time of day and the incident of child burn. Figs. 6 and 7 show the numbers of patients spread over the months of the year and days of the week.
Table 2 – Anatomical site of injury (%). Frequency (n)
Percentage (%)
165 234 123 69 42
43 61 32 18 11
Head and neck Trunk Upperextremities Lowerextremities Buttock and genitalia
The number of patients requiring mechanical ventilation is a very important epidemiological parameter especially in severely burned pediatric patients. Of all the patients in the study, 96 children underwent mechanical ventilation (25.07%). The average duration of mechanical ventilation in these patients was 8.03 5.67 days, as shown in Fig. 8. The average time spent in the intensive care unit was 10.71 10.92 days and mean total length of hospital stay was 21.55 14.55 days. Proportional representation of the number of days in ICU and total hospitalization time is shown in Fig. 9. The duration of intensive care treatment in relation to the percentage of TBSA in the period was 0.65 days per 1%TBSA. The total length of hospital stay per 1% of burned surface was fixed at 1.31 days per 1% TBSA. During the reporting period 3 children died (0.78%)
Fig. 2 – The average extent of burned area for each year of the study.
Fig. 3 – Distribution of patients by extent of burned area.
burns 38 (2012) 776–782
Fig. 4 – Etiological agents in pediatric patients admitted in our ICU 1997–2009.
Total of 184 patients (48.04%) underwent surgical therapy due to the depth of the burns. The most common procedure was excision and subsequent skin grafting. Conservative treatment was sufficient for 199 (51.96%) patients. General anesthesia was administered to each patient in the group an average of 6.23 5.99 times.
4.
Discussion
The number of children under 14 years in 1997 in the Czech Republic was 1,795,000, but in 2009 it was only 1,258,900. A similar situation (decrease number of children) was also found in the tributary area of the burn center in Brno. In spite of this
779
period of absolute decrease in the number of children, they still represent an important and specific group of patients in intensive care. The total number of admitted children for thermal trauma during this period increased mainly due to the centralization of care. The situation is different for patients requiring intensive care, where the number of admitted children decreasing, in contrast to the number of children admitted for minor burns [9]. The most common age group for hospitalization for thermal trauma were children ages 1–3 years, with the dominant etiology of burns in this age being scalding. Total number of scalded pediatric patients in our sample was 312 (81.46%). Akita et al. also identified scalding as the most frequent cause of burns in children – 68% of patients [10]. Similar results were achieved by Sharma et al. [11] and Torabian et al. [12] who accounted scalding for 67% and 71.7% respectively of all causes of burns in pediatric patients. Chen et al. in their retrospective study, which was performed on 735 pediatric burns, also adverted to the high number of scalded children. In their study group it was 92% of pediatric burns [13]. High-voltage electrical injury was detected as the mechanism of burn in 11 children of our group; all were 7–14 year old boys. None of the boys with high-voltage injuries died. Overall male to female ratio in our study was set at 1.95:1. A similar gender ratio was also reached in the study by Morrow et al. [14]. In almost all epidemiologic studies of gender ratio, boys predominate about 2:1. Maghsoudi et al. [15] found in their study a male to female ratio of 1.6:1. On the contrary, Jia et al. established gender ratio 4.42:1, but their study group was small [16]. The average extent of burns in our sample ranged from 10 to 19% TBSA. We treated in total 177 children (46.21%), who suffered this extent of burns. Papp et al. [17] also recorded this extent as the most common pediatric patients requiring intensive care. The most frequent anatomical burn sites in our study were the chest (61%) and head (43%). This location corresponds to the most frequent cause of injury – scalding. Upper and lower limbs are frequently affected in the event of flame burns or electrical injury in
Fig. 5 – Distribution of pediatric burns by the time of day.
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Fig. 6 – Distribution of pediatric burns by the month.
older children. Children in our study underwent mechanical ventilation mostly due to location of burns, not because of inhalation injury, but because of the risk of development of edema in the case of head and neck burns. This situation can lead to suffocation with the development of acute respiratory insufficiency. From the perspective of the time of the year for burn trauma, we observed a slight dominance in autumn burns (27.15%), with the least number of pediatric burns occurring in the summer (24.02%). Opposite results were reached in the study by Tarim et al. [18] They described the most common time for burns to be summer with autumn as the least frequent (42% and 16% respectively). Carroll et al. [19] reported that burns occur most frequently in the summertime, whereas Chien et al. [20] and Dedovic et al. [21] found that spring is the most common season. We identified the two most dangerous time periods for pediatric burns as 8:00–9:59 a.m. (17.76%) and 4:00–5:59 p.m. (22.45%). Most epidemiological studies report the highest risk time between 4:00 p.m. and 8:00 p.m. As in our findings, the
Lin et al. [22] study of 157 pediatric patients highlighted two dominant time periods with the first between 11:00 a.m. and 1:00 p.m. (19.7% of burned children), and the second between 5:00 p.m. and 8:00 p.m. (35.0%). The average hospital stay for patients in the study was 21.55 days and an ICU average of 10.71 days. When adjusted for the percentage of burned surface the total length of hospital stay was 1.31 days per 1% TBSA and a length of ICU stay 0.65 days per 1%TBSA. Papp et al. [17] in his study consisting of 45 pediatric burn patients of 0–16 years hospitalized in two burn centers in Finland, reported the average length of stay related to the percentage of burned area at 0.88 days and length of stay in ICU at 0.29 days. In total 3 patients from our study died. Sepsis was identified as the cause of death in all of those patients. Mortality ratio is 0.78%, which is lower in comparison with the work of Sharma et al. [11] where the mortality ratio was reported 1.3%. Xin et al. [23] in their work counted 1.1% mortality in the group of 1494 burned children; sepsis was represented as the major cause of mortality in 82.4%. But in Light’s [24] or Shou’s [25] work, the
Fig. 7 – Distribution of pediatric burns by the day of the week.
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Fig. 8 – Distribution of average duration of mechanical ventilation each year of the study.
Fig. 9 – Average duration of ICU stay/total hospital stay.
mortality ranges around 10% (10.1% respectively 9.08%). Both of these analyzes are from developing countries.
5.
Conclusion
In our report we identify the basic epidemiological characteristics of burned children requiring intensive care. The results of this epidemiological study show the need for future preventive actions focusing on the domestic environment to prevent scalding, which dominates actually all epidemiological indicators. This requires greater involvement of both parents and children, but also general practitioners. Intensive care for pediatric burn patients requires a specific approach and still represents a major challenge for medical staff.
Conflict of interest statement I declare that the article is not part of any conflict of interest.
references
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