Annals of Burns and Fire Disasters - vol. XI - n. 4 - Deceinber 1998

SEVERE BURNS IN CHILDREN IN THE LAST FIVE YEARS IN ALBANIA

Belba G, Perna L, Belba M, Isaraj S, Mingomataj L.

Mother Teresa Clinic of Burns and Plastic Surgery University Hospital Centre, Tirana, Albania

SUMMARY. This is an epidemiological and statistical survey of the occurrence of severe burns among children in Albania in the last five years. The patients taken into consideration were burned children from all parts of the country as well as from the capital of Albania, admitted to and treated in the intensive care unit of the Clinic of Burns and Plastic Surgery in the University Hospital Centre of Tirana, Albania. Special attention is paid to the body area where the burns occurred, as compared with other burned patients admitted to our ICU, the age groups most subject to severe burn injury, sex distribution, and the site of the accident. In the five-year period there was a prevalence of 10-20% and 20-30% BSA burns. The causative agents (flame, hot water and liquids, electric current, chemicals) were studied in relation to the percentages of the burns and their location in particular body areas. The treatment protocol is described, and in particular the resuscitation phase, local treatment, general therapy, and the possible complications due to burn shock or sepsis. Total mortality figures are presented, with the main causes of death. In addition to cases in which epithelialization was spontaneous, the plastic surgery approaches adopted to treat severely burned children are described. The application and combination of different surgical stages, i.e., eschar excision and meshed skin grafting at the appropriate time, are% introduced as a possible successful management option. The data obtained underline the importance of propaganda campaigns for the prevention of severe burns in children.

Introduction

The reasons why we decided to study severe burns in children were multiple, but what really prompted our decision was the observation that 93 severely burned children were admitted to our intensive care unit in the first six months of 1998, corresponding to 79% of all patients treated there during that period.
Because of a prolonged transition from one social system to another, with profound reflections on the political, economic and social life of our people, there has been a constant increase in the incidence of severe burns in children compared with past years. There has been an uncontrolled demographic displacement of the population, with people moving from the villages towards larger centres, and many of the families and social groups involved live in conditions below the average standard of living.
On the basis of the evidence provided by this group of burn patients, this paper aims to help promote the prevention of burns by making people aware of the serious danger that burns represent for children. The objectives of the study are twofold, and they will become clear with the analysis of the clinical material.
First, we will present statistical and epidemiological data regarding:

1. the diseases treated in our ICU during the five-year period
2. the occurrence of severe burns in children
3. the distribution of burns in di ' fferent age groups
4. the site and causative agent of-the accidents
5. the location, size of burn, and patient condition on admittance

Secondly, we will survey the mortality rate from a number of viewpoints:

1. shock and sepsis
2. complications
3. the various causative agents and the BSA burned
4. the different age groups and the overall mortality rate

Material and method

All severely burned children admitted to our ICU who fulfilled the relevant criteria were included in the study, which extended over the years 1993-1997.
The contingent consisted of 560 children, out of the total number of 834 patients treated in the ICU of the Clinic of Burns and Plastic Surgery in the University Hospital Centre, Tirana, Albania.
The study is of an epidemiological -statistical nature, with the clear clinical objective of promoting the improvement of our present protocols for treating severely burned children.

Results

Beginning in 1993, as shown in Table I, we observed a galoping increase in the incidence of severe burns in children, which was twice as high in 1997 as it was in 1993. No important increase was recorded in the number of burned adults or elderly patients. Burned children constituted 67% of our burn cases.

With regard to the distribution of burns according to age group (Table 11), 63.4% of the cases occurred in children in aged 1-3 yr, a stage in life that is notorious for impulsive behaviour and excessive curiosity. Boys slightly prevailed over girls, with a male/female ratio of approximately 1.2A. In 304 cases (54.4%) the children came from villages, the rest, i.e., 256 cases (45.6%), coming from towns. Ninety-four point four per cent of the accidents took place in the home.

The high rate of domestic burns reflects the inappropriate care children receive at home, compared with the care provided at pre-school and school institutions.
Table III contains details of the distribution of burns according to the causative agent in different age groups.

The commonest causative agents were hot water (38% of cases) and other hot liquids (34.5%), followed by flame (18.5 %). Electrical and chemical burns represent respectively 3.1% and 5.9% of the cases. Table III also shows the relation between the causative agent and mortality, which was higher in flame burns than in scalds, but with no marked difference between flame burns and chemical burns. The number of deaths is higher in children aged 1-3 yr, with hot water as the most frequent causative agent. These figures are explained by the ratio of 149 scalds treated to 28 fatal outcomes in this age group.
The principal criterion of admittance to our ICU is the extent of the burn. Children are admitted if they present deep 2nd- or 3rd-degree burns in more than 10% BSA. When wounds were located in critical areas, the threat to the child's life was greater, especially at the age of 0-1 yr. Burns involving 10-20% BSA prevailed (Table IV), these constituting 62.9% of our cases - again, children aged 1-3 yr old were the most frequently involved, with 231 cases. Deaths, although rare, nevertheless occurred even in children with up to 20% burns (8.5%). The death rate increased progressively with the increase in burn size.

Burns were generally located in combined areas of the body, e.g. the torso and lower limbs, as was the case in 34% of the cases (Table V). The classic diagnosis was "scald of the hips, buttocks and thighs", sustained when the child accidentally stumbled and fell into a hot liquid. Such injuries usually extended over the genital area, rendering management even more complicated.
Leaving the treatment protocol for discussion in a later part of the paper, we will now report on mortality, with an analysis of various different factors. Thanks to adequate fluid resuscitation and appropriate follow-up in the initial phase, only 0.9% of the children died within the first 48

h, i.e., during the shock phase, with a constant fall in the number of deaths in consecutive years. Mortality was high (40%) in septic patients, as a consequence of severe infections caused by S. aureus and gram-negative germs like P. aeruginosa, Klebsiella, Proteus, etc. Fifty-nine out of the 560 severely burned children (10.5%) developed complications, of which the commonest were bronchitis, bronchopneumonia, pneumonia and pleurisy. Cardiac and cerebral complications were less frequent. The death rate of patients with complications was 37%.
Among the causes of death, septic shock complicated by acute renal failure took first place, accounting for 93.4% of all deaths. Haemorrhagic stress ulcer and multiple organ failure accounted for 3.7% and 2% of deaths respectively.
Sixty per cent of the deaths occurred within the first week post-burn, 27% within two weeks and 12.1% after the second week. A synthesis of mortality rate data in the different years and age groups is presented in Table VI. The overall mortality rate was 18.8%.
The average hospital stay was 10.1 days (6.8 days in children who died).

Discussion

In the majority of cases (71.9%), the burned children came to our clinic straight from the accident site. This might imply that they received qualified medical care immediately, but on the other hand a great number of patients can be regarded as delayed cases because the time interval between the accident and initiation of treatment was rather protracted owing to transport difficulties. Eighteen per cent of the children came from district hospitals, but although they were already being treated they should be regarded as delayed patients, because transfer was effected after signs and symptoms of sepsis were established. The most difficult contingent to deal with wasthat of children treated as out-patients at incompetent centres where they were inadequately treated for some long time before being sent on to us, when their general condition had deteriorated.
The condition of the children on admittance was estimated to be severe in 73.4% of cases and very severe in 26.6%. This latter estimation was made in patients with profound haemodynamic alterations and marked irregularities in fluids, electrolytes, acid-base balance, etc.
Fluid resuscitation was performed using the Carvajal formula. We gave greater amounts of fluids, generally consisting of Ringer's lactate or 0.9% saline solutions, when the burns were located in critical areas. The same formula guided resuscitation in delayed arrivals, but the amounts given in these cases were intended to maintain urinary output at a level of 1 ml/kg/h, in order to avoid pulmonary overload. Colloids were usually given after the sixth hour post-burn, following the initial fluids. However, in cases that seemed resistant to crystalline solutions, with a poor clinical response, colloids were initiated earlier.
Antibiotics were administered only after the second day post-burn. Our treatment of choice is a combination of an aminoglucoside (mainly amikacin) with a thirdgeneration cephalosporin. This treatment was continued for 10-15 days. After the second week, protection from infection was implemented using a first-generation cephalosporin combined with an anti-staphylococcal agent.
The above schemes are based on the microbial load of the ICU environment, as found by the results of blood cultures and antibiograms. Blood transfusions were performed, depending on the blood count, when the haematocrit was lower than 30% and haemoglobin less than 8 gl%. Treatment was completed with electrolytes, antacids, antifungals, analgesics and nutritional supplements.
The surgical treatment protocol was initiated with the first debridement of the burn wounds, which was carried out under intravenous anaesthesia with ketamine, followed by the closed method using Betadine 10%. After the third day, at the end of the exudation phase, we applied silver sulphadiazine 1% until all the burned tissues separated. If the burn was deep 2nd-degree and the wounds showed epithelial islands, epithelialization was promoted by the application of antibiotic-impregnated fine mesh gauze, phytostimulin or mitosyl. In 3rd-degree wounds the surgical protocol varied in relation to the size and the causative agent of the burn, as follows:

1. In 3rd-degree burns of less than 10% BSA we performed late excision after the 7th-8th day and grafted them in a second procedure.
2. In 3rd-degree burns of more than 15% BSA we performed late excision and partial grafting, covering functional areas with autologous skin, either in sheets or meshed by 2. Later, in a second and not infrequently a third stage, the wounds were covered completely with grafts passed through a no. 4 or 6 mesher.
3. In electrical burns, as soon as the child's general condition permitted, immediately after the shock phase, we performed early excision or limb amputations as necessary.
4. In chemical burns our mainstay of management was early excision on the fourth or fifth day postburn, with re-estimation of the wound after some days followed by a further excision procedure in separate areas and grafting at the appropriate moment.

With clinical-biochemical stabilization - generally after the first surgical procedure - the child's condition began to ameliorate towards a safer prognosis. At this point a general consultation of our staff decided whether the child was to remain in the ICU or be transferred to other wards in our clinic for completion of treatment.

Statistical-epidemiological papers also take into account the clinical aspect of the treatment of the cases studied as well as anticipating scientific research. Their importance is even greater when the subject considered is the incidence of certain diseases in different social groups, especially when they encompass the entire population of a country, so that the results are available for comparison with those of other countries.
Our series of 560 cases is sufficient to provide data that can be statistically processed. As in many other countries` burns in children aged 1-3 yr continue to be a problem, the majority being due to domestic scalds."-'' Flame burns are the second most frequent type in our country, as elsewhere, while electrical and chemical burns, though rare, require special care.
The frequent occurrence of burns to our children in the home is comparable with data from most European countries, adding further evidence to the importance of prevention campaigns. Our data indicate a relatively high mortality rate, but there is also a clear tendency for reduction in consecutive years. In spite of the difficulties we face, with tremendous limitations in materials and equipment, mortality - both in the different age groups and as regards overall mortality - is comparable with that reported in countries at a similar stage of economic development. Much still remains to be done for our results to approach those of other European clinics, which currently report death rates much lower than ours.
In Albania, there is one disturbing trend. Compared with the findings of another study we performed,` there is a clear increase in the number of severely burned children, contrary to findings elsewhere. A great deal still remains to be done in the field of prevention and treatment.
With regard to prevention and its social aspect we must:

• promote greater awareness of the particular dangers that burns pose to children
• educate social groups and families living in disadvantaged conditions with regard to this issue
• encourage public institutions to increase the number of pre-school and school centres and to improve their work in the field of child health care, including burn prevention
• organize specialized medical teams for the monitoring of the health status of demographically mobile social groups

Clinically we must:

• strengthen aseptic measures in order to enhance protection from staphylococcal and Pseudomonas infection
• perform excision, with an individual approach in each case, avoiding any tendency towards extreme standardization
• create special units within ICUs for the management of severely burned children

RESUME. Les Auteurs présentent une analyse épidémiologique et statistique qui étudie les brûlures sévères des enfants en Albanie dans les années 1993-1997. Les enfants, qui provenaient de toutes les régions du pays, y inclus la capitale, ont été hospitalisés dans le Centre de Réanimation de la Clinique des Grands Brûlés et Chirurgie Plastique du Centre Hospitalier de l'Université de Tirana (Albanie). Les Auteurs ont consideré en particulier le lieu où l'accident a eu lieu, l'âge des patients, le sexe et la zone corporelle atteinte. L'analyse des résultats démontre la prévalence des brûlures de 10-20% et de 20-30% de la surface corporelle. Les Auteurs considèrent en outre les agents étiologiques qui ont causé les accidents (les flammes, l'eau et les liquides chaudes, le courant électrique et les substances chimiques) en relation avec le pourcentage de la surface corporelle brûlée et les zones particulières intéressées. Le protocole du traitement est décrit, avec un intérêt particulier pour la phase de la réanimation, le traitement local, le décours de la maladie et les complications dues au choc de la brûlure ou à la sepsis. Les Auteurs présentent les données sur la mortalité totale et les causes principales de la mort. A part les cas d'épithélialisation spontanée, ils présentent leurs expériences dans le champs de la chirurgie plastique dans le traitement de l'enfant brûlé. Ils utilisent l'excision de l'escarre et la greffe du type mesh graft, comme option possible dans la gestion de la maladie. En conclusion, les Auteurs répètent l'importance de la propagande dans la prévention des brûlures sévères des enfants.

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