% vol = 14 number = 2 prevlink = 64 nextlink = 72 titolo = "IATROGENIC BURNS IN CHILDHOOD" volromano = "XIV" data_pubblicazione = "june 2001" header titolo %>
SUMMARY. Iatrogenic burns are rare in childhood, but they include all four aetiological burn types: chemical, thermal, electrical, and radiological. We report 22 iatrogenic burns observed in 2216 children treated over a period of 10 years. The chemical burns that occurred in our clinic were caused by seepage of alcohol solutions during an operation, when the patients spent 60 to 180 min lying on solution-soaked operative linen. These burns were I or IIA degree and covered 0.5 to 4% TBSA. Re-epithelialization took 7-14 days, after topical treatment. Thermal and electrical burns also ranged from 0.5 to 4% TBSA. In all cases, the excoriated wound surfaces were covered with free split-thickness skin autografts 0.15 to 0.3 mm thick. A complicated case is discussed of a new-born that necessitated flap rotation to cover a naked elbow joint. We conclude that most often iatrogenic burns in children are associated with misuse or failure of medical equipment and with mistakes in paediatric medical care.
Childhood burns caused in the course of treatment of another disease are quite rare. They include all four aetiological burn types: thermal, chemical, electrical, and radiological.
Thermal burn injuries are witnessed mainly in newborns. Sometimes babies are bathed in water the temperature of which has not been previously checked, which leads to extensive burns. In other cases, newborns are warmed with leaky hot-water bottles. This may cause vast dorsal burns.
Electrical burns occur most often during surgery. The main cause of this complication is poor contact between the patients body and the electrical knife contact plate, the most frequent mechanism being sparking. The contact plate itself produces similar burns if not completely covered with wet gauze or if the operating table is not securely earthed. These burns are deep, with dense primary eschars that will eventually require plastic surgery reconstruction.
Chemical burns are usually produced by skin disinfectants during preparation for surgical treatment. Operative linens that are moist with alcohol act as an undiluted alcoholic poultice. Skin damage is rarely seen immediately after surgery but becomes visible the following day. A less frequent cause of direct skin injury is the presence of a chemical substance used for coagulation or disinfection, such as crystals of silver nitrate and potassium permanganate.
Iatrogenic ray burns are extremely rare in children and are usually associated with the use of Solux or other kinds of ultraviolet physiotherapeutic procedures.
During the period 1990-1999 we treated 2216 burned children, of whom 22 presented iatrogenic burns. Fifteen of these children (68%) were in-patients in our clinic and seven were being treated by our specialists in other clinics inside or outside our institute. Of those treated in our department, seven were transferred to other hospitals.
The distribution of burns by aetiology is presented in Table I. The cases were grouped statistically, and iatrogenic burn distribution and incidence were analysed.<% createtable "Table I","Distribution of burns by aetiology",";~;Thermal;Electrical;Chemical;Ray;Total@;Occurring in our clinic;-;-;6;2;8@;Transferred;2;3;2;-;7@;Treated in another hospital;4;3;-;-;7@;Total;6;6;8;2;22","",6,550,true %>
All the chemical burns that occurred in our clinic were caused by alcoholic solutions that seeped during operative field cleaning. The patients probably lay for 60 to 180 min on solution-soaked operative linen. The burns were I or IIA degree and covered 0.5 to 4% TBSA. Re-epithelialization lasted 7-14 days. In one case only, the action of iodine-alcohol led to IIB-III degree burns in 0.5% TBSA and the defect had to be covered with autograft. Ray burns occurred in two cases when Solux was used for ultraviolet treatment in donor sites. The affected area was evaluated as I degree and occupied skin adjacent to the donor site. It was successfully medicated locally with epithelializing unguents (Deflamol), followed by hydrocortisone.
All the patients transferred to the clinic with chemical burns epithelialized spontaneously after topical application of antiseptic ointments followed by epithelialization-stimulating unguents.
Thermal and electrical burns are liable to both surgical and local treatment. The eschars that formed and the operative wound surfaces ranged from 0.5 to 4% TBSA in the burned children. In all cases, the excoriated wound surfaces were covered with free split-thickness skin autografts 0.15 to 0.3 mm thick. Only one thermal burn, discussed below, necessitated the use of flap rotation to cover the naked elbow joint.
Here is the case of S.S.M, a 15-day-old newborn, patient number 20993, date 20 October 1997. The burn occurred on the first day after birth when during a 2-hour warming with an electrical warming pan a burn was discovered that involved the right brachium, the ante-brachium, the dorsal surface of the fingers, the left half of the waist, and the buttocks, covering 10% TBSA and graded as I, IIAB, and III degree in different areas (Fig. 1)<% immagine "Fig. 1","69_fig_01.jpg","Apparence of child on admission",246 %>
The child was transferred to our clinic on day 16 post-burn. On admission, dry eschars covered over 4% TBSA, involving the left half of the buttocks, the right elbow joint, and the dorsal part of the II, III, and IV right fingers. The eschars were black in colour, solid, with elevated edges and central depression, and with no wound exudation.
The childs general condition was stable, with normal biochemical and haematological laboratory values. We started local treatment. The elevated eschars were removed and the wound surfaces were dressed daily with Sofratulle. Three successive escharectomies were performed on the biologically rejected necrotic tissues. The wound surface was prepared with Epiguard. The right elbow joint cavity opened during the process of the fall-off of the eschars. Prior to the operation we administered human albumin, plasma, and blood three times.
On 12 November 1997 the remaining wound surfaces in the left buttock area and the right elbow joint were covered with free autografts. We used a 0.15 mm autograft meshed to a ratio of 1:3. Post-operatively the buttock area autograft stabilized and snapped into place. The autograft over the open elbow joint was partially destroyed. In a second stage on November 27 the open elbow joint was closed with a rotation flap and the donor site was covered with a 2-cm2 split-thickness autograft. This was followed by a trouble-free post-operative period (Fig. 2).<% immagine "Fig. 2","69_fig_02.jpg","Apparence of child on discharge",243 %>
The child was dismissed from hospital on day 53 after admission. Follow-up examinations until 1 year of age showed complete recovery of elbow joint structure and function, and a soft cicatrix in the left gluteal region.
The patients that we observed and treated outside the clinic had superficial burns limited to 0.2-1% TBSA and were treated locally until complete re-epithelialization.
Iatrogenic burns in children are quite rare and are associated with accidents in the process of paediatric treatment and care. They are most frequent in operating theatres and consist of both electrical and chemical (alcohol disinfectant) burns. These misadventures are due to misused or faulty medical equipment.1-3 Chemical burns are caused by long skin contact with alcohol disinfectants - childrens skin is significantly thin and tender.4
Also frequent are the thermal burns that form the biggest aetiological group in the neonatal period.5-9 These are usually the result of hot water scalds when a baby is bathed after birth or else they occur because of faulty hot-water bottles.
Ray burns are infrequent and are associated with misuse of physiotherapy equipment or the strong light of the operative microscope.10-12
RESUME. Les brûlures iatrogéniques dans les enfants sont rares mais elles incluent tous les quatre types de létiologie des brûlures: thermal, chimique, électrique et radiologique. Les Auteurs présentent 22 cas de brûlures iatrogéniques observées dans 2216 enfants traités pendant une période de 10 ans. Les brûlures qui se sont verifiées dans la clinique des Auteurs ont été causées par des infiltrations de solutions alcooliques pendant une opération chirurgicale. Les patients sont restés 60-180 minutes sur le linge opératoire imprégné de la solution. Les brûlures étaient de degré I ou IIA et occupaient 0,5-4,0% de la surface corporelle totale. La ré-épithélialisation était complète en 7-14 jours, après le traitement topique. Les brûlures thermales et électriques variaient de 0,5 à 4.0% de la surface corporelle totale. Dans tous les cas les surfaces excoriées ont été couvertes dautogreffes cutanées libres dépaisseur variable (0,15-0,3 mm). Le Auteurs présentent le cas compliqué dun nouveau-né qui nécessitait la rotation du lambeau pour couvrir lexposition de larticulation du coude. Les Auteurs concluent que la plupart des brûlures iatrogéniques des enfants sont associées au mauvais emploi ou à linsuffisance de léquipement comme aussi aux erreurs dans les soins infantiles.
<% riquadro "This paper was received on 15 November 2000.