Arifi H., Zatriqi K.V., Zatriqi S., Ahmeti H., Muqaj S.

University Clinical Centre Surgical Clinic, Department of Plastic and Reconstructive Surgery, Prishtina, Kosovo

SUMMARY. This is a retrospective study of children admitted for burn trauma to the Department of Plastic and Reconstructive Surgery in Prishtina, Kosovo, in the period June 1999-June 2003. The burns treated were more frequent among males (59.9% of cases) and mostly involved children in the age group 0-6 yr (79.8%). Deep burns were present in 46.4% of the patients and superficial burns in 53.6% of hospitalized cases. Preschool children (age group, 0-6 yr) constituted 54.5% of the cases, predominantly with deep burns. Scalds were the commonest cause of deep burns (71% of cases). The mean duration of hospital stay was 18.1 days; in cases treated with early escharotomy the duration was 21.3 days, with late escharotomy, 40.8 days, and with conservative treatment, 18.8 days. Of the 124 patients with deep burns, 39.5% were treated surgically, while the remaining 60.5% were necessarily treated conservatively. Early complications occurred in deep burns in 47.6% of the cases, and late complications in 34.7%. The mortality rate was 2.6%.

Introduction

Burns are among the great problems in the field of traumatology, because even after great advances in management and treatment they can still constitute a serious accident in children. The infantile population most involved are children in the age group 1-3 years old, where there is a high mortality rate. There are many complications after burns, and even when there is no life-threatening problem there are functional and also aesthetic consequences, although these may be only temporary.

Burns in children are a severe problem in Kosovo. In the years 1999-2003 they constituted 51% of the total number of burn patients admitted.

Patients and methods

A study was performed of 267 burned children treated in our Department of Plastic and Reconstructive Surgery during the period June 1999-June 2003. During this 4-yr period, our clinic admitted 519 burn patients, among whom the number of burned children in the age group 0-15 yr was 267 (51.5%).

The following variables were considered: number of children burned based on year, season, age, sex, thermal agent, TBSA burn, surgical procedure, admission time period, and mortality.

Burns management in these children included immediate cardiopulmonary resuscitation and the administration of intravenous fluids based on the Parkland formula. The local treatment of superficial burns was conservative (cleansing and dressing), while deep burns were treated surgically (early escharotomy/necrectomy and late escharotomy/necrectomy). In some children with deep burns we had to apply conservative treatment because surgical treatment was refused.

Results

The incidence of burns in children has increased to very high numbers. Of the overall number of burned patients admitted, 267 were children (51.5%). The average annual number of infantile burn patients admitted was 67. The pattern of annual admissions is shown in Table I.

The burned children treated in our clinic were more often boys (160 cases, 59.9%) than girls (107 cases, 40.1%). The age group 0-6 yr (213 cases, 79.8%) was affected more than the age group 7-15 yr (54 cases, 20.2%). The patients’ average age was 4.1 yr. The seasonal distribution of cases showed a somewhat greater proportion of cases in winter (76 cases, 28.5%). The cause of burns most involved in all degrees of burn was scalds (213 cases, 79.8%), followed by fire (38 cases, 14.2%), electricity (13 cases, 4.9%), and chemical substances (3 cases, 1.1%).

In our study deep burns were present in 124 cases (46.4%) and superficial burns in 143 cases (53.6%). The average incidence was 31 cases with deep burns per year and 36 cases with superficial burns. There was a dominance of minor burns with TBSA up to 10% (130 cases, 48.7%). The average TBSA was 3.0%. Deep burns with TBSA ranging from 11 to 20% were found in 58 patients (46.8%), while superficial burns with TBSA up to 10% were found in 87 patients (60.8%). The mean burned surface was greater in deep burns (15.6%) than in superficial burns (10.6%).

Our study also analysed our therapeutic capabilities for treatment. We applied conservative treatment in superficial burns (143 cases, 53.6%) and surgical treatment in deep burns (124 cases, 46.4%). Of these, 49 patients (39.5%) were treated surgically, and 75 (60.5%) were necessarily treated conservatively.

Overall, among all the cases of deep burns in childhood, the dominant group was that of children living in a family that refused surgical treatment (75 cases. 60.5%), followed by that subjected to late escharotomy (41 cases, 33.1%) and to early escharotomy (8 cases, 6.5%) (Fig. 1).

In relation to the thermal agent involved, surgery was the method most applied in burns caused by scalds (31 cases, 35.2%).

In relation to TBSA, surgery was the method most applied in TBSA from 11 to 20% (30 cases, 51.7%) and in the age group 0-6 yr (36 cases, 43.9%).

The average duration of hospitalization in superficial burns and deep burns was 18.1 days. With regard to burn depth there was a considerable difference in hospitalization between deep burns (25.8 days) and superficial burns (11.5 days).

The duration of hospitalization was regarded as a measure of the success of surgical treatment in deep burns. When early escharotomy was performed, the mean hospitalization period was 21.3 days, compared with 40.8 days after late escharotomy. Mean hospitalization was 18.8 days when conservative treatment was constrained because hospitalization at a certain point was refused and treatment continued on an ambulatory basis, thus making hospitalization shorter.

The early complications of superficial burns were, in order, infection (35 cases, 24.5%) (in deep burns there were more cases of infection - 55 cases, 44.4%), seroma in the graft (7 cases, 5.6%), partial graft lysis (5 cases, 4.0%), and total transplant lysis (2 cases, 1.6%). The late complications of deep burns were, in order, out of the total number of 124 cases examined, keloids (50 cases, 40.3%), hypertrophic scars (47 cases, 37.9%), and skin contracture in various joints (16 cases, 12.9%); in superficial burns there was only hyperpigmentation (47 cases, 32.9%).

Infection was more prevalent in deep burns treated conservatively (37 cases, 49.3%) than in patients subjected to late escharotomy (18 patents, 36.7%). With early escharotomy, it was not found at all. The presence of seroma/haematoma under the transplant was observed in 7 cases (5.6%) (5 cases with late escharotomy and 2 with early escharotomy). Partial lysis of the transplant occurred in 5 cases (12.2%) and full lysis in 2 cases (4.9%) with late escharotomy (Fig. 2).

Hypertrophic scarring occurred with greater prevalence after conservative treatment, and especially after enforced conservative treatment, in 33 cases (44.0%), and after late escharotomy (13 cases, 31.7%). After early escharotomy it occurred in only one case (12.5%). Keloids were not evident in cases where early escharotomy was performed with autotransplant, while after late escharotomy and autotransplant they occurred in 6 cases (28.6%). In cases where surgery was refused, this complication was noted more often (44 cases, 58.7%). Skin contractures did not occur in patients subjected to early escharotomy and autotransplant, while after late escharotomy it occurred in 2 cases (4.9%). Contractures were prevalent in deep burns when surgery was refused (44 cases, 58.7%) (Fig. 3).

The mortality rate in the 267 burned children was 2.6%. The lethal thermal agent was scalding (6 cases, 6.8%). The age group most affected was 0-6 yr (5 cases, 7.4%). All eventually fatal cases were related to deep burns and TBSA of 20-40% (5 cases) and over 40% TBSA in 2 cases. With regard to the method of treatment, only one patient subjected to late escharotomy died - the mortality rate was 2.4% in the group receiving conservative treatment, where there were 6 deaths (8.0%).

Discussion and conclusions

Burns in childhood are frequent in everyday life and constitute 33.7% of all cases admitted to our hospital. They are among the severest of all pathologies in children primarily because they are a life-threatening trauma and because of their functional and aesthetic consequences after treatment. During the 4-yr period considered in our clinic, 267 burned children were admitted. Our study considers the prevalence of such burns, also in relation to the children’s psychophysical development and to the epidemiological characteristics and the social status of Kosovo families in which these children grow and develop.

The data underline the prospects of the problem of burns, which are disruptive for Kosovo society, in view of the fact that the number of such cases is on the increase.

The cases of childhood burns treated in our clinic regarded boys more often than girls, and prevalently the age group 0-6 yr. These findings are related to the fact that this age group is more exposed to risk - the impulsive behaviour of such children and their uncontrolled curiosity impose greater care by the family. The seasonal distribution of burns in children showed a greater frequency in winter, owing to the increased use of heating equipment in the domestic environment - in small homes without many comforts, there is a concentration of objects and family control is poor.

Thermal agent burns were more frequent in the age group 0-6 yr, with scalds. This finding reflects children’s uncontrolled behaviour and mobility at this age. Fire and electricity were more often the causes of burns in the 7-15 yr age group - this is the age when the young start playing with fire without knowing the dangers involved.

Among the total number of burned children in our clinical material, there was a prevalence of superficial burns that were treated conservatively in line with the trend of modern patterns in the treatment of such cases. Deep burns were treated surgically, with the exception of 75 patients who had to be treated conservatively after surgical treatment was refused.

Surgical treatment in these burned children consisted of early escharotomy and autotransplant, which were performed in 8 cases. We must however emphasize that our department has now started to gain experience and efficiency in the surgical method. We have been performing modern surgical treatment with early escharotomy in deep burns in the two last years (2002-2003), unlike other centres which have been coping with this problem with early escharotomy since 1970, an operation routinely performed by plastic surgeons in the treatment of deep burns.

Early escharotomy was mainly used in smaller burns (TBSA, 11-20%). Compared with other centres where escharotomy is not a problem, our problem was how to cover the surface. Other centres have skin banks and they can also perform allotransplants.

Late escharotomy and autotransplant are significantly dominant in our clinical material. Late escharotomy is used in cases of burns with a TBSA of more than 40%.

Unfortunately, in our department, we are unable to apply surgical methods in burn surfaces greater than 40% TBSA because we still do not have a burns centre with permanent monitoring and versatile care in every aspect of the care of burned children. Such care requires dynamic and permanent clinical and laboratory surveillance in all phases of the evolution of the burn trauma. We lack all this in our country, just as we lack a skin bank and other synthetic materials which for other advanced centres do not represent a problem.

These data illustrate the benefits and efficiency of such methods of treatment in the reduction of the post-burn complication rate, as also seen in our study with regard to mortality and morbidity in children who suffer burn injuries.

RESUME. Les Auteurs ont effectué une étude rétrospective des enfants brûlés hospitalisés dans le Département de Chirurgie Plastique et Reconstructrice de Prishtina, Kosovo, pendant la période juin 1999-juin 2003. Les brûlures les plus fréquentes touchaient les enfants de sexe masculin (59,9% des cas), et principalement les enfants âgés de 0 à 6 ans (79,8%). Les brûlures profondes étaient présentes dans 46,4% des patients et les brûlures superficielles dans 53,6% des cas hospitalisés. Les enfants en âge préscolaire (0-6 ans) constituaient 54,5% des cas, dont la plupart présentaient des brûlures profondes. La cause la plus fréquente des brûlures profondes était l’ébouillantement (71% des cas). La durée moyenne de l’hospitalisation était 18,1 jours; dans les cas traités avec l’escarrotomie précoce elle était 21,3 jours, avec l’escarrotomie tardive, 40,8 jours, et avec le traitement conservatif, 18,8 jours. Des 124 patients atteints de brûlures profondes, 39,5% ont été traités chirurgicalement et les autres, 60,5%, ont été traités forcément en manière conservative. Dans ces patients les Auteurs ont observé des complications précoces dans les brûlures profondes dans 47,6% des cas et des complications tardives dans 34,7%. Le taux de mortalité était 2,6%.

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