SUMMARY The aims of this retrospective study covering the years 1984-1998 were: 1. to survey burn injuries in children at the present time and 2. to compare the current results with the conclusions of an analogous study performed in the years 1964-1983. A decline in the occurrence of lethal burn wounds was found, as well as in burn shock as a direct cause of death. Children 1-4 years old continue to be the most frequent victims of fatal accidents. The most common cause of burn injury in this group remains scalding in the household.
Das todliche Verbrennungstrauma bei Kindern
Chadova L., Bouska I., Toupallk P.
Das Ziel dieser Studie war: 1. die Obersicht Ober die Situation der todlichen Verbrennungsverletzungen in der Gegenwart zu gewinnen and 2. das Vergleich der neuen Ergebnisse mit den ZusammenschluBen der analogischen Studie aus den Jahren 1964-1983. Es wurde festgestellt die Herabsetzung des Vorkommens von todlichen Verbrennungsverletzungen, genauso wie des Verbrennungsschocks als unmittelbare Todesursache. Die meist bedrohte Gruppe stellen Kinder im Alter vom 1-4 Jahren dar, wobei der fuhrende Mechanismus bei der Verletzungsentstehung in dieser Alterskategorie der Verbruhung im Haushalt zugerechnet wird.
Key words: burn trauma, scald burns, accident circumstances, mortality, complications, cause of death
This study has been performed partially by comparison with an analogous study from the years 1964-1983 covering 96 children whose deaths were directly connected with a burn wound (3). The current survey is based on the deaths of 46 children (0-15 years old) following burn injury during the last 15 years (1984-1998), predominantly from Prague and the central region of Bohemia, whose bodies were examined at our institute. In order to make comparison easy, the data are arranged in a manner based on the arrangement of the prior study.
The initial step was to determine how large a role lethal burn injuries play at this age, looking at all violent deaths (e.g. from non-natural causes). The number of deaths due to burn trauma has declined - the difference between the former study (8,1 %) and the current study (5,9 %) is almost 1/4 (Tab. 1). Moreover, in the number of burn-injured children in the prior study, cases associated either with high voltage electric shocks or lightning strikes were not included, although accompanying burns are quite common. Thus, the difference between the studies could have been more dramatic if all types of burn injuries had been included.
<% createTable "Table I","Lethal injuries 1984-1998",";Lethal injuries;773@;Lethal burns;46@;Boys;32@;Girls;14@;Proportion of burns in all lethal injuries (%);5,9","",4,300,true %>The age group at highest risk is children 1-4 years old (Fig. 1). The leading cause of burn injury is usually contact with a scalding liquid. The most frequent scenario is either pulling down kettles with boiling water or falling into a pot filled with soup, which has worse consequences due to the content of fat in the soup.
<% immagine "Fig. 1","gr0000001.gif","Age distribution 1984-1998.",230 %>As far as categorizing the mechanism of injury, we distinguish between scalds and dry heat and the special cases of explosion, lightning strike and electric current injury (Tab. 2). The exact circumstances of five cases were not clear, but two of them were evidently scald burns. Scald injuries can cause death quite frequently due to the vulnerability of the young organism, which is prone to develop shock even with a small burn area or if the burn trauma is not considered serious enough to warrant immediate medical first aid.
<% createTable "Table II","Trauma mechanism 1984-1998",";Scalds ;17@;Dry heat;15@;Explosion;5@;Electric current;5@;Lightning;1@;Unknown;3","",4,300,true %>We were also interested in the extent of the burned area in children who died as a result of burn trauma (Fig. 2). They were most often burnt over 30-70 % of their total body surface area (in 24 cases).
<% immagine "Fig. 2","gr0000002.gif","Extent of burns 1984-1998.",230 %>As regards separating the two principal locations where the accidents took place, it is clear that the majority of children were burnt indoors, i.e. within reach of parents or another supervisor (Tab. 3). This situation has remained constant since such data have been collected. In addition, it is possible re-classify six cases from the outdoor to the indoor category because they obviously took place while approaching the house, thus further increasing the indoor: outdoor ratio.
<% createTable "Table III","Place of accidents 1984-1998",";Indoors ;25@;Outdoors;16@;Unknown;5","",4,300,true %>The data show that accidents in the countryside still tend to be more common than accidents in towns (Tab. 4). The distribution within the year is fairly balanced; in the warmer months (May -July), the number goes up moderately.
<% createTable "Table IV","Area of accidents 1984-1998",";Countryside ;27@;Town;19","",4,300,true %>The most frequent complication of burn injury during both study periods was sepsis (Fig. 3). During the first analysis period, sepsis was the cause of death in 46,9 % of cases, while in the years 1984-1998 sepsis was responsible for death in 45,6 % of cases, which may indicate a declining trend. Pseudomonas aeruginosa, Staphylococcus aureus and other bacteria such as Klebsiella, Proteus or Enterobacter were present in most. of the cases. Even so, effective topical anti-microbial therapy and early burn excision can significantly reduce the overall occurrence of invasive burn wound infections (2, 4).
Shock as a direct cause of death has decreased rapidly. In the earlier study, it caused death in 33 % of burn injuries, but only in 26 % in the current study. In contrast, causes of death indirectly connected with burn trauma have tended to rise. This group consists either of causes that are not amenable to therapy, because they are generally deadly by themselves (e.g. traumatic injury due to falling from a height following high voltage electric current injury), or causes that are possibly amenable to therapy but unfortunately were not treated in time (carbon monoxide poisoning or long exposure to fire).
There are some special cases that can be added to the category of indirect burn-associated deaths.
<% immagine "Fig. 3","gr0000001.gif","Causes of death in lethal burn trauma 1984-1998.",230 %> <% immagine "Fig. 4","gr0000004.jpg","Plastic catheter in vena cava inferior.",230 %> <% immagine "Fig. 5","gr0000005.jpg","Plastic canula embolised into the right ventricle and pulmonary artery.",230 %> <% immagine "Fig. 6","gr0000006.jpg","Inner hydrocephalus without obstruction in a boy who died due to extensive burns.",230 %>Case l: This 14-year-old boy sustained firstand second-degree burns over 5 % of his face and both hands. The 4th day after admission he died with the symptoms of disseminated intravascular coagulopathy (DIC). During the autopsy an 11 cm-long plastic catheter was found in the inferior vena cava, partially inserted in the right iliac vein. There was a bit of fibrin remaining around the catheter (Fig. 4).
Case 2: This 11-month-old boy sustained mostly second-degree scald burns over 70 % of his body by taking a shower following his older brother. At the autopsy, almost 50 % of the scalds were almost completely healed. As far as the case history, the boy was canulized via the vena subclavia 1. dx during the primary treatment. After admission following transport to the university hospital, this canula was removed without any resistance. A system of rotary canula exchanges was started, but re-entry to the right subclavia vein was no longer successful. He developed febrile temperatures after 3 days, reacting to antibiotics only temporarily, always a short time following a change in medication. Throughout the duration of the treatment, he developed septic shock relapses. He died on the 26th day of hospitalization with signs of DIC refracting to therapy. Within the necropsy, there was found a 3,4cmlong canula, plainly cut off at its top, embolised from the v. subclavia 1. dx. into the effluent part of the right ventricle, pulmonary trunk, reaching the left branch of the pulmonary artery (Fig. 5). The lumens of both the trunk and the branch of the pulmonary artery were almost obturated with thrombus. The absence of the second part of the canula made it impossible to determine the time of occurrence.
In another two cases, there were marked neuropathological changes. The two boys were both different ages (12 and 14,5 years old) and had suffered different causes (fire and electric current injury) of their extensive burns (30 % third-degree and 85 % third-degree skin burn injury, respectively), but their survival times were relatively longer (78 days and 75 days, respectively). Similar changes of the brain were observed in both: the meninges were without congestion but were edemic, and there was a symmetrical distension of both lateral ventricles (the inner hydrocephalus) without any sign of obstruction, accompanied with a reduction of white matter predominantly about the lateral ventricles (Fig. 6). In the microscopic findings, dystrophic changes of neurons, focal demyelinization in the white matter (red-colored lipid deposits in the granule cells using Sudan III staining; Fig. 7) and an accentuated perivascular gliosis were evident (Fig. 8). These findings point to so-called burn encephalopathy, which has been reported several times (1).
<% immagine "Fig. 7","gr0000007.jpg","Red lipid deposits in granule cells - Sudan III staining.",230 %> <% immagine "Fig. 8","gr0000008.jpg","Perivascular gliosis - hematoxylin-eosin staining.",230 %>Considering all deaths from unnatural causes, the proportion represented by lethal burn injuries has tended to decrease; the difference between the two compared periods is nearly 25 %. The decline in fatal incidences of shock can also be seen as an encouraging result. The number of „indoor" accidents within sight of adult supervision is a depressing revelation. The only advice or solution for their prevention is widespread enlightenment on every level and the continued education of all adults even partially responsible for the health of our children, such as teachers, insurance officials, and the providers of safety staffs for households. Prevention is not a task just for those individuals dealing with our health every day. In the final analysis, the treatment of such trauma carries a considerable load, both socially and economically.