Zámecníková I.¹, Tymonová J.¹, Stetinsky J.¹, Bakhtary A.², Jourová I.², Hladík M.², Trávnícek B.²

¹Burn Center of the FNsP Hospital, Ostrava,

²Pediatric and Resuscitation Departments of the FNsP Hospital, Ostrava, Czech Republic

SUMMARY. The authors present a data file of 279 children with severe and critical burn Injury; hospitalized in the Intensive Care Unit or the Pediatric Resuscitation Unit of the FNsP Hospital in Ostrava in the years 1999 - 2003. The severity of the burn trauma in children is determined by age, extent, depth, localization. circumstances of the Injury, Its mechanism, and by other serious illnesses of a child. The authors have divided the data file Into two groups, severe and critical, using classification of a burn injury in children according to the extent of injury as well as localization and other circumstances (1). Complex therapy of extensive burn Injuries In children is based on adequate fluid resuscitation, treatment of burned areas, algosedation, and appropriate antibiotic therapy. The authors have unequivocally confirmed that in the group of children with diagnosis of critical burns complications occur more often, while the overall course of illness is serious and requires more therapeutical Interventions than in the group of children with severe burns.

Key words: severe burn injury, critical burn injury, fluid resuscitation, algosedation, antibiotic therapy, burn trauma complication

INTRODUCTION

  The data file contains 279 cases of children with diagnosis of severe and critical burns. The children were hospitalized between 1999 and 2003 in the Intensive Care Unit or at the Department of Pediatric Resuscitation and Intensive Care Units of the FNsP Hospital in Ostrava.

  To evaluate the severity of a burn injury in children the critical factors are the extent and depth of the burn. the child's age, localization and mechanism of the injury, the possible presence of severe illnesses prior to injury, and other injuries (1). The extent of a burn injury in children in relation to age is routinely evaluated according to the Lund -Browder chart (Table 1).

  Classification of burns in relation to age is shown in Table 2.

  Burns up to 5% of the body surface are considered moderately severe in children, because a burn injury is never mild in children.

RESULTS

  The followed data file contained 66 critically burned children, 10 of them required artificial ventilation. The majority of the critically burned children were under 2 years of age. In the severely injured group of children 68% were 2 years of age or less, and in the critically burned group of children 68% were 2 years of age or less. In contrast, the least represented group was that of age 10 - 15, which was present in both groups to the same extent: 5% (Table 3).

  The average extent of the burn injury was examined in three age groups: up to 2 years of age, 2 - 10 years of age, and 10 - 15 years of age. In the youngest children with the diagnosis of severe injury the average extent of injury was 9.4% of a body surface. In the same age group with diagnosis of critical burn injury, the average extent of injury was 19.1%. In the second age group the average extent of burn injury in severely injured children was 11.2% and in critically injured children 30.7% of the body surface. In the last age group the avenge extent of burn injury in the severely burned children was 20.1% and in critically burned children 41.6% of the body surface. The exact representation of individual degrees in percentage is in Table 4.

  A comparison of the most commonly injured localizations reveals that in both groups of severely and critically injured children the most commonly injured body part is the trunk. The second most common localization varies between the two groups. In critically burned children the second most commonly injured body part is the head, while in severely burned children it is the upper extremities. Respiratory burn injury alone is classified as a critical burn injury (Table 5).

  Children who required artificial ventilation were hospitalized at the Pediatric Resuscitation and Intensive Care Departments. The total number of children in the data file examined was 10. Four of them underwent tracheostomy as a first step, and HFOV was necessary in two children.

  The most common complication in the data file examined was burn injury shock. The diagnosis was usually established according to the laboratory parameters. Burn injury shock occurred in all critically burned children and in about one third of severely burned children. In both groups the second most frequent complication was anemia, evaluated as a decreased level of hemoglobin under physiological values in the given age group. The third most frequent complication was severe anemia, which manifested itself clinically and required blood transfusion. Complications such as sepsis, MODS, ARDS, thrombocytopenia, inhibition of bone marrow and atelectasis in lungs occurred only in children with critical burns (Table 6).

  The basic most important part of a burn injury treatment is intravenous fluid resuscitation. To establish the necessary amount of Holds it is possible to use any of the generally approved formulae. Generally the physiological need of fluids increases according to percentage of the burned area, and according to other fluid losses. The speed of infusions is set according to the hourly diuresis, which should correspond to 1 milliliter per kilogram of the child (1).

  In the beginning of the treatment we usually administered crystalloids, most commonly Hartman's solution, and colloids, usually frozen plasma at a ratio of 1:1 The use of diuretics was reserved for cases of fluid overload. The next essential part of therapy is an adequate algosedation. In the group of children examined here, the need for analgesics. sedatives and anesthetics was very high. We administered continually Sufenta in doses of 5.8ug/kg/h, Dormicum up to 1mg/kg/h, Ketamin up to 10mg/kg/h, Diprivan up to 12mg/kg/h and Precedex up to 0.7um/kg/h. We used Novalgin, Nubain, Dipidolor, Tramal, Algifen, and Ultiva as a bolus.

  Vasopressors, usually a combination of dopamine and dobutamine, were administered in all cases of critically burned children and in 74% of severely injured children. Noradrenalin was administered for severe hypotension in 3% of the cases of critically burned children and not at all in children with severe burn injury.

  We did not prescribe antibiotics preventatively but always based on bacteriological finding from swabs from the burned areas, the upper respiratory tract and urine. In the group of critically burned children antibiotics were administered in all cases. most commonly Penicillin in 78% of the cases, followed by Cephalosporin in 45% of the cases and Clindamycin in 21% of the cases. Other antibiotics, like aminoglycocides, carbapenems, Colimycine, Targocid and Pipril were used much less frequently. In children with severe burns we used antibiotics in 74% of the cases.

  Of the antitrombotics the most commonly used are low molecular heparins, usually in two-day subcutaneous doses. Continual intravenous administration of Heparin in doses 25-36 IU/kg/h is also possible. In critically burned children antithrombotics were administered in 53% of the cases and in children with severe burn injury in 2% of the cases. From the blood derivatives, we have most commonly administered frozen plasma. Frozen plasma was administered in all critically burned children and in 92% of the cases of severely burned children.

  Administration of cry-mass takes second place in both compared groups. In the critically burned children erymasa was administered in 32% of the cases and in severely burned children in 6% of the cases. We did not include blood transfusions administered to substitute for surgical blood loss. Other blood derivates were administered significantly less often. However. in the group of children with critical burn injury Prothromplex was administered in 10% of the cases, AT III in 18% of the cases and thromboconcentrate in 6% of the cases. Its administration in severely burned children was insignificant.

CONCLUSION

  In the youngest children diagnosed with severe burns the average injury extent was 9.4% of the body surface. In children of same age with critical burns the injury extent was 19.1% of the body surface. Severely burned children aged 2 - 10 years sustained on average injury to 11.2% of the body surface and critically burned children to 30.7% of the body surface. In the oldest children the average extent of burns was 20.1% of the body surface in severely burned children and 41.6% in critically burned children. In the group of critically burned children as compared to the other group. the snore commonly injured body parts are the head and genitalia; respiratory burn injury is considered a critical burn injury. In the group of children with critical burn injury we have observed more severe course of burn trauma with more complications, requiring more frequent therapeutic interventions than in the group of children with severe burns.

REFERENCE

1. Konigová, R. Komplexní lécba popáleniny. Praha: Grada, 1999

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