High-Risk Factors causing Mortality in Pediatric Burn Patients, admitted in Burns Centre of Karachi

Objective: To evaluate the High-Risk Factors Causing Mortality in Pediatric Burn Patients, Admitted In Burns Centre of


Introduction
According to World Health Organization (WHO) 1 , a burn injury can be comprehensively defined as: "An injury caused by heat (flames, hot objects, or gases), chemicals, electricity and lightning, friction, or radiation". According to a recent report, 7.1 million burn injuries occur per year. 2 These injuries cost the lives of more than 300,000 people per year. 3 2.5% per 100,000 of these deaths are pediatric burn-related deaths. 4 Among all accidental trauma fatalities, burn injuries ranks the top third in all age groups and the top second in patients of age below 4 years. 5 Unfortunately, Children are more vulnerable to these burn injuries than any other age group, because of their skin sensitivity, small body size, and inability to evaluate and recognize lethal situations. 6 These traumatic burn injuries are the cause of permanent or temporary cosmetic and physical aberration (i.e. wound contractures), persistent pain, emotional and psychological suffering-not only for patients but also for his/her caregivers, 7 multiple expensive treatments, and surgeries with limited treatment benefits. However, the recent development in early management, treatment strategies, and surgeries, and well-equipped and well-trained medical staff have alleviated the death tolls among these pediatric burn patients. Even though with such advancement there are still some major predictors that increase the risk of morbidities within pediatric burn patients. Some of the most important categories for assessment of severity in burns is, the involvement of the following factors which can lead to increased deaths in pediatric burn patients like total body surface area (TBSA) >50% 8 , age of patient 8 , presence of inhalation injury 8 , place of wound 9 , septicemia (multi-drug resistant bacteria) after burn 10 , a late arrival in the hospital, health status of the patient during admission (i.e. lower hematocrit, lower base deficit, higher serum osmolarity, platelet count < 20,000, intravenous access, need for inotropic support), first aid interventions at the incident site, absence of well-equipped burn units, qualified medical staff, premature surgical excision and skin grafting, the inadequacy of public awareness, prevention and management of burn injuries and absence of ambulances for transport. In developing countries, like Pakistan mortality and morbidity in burn patients is high due to infections or multi-drug resistant bacteria, total body surface area (TBSA) >50%, patient age, place of wound, presence of inhalation injury. The Pakistani nation needs to work for burn victims for prevention, as burns incidence increases in the winter season. 11 Childhood burn can lead to the development of devastating physical morbidity, psychological or severe emotional and socioeconomic or economic burdens. 12 The scarce literature availability and scarce reporting on associated risk factors in burn patients. So, risk factors for mortality are not well known and strategies should be made for their prevention, like prompt referral of the burn patients to specialized burn centers or tertiary care hospitals. Therefore, this research has been conducted this study to evaluate the high-risk factors causing mortality in pediatric burn patients, admitted to the burns center of Karachi, that lead to mortality and morbidity of the pediatric burn victims. Objective: This retrospective study aimed to evaluate the high-risk factors causing mortality in pediatric burn patients, admitted to the burns center of Karachi. were included in the study after taking written consent. Detailed history regarding any allergies and co-morbidities were taken from the patient or patient family members and recorded in pre-designed Performa. This includes variables like age, gender, injury cause, type of injury, site of injury, Total body surface (TBSA), nutritional status (total protein), history of illness, chronic diseases, or congenital diseases, and other measures.

Materials and Methods
The baseline investigations and general physical examination were done. The albumin levels were measured at 3-7 days period after admission in the burns ward, with a TBSA of 5-20% to identify the severity of wounds.
The primary management is to assess the A.B.C.s and resuscitation in the burn patients to prevent lifethreatening conditions. The physical exam findings in burn patients are to record the extent of the burns, which is expressed as a percentage of total body surface area burned (% TBSA), and the depth of the burns, expressed as superficial (or first-degree), partial-thickness (or second-degree) or full-thickness (or third-degree). Children with burns of more than 20% -25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent "burn shock." Fluid resuscitation is done by the Parkland Formula. This formula estimates the amount of fluid (crystalloid: 2-4 ml/kg body weight) given in the first 24 hours in extensive burn wounds and management depends on the severity of the burn, as a superficial type of burns (superficial burns) would be managed with cleaning with soap and water, followed by dressings and pain medication, while the major type of burns (Partial or Full-thickness burns) requires prolonged treatment and hospital stay, such as skin grafting. 14 Data analysis procedure: Version 20.00 of the Social Science Statistical Package (SPSS) was used for the statistical analysis. The data of categorical variables were presented as counts and percentages. Descriptive frequencies were used for analyzing all categorical data (i.e. gender mortality).

Results
Two hundred twenty-seven (227) Pediatric admitted patients were included in this study. One hundred thirty-five (60%) participants were male while 92 (40%) were female. Mean age 4.8 ± 3.3 years with the percent of mortality being highest in the age group ranging from 1-5 years. Burn injuries on multiple sites was seen in 156 (68.7%), injury to arms and hands in 15 (6.6%), head, face, and neck in11 (4.8%), legs and feet burn injuries in 19 (8.4%) while only 3(5.3%) sustained burn injuries on trunk and Buttocks and genitalia were 6 (2.6%). The total body surface area (11-50%) was involved mostly 202 (89%) in our population. The reason for burn injury was due to scalding or hot liquids [139 (61.23%)] and Flame/Fire [77 (33.92 %)] were mostly affected. (Table 1) A significant relationship was analyzed between the nutritional status of patients as assessed by albumin levels and mortality (p=0.004) with regarding the length of time to IV access 7.5% (17) patients were resuscitated with IV fluids within the first hour of burn, 21.1% (48) within 1-4 hours, and 71.4% (162) presented after 4 hours of injury. (Table 2) The multiple region burns (involving more than three regions) were the most common category constituting 156 (68.7%) of the pediatric burn patients. The mortality rate reported in the multiple region burn category was highest, constituting 87.5% (56) of total deaths reported. Amongst the single region burnt, the trunk was the most common region that got affected in pediatric burn patients. It constituted 8.8% (20) of the patients. Buttocks and genitalia were the least common category, constituting 2.6% (6) of all patients. However, it can be depicted from the table that there is no specific site of injury with the highest mortality rate but rather multiple burns with > 50% TBSA involvement have the highest mortality rate. Therefore, it can be inferred that burn with high involvement of TBSA is the major cause of mortality among burns patients. (Table 3).

Discussion
Burn injuries are coupled with intense physical disfigurements, physiological complications, and deep psychological traumas. By the virtue of some major medical advancements in the past 20 years, the mortality rate in burn cases has reduced a lot. Improvement of critical care and nutrition of burn patients, therapeutic development (fluid resuscitation, early surgical excision), availability of multidisciplinary burn centers, and pharmacologic and nonpharmacologic management 15 18 The total body surface area (11-50%) was involved mostly 202 (89%) in our population, in contrast to our study results showed that burns of less than 20% TBSA represent the large majority of Burns cases. 16 The nutritional status of the patients was also a major predictor of the pediatric patient's mortality rate. It was related to the IV access to the pediatric patient. Burns victims who got resuscitation liquids during the first hour of injury were more likely to survive. (Table 2) The period of intravenous access was another important determinant of mortality. The burns duration of the IV line was extended up to 06 months. Burn injuries cause hypovolemia, and if not treated this can lead to hypovolemic shock. 19 Moreover, it is common among critically ill burn patients to suffer from hypoalbuminemia. The major loss of extracellular fluid from the body increases vascular permeability and results in loss of plasma proteins (i.e. albumin) -this is the hyper-metabolic and hyper-catabolic response of the body to the burn injuries. 20 Our study also highlights, that, the mortality rate was highest in the multiple regions burn 87.5% (56) of total deaths reported. Amongst the single region burnt, the trunk was the most common region that got affected in pediatric burn patients. It constituted 8.8% (20) of the patients. Buttocks and genitalia were the least common category, constituting 2.6% (6) of all patients. However, it can be depicted from the table that there is no specific site of injury with the highest mortality rate but rather multiple burns with > 50% TBSA involvement have the highest mortality rate. Therefore, it can be inferred that burn with high involvement of TBSA is the major cause of mortality among burns patients. (Table 3). Similar to our results, observed in India. 21 As this descriptive study and the limitation of this study was a small sample size and conducted in a single centre. So it is recommended that studies should extend to multicenter with a large sample size should be conducted to confirm or compare the results of this study.

Conclusion
In this retrospective study that scald or hot liquids, duration to IV access, or nutritional status of the patients, the multiple region burns with > 50% involvement of TBSA were considered as a major cause of mortality in the pediatric burn patients.