burns 41 (2015) 476–483
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
A prospective observational study investigating all children presenting to a specialty paediatric burns centre K.A. Stockton a,*, J. Harvey b, R.M. Kimble a,c a Centre for Children’s Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Australia b School of Medicine, University of Queensland, Australia c Stuart Pegg Paediatric Burns Centre, Royal Children’s Hospital, Brisbane, Australia
article info
abstract
Article history:
Aim and method: The aim of this study was to describe the mechanism of injury and outcome
Received 23 August 2014
of all children who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC) with a burn
Received in revised form
injury in the year 2013. A detailed proforma was completed prospectively at time of
16 September 2014
presentation to hospital.
Accepted 21 September 2014
Results: During the one year period, 758 children with a median age of 2 years 3 months presented with a burn injury. Overall, 12.7% of patients (n = 96) were initially treated as inpatients. Similarities existed between in and outpatients. Over half the children admitted
Keywords:
had a scald injury (53.1%). Whilst slightly higher than the outpatient scald rate of 43.1% there
Paediatric
was no statistical significant difference. However, there was a significant difference be-
Burn injury
tween inpatients and outpatients with respect to other mechanisms of injury. Contact burns
Outpatient
were under represented in inpatients (27.1%) compared to outpatients (44.5%), p < 0.05. In contrast, flame burns were over represented in inpatients, 11.5% compared to outpatients, 2.9% ( p < 0.05). Conclusion: Paediatric burns are a common cause of childhood injury. The majority of children present with small to medium sized partial thickness injuries and are managed as outpatients. In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention campaigns, data repositories must include detailed information regarding outpatient paediatric burns. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention
campaigns comprehensive demographic and information regarding mechanism of injury should be collected on all children presenting to a burns centre. Data repositories such as the Burn Registry of Australia and New Zealand (BRANZ) and the American Burn Association National Burn Repository
* Corresponding author at: QCMRI Foundation Building, Level 4 Royal Children’s Hospital, Herston Rd, Herston Queensland, 4029, Australia. Tel.: +61 7 3636 1278. E-mail address: [email protected] (K.A. Stockton). http://dx.doi.org/10.1016/j.burns.2014.09.018 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 476–483
primarily track only inpatient data. As such, little is known regarding the differences in epidemiology, aetiology or outcome of injuries between in and outpatients. While outpatient data has been reported for combined adult and children populations [1,2], mechanisms are known to differ between these groups and there is a paucity of similarly comprehensive paediatric data [3–6]. The aim of this current study was to describe the mechanism of injury, details regarding the injury occurrence, first aid received and surgical requirements of all patients who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC) with a burn injury in the year 2013 and as such represents a complete summary of both inpatients and outpatients seen at a paediatric burns unit.
2.
Method
Burn data were prospectively collected on all children aged 16 years and younger who were seen at the Royal Children’s Hospital (RCH) in Brisbane, Queensland between January 1 to December 31, 2013 inclusive. Consent was obtained from parents/guardians. Ethics approval was obtained prior to commencing this study from the Children’s Health Services Human Research Ethics Committee, based at the RCH (HREC/ 08/QRCH/085) and University of Queensland Human Research Ethics Committee (2013001001). A detailed pro forma was completed at the time of presentation for both inpatients and outpatients including the following information: Demographic data. Events leading up to and surrounding the burn injury. First aid given, both at the scene and in hospital. Depth, site and body surface area of burns.
injury are included in the results, these children are excluded from the more detailed dataset inclusive of first aid, severity and re-epithelialisation. Contrasts and similarities between inpatients and outpatients are presented.
2.1.
Data analysis
Statistical analysis was performed using SPSS software (version 22). Mean and standard deviation for outcomes were calculated unless data were not normally distributed, in which case median and interquartile range (IQR) was utilised. Inpatient data were compared with outpatient data using Chi-squared test or Fishers exact test where appropriate. Mann–Whitney U test was utilised to compare age at presentation between groups. Two tailed p values of 10%, all of whom were admitted as inpatients on presentation. Four children suffered inhalation injuries (all from house fires and all inpatients). No fatalities were recorded. Flame and friction burns were most likely to be described as deep partial or full thickness and most likely to receive grafting, with scald injuries least likely to undergo grafting. Table 2 details frequency of grafting by mechanism.
3.5.
Location/activity and time of injury
There was little difference between inpatients and outpatients with respect to geographical location of injury. Overall, most injuries occurred at home (70.3%), with a further 11.3% occurring at other residences. Injuries while away on holiday represented 6.6% of the total, with 66.0% of these being while camping. Contact with hot coals was the most common injury sustained whilst camping and most commonly occurred over school holidays or long weekends. Of the injuries that occurred in the patient’s usual residence, 53.5% were in the kitchen. Injuries that occurred at another residence – 36.3% occurred in the kitchen and 31.3% in the garden. More than half (52.1%) of incidents were directly witnessed by a parent or carer. Reliable data for time of injury was available for 84.1% of
Table 1 – Frequency and rates of admission by four most common mechanisms of burn injury – scald, contact, friction and flame. Overall percentage is calculated from the whole cohort presenting to SPPBC inclusive of chemical, cooling, radiation and other. Injury type Scald Contact Friction Flame
N
Overall %
% of injury type admitted
% of overall inpatients
% of overall outpatients
321 305 38 29
44.4 42.2 5.3 4.0
15.8 8.5 7.9 37.9
53.1 27.1 3.1 11.5
43.1 44.5 5.6 2.9
480
burns 41 (2015) 476–483
Fig. 4 – Mechanism of injury – comparison between inpatients and outpatients. Percentage of presentations for total group, inpatients and outpatients for the most common mechanisms of injury treated at SPPBC. Data is presented as percentage of each particular group, for example vehicle exhaust is 5.1% of total presentations, 8.3% of inpatient admissions and 4.6% of outpatient admissions.
children. A large percentage of burn injuries occurred between 6 and 9 PM (32.6%), Fig. 5, with the highest incidence of burns on Sunday and Saturday. January reported the most burns cases (n = 92), followed by October (n = 81), with the fewest cases presenting in June and August (n = 46) (Fig. 6).
3.6.
First aid at the scene of injury
Appropriate first aid following burn injury was defined as 20 min of cold running water (CRW) delivered either continuously
Table 2 – Number and percentage of burns grafted by mechanism of injury. Cause
Mechanism
Grafts na
Total n
% grafted
Flame Friction Contact Flame Friction Flame Scald
House fire Vehicle or motorbike Vehicle exhaust (all) Lighter/matches Treadmill Candle Water from hot water bottle Water from tap/bath/ shower/basin/bucket Water from saucepan/ kettle Coals/ashes Fat/oil Food Hot beverage Other
4 5 18 3 5 2 2
5 9 40 7 12 5 5
80.0 55.6 45.0 42.9 41.7 40.0 40.0
5
21
23.8
7
52
13.5
5 2 6 7 8
39 16 80 132
12.8 12.5 7.5 5.3
Scald Scald Contact Scald Scald Scald Other
a Grafts equates to actual patients – there were a total of 86 grafts on 79 patients.
or in total within 3 h of injury. Data were collected regarding first aid management at the scene of injury by patients and carers, 79.8% of patients were given some CRW, with 33.6% receiving 20 min. In 26.0% (n = 188) of cases, first aid provided at the scene included treatments other than CRW. When alternative therapies were used, 66.5% (n = 125) occurred in combination with cool running water, however in 63 cases these treatments were used in isolation. The most common alternative treatment used was ice in 76 cases, followed by a cold cloth (n = 31) or submerging the injured region in non-running water (n = 24).
3.7.
Theatre cases
In 2013, 13.7% of patients new to the centre underwent a procedure in theatre, with 185 procedures performed on 99 patients. During this period, 79 patients underwent split skin grafting (SSG). Time from injury to first SSG was a median time of 12 days (IQR 8.75–17.5). Fifty-two percent of inpatients underwent at least one procedure in theatre, whereas 8.9% of those managed as outpatients went on to require surgical intervention (predominantly SSG and primarily managed as a day procedure). In addition five children were admitted following initial management as an outpatient for social or feeding issues. Thus 9.7% of children initially treated as outpatients had an inpatient stay at some stage in their care.
3.8.
Outpatient appointments
Between January and December 2013, 2483 outpatient appointments were attended by 908 patients. Of these appointments 1926 were for 723 patients new to the department in 2013. The median number of appointments was 2 (IQR: 2–4), ranging between 1 and 15 appointments per child.
burns 41 (2015) 476–483
481
Fig. 5 – Time of injury where known showing increased incidence around the evening meal (n = 608). Injuries occurring between 6 p.m. and 9 p.m. Time of injury was available in 84.1% of cases.
Of the outpatient appointments, 557 were reviews of patients who sustained a burn injury prior to January 1,2013. In total 313 patients presented for review of injuries sustained before 2013, with 232 being seen once only for annual review. The mean number of appointments for these patients was 1.6 (sd = 1.40).
3.9.
Re-epithelialisation
Time to healing was defined as the number of days following injury when the burn consultant clinically evaluated the wound as being >95% re-epithelialised. Median time to re-epithelialisation was 10 days (IQR: 7–17). Following wound re-epithelialisation, 81.2% of patients were discharged from the SPPBC, whilst 18.8% required ongoing scar management.
4.
Discussion
The vast majority of paediatric burn injuries are small to moderate size and are managed as outpatients [2,3]. Despite this, the majority of studies reported in the literature only describe burn injuries requiring admission to hospital [2]. Thankfully, clinicians treating paediatric burns are increasingly identifying the need for data regarding all presentations including outpatient paediatric burns and a limited number of papers have recently been published. Brown et al. [3] provided a retrospective report on the contrasts between paediatric in and outpatients over a three year period at a Ohio Burns Centre. Demographic information, burn severity and scar management requirements were included. However, detailed information regarding the mechanism and scene of injury was
Fig. 6 – Frequency of burn injury by month of the year.
482
burns 41 (2015) 476–483
not included which is vital to inform future injury prevention campaigns. A retrospective study by Verey et al. [4] details time of day and seasonal variations in paediatric burn injury in the United Kingdom. Kemp et al. [6], conducted a prospective multicentre cross-sectional study of children with burn injury. Similar to our study and that reported in the literature hot beverage scalds were the most common mechanism of injury. However, in contrast, Kemp et al. reported a much higher rate of burns caused by hair straighteners and irons and a much lower number of children sustaining contact burns from motorbike exhausts than in our study. This is likely reflective of the climatic differences between the United Kingdom and Northern Australia. This highlights the importance of comprehensive local data to enable targeted injury prevention. Our study is the first Australian study to comprehensively report on both inpatients and outpatients in the management of paediatric burns. The initial admission rate of 12.6% at this burns unit is similar to that reported elsewhere [3] [8]. Data repositories such as BRANZ collect data on children admitted for greater than 24 h and those patients who are initially managed as outpatients and subsequently proceed to have a burn wound care procedure (e.g. split thickness skin grafting). Thus if solely relying on national burn repositories for paediatric burn data, over 80% of children presenting with a burn injury would not be included in the data set. A major strength of this study was the prospective design and inclusion of all presentations to a paediatric tertiary burns referral centre thus providing a comprehensive, accurate picture of paediatric burn injury. This study demonstrates that similar to Brown et al 2014 [3], whilst the majority of injuries seen at an Australian burns centre are not life-threatening (there have been no deaths due to burn injury at our centre over the last decade), with the majority healing in under two weeks, the burden on the child and family can be significant. Studies carried out at our centre have demonstrated that following burn injury there is a risk of post-traumatic stress disorder and delayed healing due to pain and anxiety regardless of whether the child was treated as an inpatient or outpatient [9–11]. Males accounted for approximately 60.0% of cases. A similar gender distribution has been noted in studies conducted in developed countries [3,4]. In contrast, a higher proportion of females are recorded in studies based in the Middle East [1]. Consistent with Australian inpatient data, the proportion of males in our study increased beyond 10 years [12]. This age group also saw an increase in both flame and friction burns approaching rates seen at adult centres [12]. Scald injuries were the most common mechanism of injury for both inpatients and outpatients. Contact injuries were statistically more likely to be treated as outpatients, with flame injuries treated as inpatients 11.5% of the time despite representing only 4.0% of all injuries. The most common mechanism of injury for a contact burn treated at our centre was hotplate on stove, none of these children were admitted thus would not be reported in the majority of data repositories. Relying on inpatient data alone risks under or over estimating the true frequency of particular mechanisms of injury. To our knowledge, this study is the first to compare the rates of grafting for specific aetiology of paediatric burns. Treadmill injuries required grafting in 41.7% of cases. These
injuries commonly affect the hands of the 2–3 year age group and represent a specific risk for this group. Burns from vehicle exhausts, flame and vehicle friction burns represented a high risk of requiring grafting and thus may benefit from early transfer to burns centres and surgical admission. The site of injury changes with the age of the child. Below 12 months, hand and upper limb injuries predominated consistent with international data [13]. Lower limb injuries, particularly in boys were the most common site of injury after age 10. This increase is partially attributable to an increase in exhaust injuries which accounted for 12.1% of all injuries in this age group. Of which 81.8% were boys. Knowledge regarding specific mechanisms of injury and affected age groups allows targeted injury prevention programs to be developed. The majority of paediatric burns result from preventable domestic accidents. An increased risk of childhood burn injuries corresponds with times of food preparation [14], with 6–9 p.m. being most common in Queensland. In Queensland, the majority (70.3%) of burn injuries occurred at home, similar to that reported in the literature [4,8,15–17]. Information on the cause, location and time of occurrence of these accidents allows campaigns to be developed to combat them. Similarly, targeting of specific, aetiologies such as appropriate protective clothing to prevent motorbike exhaust burns [18], guards for treadmills [19], correct extinguishing of camp fires [20] and cool touch ovens [6] may reduce the overall morbidity and associated costs of these injuries. Early first aid with cool running water has been shown to reduce the severity of burns [21]. Only a third of children received adequate first aid at the scene of injury. Whilst this is a big improvement on the 12% reported in a previous study at our centre in 2005 [22], there is still obviously room for improvement. A quarter of children received treatments not recommended and potentially detrimental (such as ice) which suggests a possible area for targeted intervention [23]. Education targeting first aid at home has the potential to increase the number of children achieving appropriate therapy at each step and boost the overall number of children receiving cold running water. Paediatric burns are a common cause of childhood injury. The majority of children present with small to medium sized partial thickness injuries and are managed as outpatients. All of these injuries are preventable. In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention campaigns, data repositories must include detailed information regarding outpatient paediatric burns.
Conflict of interest None.
references
[1] Taghavi M, Rasouli MR, Boddouhi N, Zarei MR, Khaji A, Abdollahi M. Epidemiology of outpatient burns in Tehran: an analysis of 4813 cases. Burns 2010;36(February (1)):109–13.
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[2] Kahn SA, Bell DE, Hutchins P, Lentz CW. Outpatient burn data: an untapped resource. Burns 2013;39(November (7)):1351–4. [3] Brown M, Coffee T, Adenuga P, Yowler CJ. Outcomes of outpatient management of pediatric burns. J Burn Care Res 2014;35(5):388–94. [4] Verey F, Lyttle MD, Lawson Z, Greenwood R, Young A. When do children get burnt? Burns 2014;40(7):1322–8. [5] Van Niekerk A, Rode H, Laflamme L. Incidence and patterns of childhood burn injuries in the Western Cape, South Africa. Burns 2004;30(June (4)):341–7. [6] Kemp AM, Jones S, Lawson Z, Maguire SA. Patterns of burns and scalds in children. Arch Dis Childhood 2014;99(April (4)):316–21. [7] Shakespeare PG. Standards and quality in burn treatment. Burns 2001;27(December (8)):791–2. [8] Ansari-Lari M, Askarian M. Epidemiology of burns presenting to an emergency department in Shiraz, South Iran. Burns 2003;29(September (6)):579–81. [9] Brown NJ, Kimble RM, Rodger S, Ware RS, McWhinney BC, Ungerer JP, et al. Biological markers of stress in pediatric acute burns injury. Burns 2014;40(5):887–95. [10] De YAC, Kenardy JA, Cobham VE, Kimble R. Prevalence, comorbidity and course of trauma reactions in young burninjured children. J Child Psychol Psychiatry 2012;53(January (1)):56–63. [11] Brown NJ, Kimble RM, Gramotnev G, Rodger S, Cuttle L. Predictors of re-epithelialization in pediatric burn. Burns 2014;40(June (4)):751–8. [12] Team B-NBRP. Bi-National Burns Registry – Annual Report Melbourne; 2012. Available from: http:// www.med.monash.edu.au/epidemiology/traumaepi/ burnsreg.html. [13] Laitakari E, Koljonen V, Pyorala S, Rintala R. Outpatient treated burns in infants younger than 1 year in Helsinki during 2005–2009. Burns 2014;40(May (3)):489–94.
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[14] El-Badawy A, Mabrouk AR. Epidemiology of childhood burns in the burn unit of Ain Shams University in Cairo, Egypt. Burns 1998;24(December (8)):728–32. [15] Al-Hoqail RA, Fadaak H, Wafa AW. Burn injuries at a university hospital in Saudi Arabia: an audit and concept of total quality management, 1997–2003. J Craniofac Surg 2011;22(March (2)):404–8. [16] Arshi S, Sadeghi-Bazargani H, Mohammadi R, Ekman R, Hudson D, Djafarzadeh H, et al. Prevention oriented epidemiologic study of accidental burns in rural areas of Ardabil, Iran. Burns 2006;32(May (3)):366–71. [17] Hove LM, Lindtjorn B. Epidemiology of burns in Bergen, Norway. Scandinavian journal of plastic and reconstructive surgery and hand surgery/Nordisk plastikkirurgisk forening [and] Nordisk klubb for handkirurgi 1999;33(June (2)):225–9. [18] Pym AJ, Wallis BA, Franklin RC, Kimble RM. Unregulated and unsafe: the impact of motorcycle trauma on Queensland children. J Paediatr Child Health 2013; 49(June (6)):493–7. [19] Jeremijenko L, Mott J, Wallis B, Kimble R. Paediatric treadmill friction injuries. J Paediatr Child Health 2009;45(May (5)):310–2. [20] Fraser JF, Choo KL, Sutch D, Kimble RM. The morning after the night before: campfires revisited. Med J Aust 2003;178(January (1)):30. [21] Cuttle L, Kempf M, Liu PY, Kravchuk O, Kimble RM. The optimal duration and delay of first aid treatment for deep partial thickness burn injuries. Burns 2010;36(August (5)):673–9. [22] Cuttle L, Kravchuk O, Wallis B, Kimble RM. An audit of firstaid treatment of pediatric burns patients and their clinical outcome. J Burn Care Res 2009;30(November–December (6)):1028–34. [23] Cuttle L, Pearn J, McMillan JR, Kimble RM. A review of first aid treatments for burn injuries. Burns 2009;35(September (6)):768–75.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
A prospective observational study investigating all children presenting to a specialty paediatric burns centre K.A. Stockton a,*, J. Harvey b, R.M. Kimble a,c a Centre for Children’s Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Australia b School of Medicine, University of Queensland, Australia c Stuart Pegg Paediatric Burns Centre, Royal Children’s Hospital, Brisbane, Australia
article info
abstract
Article history:
Aim and method: The aim of this study was to describe the mechanism of injury and outcome
Received 23 August 2014
of all children who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC) with a burn
Received in revised form
injury in the year 2013. A detailed proforma was completed prospectively at time of
16 September 2014
presentation to hospital.
Accepted 21 September 2014
Results: During the one year period, 758 children with a median age of 2 years 3 months presented with a burn injury. Overall, 12.7% of patients (n = 96) were initially treated as inpatients. Similarities existed between in and outpatients. Over half the children admitted
Keywords:
had a scald injury (53.1%). Whilst slightly higher than the outpatient scald rate of 43.1% there
Paediatric
was no statistical significant difference. However, there was a significant difference be-
Burn injury
tween inpatients and outpatients with respect to other mechanisms of injury. Contact burns
Outpatient
were under represented in inpatients (27.1%) compared to outpatients (44.5%), p < 0.05. In contrast, flame burns were over represented in inpatients, 11.5% compared to outpatients, 2.9% ( p < 0.05). Conclusion: Paediatric burns are a common cause of childhood injury. The majority of children present with small to medium sized partial thickness injuries and are managed as outpatients. In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention campaigns, data repositories must include detailed information regarding outpatient paediatric burns. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention
campaigns comprehensive demographic and information regarding mechanism of injury should be collected on all children presenting to a burns centre. Data repositories such as the Burn Registry of Australia and New Zealand (BRANZ) and the American Burn Association National Burn Repository
* Corresponding author at: QCMRI Foundation Building, Level 4 Royal Children’s Hospital, Herston Rd, Herston Queensland, 4029, Australia. Tel.: +61 7 3636 1278. E-mail address: [email protected] (K.A. Stockton). http://dx.doi.org/10.1016/j.burns.2014.09.018 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 476–483
primarily track only inpatient data. As such, little is known regarding the differences in epidemiology, aetiology or outcome of injuries between in and outpatients. While outpatient data has been reported for combined adult and children populations [1,2], mechanisms are known to differ between these groups and there is a paucity of similarly comprehensive paediatric data [3–6]. The aim of this current study was to describe the mechanism of injury, details regarding the injury occurrence, first aid received and surgical requirements of all patients who presented to The Stuart Pegg Paediatric Burns Centre (SPPBC) with a burn injury in the year 2013 and as such represents a complete summary of both inpatients and outpatients seen at a paediatric burns unit.
2.
Method
Burn data were prospectively collected on all children aged 16 years and younger who were seen at the Royal Children’s Hospital (RCH) in Brisbane, Queensland between January 1 to December 31, 2013 inclusive. Consent was obtained from parents/guardians. Ethics approval was obtained prior to commencing this study from the Children’s Health Services Human Research Ethics Committee, based at the RCH (HREC/ 08/QRCH/085) and University of Queensland Human Research Ethics Committee (2013001001). A detailed pro forma was completed at the time of presentation for both inpatients and outpatients including the following information: Demographic data. Events leading up to and surrounding the burn injury. First aid given, both at the scene and in hospital. Depth, site and body surface area of burns.
injury are included in the results, these children are excluded from the more detailed dataset inclusive of first aid, severity and re-epithelialisation. Contrasts and similarities between inpatients and outpatients are presented.
2.1.
Data analysis
Statistical analysis was performed using SPSS software (version 22). Mean and standard deviation for outcomes were calculated unless data were not normally distributed, in which case median and interquartile range (IQR) was utilised. Inpatient data were compared with outpatient data using Chi-squared test or Fishers exact test where appropriate. Mann–Whitney U test was utilised to compare age at presentation between groups. Two tailed p values of 10%, all of whom were admitted as inpatients on presentation. Four children suffered inhalation injuries (all from house fires and all inpatients). No fatalities were recorded. Flame and friction burns were most likely to be described as deep partial or full thickness and most likely to receive grafting, with scald injuries least likely to undergo grafting. Table 2 details frequency of grafting by mechanism.
3.5.
Location/activity and time of injury
There was little difference between inpatients and outpatients with respect to geographical location of injury. Overall, most injuries occurred at home (70.3%), with a further 11.3% occurring at other residences. Injuries while away on holiday represented 6.6% of the total, with 66.0% of these being while camping. Contact with hot coals was the most common injury sustained whilst camping and most commonly occurred over school holidays or long weekends. Of the injuries that occurred in the patient’s usual residence, 53.5% were in the kitchen. Injuries that occurred at another residence – 36.3% occurred in the kitchen and 31.3% in the garden. More than half (52.1%) of incidents were directly witnessed by a parent or carer. Reliable data for time of injury was available for 84.1% of
Table 1 – Frequency and rates of admission by four most common mechanisms of burn injury – scald, contact, friction and flame. Overall percentage is calculated from the whole cohort presenting to SPPBC inclusive of chemical, cooling, radiation and other. Injury type Scald Contact Friction Flame
N
Overall %
% of injury type admitted
% of overall inpatients
% of overall outpatients
321 305 38 29
44.4 42.2 5.3 4.0
15.8 8.5 7.9 37.9
53.1 27.1 3.1 11.5
43.1 44.5 5.6 2.9
480
burns 41 (2015) 476–483
Fig. 4 – Mechanism of injury – comparison between inpatients and outpatients. Percentage of presentations for total group, inpatients and outpatients for the most common mechanisms of injury treated at SPPBC. Data is presented as percentage of each particular group, for example vehicle exhaust is 5.1% of total presentations, 8.3% of inpatient admissions and 4.6% of outpatient admissions.
children. A large percentage of burn injuries occurred between 6 and 9 PM (32.6%), Fig. 5, with the highest incidence of burns on Sunday and Saturday. January reported the most burns cases (n = 92), followed by October (n = 81), with the fewest cases presenting in June and August (n = 46) (Fig. 6).
3.6.
First aid at the scene of injury
Appropriate first aid following burn injury was defined as 20 min of cold running water (CRW) delivered either continuously
Table 2 – Number and percentage of burns grafted by mechanism of injury. Cause
Mechanism
Grafts na
Total n
% grafted
Flame Friction Contact Flame Friction Flame Scald
House fire Vehicle or motorbike Vehicle exhaust (all) Lighter/matches Treadmill Candle Water from hot water bottle Water from tap/bath/ shower/basin/bucket Water from saucepan/ kettle Coals/ashes Fat/oil Food Hot beverage Other
4 5 18 3 5 2 2
5 9 40 7 12 5 5
80.0 55.6 45.0 42.9 41.7 40.0 40.0
5
21
23.8
7
52
13.5
5 2 6 7 8
39 16 80 132
12.8 12.5 7.5 5.3
Scald Scald Contact Scald Scald Scald Other
a Grafts equates to actual patients – there were a total of 86 grafts on 79 patients.
or in total within 3 h of injury. Data were collected regarding first aid management at the scene of injury by patients and carers, 79.8% of patients were given some CRW, with 33.6% receiving 20 min. In 26.0% (n = 188) of cases, first aid provided at the scene included treatments other than CRW. When alternative therapies were used, 66.5% (n = 125) occurred in combination with cool running water, however in 63 cases these treatments were used in isolation. The most common alternative treatment used was ice in 76 cases, followed by a cold cloth (n = 31) or submerging the injured region in non-running water (n = 24).
3.7.
Theatre cases
In 2013, 13.7% of patients new to the centre underwent a procedure in theatre, with 185 procedures performed on 99 patients. During this period, 79 patients underwent split skin grafting (SSG). Time from injury to first SSG was a median time of 12 days (IQR 8.75–17.5). Fifty-two percent of inpatients underwent at least one procedure in theatre, whereas 8.9% of those managed as outpatients went on to require surgical intervention (predominantly SSG and primarily managed as a day procedure). In addition five children were admitted following initial management as an outpatient for social or feeding issues. Thus 9.7% of children initially treated as outpatients had an inpatient stay at some stage in their care.
3.8.
Outpatient appointments
Between January and December 2013, 2483 outpatient appointments were attended by 908 patients. Of these appointments 1926 were for 723 patients new to the department in 2013. The median number of appointments was 2 (IQR: 2–4), ranging between 1 and 15 appointments per child.
burns 41 (2015) 476–483
481
Fig. 5 – Time of injury where known showing increased incidence around the evening meal (n = 608). Injuries occurring between 6 p.m. and 9 p.m. Time of injury was available in 84.1% of cases.
Of the outpatient appointments, 557 were reviews of patients who sustained a burn injury prior to January 1,2013. In total 313 patients presented for review of injuries sustained before 2013, with 232 being seen once only for annual review. The mean number of appointments for these patients was 1.6 (sd = 1.40).
3.9.
Re-epithelialisation
Time to healing was defined as the number of days following injury when the burn consultant clinically evaluated the wound as being >95% re-epithelialised. Median time to re-epithelialisation was 10 days (IQR: 7–17). Following wound re-epithelialisation, 81.2% of patients were discharged from the SPPBC, whilst 18.8% required ongoing scar management.
4.
Discussion
The vast majority of paediatric burn injuries are small to moderate size and are managed as outpatients [2,3]. Despite this, the majority of studies reported in the literature only describe burn injuries requiring admission to hospital [2]. Thankfully, clinicians treating paediatric burns are increasingly identifying the need for data regarding all presentations including outpatient paediatric burns and a limited number of papers have recently been published. Brown et al. [3] provided a retrospective report on the contrasts between paediatric in and outpatients over a three year period at a Ohio Burns Centre. Demographic information, burn severity and scar management requirements were included. However, detailed information regarding the mechanism and scene of injury was
Fig. 6 – Frequency of burn injury by month of the year.
482
burns 41 (2015) 476–483
not included which is vital to inform future injury prevention campaigns. A retrospective study by Verey et al. [4] details time of day and seasonal variations in paediatric burn injury in the United Kingdom. Kemp et al. [6], conducted a prospective multicentre cross-sectional study of children with burn injury. Similar to our study and that reported in the literature hot beverage scalds were the most common mechanism of injury. However, in contrast, Kemp et al. reported a much higher rate of burns caused by hair straighteners and irons and a much lower number of children sustaining contact burns from motorbike exhausts than in our study. This is likely reflective of the climatic differences between the United Kingdom and Northern Australia. This highlights the importance of comprehensive local data to enable targeted injury prevention. Our study is the first Australian study to comprehensively report on both inpatients and outpatients in the management of paediatric burns. The initial admission rate of 12.6% at this burns unit is similar to that reported elsewhere [3] [8]. Data repositories such as BRANZ collect data on children admitted for greater than 24 h and those patients who are initially managed as outpatients and subsequently proceed to have a burn wound care procedure (e.g. split thickness skin grafting). Thus if solely relying on national burn repositories for paediatric burn data, over 80% of children presenting with a burn injury would not be included in the data set. A major strength of this study was the prospective design and inclusion of all presentations to a paediatric tertiary burns referral centre thus providing a comprehensive, accurate picture of paediatric burn injury. This study demonstrates that similar to Brown et al 2014 [3], whilst the majority of injuries seen at an Australian burns centre are not life-threatening (there have been no deaths due to burn injury at our centre over the last decade), with the majority healing in under two weeks, the burden on the child and family can be significant. Studies carried out at our centre have demonstrated that following burn injury there is a risk of post-traumatic stress disorder and delayed healing due to pain and anxiety regardless of whether the child was treated as an inpatient or outpatient [9–11]. Males accounted for approximately 60.0% of cases. A similar gender distribution has been noted in studies conducted in developed countries [3,4]. In contrast, a higher proportion of females are recorded in studies based in the Middle East [1]. Consistent with Australian inpatient data, the proportion of males in our study increased beyond 10 years [12]. This age group also saw an increase in both flame and friction burns approaching rates seen at adult centres [12]. Scald injuries were the most common mechanism of injury for both inpatients and outpatients. Contact injuries were statistically more likely to be treated as outpatients, with flame injuries treated as inpatients 11.5% of the time despite representing only 4.0% of all injuries. The most common mechanism of injury for a contact burn treated at our centre was hotplate on stove, none of these children were admitted thus would not be reported in the majority of data repositories. Relying on inpatient data alone risks under or over estimating the true frequency of particular mechanisms of injury. To our knowledge, this study is the first to compare the rates of grafting for specific aetiology of paediatric burns. Treadmill injuries required grafting in 41.7% of cases. These
injuries commonly affect the hands of the 2–3 year age group and represent a specific risk for this group. Burns from vehicle exhausts, flame and vehicle friction burns represented a high risk of requiring grafting and thus may benefit from early transfer to burns centres and surgical admission. The site of injury changes with the age of the child. Below 12 months, hand and upper limb injuries predominated consistent with international data [13]. Lower limb injuries, particularly in boys were the most common site of injury after age 10. This increase is partially attributable to an increase in exhaust injuries which accounted for 12.1% of all injuries in this age group. Of which 81.8% were boys. Knowledge regarding specific mechanisms of injury and affected age groups allows targeted injury prevention programs to be developed. The majority of paediatric burns result from preventable domestic accidents. An increased risk of childhood burn injuries corresponds with times of food preparation [14], with 6–9 p.m. being most common in Queensland. In Queensland, the majority (70.3%) of burn injuries occurred at home, similar to that reported in the literature [4,8,15–17]. Information on the cause, location and time of occurrence of these accidents allows campaigns to be developed to combat them. Similarly, targeting of specific, aetiologies such as appropriate protective clothing to prevent motorbike exhaust burns [18], guards for treadmills [19], correct extinguishing of camp fires [20] and cool touch ovens [6] may reduce the overall morbidity and associated costs of these injuries. Early first aid with cool running water has been shown to reduce the severity of burns [21]. Only a third of children received adequate first aid at the scene of injury. Whilst this is a big improvement on the 12% reported in a previous study at our centre in 2005 [22], there is still obviously room for improvement. A quarter of children received treatments not recommended and potentially detrimental (such as ice) which suggests a possible area for targeted intervention [23]. Education targeting first aid at home has the potential to increase the number of children achieving appropriate therapy at each step and boost the overall number of children receiving cold running water. Paediatric burns are a common cause of childhood injury. The majority of children present with small to medium sized partial thickness injuries and are managed as outpatients. All of these injuries are preventable. In order to understand the true impact of paediatric burn injury and to develop appropriate targeted injury prevention campaigns, data repositories must include detailed information regarding outpatient paediatric burns.
Conflict of interest None.
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