Children

The number of pediatric burn patients admitted to hospitals is influenced by cultural differences, resource availability, and medical practice. Consequently, the number of children admitted to hospital for burns treatment has varied by geographic area from a low rate of 4.4/100 000 population in America (North, Central, and South) to a high of 10.8/100 000 population in Africa. Although the incidence rate for Asia – 8.0/100 000 population – is similar to that for Europe and the Middle East, population size determines that Asia provides care for over half of the global pediatric burn population.³¹ It is currently estimated that 435 children aged 0–19 receive treatment in emergency departments for burn injuries, and that two children die with burn injuries each day in the United States.³²

It was estimated in 2004 that 116 600 children aged 14 and under were treated for fire/burn injuries in hospital emergency rooms in the United States.³³ Of those injuries, scald burns were more common in the younger children (<5 years) and flame burns more common in older children. Children under 5 years account for nearly all scald burn deaths.³⁴ Of the children age 4 and under who are hospitalized for burn-related injuries, 65% have scald burns, 20% contact burns, and the remainder flame burns.³³ The majority of scald burns in children, especially those age 6 months to 2 years, are from hot foods and liquids, particularly coffee which may be dispensed at temperatures of up to 180°F (82.2°C), spilled in the kitchen or other places where food is prepared and served.³⁴ Hot tap-water burns, which typically occur in the bathroom, tend to be more severe and cover a larger portion of the body surface than other scald burns. Consequently, such burns, which account for nearly one-quarter of all childhood scald burns, are associated with higher hospitalization and death rates than other hot liquid burns.³⁴ Ninety-five percent of burns in children due to the operation of microwave devices are scald burns resulting from the spillage of hot liquids or food.³⁴

In a study of 541 children with burn injury, 125 were considered to be cooking injuries. The patients with such burns were, on the average, older than those with scalds related to other mechanisms (i.e. toddlers vs infants).³⁵ The burns were typically caused by hot liquids spilling from a container on an elevated table or counter on to the child’s head, neck, and trunk. The authors call attention to the difference in cooling curves for the various substances and liquids involved, which they postulate influences the severity of the burn injury.

A recent review of the American Burn Association National Burn Registry records of all pediatric patients burned between 1995 and 2007 (46 582) revealed differences in burn etiology associated with age and race.³⁶ Fifty-four percent of the patients studied were Caucasian, but non-Caucasian populations incurred 54% of the burn injuries that occurred in children younger than 5 years. Scalding was a common etiology in older African-American, Asian, and Hispanic children, and significantly less common in Caucasians. The frequency of inhalation injury was highest in African-American children and lowest in Asian children. In 4.5% of the children the injury was reported to have been intentional, with the frequency in populations of color greater (greatest in African-American children) than in Caucasian children.

Among children 14 years and under, hair curlers and curling irons, room heaters, ovens and ranges, irons, gasoline, and fireworks are the most common causes of product-related burn injuries.³⁴ Nearly two-thirds of electric injuries in children aged 12 and under are caused by household electric cords and extension cords.³⁴ Contact with the current in wall outlets causes an additional 14% of such injuries.³⁴ Boys are at higher risk of burn-related death and injury than girls, and children aged 4 and under and children with a disability are at the greatest risk of burn-related death and injury, especially from scald and contact burns.³⁴ Heavy-for-age boys are more burn prone than their normal-sized counterparts. A retrospective study of 372 children admitted to a single burn center from January 1991 to July 1997 confirmed that boys who were large for age on the basis of weight or height were over-represented in the burn population.³⁷ Interestingly, that same study indicated that boys at or under the fifth percentile for weight, and both boys and girls at or under the fifth percentile for height were also over-represented among pediatric burn patients. The authors considered the latter finding to reflect, at least in part, the effect of concomitant malnutrition or neglect.

The occurrence of tap-water scalds can be prevented by adjusting the temperature settings on water heaters or by installing special faucet valves so that water does not leave the tap at temperatures above 120°F (48.8°C).³⁴ Thermostatic valves, which shut the hot water off if the cold water fails, are the most dependable.³⁸ The results of a survey in Denmark indicated that the kitchen, not the bathroom, is the most common site of burn injury (39% of burns).³⁹ Those burns were most commonly due to contact with hot liquids.

Home exercise treadmills represent another source of burn injury in children. These injuries are a consequence of contact with a moving treadmill, most commonly involved the volar surface of the hand, and in two-thirds of patients surgical intervention in the form of skin grafting was required.⁴⁰

A change in the pattern of pediatric burns in Australia to resemble that in the United States has recently been reported. A review of 3621 children treated at the Children’s Hospital Burns Unit at Westmead, NSW, Australia, indicated that scalds accounted for 56% of pediatric burns and that contact burns, which accounted for 31% of pediatric burns, had displaced flame burns, which accounted for only 8%, as the second most frequent cause of pediatric burns.⁴¹ As expected, contact burns were typically of very limited extent (99% < 5% TBSA) and only 12% required operative intervention. The most common objects causing contact burns were, in descending order, clothing irons, stoves, oven doors, gas or electric heaters, exhaust pipes, combustion heaters, and barbecues. The same authors from the Children’s Hospital Burns Unit reviewed the management of 97 children admitted for the treatment of burn injuries caused by contact with automotive exhaust systems during a 6-year period.⁴² The patients’ ages ranged from 5 months to 15 years and the exhaust systems contacted were those of motorbikes, cars, lawnmowers, and quad bikes. The injuries were most often sustained during the summer, and in 60% of cases involved 1% or less of TBSA, ranging in extent from 0.5% to 8%. Over 66% of the burns were on the lower limbs, with the calf being the part most frequently involved. Excision and/or grafting was necessary in one-third of the patients. The authors’ emphasized prevention by the use of protective clothing and placement of an insulated guard on the exhaust pipe.

The elderly

The elderly represent an increasing segment of the population, the members of which have an increased risk of being burned and higher morbidity and mortality rates than younger patients. A review of medical records of patients admitted to a burn center during a 7-year period revealed that 221 of 1557 (11%) patients admitted were 59 years or older.⁴³ Ninety-seven (44%) of that group were women, a reflection of the higher percentage of women in the elderly population. Two-thirds of the injuries were caused by flames or explosions, 20% by scalds, 6% by electricity, 2% by chemicals, and 6% by ‘other causes.’ Forty-one percent of the injuries occurred in the bedroom and/or living room, 28% out of doors or in the workplace, 18% in the kitchen, 8% in the bathroom, and 5% in the garage or basement. Seventy-seven percent of the patients had one or more pre-existing medical conditions, and 64 patients (29%) had smoke inhalation. In 57% of patients judgment and/or mobility were impaired. Ten percent of patients tested positive for ethanol and 29% for other drugs by toxicology screening. Survival advantage was conferred by younger age, absence of inhalation injury, absence of pre-existing medical conditions, and smaller burns.

Among 111 octogenarians admitted to a burn center between 1983 and 1993, scalds caused 32% of the burns, flames 30%, contact 29%, bath immersion 7%, electricity 2%, and hot oil 1%.⁴⁴ In 18% a disease such as a stroke was considered to be directly responsible for the burn injury, and in an additional 50% of the patients a pre-existing disease was considered to be contributory. The average length of hospital stay was almost twice that of younger adults, and rehabilitation of survivors was markedly prolonged.

Scalds are responsible for 33–58% of all patients hospitalized in the United States for burns each year.⁴⁵ Data from the NEISS-All Injury Program for 2001 to 2006 revealed that 51 700 adults aged 65 or over received care in emergency departments for non-fatal scald burns during that period, representing an annual frequency of 8620 and an estimated annual rate of 23.8 visits per 100 000 population. Three-quarters of the non-fatal scald injuries occurred at home, 42% were due to contact with hot food, and 30% were caused by hot water or steam. Two-thirds of the patients were women. The burns, which involved predominantly the upper and lower limbs, were relatively minor, with 7970 (93%) being treated and released and only 510 (6%) requiring inpatient care.

A recent review of 23 180 records in the American Burn Association National Burn Repository has characterized the epidemiology and outcomes of older adults with burn injury.⁴⁶ The mean extent of burn (9.6% TBSA) and the frequency of inhalation injury (11.3%) did not significantly vary among the age groups evaluated, i.e. 55–64 years, 65–74 years, and 75 years and over. Overall, there was a male preponderance of 1.4:1, but women dominated in the oldest age group. The length of hospital stay per percent of body surface burned increased with age, as did hospital charges, even though the number of operations per patient decreased. As the group age increased, mortality also increased, as did discharge to a non-independent status. The adjusted odds ratios for mortality as calculated by logistic regression were 2.3 and 5.4 in the 65–74-year age group and the 75-years and above group, respectively, using the 55–64-year group as the reference group. The authors reported that ‘mortality decreased dramatically after 2001’ in all three groups; that reduction was attributed to a tripling of patient entry into the registry since 2001.

Yin and colleagues characterized elderly burn patients treated at a Burn Center in Shanghai.⁴⁷ In 201 patients with a mean age of 69.3 years (range 60–90 years), the majority were men; flame was the cause of burn in 53% and scalds in 40%. Almost three-quarters (73.6%) of the burns were sustained in the home, and the median extent of burn was 12% TBSA. The areas most frequently involved, in decreasing order, were the legs, arms, head, neck, and hands. Surgical intervention was undergone in 87 patients and 16 (8%) of the entire group died. Morita et al.⁴⁸ contrasted the characteristics and outcomes in 35 patients of 65 years and over with those of 41 adult patients of lesser years. The average age of the elderly patients was 78 years, and 24 of the 35 had pre-existing comorbid conditions. Compared with the younger adult patients, the elderly had a higher incidence of accidental bath tub-related burns and a lower incidence of suicide attempts. ‘Severe burns’, defined as partial-thickness burns of 30% or more TBSA, or full-thickness burns of 10% or more TBSA, were fatal in the elderly patients.

The disabled

The disabled are a group of patients considered to be burn prone. The majority of burns in the disabled occur at home and are most often scalds. The effects of disability and pre-existing disease in those patients are evident in the duration of hospital stay (27.6 days on average) and the death rate (22.2%) associated with the modest average extent of burn (10% TBSA).⁴⁹ A report on burn injury in patients, generally elderly, with dementia has emphasized the need for prevention measures to reduce the incidence of burn injuries incurred when such patients are performing the activities of daily living.⁵⁰

Military personnel

In wartime military personnel are at high risk for burn injury, both combat related and accidental. Over the past six decades the incidence of burn injury, which is related to both the type of weapons employed and the type of combat unit engaged, has ranged from 2.3% to as high as 85% of casualties incurred in various periods of conflicts (Table 3.8). The detonation of a nuclear weapon at Hiroshima in 1945 instantaneously generated an estimated maximum of 57 700 burn patients and destroyed many treatment facilities, thereby compromising the care of those burn patients.⁵¹ In the Vietnam conflict, as a consequence of the total air superiority achieved by the US Air Force and the lack of armored fighting vehicle activity, patients with burn injuries represented only 4.6% of all patients admitted to army medical treatment facilities or quarters from 1963 to 1975.⁵² The majority (58%) of the 13 047 burn patients treated in those years were non-battle injuries, only 5536 (42%) being battle injuries. The overall incidence of burns as the cause of injury in all United States military forces in Vietnam during those years may well have been higher. Allen et al.⁵³ reported that during calendar years 1967 and 1968 a total of 1963 military burn patients from Vietnam were admitted and treated at a burn unit established in a United States Army General Hospital in Japan. In accordance with the data from US Army hospitals in Vietnam, the burns in 847 (43.2%) of those patients were the result of hostile action. In the Panama police action in late 1989, the low incidence of burn injury (only six (2.3%) of the total 259 casualties had burns) has been attributed to the fact that the action involved only infantry and airborne infantry forces using small arms weaponry.

Table 3.8 Incidence of burn injury in armed conflicts

a 34% of all casualties from ships. ^bData from Renz EM, MD, Col. MC, Director U.S. Army Burn Center, Institute of Surgical Research Brooke Army Medical Center Fort Sam Houston, TX, Personal Communication, July 18, 2011 and Directorate for Information Operations and Reports, Department of Defense. Available at: http://siadapp.dmdc.osd.mil/personnel/CASUALTY/eastop.html. Accessed July 20, 2011.

As exemplified by the Israeli conflicts of 1973 and 1982, and the British Army of the Rhine experience in World War II between March 1945 and the end of hostilities in Northwest Europe, the personnel in armored fighting vehicles have been at relatively high risk for burn injury.^54,55 Burns have also been common in war at sea. In the Falkland Islands campaign of 1982, 34% of all casualties from the British Navy ships were burns.⁵⁶ The increased incidence of burn injuries – 10.5% and 8.6% in the Israeli conflicts of 1973 and 1982, respectively, compared to the 4.6% incidence in the 1967 Israeli conflict – is considered to reflect what has been termed ‘battlefield saturation with tanks and anti-tank weaponry.’^54,57 The decreased incidence of burn injuries – 8.6% in the 1982 Israeli conflict compared to the 10.5% in the 1973 Israeli conflict – has been attributed to enforced use of flame-retardant garments and the effectiveness of an automatic fire extinguishing system in the Israeli tanks.⁵⁷ Those factors have also been credited with reducing the extent of the burns that did occur. In the 1973 Israeli conflict, 29% of the patients with burns had injuries that involved 40% or more TBSA, and only 21% had burns less than 10% TBSA. In the 1982 Israeli conflict those same categories of burn represented 18% and 51%, respectively, of all burn injuries. Modern weaponry may have eliminated the differential incidence of burn injury between armored fighting vehicle personnel and the personnel of other combat elements. In the 1982 Falkland Islands conflict, in which there was little if any involvement of armored fighting vehicles, one of every seven and every six casualties in the British and Argentinian forces, respectively, had burns.^56,58 Conversely, there were only 36 (7.8%) burn casualties in the total 458 casualties sustained by US Forces in 1990 and 1991 during Operation Desert Shield/Desert Storm, in which there was extensive involvement of armored fighting vehicles.

In the current armed conflicts, Operations Iraqi Freedom and Enduring Freedom, the US Army Burn Center has provided care for all of the patients from all branches of the armed forces who sustained severe burns in the theaters of operation. Surgeons from the Burn Center have provided care at the Center and an Army general hospital in Landstuhl, Germany, at hospitals within the theaters of operation and during aeromedical transfers from the hospital in Europe to the Burn Center in San Antonio, Texas.

During the four-year period 1 March 2003–1 March 2007, 540 combat casualties with a mean extent of burn of 16.7% TBSA (range 0.1–95%) were admitted to the US Army Burn Center.⁵⁹ In 149 (27.6%) of the patients the burns involved more than 20% TBSA and inhalation injury was documented in 69 (13%). The burns were the consequence of an explosion in 342 (63%) of the patients, commonly due to detonation of an improvised explosive device (IED). The mean ISS was 16 or above in 169 patients as a reflection of significant associated injuries. Slightly more than half of the patients (51%) had mechanical trauma, most often fractures, in addition to their burn injuries. Even with the frequent presence of associated mechanical injury, only 30 (6%) of the patients died.

The 24 of the 540 patients who were burned while incinerating waste represented 10% of military burn casualties admitted to the US Army Burn Center.⁶⁰ Admission of 20 patients with such injuries during the first year of the study period prompted the distribution of a memorandum to military units in the theater of operations. This described the dangers associated with the burning of waste and articulated safety procedures. In the following year only four patients were admitted with such injuries, which represented a statistically significant decrease in the occurrence of such burns.

Aeromedical transport was used to transfer 380 (70%) of the 540 patients with combat-related burns from the US Army Landstuhl Medical Center in Germany to the Burn Center in San Antonio, Texas. Of these transported patients, 48% received mechanical ventilatory support throughout the transfer procedure. The burn patients accompanied by the Army burn flight team arrived at the burn center on average late on the third postburn day, with no in-flight fatalities.⁵⁹

Injuries caused by IEDs were characterized in a study of 100 consecutive combat casualties admitted to a British field hospital in Iraq during 2006.⁶¹ IEDs were the cause of injury in 53 of these, 12 of whom (23%), considered to have been in the trajectory of the exploding projectile, were either killed or died of wounds. Among the 41 survivors, only eight (15%) had burns and two (4%) had primary blast injury. Even though they were sited adjacent to the trajectory of the IED, all but one of the survivors had returned to military employment within 18 months.

Belmont and colleagues⁶² analyzed the injuries sustained by a US Army brigade combat team of 4122 soldiers deployed to Iraq for 15 months during the ‘surge’ phase of Operation Iraqi Freedom. There were 500 combat wounds in 390 casualties, 12 of whom had burns sustained in explosions. Seven of the burn patients, four with burns of 10–15% TBSA, were aeromedically transferred to a higher echelon of care.

In the past two years (1 July 2009 to 30 June 2011), as the intensity of the conflicts in Southwest Asia has decreased, the number of combat-related burns has decreased and only 93 burn casualties have been transferred and admitted to the Army Burn Center.⁶³ In that period, 79 (85%) of the burns were due to fire/flame, two (2%) were the result of scalds, and 12 cases (13%) had limited and scattered burns in the presence of complex soft tissue injury. During that time another 45 military personnel were admitted with burns unrelated to combat. In that group the burns were due to fire/flame in 35 (78%), scalds in five (11%), electricity in two (4%), and ‘other’ causes in three (7%). Overall, 1015 military patients have sustained burns in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) and received care at the Army Burn Center since March 2003. Those burns represent 2% of all combat casualties.⁶³

A report from the UK confirms the variable admixture of combat and non-combat burns in military personnel.⁶⁴ During the period 2001–2007 134 UK military personnel were evacuated to the Royal Center for Defence Medicine (RCDM) for the treatment of burn injury. The median age of the patients was 27 years and the mean extent of burn was 5% TBSA, range 1-70% TBSA. Sixty percent of the burns were unrelated to combat and were classified as ‘accidental’, e.g. sustained while preparing hot food and drinks, burning waste, or misusing flammable liquids. There was one fatal electric injury. During 2006–2007, 56 (59%) of the burn patients evacuated to the UK from Iraq and Afghanistan had burns sustained in combat. Those patients represented 5.8% of all combat casualties in the UK military during that time. Their burns were typically of limited extent (mean 5% TBSA) and these patients often had associated mechanized injuries. 25 or 26% of all the burn patients transferred to the RCDM during the study period underwent skin grafting. All of the evacuated patients survived.

In addition to military casualties, the infrastructure breakdown caused by armed conflict increases the injury burden in the indigenous population.⁶⁵ Information derived from a questionnaire survey administered in 1172 Baghdad households containing 7396 individuals indicated that the respondents could recall 103 injuries as having occurred during a specific 3-month period. Only four of those injuries were fire/burn-related and five were due to ‘electric shock’. In the current conflicts in Iraq and Afghanistan, up to one-third of the admissions to combat-support hospitals are for humanitarian or civilian emergency care. Analysis of 2060 children admitted to combat-support hospitals between 2002 and 2007 revealed that 204 (13.3%) of the 1537 injured patients had burns.⁶⁶ Almost twice as many children with burn injury were seen in the combat-support hospitals in Afghanistan as in Iraq. The care of such patients, which may revert to the military during armed conflicts, should be considered when planning combat medical support.

Although the risk of burn injury in the combat population is relatively high, the distribution of burn size in other than armored fighting vehicle personnel is comparable to that in the civilian population, i.e., more than 80% of the patients have burns of less than 20% TBSA. Even so, the number of burns that can be rapidly generated necessitates that planning for combat casualty care include augmentation of in-theater medical treatment facilities with personnel having burn-specific expertise, as was done by the US Army Medical Department in Operation Desert Shield/Storm.

Even in peacetime non-combat munitions incidents are common in the US Army. During a 7-year period 742 non-combat munitions incidents were reported in which 894 soldiers were injured.⁶⁷ The most common types of injury were burns, which occurred in 261 or 26.7% of all the patients injured. The high incidence of burn injury in military personnel in both war and peace will generate a subset of extensively burned patients who will require tertiary burn center care to ensure optimum functional outcome and maximum survival.