LETHALITY AT CHILDREN WITH HEAVY HEAT INJURY

V.A. Shalygin, D.D. Melnik, A.V. Shalygin

Siberian State Medical University, Tomsk, Russia

Introduction. The problem of treatment of heat injury attracts more and more attention of experts of different profile, confirming its interdisciplinary value. It is caused by the increase in number of burn injuries of the severest degree, the increase in material costs for treatment which ends with a failure or disability quite often [1,13]. According to the World Health Organization (WHO) and Children's Fund of UN (UNICEF), the rate of children’s death of heat injuries took the 3rd place among all traumatic factors after accidents on roads and drowning [3]. The problem of lethality is the most actual at children with critical heat injuries of any degree exceeding 20% of the surface of body, or burns of the IV degree more than 10%, any burns of eyes, face, ears, hands, legs and perineum, burns of respiratory tract at accompanying heavy damages and diseases [8]. Therefore the study of the reasons for lethal outcomes, identification of mistakes in assistance to patients with burns, search of ways of decrease in failures among victims with extensive thermal lesions represents practical interest for the doctor.

Main part. Material and research methods. During 1998-2013, 294 patients aged from 8 months till 16 years, with an area of burns more than 20% of body surface were treated in intensive care department and reanimation of children's city hospital №4 in Tomsk. During this period 20 children died, the lethality in this group made 6.8%. They comprise 12 (60%) boys and 8 (40%) girls, aged from 10 months till 14 years, with an area of burn wounds of 49,3±1,5% (from 30 to 80%) body surfaces. The median age of patients with lethal outcomes made 3 years (interquartile interval is10 months – 14years). At 14 victims burn is got by hot liquids, 6 cases were characterized by combined defeat of plamenevskiia of thermoinhalation injuries of lungs. All patients got infusion – transfusion, respiratory, antibacterial therapy, nutritive and inotropic support, anesthesia and local treatment of wounds.

Children with an extensive thermal trauma were estimated by features of assistance, intensity of syndrome of systemic inflammatory response, biochemical researches, microbiological blood picture. 65 patients from intensive therapy department and reanimation of children’s hospital №4 in Tomsk were examined for aggregative state of whole blood with the help of the device ARP-01 "Mednord" (non-governmental organization «Mednord», Tomsk, Russia). Blood volume for research is 2 ml. The main stages of a fibrillation, processes of a retraktion and grume lysis were fixed. Blood sampling was done right after hospitalizing, then in the morning, on the 1-3rd and the 5-7th days after receiving a trauma. Patients were divided into two groups. The first group included 45 patients with a favorable outcome of a burn disease, the second comprised 20 patients with a lethal outcome. 45 children aged from 1 year till 15 years belonging to the 1st group of health were examined for defining normal indicators of aggregate state of blood for the child population of Tomsk. Results of researches were processed on computer IBM/PC with the help of standard statistical packages ("SPSS-11.5 forWindows" and Excel). Mann — Whitney — Wilcoxon U–test and student’s t-test were used for defining the statistical importance of distinctions of continuous quantities. Continuous variables are presented as М±m (a selective average ± an error of the mean). In this research the critical level of "р" was used where it didn't exceed 0,05 (р< 0,05). It meant the reliability of the received differences.

Results and discussion.

One of criteria of an assessment of adequacy and efficiency of treatment is lethality at a certain type of a trauma. At the same time the lethality indicator at a thermal trauma at children depends not only on quality of medical process, but also on the number of other objective and subjective factors, and first of all on injury severity. Localization of burns influences on the outcome of a burn disease. Injured children with lethal outcomes, according to our data, have combined defeats of various parts of body. So, head and upper extremities was the most frequent localization of injuries of skin – 10 patients, rarer is the upper extremities and trunk – 6 children, and the rarest case is head, neck, trunk and lower extremities –4 patients. Such localization of burn wounds, apparently, causes heavier current of burn disease, and leads to the development of pneumonia which was stated at 16 people on autopsy.

As our observations showed, the lethality depends on the area of burn defining the severity of current and the outcome of burn disease. At burns of 30% of body surface the lethal outcome came at 2 patients, at burns from 30 to 45% - at 4 patients, from 45 to 50% - at 2, from 50 to 60% - at 4, more than 60% - in 8 cases. 12 children had extensive burns over 50% of body surface.

Children of preschool age got the most extensive burns more often. In our research this group was presented numerously. So, the lethality among separate age groups comprised: till 1 year – 2 patients, from 1 year to 3 years – 10patients, from 3 to 4 years – 4patients, from 10 to 12 years – 2 patients, from 12 and older - 2 patients.

The severity of injury, the terms of entrance of the patient into medical specialized institution, the quality of medical care on pre-hospital stage, complications have a certain impact on lethality indicators at heat injury [2,13,15].

Such factor as the terms of entrance of the patient into medical specialized institution, i.e. an interval from the moment of receiving a trauma to the beginning of adequate treatment (pre-hospital time) plays an important role in defining the outcome at children with a heat injury. The most favorable term of the beginning of adequate treatment for patient is the 1^st -2^nd hour after receiving a heat injury [4,13,15]. Four patients were transported from rural hospitals of the Tomsk region 17 - 96 hours after the moment of receiving an injury. Patients were delivered in a poor condition after carrying out antishock therapy on places. The average pre-hospital time of patients transported from the regional center and nearby regions of oblast made 1hour 20 minutes ±40 minutes (30 min. – 2 hours 30 min.). Entering the children's hospital № 4 in Tomsk 1 day later after receiving trauma even if an antishock therapy was carried out in rural hospitals, reduced the chances of favorable outcome of thermal trauma considerably. In our opinion, such conditions cannot be met always taking into account the peculiarities of the territory of the Tomsk region where there is a considerable remoteness of the majority of rural hospitals from the regional center, insufficient development of highways and sharply continental climate, not allowing to provide patients with hi-tech help. In this regard, qualified and specialized aid was given some hours later after receiving trauma. Similar situation was registered in Sverdlovsk and Tyumen regions, as S.P.Sakharov reports with co-authors [13].

We noted the daily volume of infusion therapy which was inadequate to severity of injury: so, the volume of infusion therapy prescribed to 4 patients in the departments of rural hospitals was always less, and comprised in average 3.70±0.15 ml/kg/h, whereas in the resuscitation and intensive therapy department of the hospital № 4 of Tomsk – 10,60±2,44 ml/kg/h (p<0,05). Similar disturbing tendency of "underestimation of the condition severity of a patient at hospital entrance and insufficient hydration in unspecialized hospitals" is noted by S.P. Sakharov with co-authors [13]. At patients with lethal outcome a day after hospital entrance and the beginning of intensive therapy, the condition remained very severe. 4 patients had a vomiting with blood impurity. Hourly dieresis at 9 patients in the period of hospital entrance was equal 3.25±0.4 ml/kg/h. However, 10 patients had an anury – there were no dieresis more than 12 hours from the moment of receiving a burn trauma, and one patient had dieresis equal to 0.61 ml/kg/h. The average duration of shock made 22.7±3.4 hours (20–74). Early necrectomy as the method of surgical treatment of burn wounds of patients in children's hospital No. 4 of Tomsk wasn't applied to present day. Multidirectional approach for preventive application of ALV was marked: the majority of children were put on ALV, as a rule, only after the development of the expressed signs of respiratory failure. An average time of putting on ALV comprised 34.2±6.9 hours (1 - 92 hour), however the area of defeat over 30% is the indication for preventive transfer ALV [6, 7].

The last decade, in the Tomsk region children die in the period of burn toxaemia, but not in the period of burn shock. In 1998-2001, 6 children had lethal outcomes in the period of burn shock. According to our data, 6 children lived to 3 days, 10 children – to 8 days, 4 children died during burn toxaemia. It emphasizes the efficiency of such moments in therapy as preventive artificial pulmonary ventilation, infusion therapy with application of modern colloids (hydroxyethylstarches), restriction of transfusion therapy, early nutritive support. The reserve of decrease of lethality rate at a thermal trauma of children is, in our opinion, the period of late terms – multiple organ failure and septic complications. In these terms provided burn wounds closing with autografts or synthetic coverings, processes of recovery can start earlier. Dynamics of lethal outcomes at children with extensive thermal defeats during 1998-2013, is presented in pic.1 which shows, that there were no lethal outcomes in children's hospital No. 4 in Tomsk during the last 3 years (2011-2013).

Pic.1. Children’s lethal outcomes at severe burns during 1998-2013.

Efficiency of carrying out intensive therapy was compared according to some criteria: existence of number of cases of SIRS development, early sepsis and complications of a burn disease. The heavy thermal trauma was accompanied by the development of organ dysfunction, and involvement of two and more bodies led to the development of syndrome of multiple organ failure which was present in both groups. So, organ dysfunctions of 2-3 bodies (2.33±0.17) systems prevailed in the group with a favorable outcome, and sepsis was verified at 35% of patients. In group of patients with a lethal outcome the development of specific dysfunction in the first days is noted – neurologic, cardiovascular and respiratory dysfunctions prevailed. The second and next days are marked by prevalence of hematologic and renal dysfunctions that emphasized severity of thermal trauma - 5,3±0,1 (4–7) systems. Sharp respiratory failure, in the form of ARDS was the indication for prosthetics of respiratory function. Our data coincide with data by S.P. Sakharov with coauthors [13]. Sepsis, along with bacteremia, was diagnosed during lifetime for 15(75%) patients of this group. Bacteremia is revealed by us at 12 patients (60,6%), i.e. at every second patient. Among activators Ps was in the lead. Aeruginosae – 8 cases (40%), on the second place was S. Aureus – 6 positive results (30%), the third place was taken by Acinetobacter revealed at 4 people (20%), further there were Enterobacteriacea family activators – 1 case (5%) and Klebsiellae – 1 case (5%).

Reserve of decrease in a lethality at a thermal trauma at children is, in our opinion, the period of heavy burn shock and the period of a burn toxemia which are accompanied by essential pathological changes in all links of a hemostasis, the speed and the development severity of which are closely connected with an outcome of a burn disease [13,14]. It is possible to look at this category of patients from the point of view of changes of their hemostasis.

According to the results of hemostasis study patients were divided into two groups. The first group included 45 patients with a favorable outcome of a burn disease; the second group included 20 patients who died in different stages of a burn disease: 6 – in the period of burn shock, 10 - in the period of a sharp burn toxemia (5-8 days after a thermal trauma), 4 - in later terms. In real time the graphic curve was constructed, chronometric and amplitude indices were calculated and estimated. On the basis of our own experience, as criterion for assessment of a condition of initial phases of a fibrillation and intensity of activation of system of hemostasis the coagulation constant "by r + k" — the sum of the period of reaction and the thrombin constant, equal according to the data obtained in group of control - was chosen to 10.97±0.19 minutes. If during hospital entrance value of the index "r+k" was less than 6 minutes, it corresponded to burn shock of the 3 degree [12]. The development of frustration of hemostasis on hypercoagulation type formed the basis for carrying out operated hypocoagulation [9, 11].

Table 1

Dynamics of an integrated indicator "a constant of coagulation r+k" (min.) in the group with a favorable and lethal outcome (М±m)

Groups	Entrance	A day later	3 days later	5-7 days later
Control	10,97±0,19	10,97±0,19	10,97±0,19	10,97±0,19
Patients with favorable outcome (n=45)	5,88±0,20*	7,70±0,49*	7,42±0,20*	9,06±0,44*
Patients with lethal outcome (n=20)	4,68±0,58**	5,46±0,34**	6,88±0,33**	6,74±0,20**

* - reliability of differences in comparison with normal indicators, р<0.05.

** - reliability of differences between groups of research, р<0.05.

According to the dynamics of an indicator "r+k", high pro-coagulative potential was seen to remain at patients with lethal outcome throughout the sharp period in the hemostasis system, and the group of patients with a favorable outcome of burn trauma was characterized by gradual recovery index against a background of operated hypocoagulation and volume corrected therapy (tab. 1).

Differences in the functional condition of all components of hemostasis and, in particular "r+k" indicator, in compared groups of children with severe burns during entrance, a day later, 3 days later, and 5-7 days after the beginning of intensive therapy of shock and a toxemia, were becoming even more significant. The group of patients with favorable outcome of a burn disease was characterized by the signs of relief of hemostasis disorder and reliable tendency to the restoration of coagulation constant. The patients with lethal outcome of thermal trauma, in considered terms, had hemostasis disorder in progress, despite intensive therapy: hyper - hypocoagulative syndrome held out, there were progressing clinical symptoms of multiple organ failure.

All dead patients had critical deep burns more than 30% of body surface. Six patients died in shock. Changes in the internal, found on autopsy, were various. Almost all dead patients (18 of 20 patients) had hypostasis of brain substance and pia mater. There was a plethora of vessels and the microthrombi, loosening and hypostasis in pia mater. In brain tissue there was uneven blood volume, capillaries spasm and arteriole. These changes, it is frequent (at 16 of 20), were replaced by dystonia and hyperemia of small vessels in which sludge and stasis of blood corpuscles were found. Bronchus of lumen in lung tissue are narrowed, teethridge are fallen down, dilated in some places. Capillaries of interalveolar septum were full-blooded. The diagnosis of pneumonia was verified at 16 patients. With thermoinhalation injuries of lungs, 6 patients had parts of soot of black color and concentrated epithelium in small bronchial tubes. Partial dystrophies of myocardium, liver and kidneys were frequently found at autopsy. In the mount of heart there was cloudy degeneration of cardiac hystiocyte. Capillaries and small vessels of heart were full-blooded. There was a decrease in concentration of a glycogen up to its total disappearance with expressed hyperemia of capillaries and small vessels. Dystrophy and necrobiosis of epithelium of convoluted renal tubule were found in kidneys. Homogeneous or light pink mass was found in the lumens of glomerule capsules. Even patients who died on the 3d -5th -8th day after a burn had these changes. Dystrophy of specified organs was not found only in one case - death of 13-year-old patient in the first day after burn. The most evident changes were found in gastrointestinal tract. Erosive gastritis, duodenal ulcer, bleeding from stress ulcer [Curling's], expressed enteroparesis were diagnosed. Russian clinical physicians and pathologists [5, 10, 2] connect all these disorders found in organs on autopsy at children with extensive burns with disorder of intravascular coagulation or disseminated intravascular coagulation of blood.

Thus, underestimation of the severity of the condition of a patient during entrance into unspecialized hospital, volume and quality of infusion therapy deserved purposeful correction. The most numerous group of children with lethal outcomes are patients with an area of lesion over 50% (12 cases - 60%). Such burn can be considered critical.

Conclusion.

The results of scientific researches, improvement of methodology of therapy of burn disease with use of methods of efferent therapy in the conditions of operated hypocoagulation allowed reconsidering the indications to transfusion of donor blood products, to reduce hospitalization time due to the reduction of the number of superlative complications and improvement of quality of treatment. The lethality in group of patients with an area of lesion more than 20%, made 6.8%. The most numerous group of children with lethal outcomes are patients with an area of lesion over 50% - 12 cases (60%). Such burn can be considered critical.

The retrospective analysis showed that 20% of children with the extensive burns transferred to hospital in late terms from the moment of trauma had a higher risk of infectious complications and percent of lethal outcomes, due to not enough antishock therapy. Timely adequate respiratory, antishock and antibacterial therapy with objectifying of a burn shock allowed carrying out surgeries depending on the severity of the condition of patients. It is necessary to note, that there were no lethal outcomes during 3 years (20011-2013).

Thus, the use of new technologies in clinical practice in diagnostics and treatment of children with a heavy thermal trauma allowed lowering lethality during the considered period of work.

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