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Volume: 1 Issue: 4 December 2021

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ARTICLE
Treatment of the Pediatric Patients With Fire Injuries

ABSTRACT

OBJECTIVES: Among children, adolescents are most at risk of burns from fire. These occurrences are often associated with unsafe behavior and experiments with fire, flammable materials, and explosive materials. In this report, we have presented our experiences with treating children severely burned by fire.
MATERIAL AND METHODS: Our study involved 5 cases of children who were burned by fire over the past 2 years.
RESULTS: Ages of the children ranged from 2 to 17 years, and patients were exclusively boys. Burn area ranged from 10% to 47% of total body surface area and were deep second-degree B and third-degree burns. All children required staged surgical treatment, including excision of necrosis, temporary wound closure with skin substitutes, and then split thickness skin grafts. Hospitalization time ranged from 3 to 23 weeks. All patients were discharged home with wounds healed. After discharge, outpatient rehabilitation with the use of physical therapy, compression therapy, and laser therapy were initiated.
CONCLUSIONS: The applied treatment enabled the patients to fully return to physical well-being and normal social functionality.


KEY WORDS: Adolescent, Burns, Child, Flame, Scars

INTRODUCTION
Among burn injuries, about 3% involve pediatric patients, and these mostly occur between the ages of 0 and 3 years. Causes of burns in the pediatric population depend on age. The youngest children mainly have scalds and contact injuries. However, in adolescents, fires become the most frequent cause of burns. These injuries are often the result of irresponsible and risky behaviors.

Fire burns, due to their severity, usually require a multidirectional approach, with surgical treatment that includes debridement, specialist dressings, and skin transplant, as well as intensive care with fluid resuscitation, renal replacement therapy, and nutritional support. Patients with severe fire injuries also need prolonged rehabilitation because of scars and contractures.

MATERIALS AND METHODS
Our study included 5 patients with fire injuries who were treated during the past 2 years in the Uppersilesian Child’s Health Centre (Katowice, Poland). All patients were male, with ages that ranged from 2 to 18 years.

RESULTS
All presented patients were burned by various sources of open fire. The depth of the burns was assessed as second- and third-degree, and the area ranged from 10% to 47% of total body surface area (TBSA). Fortunately, none of the children had airway burns. Two children required treatment at the intensive care unit for 16 and 112 days, respectively. The length of stay in the hospital ranged from 17 to 127 days (mean of 51 days). All patients were discharged home with wounds healed. The most important clinical data are summarized in Table 1.

Patient 1
Patient 1 was a 3-year-old boy with severe burns as a result of self-ignition of the car seat in which the child was fastened; the patient had extensive third-degree burns. The burned area covered occiput, the dorsal part of thorax, the lumbar region, both buttocks, and the posterior surface of both lower limbs, with at least 47% of TBSA (Figure 1).

The serious condition of the patient caused admission to the intensive care unit (ICU). Intensive treatment included mechanical ventilation, fluid resuscitation, and catecholamine infusion. Because of later development of renal failure, renal replacement therapy was also required.

The necrotic tissues were deeply resected during the first 72 hours after injury. Half of the burned area was covered by autologous skin grafts. A deficit of donor area caused the need to close the remaining wounds in a different manner. A bilayer synthetic dermal matrix was applied for temporary closure of wounds. Later, the matrix was the basis for autologous skin transplant. The procedure allowed for time needed for donor sites to heal before subsequent skin donation. It also caused the restoration of the damaged layer of the dermis.

Healing of burn wounds was complicated by infection with Aspergillus fumigatus, which necessitated additional procedures, including wound cleaning, specialist dressings, and subsequent skin grafts.

During his hospital stay, which lasted 127 days, the patient required a total of 86 surgical procedures to heal all burn wounds.

After discharge to home, the patient began intensive rehabilitation and scar treatment. A combination of pulsed dye laser (PDL) therapy, compression therapy, physiotherapy, and steroid injections was applied. After discharge, the scars were scored 12 points on the Vancouver Scar Scale; after the applied treatment, there was a decrease to 5 points (Figure 1). Although treatment is not yet completed, the patient has regained full physical mobility with no contractures or skeletal deformations.

Patient 2
A 10-year-old boy was admitted to the emergency department due to extensive burns caused by explosion of oxyacetylene container in his father’s workshop. At arrival to the emergency department, second-degree 2A/2B burns of 45% of TBSA were shown. The affected area covered the face, dorsal part of the trunk, right upper area, and both lower limbs (Figure 3). On admission to the hospital, the boy’s general condition was good, but the burns were not as severe because the child was thrown into a garden pool by his father immediately after the explosion.

Surgical treatment started with debridement with use of VersaJet II. Temporary wound closure was obtained with use of silver dressing. Unfortunately, during the treatment, allergic reaction to silver was observed. The patient required removal of the silver dressings and application of Suprathel. In the following days, autologous skin transplants were performed. Although the initial result was good, wound healing became prolonged as a result of a mental breakdown due to death of the patient’s father in the same accident. The patient was hospitalized for 53 days.

Outpatient rehabilitation began immediately after the patient was discharged home. It included PDL therapy, compression therapy, physiotherapy, and steroid injections. Efforts of the team and the patient improved the scars from 9 to 4 points on Vancouver Scar Scale (Figure 4).

Patient 3
A 12-year-old boy was harmed by a schoolmate with a homemade flamethrower. This resulted in second- and third-degree burns of face, neck, and thorax. Burns covered almost 10% of TBSA (Figure 5).

Debridement was done with VersaJet II, and split thickness skin grafts were performed. Wound healing was successful, and the patient was discharged home after 17 days.

Scar treatment started with PDL therapy followed by microneedling. A good treatment effect was obtained, with reduction from 8 to 2 points on the Vancouver Scar Scale (Figure 6).

Patient 4
A 14-year-old adolescent boy presented with second-degree and third-degree burns, which covered 30% of TBSA. The burned areas affected the face, neck, anterior part of trunk, and all extremities (Figure 7). The patient had kicked a gas canister into a campfire. Because of parental ignorance, the boy presented to the emergency room on the next day. Parents brought the child to the hospital because of extensive blisters covering large surfaces of the body.

After admission to the emergency department, initial debridement was performed. There were no burn injuries to airways, and the patient was hospitalized in the pediatric surgery department, without need for ICU treatment. The child had been qualified for necrotic tissue resection and split thickness skin grafts to cover the burn wounds. Because of the extensiveness of burns, surgical treatment was divided into stages. Temporary dressings with ionic silver were used between subsequent procedures. The patient was hospitalized for more than 27 days. The boy’s attitude was important for treatment success. Burn wound closure and healing were obtained.

Scar treatment included 6 sessions of PDL procedures, followed by a combination of compression therapy and physiotherapy. The Vancouver Scar Scale score decreased from 10 to 5 points. The patient regained full physical mobility (Figure 8).

Patient 5
A 17-year-old young man initially diagnosed with schizophrenia was admitted to the hospital after a fire explosion. The patient had poured gasoline into the heating stove during his school workshop. Burn involvement was 21% of TBSA with second-degree and third-degree burns. The regions affected included the face, neck, superior part of the thorax, wrists, and hands (Figure 9).

Extensive burns of the face and neck area combined with massive edema and micrognathism required intubation and ICU treatment. There were no burns to the airways.

Surgical treatment consisted of debridement by tangential excision. Wounds over the face healed spontaneously after application of ointment dressing. The neck area required numerous necrotic tissue removal procedures combined with silver dressings. Despite these efforts, autologous skin transplant was required. Burn wounds on extremities were covered with Suprathel skin substitute. Proper epithelialization was observed. The patient was discharged from the hospital with his wounds almost completely healed and is currently undergoing outpatient rehabilitation (Figure 10).

DISCUSSION
Epidemiology of burns among children can greatly vary and can depend on such factors like the inhabited region and the social status of the family. In low- and middle-income countries, fire burns are most often associated with activities like cooking or heating homes. In high-income countries, burns with fire, especially among adolescents, are caused by irresponsible behavior, such as playing with fire and explosives.1,2

Burns caused by fires are worldwide major therapeutic problems. They are usually deeper and more extensive than other types of burn injuries. Respiratory tract burns are also common among victims of fires and explosions. Because of the extensiveness of these burns, multiorgan failure may develop. This necessitates long-term treatment in the ICU.3,4

Fortunately, among the patients presented in this report, there were no airway burns. Only 2 patients required ICU therapy, 1 because of multiorgan failure and the other for massive edema of the face and neck.

Most pediatric burns are superficial and heal spontaneously within 2 weeks. They require only conservative treatment. Deeper burns occurring from fires require numerous surgical procedures, including skin grafting and, in the case of extensive burns, the use of skin substitutes.5,6

These features were shown in our patients. All needed surgical debridement and autologous skin grafting. One child required skin matrix because of extensive burn wounds. Another problem related to fire burns is the possibility of extensive scars, which cause contractures and severe esthetic defects.

There are many options for treating burn scars. The best results are achieved by combining different methods of therapy. The use of laser therapy in combination with physical therapy and compression garments usually provides good results. Plastic surgery may be necessary for particularly severe scars.7,8

In our patients, the use of combination therapy based on PDL therapy, steroid injections, and compression therapy provided good results. In all patients, it was possible to avoid distortions and contractures and to obtain satisfactory esthetic results.

CONCLUSIONS
Treatment of pediatric patients with severe burns requires a multidirectional approach. The applied treatment enabled our patients to fully return to physical well-being and normal functionality in the society; however, all still required multi-specialist care and rehabilitation.

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Volume : 1
Issue : 4
Pages : 157 - 163


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From the 1Department of Paediatric Surgery and Urology, Uppersilesian Child’s Health Center, Katowice, Poland; and the 2Department of Paediatric Surgery, Medical University of Silesia, Katowice, Poland
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Anna Zioła, Oddział Chirurgii i Urologii, Górnośląskie Centrum Zdrowia Dziecka, ul. Medyków 16, 40-752 Katowice, Poland
Phone: +48 508 870 127
E-mail: amgziola@gmail.com