Differences in Assessments of Total Burn Surface Area Involving Children Transferred To A Burn Center for Treatment – Experience In Southern Brazil

Research Article

Thromb Haemost Res. 2022; 6(3): 1085.

Differences in Assessments of Total Burn Surface Area Involving Children Transferred To A Burn Center for Treatment – Experience In Southern Brazil

Saviatto LG, Picasky JP, Azevedo BBS, Feijó RS, Camacho JG, Soares FF and Pereima MJL*

Burn unit, Joana de Gusmão Children Hospital, Department of Pediatric, Federal University of Santa Catarina, Florianópolis, Brazil

*Corresponding author: Mauricio José Lopes Pereima Departament of Pediatric, Centro de Ciências da Saúde Universidade Federal de Santa Catarina, Campus Universitário David Ferreira Lima, Trindade - CEP 88040-900 Florianopolis - Santa Catarina - Brazil

Received: November 08, 2022; Accepted: December 17, 2022; Published: December 23, 2022

Abstract

Purpose: To analyze discrepancies between the evaluation of total body surface area (TBSA) of burn injuries involving children performed by clinicians at hospitals and clinics in southern Brazil before patients are transferred to a Burn Care Unit (BU) and the same evaluation by trained burn specialists, in order to determine the accuracy of burn size estimation and to evaluate clinical data to inform whether efforts to increase knowledge are warranted to optimize early management and treatment of burned pediatric patients.

Methods: This is an observational study in which data was analyzed involving burn patients transferred from regional hospitals and clinics for admission to Joana de Gusmão Children’s Hospital, located in the city of Florianópolis in southern Brazil, that maintains a BU for referral of pediatric patients. The analysis consists of comparisons between the estimated values of TBSA of the burn obtained from the “Transferred burnt patient form” completed by the referring clinician and values registered in patient records upon arrival at the BU. In addition, other quantitative and qualitative data, such as burn mechanism patient age, and whether resuscitation with intravenous (IV) fluids occurred, were collected to further inform management and treatment of the injuries.

Results: At the early assessment, there was overestimation of TBSA burned in 76.4% of patients (n = 39), 32 of those had a TBSA of less than 15%, and the mean TBSA estimate was 291% higher (p-value 0.0001). The 1-4 age group represented the largest group of patients, 56.4% (n =29), and the most common mechanism of burn was due to heated water in 60.8% (n=31) of the cases. There was correlation (p-value 0.014) between increased length of hospitalization and burn mechanism when the burn was caused by direct contact with fire or electric shock which resulted in patients staying for 26 ± 9.35 days. In addition, 66.7% of patients included in this study had been administered IV fluids at the city of origin prior to arriving at the children’s BU.

Conclusion: When the estimate of the TBSA of the burn obtained by non-specialists, was compared to the estimate after admission to a specialized burn unit, there was an overestimation in most cases and this has the potential to lead to mismanagement of pediatric burn patients.

Keywords: Burn wound; Children; Burn unit; Body surface area

Introduction

In Brazil, burn injury represents a major concern in public health with an incidence of more than 1 million cases per year and, of those, 40 thousand require hospitalization and children account for two thirds of the cases [1,2]. In the United States, burn injury, traffic accidents, drowning, and suffocation represent the four most common causes of unintentional injury, which is the major cause of death category for children ages 1 through 14 years. Burn injury is defined as trauma to skin layers and adjacent tissue caused by a variety of energy sources such as electrical, chemical, thermal or radioactive. Therefore, the rupture of skin integrity means the loss of a protective barrier that compromises thermal control and hydro electrolytic homeostasis [4,5].

In order to assess the patient according to burn severity to determine patient management and prognosis, specific variables must be considered such as depth of the burn injury, patient age, burn mechanism, and the Total Body Surface Area (TBSA) affected by the injury [6]. The TBSA estimation has great relevance because it allows categorizing the patient according to the extent of the burn [7,8]. The TBSA of partial and full thickness burns can be estimated using a variety of methods. The earliest evidence of this approach was found to occur in the19th century with use of the Berkow estimation which is considered a precursor to two rules widely used nowadays; the “rule of palm” and “Wallace’s rule of nines.” [9] This latter tool identifies anatomical regions as multiples of 9 of TBSA affected by a burn and, like the “rule of palm”, uses a parameter that the surface of the palm of the hand represents 1% of TBSA [9,10]. Both of these methods are considered to be fatly, as they can incorrectly estimate TBSA burned especially if the patient is overweight or is a pediatric patient [10]. The Lund and Browder method is recognized as the most accurate for use in the pediatric population, because it considers the age of the patient when estimating TBSA [9]. Besides these methods, new technology allows the TBSA burn estimation to be performed using a smartphone Application (app) [9,10].

An adequate TBSA evaluation of a burn is the critical starting point that leads to correct management of the patient because it is crucial for calculating the volume of intravenous fluid to administer in resuscitation therapy, a treatment proven to impact survival rates [11]. Incorrect evaluation of the TBSA burned can be harmful and result in serious complications to those with more than 20% of body surface compromised by burnt tissue [12,13]. An underestimation of the TBSA can lead to hypovolemia and, as a consequence, kidney failure, acute tubular necrosis, bacterial translocation from the gastrointestinal tract in intestinal ischemia, and burn deepening at Jackson’s stasis zone [11,14,15]. In contrast, over hydration, when it exceeds the value calculated through Parkland’s formula, may cause a phenomenon described by Pruitt as “fluid creep” that originates from edema in burnt and non burnt tissue. It may also cause compartmental abdominal syndrome or deepening of the burn with compromised tissue perfusion and infections [16]. Literature suggests that overestimations of the TBSA burn are more common than underestimations, because calculations require expert knowledge of burn injuries [10,13]. Discrepancies greater than 2 to 3% may result in increased mortality rates [10,14]. Furthermore, although patients given an underestimation of the TBSA burn might receive inadequate fluid resuscitation before transfer to a BU, patients given an overestimation of TBSA burn could have been managed at the original medical facility instead of overloading the BU center. with an unnecessary transfer [17].

The purpose is analyze discrepancies between the evaluation of the Total Body Surface Area (TBSA) of burn injuries involving children performed by clinicians at hospitals and clinics in southern Brazil before patients are transferred to a Burn Care Unit (BU) and the same evaluation by trained burn specialists, in order to determine the accuracy of burn size estimation and to evaluate clinical data, such as medical interventions and length of hospitalization, to inform whether efforts to increase knowledge are warranted to optimize early management and treatment of burned pediatric patients.

Methods

This is an observational study in which data collected over a period of eight months was analyzed involving burn patients transferred from regional hospitals and clinics for admission to the Burn Care Unit (BU) at Joana de Gusmão Children’s Hospital (HIJG) .The hospital serves as referral center for pediatric patients for the state of Santa Catarina in southern Brazil and is located in the state’s capital, Florianópolis, with an estimated population of 7,338,473. [18] The analysis consists of comparison between the values of TBSA of the burn obtained in the form “Transferred burnt patient form” (Figure 1) completed by the referring clinician and values registered in patient records upon arrival at the BU. In addition, other quantitative and qualitative data, such as burn mechanism, patient age, and whether resuscitation with intravenous (IV) fluids occurred, were collected to further inform management and treatment of the injuries. The whole process was grounded in the guidelines established by the National Health Council of Health Ministry of Brazil for research regarding human beings [19]. This guideline provides rules and standards in bioethics, granting rights and duties concerning persons involved in scientific research and its outcomes [20].