Management of the high-risk pediatric burn patient.
OBJECTIVE
Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual. The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns.


METHODS
A review was done of children with all 3 risk factors over a recent 9-year interval. All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen. Data are expressed as mean +/- SD.


RESULTS
There were 26 children admitted with all 3 risk factors. Their average age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface. All required mechanical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days). Two children underwent tracheostomy; all others were treated with protracted oral intubation. Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO. Only 7 children (27%) never had any bacteremia. Ventilator-related pneumonia occurred in 8 children (31%). Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn). After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency.


CONCLUSIONS
A high rate of survival can be expected in young children with large burns and inhalation injury.
Sheridan
R L
RL
Shriners Burns Hospital, Boston, MA 02114, USA.
Schnitzer
J J
JJ
D002056:Burns / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D002059:Burns, Inhalation / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D002675:Child, Preschool; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D008297:Male; D009569:Nitric Oxide / Q000008:administration & dosage; D011379:Prognosis; D012121:Respiration, Artificial; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D014139:Tracheostomy
D009569:Nitric Oxide