V. Kapur2,3, G. Michlig2, K. L. Haines3, D. Rhee1 1Johns Hopkins University School Of Medicine, Pediatric Surgery, Baltimore, MD, USA 2Johns Hopkins University, School Of Public Health, Baltimore, MARYLAND, USA 3Duke University Medical Center, Trauma, Acute Care And Critical Care Surgery, Durham, NC, USA
Introduction: Pediatric burns in under-resourced countries(URC) are specifically associated with significant morbidity and mortality. Higher Total Burn Surface Area (TBSA) is a major predictor of increased mortality. Standardized Burn management protocols(multidisciplinary care, early nutrition, antibiotics, IV fluids) have been shown to improve mortality outcomes for less severe burns without increasing resources. We hypothesize that these protocols are not implemented evenly globally.This study uses the WHO Global Burn Registry(GBR) to evaluate how pediatric burn mortality differs by TBSA between URC and well-resourced countries (WRC).
Methods: We performed a retrospective review of pediatric(<18 years) burn injuries in the GBR from 2016 to 2021. TBSA was categorized as <10%, 10-20%, 20-30%, 30-40%, 40-50%, >50%. Mortality was the primary outcome. Demographic factors, country income, burn severity, burn location, facility factors and cause of burn were studied using bivariate logistic regression, followed by a multivariable logistic regression of significant covariates. The lethal area 50 index (LA50) (TBSA associated with 50% mortality) was compared between WRC and URC.
Results:3,522 pediatric burn cases were included.1,432 patients were in URC(40.7%), while 2,090 patients were in WRC(59.3%). Patients were more likely to sustain burns<10% in WRC (53.7% vs 40.9% p<0.001) and less likely to have >40%( 5.6% vs 9.9%% p<0.001) compared to URC. The overall mortality rate in URC was 19.5% compared to 4.3% in WRC (p<0.001). The mortality rate increased with each increasing category of TBSA (1.0% for <10%burns, 4.4% for 10-20%, 13.7% for 20-30%, 28.9% for 30-40%, 54.5% for 40-50%, 84.9% for>50%, p<0.001). There were significantly increased odds of dying in a URC compared to WRC in all TBSA categories except >50%. These odds were highest for 20-30%(OR 131.76; p<0.005), 30-40%(OR 9.45; p<0.005) and 40-50%(OR 71.38; p<0.005). The LA50 in WRC was 60%, while in URC it was 40%.
Conclusion:There is an increased risk of death from pediatric burn injuries in URC compared to WRC. This study demonstrates that the most significant disparities in mortality between WRC and URC are for patients with 20- 50% TBSA burns.Globally, mortality is uniformly low for <20% burns, while devastatingly high for>50% burns.The disparities in mortality for 20-50% burns may be improved by implementing sustainable protocols in URC, which have been proven to work across hospital systems in the developed world.
