291
Bums (1990)16,(4)291-293 PrinkdinGreat Britain
Scald accidents during water aerosol inhalation infants
in
M. K. H. Ebrahim’, R. L. Bang’ and A. R. A. Lari’ ‘Mubarak Kuwait
Al-Kabeer
Hospital
(Teaching),
Kuwait and ‘Department
of Surgery,
Faculty of Medicine,
Kuwait University,
A study of 193 infants admitted for burns over a ICyear perid rev.&d 11 infants (5.7per cent) had sustained scala5 during the process of water aerosol inhalation. The water aerosol inhalation therapy was prescribed for respiratory tract infection and carried out at home using eitheran ekctric !&le or a saucepan. It appears that infants are prone to this type of injury because of Ihe difficulty of keeping them still during therapy and their inquisitiveness to explore their surroundings. The resulfing scalds added to fk morbidity of those chitiren already suflering from respiratory tract infections. These accidenfs uw easily be prevented by fk alfernafive use of a humidifier.
Introduction Water inhalation as an aerosol from a boiling kettle (the visible vapour from a boiling kettle is an aerosol of water, it is not steam, which is invisible (Laurence and Bennett, 1980)) with or without tincture of benzoin is a fairly commonly accepted form of adjunct therapy in cases of respiratory tract infection. Water aerosol inhalation, a warm moist environment and tincture benzoin often give relief, exert a soothing effect and promote secretions, probably through their mucolytic effect (Hughes, 1978; Laurence and Bennett, 1980; Trounce, 1983). Over the years the methods have changed from Nelson’s inhaler to electric kettles and now humidifiers. When the therapy is carried out at home either an electric kettle or a saucepan is used. The child sits on either mother’s or father’s lap, with the boiling water source in front and covered by a bed sheet. In spite of the parent’s awareness about the dangers and their great care, the infant often does not keep still and sometimes manages to tip the container of boiling water, thereby resulting in scalds (Figure I). Scalds occurring in this manner are not documented in the literature. We have treated II infants who sustained this injury.
Patients and methods From 1984 to 1987, 193 infants up to 2 years of age with bum injuries were admitted to The Burns Unit, Ibn Sina Hospital and to the Plastic Surgery Unit, Mubarak AlKabeer Hospital, in Kuwait. Analysis of our data showed that 11 patients’ scalds were due to water aerosol inhalation 0 1990 Butterworth-Heinemann 030.5-4179/90/040291~3
Ltd
Figure 1. The mechanism of water aerosol inhalation at home and the manner in which an accident occurs. shown diagram-
matically. accidents. The patients were suffering from respiratory tract infection prior to the bums and the inhalation therapy was advised by the treating doctor. The inhalation was carried out at home using an electric kettle in four patients and a saucepan in seven patients. Six patients sustained scalds during their first inhalation, the rest at the second session. Upsetting the boiling water pot by the infant was the mechanism of injury in all patients. The resultant scalds were variable in severity but all were partial skin thickness in depth and were treated conservatively. The various clinical data for these 11 patients are shown in Table 1.
Bums (1990) Vol. 16/No. 4
292
Table I. Clinical data
Patient no.
Sex
Age (mth)
1 2 3 4 5 6
M F F M F M
2 6 16 18 17 14
: 9 10 11
F M M M
22 24 12 20 16
Areas of burn
Time of burn Nationality
a.m.
p.m.
%TBSA
Ebyptian Pakistani Jordanian Kuwaiti Pakistani Egyptian
Y Y Y
Y Y Y -
45 5 12 17 12 10
Jordanian Lebanese Jordanian Syrian Jordanian
Y -
Y
7 6 12 5 7
y Y
Surgery required (postburndays)
Hospital stay (days)
Complete healing (days)
YYYYY---y-YY-YY-Y -_y_ YY-Y--Y-Y-
27 19 18 -
39 5 27 7 19 13
39 27 30 10 19 20
---y_---YY-YYYYY Y YY-Y--
-26 -
339
40 12 13 12 11
H
AT
PT UL LL
--Y
P
Y
: 1
Ii, head and neck; AT, anterior trunk; PT. posterior trunk; UL, upper limbs; LL, lower limbs; P, perineum Y, yes.
Results A review of all 193 infants revealed that scalds were the largest single cause of admission to hospital in this group (F&we 2), with a male to female ratio of 1.6 : I. Among our II patients (Table I), the male to female ratio was 1.2 : I. The age varied from 2 months to 24 months with a mean of 15.1 months. In four patients the accident occurred in the morning, the rest in the evening. One patient was Kuwaiti, the rest were of differing other nationalities (TiiableI). The pattern and percentage of burn surface area affected was variable, involving all parts, but the lower limbs were more frequently involved. The total burn surface area varied from 5 per cent to 45 per cent with a mean of 12.5 per cent. This type of accident caused mainly partial skin thickness bums in all patients who were treated conservatively. Seven patients showed complete spontaneous healing while in four patient9 small residual areas covering less than 10 per cent of the original burn remained unhealed at 21 days. These
Figure2. Hot water scalds affect 107 predominant aetiology in infant burns.
patients
and
is the
needed skin grafting. The mean hospital stay was 14.7 days. The time taken for complete healing was from I I days to 40 days with a mean of 21.1 days. Five patients had postbum problems in the form of postburn contracture, hypertrophic scars and dyschromia.
Discussion Scalds are a common cause of bums amongst children in Kuwait. The epidemiological study by Bang and Mosbah (1988) showed that 26.5 per cent of all burns were due to hot water scalds. In children up to 2 years of age a hot water scald is the aetiological factor in 55.4 per cent (Figure Z) of patients. The major$y of these occurred at home. Childhood scalds are regrettable, especially when affecting young children. Our involvement with the treatment and longterm management of burned patients has shown that the functional and cosmetic results of a treated burn are usually very disappointing (Herd et al., 1986). This causes physiological and mental problems and most of these injuries are preventable (Lyngdorf, 1986). These facts indicate that effort is needed in devising ways of prevention, and the aetiological factors should be continually analysed. Children up to 2 years of age are particularly at risk of respiratory tract infection, and water aerosol inhalation is usually prescribed. Although parents understand the danger of accidental spillage during the therapy at home, the child, through his/her inquisitive behaviour and movement, may knock over the container. The parents of all our patients reported that during the inhalation process the child knocked the pot over and spillage of water caused the scald. Pulling the electric kettle flex (Burd and Burd, 1985) and accidental spillage from saucepans in the kitchen as a cause of scalds have been highlighted, but scalds from electric kettles and saucepans, as occurred in our patients, have not been mentioned, although the result is the same. Baxter (1967) encountered children with typical clinical and radiological pictures of acute epiglottitis, who had sustained burns of the pharynx following inhalation of steam or the ingestion of a very hot beverage. Similarly local laryngeal oedema and obstruction resulting from the inhalation of steam during a scald injury in infants have been reported by Cudmore and Vivori (1981). Thus there is the possibility of upper respiratory tract bums due to water aerosol inhalation, but none of our patients showed this.
293
Ebrahim et al.: Scalding during water aerosol inhalation
containers with a safety valve on the top (Figure3) and can be put on a table far away from the child. We strongly recommend the use of humidifiers for water aerosol inhalation at home to prevent scalds especially in infants.
plastic
References
Figure 3. A humidifier: safety valve.
the container
is plastic and there is a
During the period of our study amongst 19.3 patients there were 107 (55.4 per cent) hot water scalds ([email protected] 2). If we calculate for our I I patients that constitutes 10.2 per cent of all hot water scalds in this age group. We suspect that some of the minor degree scalds due to this aetiology either did not attend hospital or are not documented. This type of injury adds to the morbidity in an already ailing child which is manifest as a prolonged hospital stay and the time taken for healing. As these scalds are more or less preventable, effective prevention should decrease the incidence of scalds. At the same time it will reduce the morbidity of infants and the anxiety of the parents. These accidents can be prevented if a humidifier is used for the inhalation therapy. It is relatively cheap, safe and easy to use. There are many types on the market, with a price range of IO-35 KD (35-123 US$). Most of these have
Bang R. L. and Mosbah K. M. (1988) Epidemiology of burns in Kuwait. Bums 14, 194. Baxter J. D. (1967) Acute epiglottitis in children. hyngosc~pe 77, 1358. Burd D. A. R. and Burd E. (1985) The electric kettle flex, a cause for concern. Bum 12,136. Cudmore R. E. and Vivori E. (1981) Inhalation injury to the respiratory tract of children. Pmg. Pediak Surg. 14, 173. Herd A. N., Widdowson P. and Tanner N. S. B. (1986) Scalds in the very young! Prevention or cure? Burns 12, 246. Hughes D. T. D. (1978) Cough suppressants, expectorants and mucolytic agents. Br. Med. J 1, 1202. Laurence D. R. and Bennett P. N. (1980) Cough respiratory stimulants and vomiting. In: Clinical Pharmacolw, 5th edn. Edinburgh: Churchill Livingstone, pp. 547-5~9. Lyngdorf P. (1986) Epidemiology of scalds in small children. Bums 12, 250. Trounce J. R. (1983) Emetics and cough remedies. In: Clinical Phmcology for Nums, 10th edn. Edinburgh: Churchill Livingstone, pp. 68-74.
Paper accepted
3 February
1990
Correqmdence shouti be addressedto: Dr R. L. Bang, Department Kuwait.
James Laing Memorial Essay The British Bum Association has instituted a memorial essay to be awarded annually in memory of James Ellsworth Laing, Burn Surgeon, founder member of the British Bum Association and a former Editor of this Journal. There is a prize of up to f500 for the winning essay. The subject for the sixth essay is: ‘Pain relief in burns The essay should be confined to not more than 10 000 words and correspondingly less if up to 6 Figures and/or Tables are included. The substance of the essay should not already have been published since the winning essay will be published in this Journal. The essays will be assessed anonymously. All persons interested in the problems associated with burning injury are eligible to submit an essay. The deadline for submission of an essay (4 copies) is 31 December 1990. Completed essays and any queries should be sent to the Secretary of the British Burn Association: Dr J. C. Lawrence, PhD., The Burns Research Group, Accident Hospital, Birmingham 815 INA. U.K. The title and author(s) of the winning
of
Surgery, Faculty of Medicine, PO Box 24923, Safat 13110,
essay will be announced
in March or April, 1991.
Bums (1990)16,(4)291-293 PrinkdinGreat Britain
Scald accidents during water aerosol inhalation infants
in
M. K. H. Ebrahim’, R. L. Bang’ and A. R. A. Lari’ ‘Mubarak Kuwait
Al-Kabeer
Hospital
(Teaching),
Kuwait and ‘Department
of Surgery,
Faculty of Medicine,
Kuwait University,
A study of 193 infants admitted for burns over a ICyear perid rev.&d 11 infants (5.7per cent) had sustained scala5 during the process of water aerosol inhalation. The water aerosol inhalation therapy was prescribed for respiratory tract infection and carried out at home using eitheran ekctric !&le or a saucepan. It appears that infants are prone to this type of injury because of Ihe difficulty of keeping them still during therapy and their inquisitiveness to explore their surroundings. The resulfing scalds added to fk morbidity of those chitiren already suflering from respiratory tract infections. These accidenfs uw easily be prevented by fk alfernafive use of a humidifier.
Introduction Water inhalation as an aerosol from a boiling kettle (the visible vapour from a boiling kettle is an aerosol of water, it is not steam, which is invisible (Laurence and Bennett, 1980)) with or without tincture of benzoin is a fairly commonly accepted form of adjunct therapy in cases of respiratory tract infection. Water aerosol inhalation, a warm moist environment and tincture benzoin often give relief, exert a soothing effect and promote secretions, probably through their mucolytic effect (Hughes, 1978; Laurence and Bennett, 1980; Trounce, 1983). Over the years the methods have changed from Nelson’s inhaler to electric kettles and now humidifiers. When the therapy is carried out at home either an electric kettle or a saucepan is used. The child sits on either mother’s or father’s lap, with the boiling water source in front and covered by a bed sheet. In spite of the parent’s awareness about the dangers and their great care, the infant often does not keep still and sometimes manages to tip the container of boiling water, thereby resulting in scalds (Figure I). Scalds occurring in this manner are not documented in the literature. We have treated II infants who sustained this injury.
Patients and methods From 1984 to 1987, 193 infants up to 2 years of age with bum injuries were admitted to The Burns Unit, Ibn Sina Hospital and to the Plastic Surgery Unit, Mubarak AlKabeer Hospital, in Kuwait. Analysis of our data showed that 11 patients’ scalds were due to water aerosol inhalation 0 1990 Butterworth-Heinemann 030.5-4179/90/040291~3
Ltd
Figure 1. The mechanism of water aerosol inhalation at home and the manner in which an accident occurs. shown diagram-
matically. accidents. The patients were suffering from respiratory tract infection prior to the bums and the inhalation therapy was advised by the treating doctor. The inhalation was carried out at home using an electric kettle in four patients and a saucepan in seven patients. Six patients sustained scalds during their first inhalation, the rest at the second session. Upsetting the boiling water pot by the infant was the mechanism of injury in all patients. The resultant scalds were variable in severity but all were partial skin thickness in depth and were treated conservatively. The various clinical data for these 11 patients are shown in Table 1.
Bums (1990) Vol. 16/No. 4
292
Table I. Clinical data
Patient no.
Sex
Age (mth)
1 2 3 4 5 6
M F F M F M
2 6 16 18 17 14
: 9 10 11
F M M M
22 24 12 20 16
Areas of burn
Time of burn Nationality
a.m.
p.m.
%TBSA
Ebyptian Pakistani Jordanian Kuwaiti Pakistani Egyptian
Y Y Y
Y Y Y -
45 5 12 17 12 10
Jordanian Lebanese Jordanian Syrian Jordanian
Y -
Y
7 6 12 5 7
y Y
Surgery required (postburndays)
Hospital stay (days)
Complete healing (days)
YYYYY---y-YY-YY-Y -_y_ YY-Y--Y-Y-
27 19 18 -
39 5 27 7 19 13
39 27 30 10 19 20
---y_---YY-YYYYY Y YY-Y--
-26 -
339
40 12 13 12 11
H
AT
PT UL LL
--Y
P
Y
: 1
Ii, head and neck; AT, anterior trunk; PT. posterior trunk; UL, upper limbs; LL, lower limbs; P, perineum Y, yes.
Results A review of all 193 infants revealed that scalds were the largest single cause of admission to hospital in this group (F&we 2), with a male to female ratio of 1.6 : I. Among our II patients (Table I), the male to female ratio was 1.2 : I. The age varied from 2 months to 24 months with a mean of 15.1 months. In four patients the accident occurred in the morning, the rest in the evening. One patient was Kuwaiti, the rest were of differing other nationalities (TiiableI). The pattern and percentage of burn surface area affected was variable, involving all parts, but the lower limbs were more frequently involved. The total burn surface area varied from 5 per cent to 45 per cent with a mean of 12.5 per cent. This type of accident caused mainly partial skin thickness bums in all patients who were treated conservatively. Seven patients showed complete spontaneous healing while in four patient9 small residual areas covering less than 10 per cent of the original burn remained unhealed at 21 days. These
Figure2. Hot water scalds affect 107 predominant aetiology in infant burns.
patients
and
is the
needed skin grafting. The mean hospital stay was 14.7 days. The time taken for complete healing was from I I days to 40 days with a mean of 21.1 days. Five patients had postbum problems in the form of postburn contracture, hypertrophic scars and dyschromia.
Discussion Scalds are a common cause of bums amongst children in Kuwait. The epidemiological study by Bang and Mosbah (1988) showed that 26.5 per cent of all burns were due to hot water scalds. In children up to 2 years of age a hot water scald is the aetiological factor in 55.4 per cent (Figure Z) of patients. The major$y of these occurred at home. Childhood scalds are regrettable, especially when affecting young children. Our involvement with the treatment and longterm management of burned patients has shown that the functional and cosmetic results of a treated burn are usually very disappointing (Herd et al., 1986). This causes physiological and mental problems and most of these injuries are preventable (Lyngdorf, 1986). These facts indicate that effort is needed in devising ways of prevention, and the aetiological factors should be continually analysed. Children up to 2 years of age are particularly at risk of respiratory tract infection, and water aerosol inhalation is usually prescribed. Although parents understand the danger of accidental spillage during the therapy at home, the child, through his/her inquisitive behaviour and movement, may knock over the container. The parents of all our patients reported that during the inhalation process the child knocked the pot over and spillage of water caused the scald. Pulling the electric kettle flex (Burd and Burd, 1985) and accidental spillage from saucepans in the kitchen as a cause of scalds have been highlighted, but scalds from electric kettles and saucepans, as occurred in our patients, have not been mentioned, although the result is the same. Baxter (1967) encountered children with typical clinical and radiological pictures of acute epiglottitis, who had sustained burns of the pharynx following inhalation of steam or the ingestion of a very hot beverage. Similarly local laryngeal oedema and obstruction resulting from the inhalation of steam during a scald injury in infants have been reported by Cudmore and Vivori (1981). Thus there is the possibility of upper respiratory tract bums due to water aerosol inhalation, but none of our patients showed this.
293
Ebrahim et al.: Scalding during water aerosol inhalation
containers with a safety valve on the top (Figure3) and can be put on a table far away from the child. We strongly recommend the use of humidifiers for water aerosol inhalation at home to prevent scalds especially in infants.
plastic
References
Figure 3. A humidifier: safety valve.
the container
is plastic and there is a
During the period of our study amongst 19.3 patients there were 107 (55.4 per cent) hot water scalds ([email protected] 2). If we calculate for our I I patients that constitutes 10.2 per cent of all hot water scalds in this age group. We suspect that some of the minor degree scalds due to this aetiology either did not attend hospital or are not documented. This type of injury adds to the morbidity in an already ailing child which is manifest as a prolonged hospital stay and the time taken for healing. As these scalds are more or less preventable, effective prevention should decrease the incidence of scalds. At the same time it will reduce the morbidity of infants and the anxiety of the parents. These accidents can be prevented if a humidifier is used for the inhalation therapy. It is relatively cheap, safe and easy to use. There are many types on the market, with a price range of IO-35 KD (35-123 US$). Most of these have
Bang R. L. and Mosbah K. M. (1988) Epidemiology of burns in Kuwait. Bums 14, 194. Baxter J. D. (1967) Acute epiglottitis in children. hyngosc~pe 77, 1358. Burd D. A. R. and Burd E. (1985) The electric kettle flex, a cause for concern. Bum 12,136. Cudmore R. E. and Vivori E. (1981) Inhalation injury to the respiratory tract of children. Pmg. Pediak Surg. 14, 173. Herd A. N., Widdowson P. and Tanner N. S. B. (1986) Scalds in the very young! Prevention or cure? Burns 12, 246. Hughes D. T. D. (1978) Cough suppressants, expectorants and mucolytic agents. Br. Med. J 1, 1202. Laurence D. R. and Bennett P. N. (1980) Cough respiratory stimulants and vomiting. In: Clinical Pharmacolw, 5th edn. Edinburgh: Churchill Livingstone, pp. 547-5~9. Lyngdorf P. (1986) Epidemiology of scalds in small children. Bums 12, 250. Trounce J. R. (1983) Emetics and cough remedies. In: Clinical Phmcology for Nums, 10th edn. Edinburgh: Churchill Livingstone, pp. 68-74.
Paper accepted
3 February
1990
Correqmdence shouti be addressedto: Dr R. L. Bang, Department Kuwait.
James Laing Memorial Essay The British Bum Association has instituted a memorial essay to be awarded annually in memory of James Ellsworth Laing, Burn Surgeon, founder member of the British Bum Association and a former Editor of this Journal. There is a prize of up to f500 for the winning essay. The subject for the sixth essay is: ‘Pain relief in burns The essay should be confined to not more than 10 000 words and correspondingly less if up to 6 Figures and/or Tables are included. The substance of the essay should not already have been published since the winning essay will be published in this Journal. The essays will be assessed anonymously. All persons interested in the problems associated with burning injury are eligible to submit an essay. The deadline for submission of an essay (4 copies) is 31 December 1990. Completed essays and any queries should be sent to the Secretary of the British Burn Association: Dr J. C. Lawrence, PhD., The Burns Research Group, Accident Hospital, Birmingham 815 INA. U.K. The title and author(s) of the winning
of
Surgery, Faculty of Medicine, PO Box 24923, Safat 13110,
essay will be announced
in March or April, 1991.
