Analysis of the efficiency of an emergency network for the treatment of multiple burn victims.

OBJECTIVE
to evaluate the effectiveness of the adopted strategy and the care quality for pediatric trauma in the survival of patients attended after a disaster in a city in the interior of Minas Gerais state, compared to the expected results of studies on infant mortality in major burns.


METHODS
retrospective observational analysis of ten patients who were burned and transferred to a trauma reference center. We used the modified R-Baux score to estimate the expected mortality. We compared the expected mortality predicted by R-Baux score and the actual mortality determined from one-ratio test. We also compared time of post-trauma admission with mortality and burned body surface area with mortality.


RESULTS
mean R-Baux score was 75.2, which means an expected mortality of 5% among major burn patients. However, in this study, mortality in the group of children with large burned body surface area was of 60%, p=0.001, a rate far beyond that expected in literature.


CONCLUSION
despite the innumerable variables, we consider the hypothesis of the pediatric trauma care infrastructure being inferior than the one needed in the state. This study suggests a greater incentive for public policies concerning pediatric trauma care, prepared referral center, well-established transfer agreements, and optimization of catastrophe plans, in order to reduce morbimortality of patients who survive the first hour after trauma.


INTRODUCTION
O n October 5 th , 2017, in the city of Janauba, about 557km from Belo Horizonte (MG), the watchman of a municipal education center set fire to himself, other employees, and the children of the nursery where he worked, provoking a great tragedy 1 .At that time, there were 75 children and 17 employees.Four children died on the spot.One died during the transport to the city of Montes Claros (MG), located 134km from Janauba.Santa Casa de Montes Claros confirmed the death of two other children in the afternoon of the following day.
After screening in the origin city, the ten most severe cases were referred to Hospital João XXIII (HJXXIII), in Belo Horizonte.In this hospital, three other children did not resist, totalizing ten infant deaths.HJXXIII is the largest trauma reference center in Latin America 2 , and, for the tragedy in Janauba, the hospital triggered its catastrophe plan: reorganization strategy of teams, sectors, and hospital resources, in order to optimize and prioritize care in challenging situations where the demand for care disproportionately grows in relation to the capacity offered by the institution 3 .
The total daily attendance capacity of HJXXIII is 400 patients, but the hospital can receive, in disaster situations, up to 80 people only in its emergency unit.
The most elaborate level of the catastrophe plan was put into practice for the trauma in question: triggering the network to get the aid of other hospitals, concerning the reservation of beds and the reassignment of previously hospitalized patients; Original Article

Análise da eficiência de uma rede de urgência para tratamento de múltiplos queimados.
total release of beds in the polytrauma room and of vacancies from the pediatric ICU; the pediatric emergency team (17 professionals presented themselves) and intensivist pediatricians, besides the Plastic Surgery, Anesthesiology, and Toxicology (due to smoke inhalation) teams, were extraordinarily called up.All elective procedures were suspended.
The present study aims to evaluate the survival of the pediatric patients attended at HJXXIII after Janauba tragedy in comparison to the expected results of studies on infant mortality in major burn patients.From the outcome, it is expected to analyze the possible factors that influenced this mortality.

METHODS
Retrospective observational analysis of ten patients who were burned and transferred to HJXXIII in Belo Horizonte, from October 5 th to 7 th , 2017.
We analyzed only the victims of Janauba tragedy, screened at the scene, needing attendance at a reference center and being able to survive during transport.Victims who were treated at the regional reference hospital or who died at the site, or during transportation, were not considered.
This study is part of the research project on pediatric trauma, authorized under number 094B/ 2017 by the Ethics and Research Committee of Fundação Hospital de Minas Gerais.
The following variables were collected: gender, age, time between the traumatic event and the admission to the reference unit, length of hospital stay, total body surface area (TBSA) for second and third-degree burns, presence of airway injury or inhalation injury, and mortality.Modified where R=1 if there is inhalation injury and R=0 if there is no inhalation injury.The value found in a normogram is then placed to evaluate the expected mortality from that value.
We also compared the time of post-trauma admission with mortality, and the body surface degree with mortality.These comparisons were performed using Mann-Whitney test, since the sample was small.The analyses were performed using MINITAB software (version 18).The adopted significance level was 5%.

HJXXIII attended ten children (60% females)
who were victims of severe burns in the described period.The mean age was 4.6 years.All were injured by inhalation and intubated in the pre-transference period.Of this total, six children had skin burns and four suffered only inhalation injury.The mean TBSA was 27.6%.The mean time from trauma up to hospital admission was 18.5 hours and the mean hospital stay at HJXXIII was 23.5 days.The overall in-hospital mortality at HJXXIII was 30% (Table 1).Two stable children were transferred to another hospital after a 24-hour observation period by the referral team.
Patients were evaluated as major burn patients, that is, those with burns covering more than 20% of total body surface area.The expected mortality predicted by R-Baux score was calculated for each one of these patients, according to table 2.
For this latter group, therefore, the mean age was 4.6 years, and the mean burned body surface area was 54% (Table 3).The mean R-Baux score was 75.2, which means an expected mortality of 5%.However, the actual mortality in this group was 60%, p-value =0.001.
Finally, table 4 illustrates the following comparisons: the time between the traumatic event and the admission to the reference unit with the body surface grade and mortality.There was no significant difference for these comparisons.

DISCUSSION
Pediatric trauma is still responsible for most child and adolescent deaths in Brazil 4 .Despite this, few studies on the subject are widespread, and few are the reference hospitals that are qualified to treat pediatric trauma, not only in Brazil, but also in the world 5,6 .Following the national trend, the pediatric age group is the one that presents A second aspect noted in the study was that there was no association between mortality and TBSA (p-value =0.069), which may be explained by the small sample size.Although airway lesions are critical in the treatment of burns, children with only inhalation lesions had length of hospital stay and expected mortality in agreement with literature, whereas patients with skin lesions presented higher morbimortality.The essential treatment of a major burn patient, with significant skin destruction, is volume resuscitation in the first hours, followed by infection prevention care 8,9 .Updates on volume resuscitation and infection prevention in burns could be themes best worked out with state emergency teams and could have modified the outcome of the major burn patients.In this group (with more than 20% TBSA), mortality was higher in comparison with that predicted by R-Baux score (p-value =0.001).
Modified R-Baux score was used in this study, because it is considered to be one of the best prognostic scoring system in burns.Modified R-Baux score considers as decisive prognostic factors: age, total burned surface area, and inhalation injury 10 (presence or absence).This score has already been validated in previous studies and, despite the criticism regarding the pediatric population (because, in infants, observed mortality is usually higher), it is still one of the most reliable scores [10][11][12][13] .The adjustment of the score for the pediatric population, P-Baux, has already been attempted; however, the methodology and its validation are still under development 12,13 .
Rev Col Bras Cir 46(2):e2115 Although it is a limited study, due to the scarce literature on predictors of pediatric trauma mortality 13

R-
Baux score was used to estimate the expected mortality.Then, we compared the expected mortality predicted by R-Baux score and the actual mortality determined from one-ratio test.R-Baux score is calculated by the following formula: R-Baux score = TBSA + age + [17 x R], the great majority of deaths which occur outside the hospital due to burns.From 2008 to 2014, this proportion was 85%7 among children aged five to 14 years.This fact, taking into account a national reference center, raises the question of whether the care for traumatized children in this study could present a better outcome than the one achieved.Janauba tragedy was an event that mobilized the emergency network of Minas Gerais state, being important the data analysis in order to evaluate ways to improve the system for other possible catastrophic situations.In the present study, it was observed that the time between the traumatic event and the admission to the reference unit was prolonged, in average, 18.5 hours.It is known that, for those with a burned body surface, the definitive airway management technique in the first hour after trauma and the volume resuscitation technique in the first eight hours are critical measures for patient's survival8 .It is inferred, therefore, that children arrived late at the definitive reference unit, and, given the geographical distances to this reference center (557Km) and to the regional center (Montes Claros, 134km), it was not possible to perform the immediate care before arriving at the final destination.This delay was due both to the great distance from the city to the capital and to the great number of victims.The fact that children arrived at the reference center after the most critical resuscitation hours may justify the absence of an association between mortality and the time between the traumatic event and the admission to the reference unit, since there were no children who arrived within the first initial eight hours to compare the outcomes.If children had arrived within the first eight hours after trauma, there could have been a significant change in mortality.

Table 1 .
Burn victims transferred to João XXIII Hospital according to the time between the traumatic event and the admission to the reference unit, gender, age, TBSA, airway injury, death, and length of hospital stay.

Table 3 .
Characteristics of the group of major burn patients (BBS>20%).

Table 4 .
Comparing the time between the traumatic event and the admission to the reference unit with the body surface grade and mortality.