End of life in the pediatric burn patient.

Up to 60% of deaths in pediatric intensive care units occur after placing limits upon life-sustaining treatment. Two-thirds of limitations are made on the last day of life. Our aim was to characterize the timing, indications, and implementation of "do not resuscitate" (DNR) orders and the withdrawal of support from children with severe burns. A retrospective evaluation was conducted of all deaths in a pediatric burn unit over a 7-year period. Values are presented as mean +/- SD; two-tailed t-tests and Fisher's exact tests were used for analysis. Of the 29 deaths (total admissions = 1261; 2.3% death rate), 12 were of patients with DNR status. Active withdrawal of support occurred for 15 patients: 10 with DNR orders, 5 without. There was no difference in age, burn size, inhalation injury, etiology of injury, cause of death, intensive care unit days, or ventilator days between DNR patients and non-DNR patients. Of the 12 patients with DNR status, only five had orders indicating no cardiopulmonary resuscitation (CPR), no vasopressors, and no cardioversion. The mean time from DNR to death was 22.9 +/- 49.6 hours (median, 2.75 hours). Patients without DNR orders before death had more CPR attempts (0.8 +/- 0.6 vs. 0.3 +/- 0.6; P < .05). At the time of death, few patients with DNR orders were receiving vasopressors (two patients) or underwent CPR (1 patient). Of the 17 patients without DNR orders, 12 underwent resuscitative efforts: CPR (11), vasopressors (12), or cardioversion (9). No resuscitative efforts were undertaken for four children, two with DNR orders. For the acutely injured child there is a strong tendency to wait until the last possible hours of life to address limitation of life-sustaining measures. Documentation of limitation of care was not previously addressed in nearly a third of cases in which support was actively withdrawn. Once a decision to limit support was made, the majority of children proceeded rapidly to death. Further evaluation of the indications, timing, and implementation of DNR orders for children with severe burns is warranted.

Instant cup of soup: design flaws increase risk of burns.

Prepackaged soups are a frequent cause of burn injury. We hypothesize that package design increases the risk for burn injury by affecting container stability. All pediatric scald burns caused by soup, between June 1997 and August 2004, were reviewed for burn and patient characteristics. Instant or "ready-to-eat" soups also were purchased. Safety statements and recommendations as to use of the microwave oven were documented. The height and the areas of the base and top were compared to the angle that a container would tip over on to its side. During the study period, 99 admissions and 80 outpatients were treated for burns caused by soup. Although the burn size was small (mean 5% TBSA) 22 patients required grafting. Of 13 different soups, 11 required the addition of hot water, and 2 were prepackaged for eating out of the container. Twelve containers had round bases and were tall and narrow, with one being shorter and rectangular. The measurements that correlated with the ease of tipping over were the base area, top area, and the ratio of height/base area. The most significant contributor to the ease of tipping over was height. Instant soups are packaged in containers that tend to be tall with a narrow base that predisposes them to being knocked over and spilled. Simple redesigning of instant soup packaging with a wider base and shorter height, along with the requirement for warnings about the risks of burns would reduce the frequency of soup burns.