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\begin{document}


\def\RunningAuthor{Thamir M. Kadhim}
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\articleType{Original Article}
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\title{\textbf{Iatrogenic pulmonary edema as a cause of death in burns}}
\author{Thamir~M.~Kadhim\textsuperscript{*}~\\[5pt]{Department of Pathology, College of Medicine, University of Al-Qadisiyah, Iraq}}

\begin{abstract}
Global mortality from the burn is decreasing while in Iraq is still rising. This study was designed to determine the paucity of data regarding the cause of death in the burn, which may be a participating factor and should eliminate it. A post-mortal field study was conducted in the Department of Forensic Medicine in the province of Babylon, Iraq, for a year period, from the 1st of January 2017 to the 1st of January 2018. The total deaths were 1310, and the whole number of deaths by burn accidents in Babylon, Iraq, was 81(6.18\% of all causes of death in a year). 65 were females (80.24\%), 16 were males (19.75\%). Deaths with no history of admission more than 3day in burn units, age over 45years, cardiovascular diseases patients, heavy smokers, inhalational injuries victims, all were excluded, so 68 burn victims were subjected to a full, typical autopsy at the Department of Forensic Medicine in the province of Babylon for one year period, with all necessary laboratory tests, in order to diagnose the direct cause of their death. For assessing small size area burn, we used small paper the size of the victim whole hand (represent 1\% of TBSA), for a larger area, the Lund and Browder chart was used. Deaths were divided into 2 groups according to the period of admission at the burn unit. The first group (3-7 days of admission) with 60 victims, and the second (more than 7 days) with 8 victims. 17 victims with in the first group, had no prominent autopsy findings, but severe pulmonary edema, edema of other organs, no pathogenic organisms were isolated, the laboratory tests were accepted. Their medical records in the burn unit showed overestimation in the assessment of burn area size above the actual percentage by (20-35\%). The major causes of death in the first group were septicemia 42.46\%, pneumonia 32.35\% and primary pulmonary edema 25\%, caused mainly by overloading the circulation with fluids. Precise assessment of burn area size, ensuring proper fluid replacement and lowering the mortality rate.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}autopsy,\newline iatrogenic,\newline pneumonia,\newline septicemia,\newline TBSA (total body surface area)
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Thamir~M.~Kadhim~\\ Phone:\ +964 780 192 3542~\\  Email:\ alsafythamir@gmail.com
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\section{Introduction}
The burn is injuries to the skin and other body organs, either local or generalized, caused by heat (flame, hot liquids, gasses, vapor or radiations \unskip~\citep{665681:15698933}. As to say, caused by the transfer of energy from a physical or chemical source into living tissues, which causes disruption of their normal metabolic processes and commonly leads to irreversible changes that end in tissue death \unskip~\citep{665681:15698945}. Heat injury may arise following a defect in body temperature control. Mammalian tissues can survive only within a relatively narrow range of temperatures, approximately 20 to 44-degree centigrade \unskip~\citep{665681:15698937}. Burn accidents occur with different incidence among world countries. In Great Britain, about 175000 people visit hospitals every year because of burns. About 13000 of them need admission to burn units. 1000 of them need intravenous fluids. 50\% of them are below the age of 16 years \unskip~\citep{665681:15698940}. The burn is a global public health problem accounting for an estimated 180000 deaths annually. The majority occur in low and middle-income countries, and almost two-thirds occur in the WHO African and Southeast Asia regions. In 2007, about 11 million burn patients seeking medical care around the world. In 2008, the United States of America had 410000 burn accidents, and 40000 of them need hospital care. In the United States of America also and in 2000, the total cost of caring children affected with burn was more than 211 million American dollars. IN 2007, and in Norway, the cost was about 10.5 million euros. This cost is about 26 million American dollars every year in South Africa to manage burns from Cookstove accidents. In many high-income countries, burn death rates have been decreasing, and the rate of child deaths from Burns is currently over 7 times higher in low and middle-income countries than in high-income countries \unskip~\citep{665681:15698946}. In Iraq, statistics indicate that burn accidents account for 6-14\% of all cases in the Department of Forensic Medicine in Baghdad \unskip~\citep{665681:15698933}. The main factors determining the deleterious effects of heat are the temperature and the duration for which it is applied. This is amply clear from the observations of Moritz and Henriques, who found that the lowest temperature that would produce damage was 44\ensuremath{^\circ}C though the time required to produce burn was of the order of about 5 hours, whereas if the object was at 60?C, it required only 3 seconds to cause burn \unskip~\citep{665681:15698939}. The cremation facts in the cemeteries show that the human body turns to ash in an hour or an hour and a half at a temperature of 1800 degrees Fahrenheit. Deaths due to fire may be either immediate or delayed. Immediate deaths are due to either direct thermal injury to the body that is Burns of the skin or, more commonly to a phenomenon called smoke inhalation. Deaths within the 1st, 2, or 3 days are due to shock fluid loss or acute respiratory failure due to inhalation of hot gasses with injury to the respiratory tree. Deaths after this period are generally due to sepsis or a chronic respiratory insufficiency \unskip~\citep{665681:15698935}. The assessment of burn size should be precisely estimated. The whole hand of the patient is 1\% of total body surface area and used with small area burn, while in larger area size burn, Lund and Browder chart should be used. The rule of nines gives an approximated percentage of burn size. Maintaining circulation with intravenous fluids after burns is important to perfuse vital organs and the skin. Children with burn over 10\% and adults with burn over a 15 \% total body surface area are in need of intravenous fluid resuscitation. The intravenous fluids used for replacement therapy could be estimated by Parkland formula,

Total percentage body surface area X weight (kg ) X 4 = Volume ( ml ).

The key to monitoring resuscitation is urine output, which should be 0.5-1ml /kg, and the value of 2ml/kg necessitates lowering the infusion rate \unskip~\citep{665681:15698940}. Importantly, signs like pulmonary rales, lower extremity edema, and jugular vein distension have significant limits for assessing fluid overload \unskip~\citep{665681:15698944}. Lungs are one of the organs in which adverse effects of fluid overload are most evident and can lead to acute pulmonary edema or acute respiratory distress syndrome \unskip~\citep{665681:15698943}. The badly burned patient should not be overhydrated in the initial phase of therapy \unskip~\citep{665681:15698941}.
    
\section{Materials and Methods}
A post-mortal field study was conducted in the Department of Forensic Medicine in the province of Babylon, Iraq, for a year period, from the 1st of January 2017 to the 1st of January 2018. The total deaths were 1310, and the number of deaths from burn alone was only 81. Deaths with no history of admission to burn units more than three days, age over 45years, cardio-pulmonary patients (from medical history, and relatives), heavy smokers, and those who had an inhalational injury, were excluded. The focus of this study is lung, so we excluded any condition that could affect the lung before a burn accident. The age, sex, days of admission, occupations, and places of residence, were recorded. Typical post-mortal dissection, full histopathological and toxicological examinations were done (samples were taken from organs, blood, and urine). A blood culture test was used for identifying pathogenic organisms (blood samples were aspirated from the left ventricle of the heart), a ten ml gage sterile plastic syringe was used. Liver and kidney function tests were applied to samples of blood. To assess a small size area burn, we used a small piece of paper about the size of the hand of the diseased patient (represents 1\% TBSA). For a larger area, the Lund and Browder chart was used. By assessing the area size of the burn, and comparing results with that from medical records of the burn unit, overestimations in the percentage of burn area in hospital records, were found. The autopsy cases were divided into two categories, according to days of admission in the burn unit. 
    
\section{Results and Discussion}
The total deaths were 1310, and the number of deaths from burn alone was only 81 (6.18\%). Of these, 65 were females (80.24\%), and 16 were males (19.75\%). 41 deaths occurred in the winter season (50.61\%), 40 in summer (49.38\%). All deaths occurred in low and middle socio-economic class (occupation, and place of residence). After exclusion ( deaths with no history of admission to burn units more than three days, age over 45years, cardio-pulmonary patients - from medical history, and relatives-, heavy smokers, and those who had an inhalational injury), a full typical autopsy was done for 68 deaths. 58 were females (85.3\%), 10 males (14.7\%). Age range (2-45 years). 61 cases were due to flame fire (89.7\%) and 7 cases were scalded burn (10.29\%). The range of area size of burn (15-85\%) TBSA. By comparing the estimated area size of the burn, with that mentioned in the medical data records of the burn unit, overestimations of burn area size were found in the burn unit records with a range of (15-35\%) TBSA. According to days of admission to burn unit, the cases were divided into two groups: the first group (3-7days) with 60 burn victims (88.23\%), and the second (more than 7days) with 8 victims (11.76\%). Pseudomonas aeurigenosa and Klebsiella are the main microorganisms isolated separately or together in 58 cadavers (85.29\%).  The major cause of death in the first group was septicemia (29 victims) (48.33\%), and pneumonia (14 victims) (23.33\%). In the rest 17 burn victims (28.33\%), there were no pathogenic organisms isolated. The only evident internal autopsy findings were marked pulmonary edema and edema of the other internal organs. The supportive laboratory test results are accepted. The medical records of burn units of these 17 victims had no evidence of hepatic failure, with accepted urine output, the postmortal liver and kidney function test showed values near to normal (taking into consideration the normal elevations in values of urea and liver enzymes after death). The actual area size of burn range (25-55\%), while the burn unit data mentioned elevated area sizes than actual sizes by (20-35\%). The cause of death was primary pulmonary edema. The cause of death in the second group was pneumonia. 

The major causes of death in the first and second groups of our study were septicemia and pneumonia. This concurs with current literatures \unskip~\citep{665681:15698942,665681:15698936,665681:15698934,665681:15698938}. In 17 victims (25\%), the cause of death was primary pulmonary edema, caused mainly by overloading the circulation with extra I.V. fluids. This concurs with the study of \unskip~\citep{665681:15698941} and \unskip~\citep{665681:15698943}. Precise assessment of burn area size, ensuring proper fluid replacement and lowering mortality after burns. 
    
\section{Conclusions}
It is obvious from the current study and the studies about burns around the world that septicemia and pneumonia are the major causes of death in burns. Because of these clear data, burn death rates have been decreasing in many high-income countries, through both procedures of prevention and improvement in caring burn patients. In a quarter of our samples of diseased patients, the cause of death was iatrogenic excessive volume of intravenous fluids as replacement therapy. Precise assessment of burn area size, ensuring proper fluid replacement and lowering mortality after burns
    

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