Multiple Organ Failure as a Cause of Death in

Patients With Severe Burns

Outi Kallinen, MD,* Kreu Maisniemi, MD,† Tom Böhling, MD, PhD,‡
Erkki Tukiainen, MD, PhD,* Virve Koljonen, MD, PhD*

The aim of this study was to investigate the causes of death in patients with burns using
both medicolegal autopsy reports and clinical data collected during treatment to specify ir-
reversible organ dysfunctions leading to death. Burn deaths occurring in the Helsinki Burn
Center from 1995 to 2005 were identified in the hospital database. The clinical charts and
medicolegal autopsy reports were retrieved and compared. The data were evaluated by plas-
tic surgeons specialized in burn care, an intensivist, and a pathologist, with special reference
to organ-specific changes in the autopsy reports. From 1999 to 2005, there were 71 burn
deaths in the Helsinki Burn Center of which 40% was caused by multiple organ failure
(MOF). Death from untreatable burn injury was recorded in 28 patients, whereas other
causes were scarce. MOF patients displayed approximately four organ failures on average,
ranging from three to eight. All 28 MOF patients were recorded to have acute renal failure,
followed by liver damage, of which four patients had acute or chronic liver failure. Sepsis
was always affiliated with MOF as a cause of death. In conclusion, careful examination of
MOF as a cause of death revealed several organ failures: four organ failures per patient.
Acute renal failure was noted in all MOF patients. Sepsis was always affiliated with
MOF. (J Burn Care Res 2012;33:206 –211)

Burn injury is the most devastating form of injury a
person can encounter. Lives continue to be lost to
burn injuries despite improved patient care, and the
exact cause of death after burn trauma is not always
clear. Comparison of premortem clinical diagnosis and
autopsy findings has revealed some diagnostic discrep-
ancies1,2; thus autopsies may reveal unexpected systemic
effects of thermal injury. Furthermore, prolonged inten-
sive care and duration of mechanical ventilation have
also been associated with multiple organ dysfunction
syndrome and severe sepsis.3
The American Burn Association’s registry of the
causes of burn mortalities indicates that almost 50% of
nonsurvivors died of organ failure.4 This finding is
further substantiated by recent literature, which sug-
From the Departments of *Plastic Surgery and †Anaesthesia and
Intensive Care, Helsinki University Hospital; and ‡Department
of Pathology, Helsinki University and HUSLAB, Helsinki,
Finland.
Supported by departmental sources.
Address correspondence to Virve Koljonen, MD, PhD, Department
of Plastic Surgery, Töölö Hospital, P.O. Box 266, FIN 0029
HUS, Finland.
Copyright © 2012 by the American Burn Association.
1559-047X/2012
DOI: 10.1097/BCR.0b013e3182331e73
gests that the commonest cause of death in patients
with burns in the developed countries is multiple or-
gan failure (MOF)/multiple organ dysfunction syn-
drome/systemic inflammatory response syndrome
(SIRS).5,6 By definition, all of these conditions affect
at least three organs. This makes pinpointing the clin-
ical diagnosis of death especially challenging. Severe
MOD and severe sepsis are both related to burn size,
age, and male sex. Both are related to the length of
stay in intensive care and duration of mechanical ven-
tilation.3 Sepsis is a clinical syndrome that compli-
cates severe infection and is characterized by systemic
inflammation and widespread tissue injury. MOF is a
continuum, with increased physiological derange-
ments in individual organs; it is a process rather than
an event.7
Death in burn patients with MOF has not been
assessed extensively by autopsy studies; information
on organ-specific changes due to systemic perturba-
tion caused by thermal damage is scarce. The aim of
this study was to investigate the causes of death in
patients with burns using both medicolegal autopsy
reports and clinical data collected during treatment to
specify irreversible organ dysfunctions leading to
death. The study is based on a retrospective review of
11 years of clinical data and autopsy reports (January

206
Journal of Burn Care & Research
Volume 33, Number 2
1, 1995, to December 31, 2005) from the Helsinki
Burn Center, Helsinki University Hospital, Helsinki,
Finland.
PATIENTS AND METHODS
All admissions due to burn injuries, deaths, and au-
topsy reports were identified from the hospital insti-
tutional database. Inclusion criteria of the study were
adult (age ⱖ18 years) burn patient who died in the
Helsinki Burn Center, Helsinki University Hospital,
Helsinki, Finland, from January 1, 1995, to Decem-
ber 31, 2005.
The hospital charts were reviewed in detail by one
author (O.K.) who did not have any previous knowl-
edge or contact with the patients. This ensured that the
information of the chart was recorded without the bias
that is inherent when one has treated a patient who died.
The following data were obtained from the clinical
medical records: age, gender, underlying primary diag-
noses, smoke inhalation injury, injury characteristics, %
TBSA burned, length of hospital stay, and clinical cause
of death. For comparison of different cohorts, prognos-
tic indexes Baux score8 and abbreviated burn severity
score (ABSI)8,9 were calculated.
All patients underwent medicolegal autopsies. Pa-
thologists macroscopically examined the bodies and
microscopic specimen of organs were obtained and
attentively analyzed. All the findings, normal and ab-
normal, were documented. The autopsy diagnoses
were obtained from the final autopsy reports.
A team of two plastic surgeons, burn care experts,
an intensivist, and a pathologist evaluated all the data
collected with special focus on organ-specific changes
in the autopsy reports to conclude a MOF diagnosis.
MOF was defined as the cause of death if a patient
displayed three or more organ failures. Organ failures
noted were CNS, pulmonary, cardiac, vasomotor, he-
matological, hepatic, gastrointestinal, renal, and ad-
renal. An organ failure could be either clinically indis-
putable, eg, blood culture positive sepsis, or noted
only at the autopsy, eg, cellular damage.
Data are presented as mean and range except for
number of organ failures, which is presented as
median ⫾ SD. The internal review broad of the hos-
pital approved the study protocol.
RESULTS
A total of 1370 patients were admitted to the Hel-
sinki Burn Center due to burn injury during the
11-year study period. Of these patients, 74 died in
the burn center, creating an overall mortality rate
of 5.4%. Three patients were excluded because of
Kallinen et al 207
insufficient data. The final study population con-
sisted of 71 patients.
All 71 patients underwent medicolegal autopsies; de-
mographic characteristics of the patients are given in
Tables 1 and 2. Of these, 32 patients were assessed and
considered to have no hope of survival within 24 hours
of the burn injury, taking into account the etiology,
extent of the burn injury, age, and comorbid conditions.
These patients received comfort care. In this article, the
cause of death in these patients is referred to as “burn
death,” unless autopsy showed other specific causes of
death. The remaining 39 patients received active treat-
ment. Demographic characteristics of the patients are
presented in Table 1.
Autopsy-revealed Causes of Death
There were 28 cases of both MOF and burn deaths.
MOF and burn deaths were the leading causes of
death for the majority of the patients; together they
accounted for 56 (79%) of the deaths. Causes unre-
lated to MOF were recorded for 15 (21%) patients.
MOF Deaths
Of the 28 patients in the MOF death cohort, 23
(82%) were male and 5 (18%) were female. The mean
age was 50.4 (range, 31– 81) years. The mean %
TBSA (43.4%) burned was slightly smaller in the
MOF deaths group than in the all patients cohort
(49.4%) and considerably larger compared with
23.4% in the other causes of death group. In the burn
death group, the mean % TBSA burned was 69.2.
The mean length of hospital stay was 16.9 days
with range from 1 to 98 days. Baux scores varied
between 52 and 138, mean 93.7. The ABSI scores
ranged from 5 to 13, mean 9.2. Only two in this
cohort received comfort care and majority were on
active treatment regimen. On average, patients had
4 ⫾ 1.62 organ failures (range, 3 to 8); Table 3 pres-
ents the specific organ failures in the MOF death
group.
All 28 MOF patients were recorded to have acute
renal failure followed by subsequent liver damage in
23 patients. Acute liver injury with according histo-
logical findings was seen for 16 patients. Four pa-
tients had both acute and chronic cirrhotic liver dam-
ages, ie, acute on chronic liver failure (ACLF). Three
patients displayed only cirrhotic liver damage that was
present before injury.
Lungs were affected in 18 MOF patients. Two
types of pulmonary injuries were documented: acute
respiratory distress syndrome in six cases and pneu-
monia in eight cases. Although 14 patients were di-
agnosed with only one type of lung injury, four pre-
sented with both acute respiratory distress syndrome
 Journal of Burn Care & Research
208 Kallinen et al March/April 2012

Table 1. Demographic data and injury characteristics of 71 burn victims

Other Causes
All Patients MOF Deaths Burn Deaths of Death*

No. patients (M/F) 71 (50/21) 28 (23/5) 28 (19/9) 15 (8/7)

Age (yr), mean (range) 57.5 (24–94) 50.4 (31–81) 56.0 (24–93) 67.5 (38–94)
Care type, n (%)
Active 39 (54.9) 26 (92.9) 0 (-) 13 (86.7)
Comfort care 32 (45.1) 2 (7.1) 28 (100) 2 (13.3)
% TBSA burned, mean (range) 49.4 (4–100) 43.4 (7–90) 69.2 (24–100) 23.7 (4–63)
Burn location
Head and neck 49 21 22 6
Upper extremity 60 26 24 10
Anterior trunk 61 26 27 8
Back 47 16 23 8
Lower extremity 59 20 27 12
Mechanism of trauma, n (%)
Flame 62 (87.3) 24 (85.7) 26 (92.9) 12 (80)
Hot air sauna burn 6 (8.4) 2 (7.1) 2 (7.1) 2 (13.3)
Hot water 2 (2.8) 1 (3.6) 0 1 (6.7)
Electric 1 (1.4) 1 (3.6) 0 0
Inhalation injury 23 10 12 1
LOS (d), mean (range) 10.7 (1–98) 16.9 (1–98) 1.2 (1–2) 13.6 (1–36)
Baux/ABSI, mean (range) 105.6 (42–152)/ 93.7 (52–138)/ 125.2 (80–152)/ 91.2 (42–118)/
10.2 (4–15) 9.2 (5–13) 12.2 (7–15) 8.2 (4–11)
Circumstance of injury, n (%)
Accidental 58 (81.7) 24 (85.7) 19 (67.9) 15 (100)
Intentional 10 (14.1) 3 (10.7) 7 (25) 0 (0)
Undetermined 3 (4.2) 1 (3.6) 2 (7.1) 0 (0)

* Other causes of death include four pneumonias, two rhabdomyolysis, two arrhythmias, two hypoxic brain damages, and one of the each: pulmonary embolism,
coronary artery disease, failed tracheostomy, kidney failure, and embolia of the arteria mesenterica superior followed by the necrosis of the mesenterium.
MOF, multiple organ failure; LOS, length of hospital stay; ABSI, abbreviated burn severity score.

and pneumonia simultaneously. Hematological inju-
ries were found in 16 patients. Blood culture proven
sepsis was evident in 13 patients; 3 patients showed
disseminated intravascular coagulation.
CNS damages were recorded in 12 patients: anoxic/
hypoxic brain damage/small hemorrhages in 6 pa-
tients, edema of the brain in 5 patients, and edema of
the brain and recent cerebral infarction in 1 patient.
Gastrointestinal complications were found in 10 pa-
tients: paralysis of the gastrointestinal track for 5 pa-
tients, acute pancreatitis in 4 patients, and paralysis of
the gastrointestinal track in 1 patient. A pathological
finding of inflammatory changes from esophagus to
bowel and pancreatitis was also seen. Cardiac compli-
cations were recorded in four patients, including two
with myocardial infarction and two with pericarditis.

Table 2. Demographic data and injury characteristics of 71 burn victims according to age groups

Age No. %TBSA, Mean Inhalation Injuries, MOF Burn Other Causes
Group (yr) Patients (Range) n (% of Patients) Deaths Deaths of Death

20–30 4 97.7 (95–100) 1 (25) 0 4 0

31–40 11 53.1 (4–100) 6 (55) 7 3 1
41–50 10 61.2 (25–96, 5) 3 (30) 7 3 0
51–60 20 48.8 (7–100) 6 (30) 9 6 5
61–70 13 42.2 (6–70) 6 (46) 3 7 3
71–80 5 33.8 (22–50) 1 (20) 1 2 2
81–90 6 30.5 (13–60) 0 1 2 3
91–100 2 22 (4–40) 0 0 1 1
Journal of Burn Care & Research
Volume 33, Number 2 Kallinen et al 209

Table 3. Organ failures in 28 patients who died of Burn Deaths

multiple organ failure Large burn injury was the direct reason of death for
% of MOF 28 patients of whom 19 (68%) were male and 9
Organ N Patients (32%) were female. All patients received comfort
care. The mean age was slightly younger than in the
Renal 28 100
all patients cohort being 67.5 years. The % TBSA
Hepatic 23 82.1
burned varied from 24 to 100%, with a mean of
Acute 16 57.1
Cirrhosis ⫹ acute 4 14.3 69.2%, which was the highest compared with the
Cirrhosis 3 10.7 other two groups. The mean length of hospital stay
Pulmonary 18 64.4 was 1.2 days. The mean Baux and ABSI scores were
Pneumonia 8 28.6 125.2 and 12.2, respectively.
ARDS 6 21.4
Pneumonia ⫹ ARDS 4 14.3
Hematologic 16 57.1
DISCUSSION
Sepsis 13 46.4
DIC 3 10.7 Herein, special reference has been made to organ-
Vasomotor 15 53.6 specific changes in patients with severe burns by com-
Tachycardia episodes 14 50 paring the clinical charts with autopsy findings. Ap-
Bradycardia episodes 1 3.6 proximately 40% of all deaths were due to MOF. This
CNS 12 42.9
number is somewhat smaller than published previ-
Gastrointestinal 10 35.7
ously, however in line with previous literature. In a
Intestines 5 17.9
Pancreatitis 4 14.3 survey by Bloemsma et al5 from the Rotterdam Burn
Intestines ⫹ pancreatitis 1 3.6 Center, the incidence of MOF was nearly 65%. How-
Cardiac 4 14.3 ever, they only included patients with an active care
AMI 2 7.1 regimen for the analysis. The number of MOFs in this
Pericarditis 2 7.1 study would be identical to theirs when including
Adrenal 3 10.7 only active care group; in the active care group, the
MOF, multiple organ failure; ARDS, acute respiratory distress syndrome; DIC,
incidence of MOF was 67%.
disseminated intravascular coagulation; AMI, acute myocardial infarction. Previous studies have shown that autopsies reveal
14 to 18% of previously undetected findings in pa-
tients with burns.1,2 Furthermore, 4.5 to 5.6% are
major diagnoses for which detection before death
The adrenal gland was affected in three patients would have led to altered therapy or survival. In Fin-
whom demonstrated bilateral adrenal hemorrhage. land, law requires medicolegal autopsies when a per-
son dies after a burn accident. A State pathologist
Other Causes of Death performs these autopsies at the Department of Foren-
In this cohort, there were 15 (21%) patients, of whom sic Medicine. This makes Finland especially suitable
8 (53%) were male and 7 (47%) female. The mean age for a cause of death study, because all burn victims
of 67.5 years was considerably older than in other who die undergo autopsies.
groups. The TBSA burned varied from 4 to 63%, with Nowadays, the first few days after a large burn in-
a mean of 23.7%. The mean length of hospital stay jury are usually survived and factors such as SIRS,
was 13.6 days. Baux and ABSI scores were lower than MOF, sepsis, and other complications contribute to
in other groups, being 91.2 and 8.2, respectively. later fatality.3,10 Interesting enough, two burn death
Only 2 patients in this group received comfort care patients were diagnosed with MOF in the medicole-
and 13 were on an active treatment regimen. gal autopsy. They both survived only 1 day, in con-
Causes of death in the order of prevalence were trast to other MOF patients who survived a minimum
pneumonia in four cases, rhabdomyolysis in two, car- of 3 days. This raises an ever-interesting question: in
diac arrhythmias in two, and hypoxic brain damage in burn victims, is MOF result of other contributing
two cases. In addition, one of the each of the follow- factors such as sepsis or is MOF an independent sys-
ing was recorded: pulmonary embolism, coronary ar- temic manifestation of thermal injury itself? In the
tery disease, failed tracheostomy, renal failure, em- literature, there are articles both in favor of and
bolus of the superior mesenteric artery followed by against these assumptions.3,10 –12
the necrosis of the mesenterium. All thromboembolic In this study, none of the patients died exclusively
complications were recorded in this cohort. due to sepsis. Nonetheless, 54% of the patients who

210 Kallinen et al
died from MOF did not present sepsis and recipro-
cally 45% had sepsis. Although infection is the most
frequent complication in thermal injuries,13 the num-
ber of patients dying of septicemia has declined.5 In
this study, there was only a small difference between
the patients who died due to MOF with and without
sepsis; this makes the assumption of a shift in the
cause of death after burn injury unreliable. To make
this conclusion, a large number of subjects in a mul-
ticenter study will be necessary. Our results show that
sepsis is always affiliated with MOF. Because of the
retrospective nature of reviewing clinical diagnostic
impressions from the medical records and correlating
them with postmortem findings, it is difficult to pin-
point the order of appearance of sepsis and MOF.
Furthermore, the SIRS and sepsis are similar with the
exception that in sepsis the systemic inflammatory
response is caused by infection.14 Our results show
that clinicians should be aware of signs and symptoms
of sepsis or SIRS/MOF in burn patients and that
these findings should lead to broad thinking about
the etiology for the deterioration.
In the MOF deaths cohort, three patients pre-
sented with cirrhotic liver disease that was present
before injury. There was no evidence that cirrhotic
liver disease, with no signs of acute findings in three
patients, contributed to evolution of MOF directly.
Chronic cirrhotic liver disease may deteriorate the
general condition of these patients, making them
more prone to systemic hypermetabolic response in-
duced by a large burn injury.
Four patients presented with ACLF, a newly
coined term to describe simultaneous coexistence of
two liver conditions, one of them being chronic or
long standing and the other acute and associated with
MOF.15 To the best of our knowledge, this is the first
time that ACLF is associated with burns.
The most frequently encountered organ failure was
renal failure in all 28 (100%) MOF patients. This is an
interesting finding, because according to other stud-
ies, lungs are the most frequently affected organs in
the MOF setting.5,6 Acute renal failure is a feared
complication of critical illness16,17 and especially
feared among burn patients.18,19 The mortality rate
among burned patients who developed acute renal
failure has been reported between 28 and 100% in the
recent studies.20,21 Furthermore, early acute renal
failure is associated with early MOF in patients with
burns.17,19 Our study shows that early signs of renal
failure should serve as a motivation to further inves-
tigate renal function and prevent its progress to
MOF. Renal failure was usually affiliated with MOF,
except in one case. In the cohort “other causes of
death,” one patient died of solitary renal failure, with
Journal of Burn Care & Research
March/April 2012
no evidence of other organ failures in the clinical
charts or autopsy report.
As a conclusion, sepsis and MOF are frequent
causes of death in patients with severe burns. Careful
examination of MOF as a cause of death revealed
several organ-specific failures. None of the patients
died exclusively due to sepsis, which was affiliated
with MOF in 54% of the patients. In a clinical setting,
signs of sepsis in burn patients should lead to more
careful examination of possible organ dysfunctions to
avoid the continuum to MOF. The most frequently
encountered organ failure in MOF deaths was renal
failure, with an incidence of 100%.
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