Suicide by self-inflicted burns – A persistent psychiatric problem

Self-inflicted burns are a relatively uncommon but profound attempt at suicide. Twenty years ago, we first reviewed our experience with self-inflicted burns. With this current study, we sought to determine whether there had been any change in the incidence or outcomes of self-inflicted burns. All burn patients admitted between January 1, 2012, and December 31, 2021, with self-inflicted burns were compared with all other admissions. The frequency of self-inflicted burns and confounding risk factors of patients with self-inflicted burns remained unchanged. A large proportion (87.4 %) of the patients had psychiatric disease. They also had larger burns and higher mortality than accidental burns. Unexpectedly, logistic regression analysis that controlled for age, total percent total body surface area (TBSA) burn, sex, and inhalation injury revealed that those patients with self-inflicted burns had 72 % lower odds of dying than the general population. In conclusion, there has been no improvement in the incidence of self-inflicted burns. They result in very severe injuries, but when age, burn size, gender, and inhalation injury are controlled for, they have at least as good a chance for survival as the general burn population.     

Mortality in paediatric burns at the Women’s and Children’s Hospital (WCH), Adelaide,South Australia: 1960–2017

BackgroundBurn injuries are the third leading cause of preventable death in children worldwide, resulting in over 100 000 annual hospitalisations. In the paediatric population, scalds are the commonest mechanism and burn injuries of greater than 40% total burn surface area (TBSA) are associated with a high mortality and morbidity rate.AimsThe aim of this study was to review mortality in paediatric burns in a tertiary burns centre over a 60-year period, providing an understanding of local causes of mortality and directing future clinical research.MethodsWe reviewed data collected prospectively from patients treated for burn injuries at the WCH from 1960 to 2017. Data of age, gender, mechanism of injury and TBSA were collected. TBSA of 40% and greater were included in the study.ResultsAll patients with total burn surface area (TBSA) less than 40% survived. There were a total of 75 patients who sustained burns of or greater than 40% TBSA. Overall mortality was 34% (26 of 75) of which 24 occurred in the 1960s. Of the 21 patients who died of flame burn injuries, 12 of them were described as clothes catching alight from being in close proximity to the source of flame. Average length of stay for patients who did not survive was 7 days (1–26).ConclusionMortality has since declined and the prognosis for survival good, even in TBSA of greater than 90%. The investigations in fabric flammability led by Dr Thomas Pressley and Mr Murray Clarke prompted the rewriting of Australian standards for production of children’s clothing. This, in combination with advances in paediatric resuscitation, surgical techniques as well as wound care has improved survival rates and outcomes in extensive burn injuries. Future studies focus to see not only better survival rates, but also better aesthetic and functional outcomes in burn survivors.     

Self-inflicted burns: an eight year retrospective study in Finland

The aim of this study was to investigate differences in characteristics of burn patients who had attempted suicide, as compared with other burn patients admitted to the Helsinki Burn Centre during 1989-97. Burn patients were first drawn from a computerised register, after which a psychiatrist examined their medical records and ascertained the suicide attempters. Of the total of 811 burn patients, 46 (5.7%) had attempted suicide. The median total body surface area (TBSA) of suicide attempters (24.0%) was markedly higher than in the other patients (6.0%, P < 0.001). Flame was a much more common cause of burns among suicide attempters (82.1%) than among the remainder (44.5%, P < 0.001). Suicide attempters were also more often unemployed (28.2 versus 12.9%) or on disability pension (30.8 versus 7.1%) before the injury (P < 0.001). Although the proportion with self-inflicted burns among all burn patients was not high, the markedly higher severity of their burns makes them an important clinical subgroup for further study.     

A review of the trends of self-inflicted burns

During 1979-1998, 7139 patients were admitted to the Birmingham Burns Centre. Of these, 184 patients were identified with self-inflicted burns. There were 115 males and 69 females. The mean age was 37.4 +/- 14.6 years and mean size of burn was 41.1 +/- 31.3% of total body surface area (TBSA). The yearly admissions of these burns appeared to show a decline, while their percentage as compared to burn admission from other causes showed a rise in the trend. Statistically, however, these trends were not different from zero. During the studied period, there were 446 deaths, of which 81 (18%) were due to self-inflicted burns. The mortality in the self-inflicted burn patients was therefore 44%. The average size of burn in those who died was 67% TBSA, while in those who survived was 21% TBSA. The observed mortality when compared with expected mortality, as derived from mortality probability chart, showed that the self-inflicted group had the same risk of dying as burns from other causes. The methods of burning were not available in 16 patients. In the remaining, self-immolation with an accelerant was the most preferred method followed by ignition of clothing without an accelerant (98 and 37 patients, respectively). In conclusion, self-inflicted burns remain a regular cause of admission to burn units. The extent of their burn is often large, because a majority use an accelerant, and thus, accounts for the high mortality in this group.     

Long-term survival among elderly after burns compared with national mean remaining life expectancy

IntroductionAs compared to younger adults, older people have a greater risk of domestic accidents, such as burns, and their prognosis is worsened by a diminished physiological ability to face a thermal trauma. The in-hospital mortality is adversely affected by old age and burn size, whereas less is known about the long-term-survival in elderly patients who survive a burn injury. The aim of this study was to investigate if elderly burn patients after discharge from a Swedish National Burn Centre have a shorter remaining life compared to the national population, by using calculated remaining Life Expectancy (rLE).MethodsIn this retrospective study we included all patients who were admitted for burns to the Linköping Burn Centre during 1993–2016 and who were 60 years or older and alive, at the time of discharge. The control group was extracted from Statistics Sweden, the national statistics database, and consisted of all individuals from the Swedish population matched for each patient in the study group, by sex and age at the year of discharge. The proportion who died before reaching the rLE was compared between the study population and the control group by calculating risk ratio.ResultsThe study group consisted of 111 former patients and 77 of them (69%) died before reaching the rLE, with mean 4.7 years of life lost (YLL), which was 33% more than that (52%) of the control group (RR 1.33, 95% CI 1.18–1.51). Burn related factors, such as TBSA % or FTB % were not found to account for this effect.ConclusionWe found that the long-time survival of elderly patients after burns is shorter than that of a national control, the magnitude of which is quantitatively important. The current study does not support that burn related factors account for this effect and the reason should therefore be sought in other factors, such as e.g., co-morbidity or psychosocial issues.     

Effect of comorbidities on clinical outcome of patients with burn injury — An analysis of the German Burn Registry

BackgroundSevere burn injuries are associated with high morbidity and mortality. Well-implemented scoring systems for patients with major burns exist in the literature. A major disadvantage of these scores is the partial non-consideration of patient-related comorbidities. Published data on this matter is limited to small study cohorts and/or single center studies. Further, the effect of comorbidities on clinical outcome of patients with severe burn injuries has not yet been examined nationwide in a large cohort in Germany. Hence, the aim of this study was to examine the influence of comorbidities on clinical outcome of these patients based on data from the national registry.MethodsAnonymized data from a total of 3455 patients with documented burns of 1% or more Total Burn Surface Area (TBSA) and over 16 years of age included in the German Burn Registry between 2017 and 2018 were analyzed retrospectively. Data included burn extent, body weight, age, burn depth, inhalation injury, comorbidities, mortality, number of operations and length of hospital stay (LOS).ResultsIn the logistic regression analysis age (OR 1.07 [1.06–1.09], p < 0.001), TBSA (OR 1.09 [1.08–1.11], p < 0.001), IHT (OR 2.15 [1.44–3.20], p < 0001), third degree burn (OR 2.08 [1.39–3.11], p < 0.001), Chronic Obstructive Pulmonary Disease (COPD) (OR 2.45 [1.38–4.35], p = 0.002) and renal insufficiency (OR 2.02 [1.13–3.59], p = 0.017) influenced mortality significantly. If a patient had more than one comorbidity, mortality was higher and in-hospital length of stay (LOS) longer. Renal insufficiency was significantly (p < 0.001) associated with the most prolonged LOS by 11.44 days. TBSA (p < 0.001), Abbreviated Burn Severity Index (ABSI) > 3 (p < 0.001) and IHT (p = 0.001) correlated with the amount of required surgeries and significantly predicted the need for intubation. Patients with arrhythmia significantly required more surgeries (p = 0.041), whereas patients with COPD required significantly less surgical interventions (p = 0.013).ConclusionPreexisting comorbidities have a significant impact on the clinical outcome of patients with severe burn injuries. Further investigation is warranted in order to supplement existing prognostic scores with new mortality-associated parameters.     

Self-inflicted burns, outcome and cost

INTRODUCTION: Self-inflicted burns represent a small number of total admissions to a burns unit, yet they constitute a major workload. METHODS: A retrospective analysis of self-inflicted burns admitted between 1998 and 2002. RESULTS: One thousand six hundred and fifty six patients were admitted with acute burn injuries, of these 56 were self-inflicted. 24 patients had a previous history of self-harming and 22 were unemployed. History of a psychiatric illness was found in 46 patients. Flames caused 46 out of 56 injuries. Mean total body surface area (TBSA) was 27%. Approximately 39% needed admission to intensive care unit (ICU). The mortality rate was 25%. On discharge, 29% of the patients re-self harmed. CONCLUSION: Self-inflicted burns have a poorer outcome. Improving the psychiatric and social support can reduce the incidence of self-harming behaviour, its repetitiveness and subsequently the cost of burn care.     

Incidence of self-inflicted burn injury in patients with Major Psychiatric Illness

IntroductionPsychiatric disorders are mental illnesses that impair judgment, thought process and mood that can result in physical and emotional disability. According to DSM-IV, mental disorders increases risk of traumatic injury, particularly burn [1] (American Psychiatric Association, 2013). However, there are few studies that look at patients with pre-existing major psychiatric disorders and burn outcomes. We aim to assess the incidence and intentionality of burn injury in patients with pre-existing psychiatric disorders.MethodsThis is a retrospective study of patients admitted to the UNC Jaycee Burn Center from 2002 to 2015 and entered in the burn registry. Variables analyzed include basic demographics, insurance status, total body surface area (TBSA) of burn, Charlson comorbidity index (CCI), burn etiology, presence of inhalation injury, burn circumstance, intensive care unit (ICU) and hospital length of stay (LOS) and mortality. Chi-square, Analysis of Variance (ANOVA), Kruskal–Wallis test and Multivariate logistic regression was used to analyze the data.Results11,650 adult and pediatric patients were entered in the burn registry from 2002 to 2015 and 494 (4.2%) adult and pediatric patients had preexisting major psychiatric illness (MPI). Within the large cohort of admitted burn patients, 90 (0.8%) patients presented with self-inflicted burn injuries. 41% of patients with SIB (n = 37/90) had MPI. The incidence of self-inflicted burn injury (SIB) within the MPI (n = 494) cohort was 7.5% (n = 37). Mean age of patients with and without self-inflicted burn injury was 35.3 (±11.6) vs. 41.8 (±17.3), respectively. Mean TBSA was significantly higher in patient with SIB at 18.6 (±16.5) vs. 8.5(±12.2) p < 0.001. Non-white race had significantly higher rate of SIB compared to white cohort. There was no significant difference in mortality rates between SIB and Non-SIB (5.4% vs. 3.7%, p = 0.609), respectively. Median Hospital LOS was significantly increased in patients with SIB compared to NSIB 31 (IQR = 55) vs. 9 (IQR = 20) days, p = 0.004. Multivariate logistic regression for predictors of self-inflicted burn injury showed that minorities were more likely to incur self-inflicted burn injury among patients with major psychiatric illnesses.ConclusionThe incidence of self-induced burn injury in patients with MPI is low and of all the self-inflicted burn patients, 60% did not have a major psychiatric illness identified. Our findings emphasize the importance of identifying patients with MPI with or without self-induced injury that may benefit from more extensive psychiatric screening after burn and counseling, particularly minority patients as they may benefit from additional mental health counseling following severe burn.     

Severe burns in Australian and New Zealand adults: Epidemiology and burn centre care

IntroductionStudies describing the epidemiology of severe burns (>20% total body surface area) in adults are limited despite the extensive associated morbidity and mortality. This study aimed to describe the epidemiology of severe burn injuries admitted to burn centres in Australia and New Zealand.Materials and methodsData from the Burns Registry of Australia and New Zealand (BRANZ) were used in this study. Patients were eligible for inclusion if they were admitted between August 2009 and June 2013, were adults (18-years or older), and had burns of 20% total body surface area (TBSA) or greater. Demographics, burn characteristics and in-hospital mortality risk factors were investigated using multivariable Cox proportional hazards analysis.ResultsThere were 496 BRANZ registered patients who met the inclusion criteria. Over half of the patients were aged 18–40 years and most were male. The median (IQR) TBSA was 31 (25–47). Most (75%) patients had burns involving <50% TBSA, 58% sustained their burn injury at home, and 86% had sustained flame burns. Leisure activities, working for income and preparing food together accounted for over 48% of the activities undertaken at the time of injury. The in-hospital mortality rate was 17% and the median (IQR) length of stay was 24 (12–44) days. Seventy-two percent were admitted to an intensive care unit (ICU) and 40% of patients had an associated inhalation injury. Alcohol and/or drug involvement was suspected in 25% of cases.ConclusionThis study describes the demographics, burn injury characteristics and in-hospital outcomes of severe burn injuries in adults whilst also identifying key predictors of inpatient mortality. Key findings included the over-representation of young males, intentional self-harm injuries and flame as a cause of burns and highlights high risk groups to help aid in the development of targeted prevention strategies.     

Self-inflicted burns: A case series

Self-inflicted burns are regularly admitted to burns units worldwide. Most of these patients are referred to psychiatric services and are successfully treated however some return to hospital with recurrent self-inflicted burns. The aim of this study is to explore the characteristics of the recurrent self-inflicted burn patients admitted to the Royal North Shore Hospital during 2004–2011. Burn patients were drawn from a computerized database and recurrent self-inflicted burn patients were identified. Of the total of 1442 burn patients, 40 (2.8%) were identified as self-inflicted burns. Of these patients, 5 (0.4%) were identified to have sustained previous self-inflicted burns and were interviewed by a psychiatrist. Each patient had been diagnosed with a borderline personality disorder and had suffered other forms of deliberate self-harm. Self-inflicted burns were utilized to relieve or help regulate psychological distress, rather than to commit suicide. Most patients had a history of emotional neglect, physical and/or sexual abuse during their early life experience. Following discharge from hospital, the patients described varying levels of psychiatric follow-up, from a post-discharge review at a local community mental health centre to twice-weekly psychotherapy. The patients who engaged in regular psychotherapy described feeling more in control of their emotions and reported having a longer period of abstinence from self-inflicted burn. Although these patients represent a small proportion of all burns, the repeat nature of their injuries led to a significant use of clinical resources. A coordinated and consistent treatment pathway involving surgical and psychiatric services for recurrent self-inflicted burns may assist in the management of these challenging patients.     

Characteristics and predictors of mortality in-hospital mortality following burn injury in infants in a resource-limited setting

PurposeBurn outcome data in infants is lacking from sub-Saharan Africa. We, therefore, sought to assess the characteristics and predictors of in-hospital burn mortality in a resource-limited setting.MethodsWe performed a retrospective study of the prospectively collected Burn Injury Surveillance database from June 2011 to December 2019. We performed bivariate analysis and Poisson regression to assess risk factors for mortality in our infant burn population.Results115 (7.3%) infants met inclusion criteria. The median age of 8 months (IQR: 6–10) and primarily male (n = 67, 58.8%). Most burns were from scald (n = 62, 53.9%). Infant burn mortality was 12.2%. Poisson multivariable regression to determine burn mortality risk in infants showed that increased %TBSA burns (RR 1.04, 95% CI 1.01–1.07) and flame burns (RR 3.08, 95%CI 1.16–8.16) had a higher risk of mortality. Having surgery reduced the relative risk of death for infants with burns.ConclusionWe show that factors that increase infant burn mortality risk include percent total body surface area burn, flame burn mechanism, and lack of operative intervention. Increasing burn operative capability, particularly for infants and other children, is imperative.     

Burns in pregnancy

A 9-year prospective study of burns in pregnant women hospitalized at the Sina hospital burn center was conducted to determine the etiology and outcome of pregnant patients. Fifty-one patients (27.45% self-inflicted, 72.55% unintentional) were identified and stratified by age, burn size, presence or absence of inhalation injury, trimester of pregnancy, maternal and fetal mortality, and cause of burn. The mean patient age was 24.2 years. There were 20 maternal deaths and 23 fetal deaths. The majority of which (maternal: 13 and fetal: 13) were among self-inflicted burned pregnant women. The mean burn size was 37.7%, and was significantly larger for nonsurvivors of mother than survivors (68.8% versus 17.6%; p<0.001). In the 51 pregnant women, as the total burned body surface area exceeds 40%, both maternal and fetal mortality reaches 100%. Inhalation injuries were strongly associated with large burns, and were presents in all suicide patients. Kerosene ignition (68.6% of all patients, 100% of self-inflicted patients) was the most common type of burn. Large burn size was the strongest predictor of mortality of mother and fetus followed by the presence of inhalation injury.     

Pregnancy and burns: Guidelines for safe management

BackgroundIThe incidence of burns in pregnancy is very low, therefore little is confirmed in the specific management of pregnant women who are burned.PurposeWe conducted a study to survey the frequency of pregnancy in our patients and evaluate the risk factors of mortality for mother and foetus. Finally we provide recommendations about management of mother and child.Materials and methodsRetrospectively, we surveyed data of our pregnant patients for an 18 year period. All demographic data, gestational age, history of previous pregnancy or miscarriage, diabetes, suicide, number of operations, presence of inhalation injury, TBSA, percentage of burn in abdomen and lower extremity, early excision and outcome of mother and foetus were gathered in a special questionnaire. Uni-variate regression and multi-variate regression were done for mortality of mother and child.ResultsWe treated 89 pregnant patients. Mean (SD) of mother's age and their pregnancy age were 24.08 ± 5.56 years and 19.18 ± 9.24 weeks, respectively. Mean TBSA (SD) was 36 (18%). Median of TBSA was 38 (IQR: 25, 70). Median of TBSA in Abdomen was 8 (IQR: 7, 9). Median of TBSA in lower extremities was 18 (IQR: 9, 34). Nine cases were due to attempted suicide. For 34 patients skin grafting was done. The main cause of death of the mothers was sepsis. The infections were due to Pseudomonas aeruginosa, Acinetobacter, E. coli, Klebsiella and Staphylococcus. In uni-variate regression model, TBSA, gestational week, and burns involving the abdomenwere related to maternal mortality. In multi-variate regression model, TBSA had high influence on maternal mortality, with every percent of burn surface area, the risk of mortality increased by 3.4% (p-value <0.005). In a uni-variate regression, TBSA and abdominal burn was associated with foetal mortality. However, in the multi-variate regression, only inhalation injury and TBSA had association with foetal mortality. Inhalation injury increased foetal mortality up to 16 times (p-value <0.05).ConclusionTBSA burned is the only major risk factor of maternal mortality. TBSA burned and inhalation injury are the main risk factors of foetal mortality.     

Mortality following combined burn and traumatic brain injuries: An analysis of the national trauma data bank of the American College of Surgeons

BackgroundSevere burn and traumatic brain injuries (TBI) lead to significant mortality, and combined burn-TBI injuries may predispose towards even worse outcomes. The purpose of this study was to investigate the mortality of patients with burn, burn with non-TBI trauma, and combined burn/TBI to determine if combined injury portends a worse outcome.MethodsWe obtained the National Trauma Data Bank from 2007 to 2012, identifying 32,334 patients with burn related injuries, dividing this cohort into three injury types: BURN ONLY, BURN with TRAUMA/NO TBI, and BURN with TBI. For each patient, demographic data was obtained, including age, gender, presence of trauma, TBI, or inhalation injury, burn total body surface area (TBSA), Glasgow Coma Scale, Injury Severity Score, and mortality. Multivariable logistic regression was performed.ResultsAge, gender, and TBSA were similar across the three injury groups, but the incidence of inhalation injury was doubled in the BURN with TRAUMA/NO TBI (15.4 %) and BURN with TBI (15.3 %) groups when compared to the BURN ONLY (7.2 %) group. Mortality differed across injury categories after adjusting for age, TBSA, and inhalation injury. Increased mortality was seen in BURN with TRAUMA/NO TBI versus BURN ONLY (OR = 1.27 [1.06, 1.53]) and was higher when comparing BURN with TBI versus BURN ONLY (OR = 4.22 [2.85, 6.18]). BURN with TBI also had higher mortality when compared to BURN with TRAUMA/NO TBI (OR = 3.33 [2.30, 4.82]). The logs odds of mortality also increased with increasing age, TBSA and presence of inhalation injury.DiscussionThis analysis of the NTDB suggests that mortality following burn-related injuries may be higher when burn injury is combined with TBI when compared to burns with other trauma, even after correcting for age, TBSA, and inhalation injury. Further clinical and laboratory research is needed to validate these findings and better understand how to optimize combined TBI and burn injury treatment.     

Changes in serum phosphorus level in patients with severe burns: A prospective study

BackgroundThe second most abundant mineral in the body, phosphorus (P), is absorbed in the small intestine after ingestion enhanced by 1,25-dihydroxy vitamin D, and its excretion is exclusively regulated by the kidney. It is clinically significant, aside from its disturbance in burn ICU patient’s P mechanism. The increasing rate of morbidity and mortality among the patients can be associated with severe hypophosphatemia. The current study aimed at investigating the changes in serum P levels in the early period after burns, the relationship between serum P level and TBSA (total body surface area) of burn, and the impact of hypophosphatemia on patients’ clinical outcomes.Material and methodsThe current prospective, observational study was conducted on 137 patients hospitalized in the burn intensive unit (BICU) of Velayat Sub-specialty Burn and Plastic Surgery Center from December 2015 to May 2017. According to the TBSA percentage, the patients were divided into three groups. The level of serum P was determined in the 1st, 3rd, 5th, 7th, and 9th days of hospital stay and before discharge. To evaluate the trend of P changes in the sixtime-points, the average changes along with 95% confidence intervals (CI) were used for multivariate analysis of variance with repeated measures (repeated measures ANOVA). A P-value of 0.05 or less was considered statistically significant. The analyses were performed using SPSS software, version 19 (SPSS Inc.).ResultsTotally, 137 patients (70% male, mean age 32 ± 21years, and TBSA 32.6 ± 14%) were included in the study. The overall incidence of hypophosphatemia was 75.1%. Hypophosphatemia developed as early as 1.66 ± 0.136 (95%CI: 1.4–1.9) days after injury. The highest decrease in the serum P level was observed on the 3rd and 5th days after burn as 2.78 mg/dL and 2.85 mg/dL, respectively (P-value = 0.001). A correlation was observed between TBSA and serum P level. The mean serum P level decreased with increasing the percentage of burns. There was a correlation between serum P level and mortality; therefore, a decrease in serum P level increased the patient's mortality rate (P < 0.05).ConclusionThe current study highlighted that hypophosphatemia is often observed in patients with burn injuries during their hospitalization. It is potentially beneficial to identify patients at risk of hypophosphatemia. Therefore, it is suggested that P level be assessed regularly in patients with burn injuries for the timely initiation of P replacement therapy.     

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study

IntroductionBurn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn.Patients and methodsA prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned.ResultsIn our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs.Discussion and conclusionMean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work.