Burns to the head and neck: Epidemiology and predictors of surgery

Background

The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres.

Methods

A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003–2007).

Results

Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n = 1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn.

Conclusions

One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years.     

In the media: Burns as a method of assault

Aim

The aims of this study were to determine whether a change occurred in the pattern of assault burn injury cases hospitalised to the adult state burns unit, Western Australia, from 2004 to mid-year of 2012, and to compare patient and burn characteristics of adult assault burns with those admitted for unintentional burns.

Methods

Study data were obtained from the Royal Perth Hospital (RPH) Burns Minimum Dataset (BMDS). Aggregated data of unintentional burn admissions during the same period were provided by the BMDS data manager to enable comparisons with assault burn patients.

Results

Assault burn admissions during 2004–2012 accounted for approximately 1% of all adult burn hospitalisations. All assault victims were burned by either thermal or scald agents. A high rate of intubation (24%) and ICU admission (1 in 3 cases) was observed in the fire assault group. The six assault cases undergoing intubation were severe burns, median TBSA 50%, most commonly affecting the face, head and torso, half of these cases had inhalational injuries and also required escharotomies.Comparison of admissions by calendar period showed no statistically significant differences in demographic, burn cause or TBSA%. However, statistically significant differences were found for pre-morbid psychiatric history (15% vs. 58%, p = 0.025) and concomitant fractures or dislocations (46% vs. 2%), p = 0.011).

Conclusions

While the proportion of assault burn admissions per total burn admissions steadily increased from 0.4% in 2009 to 1.5% in mid-2012, this proportion did not exceed that peak level observed of 2.1% for 2004.     

Epidemiology of burns in the United Arab Emirates: Lessons for prevention

Purpose

To study mechanism, risk factors and outcome of hospitalized burns so as to give recommendations for prevention.

Methods

Burn patients admitted to Al Ain hospital for more than 24 h or who died after arrival were studied over 4 years. Demographics, burn type, location and time of injury, total body burned surface area (TBSA), body region, hospital and ICU stay and outcome were analyzed.

Results

203 patients were studied, 69% were males and 25% were children under 5 years old. The most common location for burn was home. Women were burned more at home (p < 0.0001). 28% of patients were injured at work with more men (p < 0.0001) and non-UAE nationals (p < 0.01). Scalds from water, tea were the major hazard at home, while majority of burns at work were from gas and flame. Burns caused by gas and flame had larger TBSA and longer ICU stay. Six (3%) patients died and nine (4%) were transferred to the specialized burn center.

Conclusions

Safety education for caregivers and close supervision of young children is important to reduce pediatric burns. Occupational safety education of young men could prevent burns caused by gas and flame.     

Epidemiology of hospitalized burn patients in a tertiary care hospital in South India

Background

The epidemiological pattern of burns varies widely in different parts of the world. To suggest effective preventive measures, an insight into the pattern of injury is desirable. However, data on burn victims and outcome is limited from this part of the world.

Methods

This study was conducted in the Department of Surgery, from April 2006 to April 2007. All consecutive patients with major burns admitted for in-hospital treatment during the study period were included in the study. The data collected included age, gender, cause and mode of burns, presence or absence of inhalational injury, facial burns, time delay from burn injury to admission in the hospital, burns depth, total body surface area distribution of burns, associated injuries and co-morbid illness, microbiological profile and outcome. Inhalational injury was assessed by clinical examination as bronchoscopy was not available.

Results

A total of 222 consecutive patients admitted for in-hospital treatment of burn injury were included in the study. 177 patients were adults and 45 were <13 years of age. The female:male ratio was 1.7:1. In adults, 52.5% of burns were due to non-intentional injury and 43.9% were due to self-immolation. In patients <13 years of age, 95.6% of cases were due to non-intentional injury. The mean TBSA was 48.75% and 30.18% of patients had predominantly deep burns. The overall mortality was 60.8%. The predominant organisms colonizing the burn wound were Pseudomonas aeruginosa (81.1%) followed by Acinetobacter species and MRSA. Multivariate logistic regression analysis of factors predicting survival in patients with burn injury showed that TBSA > 30%, age > 20 years, female gender and presence of facial injury were statistically significant as predictors of risk of death.

Conclusions

In patients with burns, total body surface area involvement more than 30%, age more than 20 years, female gender and presence of facial injury are statistically significant, as predictors of poor outcome and risk of death. The strongest association was seen with facial injury, which increased the risk of death by fourfold.     

The characteristics of elderly burns in Shanghai

Objective

This study aims to analyse the epidemiologic characteristics of severe burn in the elderly in Shanghai and to discusses a possible prevention programme for this population.

Methods

A retrospective review of all medical records of elderly patients (aged 60 and older) admitted with acute burns to the Burn Center of the RuiJin Hospital between January 1996 and December 2004 was carried out. Patient demographics, etiology of burn, mechanism of injury, burn extent, anatomical areas burned, number of operations, and outcomes were reviewed.

Results

A total of 201 (5.8% of hospitalised patients) elderly patients (mean age (±SD) of 69.3 ± 7.1 years (range 60–90 years)) were admitted. Majority of the patients were men (62.2%) and the most common etiologies were flames (52.7%) and scalds (39.8%). The majority of burns occurred at home (73.6%), followed by burns at workplace (15.9%) and public areas (10.5%). The median total body area burned was 11.7% (range 0–84%), and the majority of burns were classified as mild (60.2%) and moderate (32.8%). Predominant anatomical areas involved were the legs (76.1%), arms (67.2%), head and neck (49.8%) and hands (49.3%). The most common pre-injury conditions were cardiovascular diseases (25.9%), diabetes (8.5%) and neurological diseases (6%). Eighty-seven patients (43.3%) required surgical treatment. The most common complications were multiple organ failure (2%), pneumonia (1%) and wound infection (1%). Sixteen patients (8%) died: half of them in hospital, and the rest at home. There was a significant correlation between post-injury complications and death (r = 0.69, p < 0.001). The mean total hospitalisation cost was ¥22993.09 (US$ 3381.34).

Conclusions

Domestic and workplace burns with devastating consequences are very common in the elderly population in Shanghai. Burn prevention education and implementation of safety measures at home and at workplace would help reduce such incidences.     

Laser Doppler Imaging prediction of burn wound outcome in children: Is it possible before 48 h?

Background

Laser Doppler Imaging (LDI) assists in prediction burn wound outcome. Previous data has validated this technique in children between 48 and 72 h after burn.

Aim

To evaluate the ability of Laser Doppler Imaging (LDI) to predict burn wound outcome in paediatric patients prior to and after 48 h from the time of injury.

Methods

A prospective evaluation was performed in 400 children over a 12-month period that presented to our burns clinic. Patients were divided into two groups: those that presented within 48 h of injury (n = 160) and those that presented after 48 h (n = 240). Patients were reviewed until healing had occurred or operative intervention was required.

Results

The median age of the patients was 2.4 years (range 0.1–15.9 years). For patients who presented within 48 h, the sensitivity and specificity of the LDI was 78% and 74% respectively compared to 75% and 85% for those scanned after 48 h. This difference was not statistically significant.

Conclusions

LDI predicted burn wound outcome in children within 48 h of the burn wound. Moderate degrees of movement, infection, whether first aid was administered and type of dressing did not impact on the accuracy of LDI.     

Incidence and treatment of burns: A twenty-year experience from a single center in Germany

Objective

To analyze trends in incidence and treatment of thermal injuries over the last two decades.

Methods

We retrospectively reviewed our local single center database of patients with thermal injuries admitted to the burn intensive care unit (BICU) of the Cologne-Merheim Medical Center (University Hospital of Witten/Herdecke). The cohort was divided into two groups according to the decade of admission and the epidemiology and clinical course of the patient sample admitted during the period 1991–2000 (n = 911) was compared to that of 2001–2010 (n = 695).

Results

The following variables were significantly different in the bivariate analysis: mean age (39.8 years vs. 44.0 years), burn size of total body surface area (23.2% vs. 18.0%) and size of 3rd degree burns (9.6% vs. 14.9%). The incidence of inhalation injury was significantly lower in the last decade (33.3% vs. 13.7%) and was associated with a shorter duration of mechanical ventilation (10.8 days vs. 8.5 days). The ABSI-score as an indicator of burn severity declined in the second period (6.3 vs. 6.0) contributing partially to the decline of BICU length of stay (19.1 days vs. 18.8 days) and to the mortality rate decrease (18.6% vs. 15.0%).

Conclusion

The severity of burn injuries during the last two decades declined, probably reflecting the success of prevention campaigns. Concerning mortality, the chance of dying for a given severity of injury has decreased.     

Sustained high incidence of injuries from burns in a densely populated urban slum in Kenya: An emerging public health priority

Introduction

Ninety-five percent of burn deaths occur in low- and middle-income countries (LMICs); however, longitudinal household-level studies have not been done in urban slum settings, where overcrowding and unsafe cook stoves may increase likelihood of injury.

Methods

Using a prospective, population-based disease surveillance system in the urban slum of Kibera in Kenya, we examined the incidence of household-level burns of all severities from 2006–2011.

Results

Of approximately 28,500 enrolled individuals (6000 households), we identified 3072 burns. The overall incidence was 27.9/1000 person-years-of-observation. Children <5 years old sustained burns at 3.8-fold greater rate compared to (p < 0.001) those ≥5 years old. Females ≥5 years old sustained burns at a rate that was 1.35-fold (p < 0.001) greater than males within the same age distribution. Hospitalizations were uncommon (0.65% of all burns).

Conclusions

The incidence of burns, 10-fold greater than in most published reports from Africa and Asia, suggests that such injuries may contribute more significantly than previously thought to morbidity in LMICs, and may be increased by urbanization. As migration from rural areas into urban slums rapidly increases in many African countries, characterizing and addressing the rising burden of burns is likely to become a public health priority.     

Epidemiological analysis of burn patients in East Bulgaria

Objective

The purpose of the study was to identify the basic epidemiological characteristics of burn patients in East Bulgaria, as well as to analyze trends in burns in the region over the last decade.

Methods

Retrospective data of burn patients treated at Military Hospital-Varna, in the period January 2002–December 2011, was reviewed and statistically interpreted in terms of patients and burn demographics; etiology; place of incidents; hospital stay and mortality. Trends were observed for the entire period and comparative analyses of patients’ data were made between two periods: first – 2002–2006 and second 2007–2011.

Results

A total of 2627 burn patients, median age 41 years (IQR 9–61) were admitted to our burn unit. For the entire period the most affected age groups were ≤4 years (21.6%) and ≥65 years (21.1%). Hospitalized patients increased in the second period (n = 1701) compared to the first one (n = 926), while the size of total burn surface area decreased (first period – 9.8% vs. second period – 10.6%). Scald (51%) and flame (23.8%) were the most frequent aetiological agents for both periods. Work related burns reduced in the second period (9.4% vs. 4.9%), while home burns (90.6 vs. 95.1%) increased. Hospital stay declined from 17days (2002–2006) to 7days (2007–2011), whereas mortality rate slightly increased (first period – 2.3% vs. second period – 3.6%).

Conclusion

Burns remain a significant health problem in Bulgaria. The future preventive actions should take into account the observed changes in burn demographics and target the most vulnerable groups.     

Acute burn induced coagulopathy

Background

Acute traumatic coagulopathy is well described in the trauma population. Major burns are characterised by a similar endothelial injury and cellular hypoperfusion. These features could be a driver for an acute burn induced coagulopathy (ABIC).

Methods

Patients admitted to a regional burn centre over a 71 months period with a total body surface area burn of 30% or more were identified. The metavision electronic patient database was scrutinised for a predetermined list of demographics, interventions and admission investigations to identify any clinically significant ABIC.

Results

On admission 39.3% of the 117 patients analysed met our criteria for a coagulopathy. Of the patients with a coagulopathy, 71.7% had an elevated Prothrombin Time (PT), 2.2% had an elevated Activated Partial Thromboplastin time (APPT) and 26.1% had an elevation of both. Patients with a coagulopathy received a similar volume of fluid (p = 0.08). There was a statistically significant correlation between the PT and the abbreviated burn severity index (p = 0.0013, r = 0.292) and serum lactate (p = 0.0013, r = 0.292). ABIC was an independent predictor of 28 day mortality, OR 3.42(1.11–10.56).

Conclusion

In patients with major thermal injuries a clinically significant ABIC exists. Early diagnosis and treatment of ABIC should be considered particularly in those undergoing total burn wound excision.     

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

Background

There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate.

Methods

Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS).

Results

There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2–10), and median age 36 years (IQR 23–50). The results show ISS is a good predictor of death for burns when ISS ≤ 15 (OR 1.29, p = 0.02), but not for ISS > 15 (ISS 16–24: OR 1.09, p = 0.81; ISS 25–49: OR 0.81, p = 0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82–85%) and BISS of 95% (95% CI 92–98%), demonstrated superior performance of BISS as a mortality predictor for burns.

Conclusion

ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.     

Stroke after burn: Population data analysis

Purpose of the study

We aimed to describe a population cohort study of burns with the prevalence of stroke, and discuss possible etiologies.

Analytical methods

This study uses data obtained from the Longitudinal Health Insurance Database 2005 (LHID2005). The study cohort consisted of all patients who had diagnoses of burn recorded in the database (ICD-9-CM codes 948) between January 1 2004 and December 31 2008 (N = 1549).

Main findings

The patients with burn and the comparison cohort are 7410 patients, 146 experienced stroke during the follow-up period of up to 5 years. In average, the burn patients suffered from stroke by 1.48 years after burn. The hazard ratio of stroke was 1.74 (95% CI, 1.15–2.63) for patients with TBSA burn <20%, 3.78 (95% CI, 1.39–10.26) for patients with TBSA burn ≥20%. The adjusted hazard ratio of ischemic stroke was 1.63 for patients with TBSA burn <20%, 2.96 for patients with TBSA burn ≥20%, whereas the hazard ratio of hemorrhagic stroke were not significant (p = 0.231).

Conclusions

In our study, severe burned patients, more than 60 years of age, had higher risk of stroke in their recovery life. We suggest close follow up for the burn patients in high risk of stroke.     

Epidemiologic investigation of burns in the elderly in Sichuan Province

Objective

This study analysed the epidemiology of burns in the elderly in Sichuan Province, China, with the objective of formulating a prevention programme.

Methods

A retrospective review of elderly patients admitted to the Burn Centre of West China Hospital during 2003–2009 was performed, including patient demographics, education and burn aetiology.

Results

A total of 103 patients, mean age 69.5 years (range 60–95 years; 58 male, 45 female) were admitted. The most common causes of burn were flames (51.5%), scalding (37.9%), electrical (4.9%) and chemical (2.9%), respectively. The majority occurred at home (68.9%), principally in the kitchen (35.9%), while 19.4% occurred in the workplace. Burns with total body surface area (TBSA) of 0–10% accounted for 52.5% of those admitted for treatment; 10–30% TBSA burns accounted for 20.3%; 30–50% TBSA burns accounted for 15.5%; and burns with a TBSA >50% accounted for 11.7%. Only 6% of patients received appropriate first aid, and 32% did not receive treatment until more than 24 h after injury. The education level was lower in the rural group. Both urban and rural groups had little knowledge of first aid for burns.

Conclusions

Burn-prevention programmes should promote improved living conditions and medical insurance, with prevention education for the elderly, especially in rural areas.     

The correlation between burn mortality rates from fire and flame and economic status of countries

Introduction

Over 95% of burn deaths occur in low- and middle-income countries globally. However, the association between burn mortality rates and economic health has not been evaluated for individual countries. This study seeks to answer the question, how strong is the correlation between burn mortality and national indices of economic strength?

Methods

A retrospective review was performed for 189 countries during 2008–2010 using economic data from the World Bank as well as mortality data from the World Health Organization (WHO). Countries were categorized into four groups based on income level according to stratification by the World Bank: low income, lower middle income, upper middle income, and high income. The Pearson correlation coefficient was used to estimate presence and strength of association among death rates, Gini coefficient (measure of inequality of distribution of wealth), gross domestic product (GDP) per capita, and gross national index (GNI) per capita.

Results

Statistically significant associations (p < 0.05) were found between burn mortality and GDP per capita (r = −0.26), GNI per capita (r = −0.36), and Gini (r = +0.17).

Conclusions

A nation's income level is negatively correlated with burn mortality; the lower the income level, the higher the burn mortality rates. The degree to which income within a country is equitably or inequitably distributed also correlates with burn mortality.

Significance

Both governmental and non-governmental organizations need to focus on preventing burns in low-income countries, as well as in other countries in which there is marked disparity of income.     

Cutaneous microcirculatory assessment of the burn wound is associated with depth of injury and predicts healing time

Rationale

Current trends for the treatment of deep partial thickness and full-thickness burns include early excision and skin grafting. In this study we retrospectively evaluated the ability of Laser Doppler Flowmetry (LDF), taken within 24 h of the burn to predict: (1) burn wound depth and (2) wounds which would heal in less than 21 days.

Method

The Laser Doppler Flowmeter (O2C, LEA Medizintechnik, Germany) was employed to non-invasively measure the cutaneous microcirculation of 173 selected areas on 28 patients who suffered burns.

Results

A distinct association between initial flow (<24 h after burn injury) and the clinical assessment of depth of burn wounds was observed. Wounds demonstrating an initial blood flow of >100 AU were, in 93.1% of cases, correctly (positively) predicted for spontaneous healing within 21 days. A blood flow of <100 AU (negatively) predicted in 88.2%, those wounds which would not go on to heal within 21 days. Sequential measurement analysis (<24 h, 3 days after injury and 6 days after injury) revealed no significant decrease in skin perfusion velocity or flow rate.

Conclusion

LDF can provide immediate results for early determination of burn wound depth and is useful in selecting patients for conservative treatment of their burn wounds.     

A novel means to classify response to resuscitation in the severely burned: Derivation of the KMAC value

Background

Resuscitation fluid rates following burn are currently guided by a weight and burn size formulae, then titrated to urine output. Traditionally, 24 h resuscitation is reported as volume of resuscitation received without direct consideration for the physiologic response. We propose an input-to-output ratio to describe the course of burn resuscitation and predict eventual outcomes.

Methods

We reviewed admissions to a burn center from January 2003 through August 2006. Inclusion criteria were ≥20%TBSA, admission ≤8 h after burn, and survived ≥24 h. Demographics, input volume and urine output, and clinical outcomes were recorded. A ratio of input volume (cc/kg/%TBSA/h) to urine output (cc/kg/h) was calculated at 24 h. The ratio of fluid intake to urine output reflecting an ‘expected’ response was developed: 4 cc/kg/%TBSA/24 h (0.166 cc/kg/%TBSA/h) divided by 0.5–1.0 cc urine/kg/h for an expected range 0.166–0.334. Subjects were classified based upon the ratio: over-responders (<0.166), expected (0.166–0.334), or under-responders (>0.334). Clinical outcomes were compared and concordance of classification to values was calculated at 12 h.

Results

102 subjects met inclusion criteria; 29 in the over-responders, 37 in the expected, and 36 in the under-responders. Resuscitation volume was directly proportional to the calculated ratio while urine output was inversely proportional. Group mortality was 21%, 11%, and 44%, respectively, with a significant difference between the expected and under-responders (p < 0.002). We found decreased ventilator-free days in the under-responders, and when deaths were excluded, decreased ICU-free days as well (p < 0.05). Concordance of paired data gathered at 12 h and 24 h was 67% for the under-responder group.

Conclusions

We describe a novel ratio to classify acute resuscitation after severe burn including the patient's response. Such a classification is associated with eventual outcomes.     

Serum phosphate level in burn patients

Introduction

Despite plasma phosphate imbalance being rare, it is a relatively common finding in certain subsets of burn patients. It may occur due to the burn itself or as a result of the treatment. Severe hypophosphataemia (<1.0 mg dl⁻¹) is associated with a significant morbidity and a fourfold increase in mortality. In this study, the relation between serum phosphate level and the total body surface area (TBSA) of the burn was compared.

Methods

According to the percentage of TBSA of the burn, the patients (n = 155) were divided into three groups: group A with 20–29% TBSA burns, group B with 30–39% and group C with more than 40% TBSA burns (62, 48 and 45 patients, respectively).Analysis of variance (ANOVA)-repeated measure was used to detect any statistically significant difference in the three post-burn time-points of 3rd, 6th and 9th days and the mean score of the serum phosphate level between the three groups.

Results

The incidence of hypophosphataemia at 9th post-burn day in the three groups was 6.1%, 32.4% and 73.5%, respectively. There were significant differences (p < 0.05) between mean serum phosphate levels of groups A and C, B and C and A and B as well. We found significant differences between the three post-burn follow-up time stages.

Discussion

We have shown that hypophosphataemia, defined as mean serum phosphate levels below 3.0 mg dl⁻¹, was very common following burn, based on 75.6% of patients with more than 40% burn at the 3rd post-burn day. As the percentage of TBSA of burn increases, the incidence of hypophosphataemia significantly increases. We suggest that phosphate level be routinely measured after a major burn, especially in patients with a complicated course, so that appropriate replacement therapy may be started in a timely manner.     

Cologne burn centre experience with assault burn injuries

Objective

To evaluate demographic and socioeconomic factors associated with assault burn injuries.

Background

Assault by burning demonstrates a rare but severe public health issue and accounts for unique injury characteristics in the burn intensive care unit (BICU).

Methods

We conducted a retrospective cohort study involving patients with thermal injuries admitted to the BICU of a university hospital. The patient cohort was divided into two groups (ABI group: patients with assault burns, n = 41; Control group: population of all other burned patients admitted to the BICU, n = 1202). Bivariate and multivariate analyses including demographic and socioeconomic data were used to identify factors associated with assault burns.

Results

Forty-one assault-related burn victims were identified in the study period. This represents 3.3% of all significant burns admitted. Comparing battery victims with the control population, assault patients were more likely to be young (mean age 36.2 years vs. 42.2 years) and immigrants (41.5% vs. 15.1%). Furthermore, marital status (65.9% vs. 40.8% singles), employment status (36.6% vs. 9.7% unemployed) and insurance status (41.5% vs. 12.3% social insurance) were significantly different in the bivariate analysis. Logistic regression evaluation identified three variables that were independently associated with assault burns: younger age (≤25 years) (odds ratio, 2.54 [95% confidence interval, 1.29–5.02]; p = 0.007), ethnic minority (odds ratio, 3.71 [95% confidence interval, 1.91–7.20]; p < 0.001) and unemployment (odds ratio, 4.02 [95% confidence interval, 2.03–7.97]; p < 0.001).

Conclusions

The high incidence of youngsters, unemployment and the great proportion of immigrants in victims of assault might provide several opportunities for community-based psychosocial and occupational programs. A multidisciplinary approach targeting issues specific to the violent nature of the injury and the socioeconomic background of the victims may be of benefit to improve their perspectives for rehabilitation.