The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the firs, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0–10 years old (40 per cent) and moderate to major burns in the age group 21–30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.     

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.     

Thermal injury in the elderly: when is comfort care the right choice?

The factors contributing to a higher mortality rate in elderly thermal injury victims are not well delineated. The purpose of this study is to determine the impact of the initial injury, medical comorbidities, and burn size on patient outcome and to determine a level of injury in this population when comfort care is an appropriate first choice. Individual medical records of patients over 65 years of age admitted to our burn center over a 10-year interval were reviewed for patient demographics, mechanism of injury, total body surface area (TBSA) burned, medical comorbidities, use of Swan-Ganz catheters, evidence of inhalation injury, level of support, and patient outcome. The mechanisms of thermal injury were flame (68%), scald (21%) and electrical or chemical contact (11%). Twenty-six preventable bathing, cooking, and smoking-related injuries were seen (33%). The average TBSA was 25 per cent. Average length of stay varied depending on outcome. The overall mortality rate for this group was 45 per cent. Patients older than 80 years with 40 per cent or greater TBSA burned had a 100 per cent mortality rate despite aggressive treatment. Burn wound size correlated better with probability of poor outcome than age. Thermal injuries in the elderly are becoming more important with the aging of our population. Underlying medical problems--specifically chronic obstructive pulmonary disease--do play a role in increased patient morbidity and mortality. This study shows that age greater than 80 years in combination with burns greater than 40 per cent TBSA are uniformly fatal despite aggressive therapy. We believe that delaying the start of comfort-only measures in this situation only prolongs the pain and suffering for the patient, the family, and the physician.     

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.     

Burn injury and management in Liberia

Burn care in developing countries remains a challenge. This paper reviews the acute burn care of 21 patients admitted during a 1-year period to a hospital in Liberia. Lack of supplies and education, coupled with the local belief system, reflect on patient management. The study population to falled 21 patients, ranging from 1 to 62 years of age. TBSA burns ranged from 2 to 60 per cent (mean 21 per cent), 61 per cent of patients were grafted. The time between burn and graft varied between 5 and 96 days (mean 29.8). Graft take varied between 40 and 100 per cent (mean 81 per cent). Of the grafted patients 66.6 per cent received blood (average 732 ml). At the time of presentation 61.9 per cent of patients had other illness. The average number of hospital days was 37.9 (range 2–76). The mortality rate was 14.2 per cent. When managing burns in a developing country, adaption of a simple, clearly defined method of treatment, together with education of the caregivers, is suggested. As in the developed world, however, prevention is the critical factor.     

A policy of early excision and grafting in elderly burn patients shortens the hospital stay and improves survival

Early excision and grafting of the burn wound appears to shorten the hospital stay and decrease mortality in children and adults. However, whether an early surgical approach is safe in elderly burn patients has not been resolved. To answer this question we carried out a prospective study of early surgery in 114 consecutive patients over the age of 50 years. Patients were generally operated on between post-burn days 2 and 5. The mean age of the patients was 68 years, with a burn size of 22 per cent, of which 13 per cent was full thickness skin loss. The mean hospital stay of the surviving patients was reduced by 40 per cent compared to national averages (P less than 0.001). The mortality rate for the entire group of patients was 17 per cent, with 2 deaths in the 65 patients with burns less than 20 per cent total body surface area (TBSA). Although the mortality rate for patients with burns greater than 20 per cent TBSA was 35 per cent, this was less than predicted (P less than 0.05). The improvement in survival appeared to be due to a decrease in the incidence of lethal burn wound infections.     

Epidemiology and mortality of burns in a general hospital of Eastern Sri Lanka

This 2-year prospective study examined the epidemiology and mortality of 345 patients admitted with burn injuries. Sixty-four percent of all burns were accidental in nature and at least 25% were self-inflicted. The rest were due to assaults or had a doubtful cause. The median age was 22 years. Forty-one percent of the accidents were due to the fall of a homemade kerosene bottle lamp. The main cause was flames, followed by scalds. Females outnumbered males in all categories of burns except cases of assault, and suffered from a higher mortality. Most at risk of accidental burns were children between 1 and 4 years, who suffered primarily from scalds. Self-inflicted burns were most common among women aged 20–29 years. The overall median total body surface area (TBSA) burned was 16%. Self-inflicted and ‘doubtful’ burns were much more extensive and more often fatal than accidental ones. The overall mortality rate was 27%. Burns involving more than 50% of the body surface area were invariably fatal. Mortality was highest in the elderly and in the 20–29 years age group. Burns were the first single cause of mortality in the surgical wards. The case is made for the establishment of more Burns Units.     

Acute appendicitis during pregnancy

Forty-one appendectomies were performed on pregnant patients during the period 1973-1983. The preoperative diagnosis of acute appendicitis was correct in 57 per cent of the cases (24 patients). Presenting complaints, physical examinations, and laboratory analysis did not prove helpful in establishing the diagnosis. The incidence of acute appendicitis during pregnancy was 1:4172 (birth/pregnancy). Rapid surgical intervention probably contributed to the low (25%) incidence of perforated appendices. A transverse incision and general anesthesia were preferred. There was no maternal mortality and a 2 per cent rate of fetal loss.     

Comparative coagulation abnormality patterns in moderately and severely burned patients

Coagulation abnormalities are known to increase morbidity and mortality in severely burned patients. Coagulation abnormalities in moderately burned patients were compared for similar effects. Prothrombin and partial thromboplastin in both moderately and severely burned patients showed no important abnormalities. However, an abnormally increased platelet count during the third week post burn in moderately burned patients did not occur in the severely burned, who maintained low normal levels. The moderately burned had a mortality rate of 5–8 per cent compared to 42 per cent in the severely burned group.     

Anaphylatoxin formation in plasma and burn bullae fluid in the thermally injured patient

Plasma anaphylatoxins (C3a and C5a) were measured in 19 thermally injured patients with a mean total burned surface area of 39 per cent (range 10-90 per cent) of partial and full skin thickness loss. Extensive burns were associated with increased anaphylatoxin activity. Patients with greater than 50 per cent burned surface area had higher plasma C3a and C5a concentrations than patients with 10-25 per cent burns (P less than 0.001) 1 week after injury. Six out of seven patients with greater than 50 per cent burned surface area developed adult respiratory distress syndrome (ARDS) and four out of seven bacteraemia. Twelve patients had 10-25 per cent burns and none of them developed ARDS or bacteraemia. The mean C3a concentration per millilitre of fluid from the burn bullae from nine different individuals was 2570 +/- 260 ng/ml. The C5a content in fluid from the bullae did not differ from the corresponding plasma range. Increased anaphylatoxin activity might explain extensive extravasation of fluid in burned patients. This increase might also be one reason for leukocyte accumulation in burned areas.     

Analysis of 105 patients admitted over a 2-year period to a modern burns unit in Saudi Arabia

This is an epidemiological survey of 105 burned patients treated between May 1986 and May 1988 in a modern Burns Unit in Saudi Arabia. Hospitalization time ranged from 1 to 100 days with a mean of 17 days. The mean age of the patients was 9 years. Sixty (57 per cent) of the patients were males and 45 (43 per cent) were females. The main causes of injury were hot liquids (57.7 per cent) and fire (33 per cent). The mean extent of injury was 19 per cent TBSA. Burns covered less than 40 per cent TBSA in 91 out of 105 patients (87 per cent). Deep burns did not exceed 100 units of burned skin in 48 out of 55 patients (87 per cent). Urgent escharotomy was done in 14 patients. Early excision and skin grafting was carried out in 34 patients. Complications included six cases (5.7 per cent) with septicaemia, one (0.9 per cent) with disseminated intravascular coagulopathy, three (2.9 per cent) with amputation and one (0.9 per cent) with stress gastric ulcer. Seven patients discharged themselves against medical advice. Five patients died. The favourable results in this series were attributed mainly to the low severity of burns and partially to the short delay between injury and admission, early surgery and remarkably good facilities. Childhood scalds in this region of the world could possibly be reduced by changing the family habit of having tea at floor level and recommending wide-based tea-pots.     

Hand burns in children under 5 years of age

In order to evaluate the epidemiology and functional results of hand burns in young children, 92 consecutive patients (126 hand burns) under age 5 years admitted to a Burn Center were reviewed. Scald burns (49 per cent) were most common, followed by flame (34 per cent), contact (14 per cent) and electrical burns (3 per cent). The child was left unattended by an adult in 53 per cent of cases and documented abuse was present in 6 per cent. The mean total body surface area (TBSA) burned was 17 per cent, and 77 patients (85 per cent) had additional burns in other areas (arms 34 per cent, legs 31 per cent, chest 29 per cent and face 27 per cent).

Palmar burns occurred in 24 hands (19 per cent), dorsal in 41 (33 per cent), while both surfaces were burned in 61 (48 per cent). Joints involved included the MP in 96 (76 per cent). PIP in 87 (69 per cent) and DIP in 80 (63 per cent). The depth was superficial partial thickness in 53 (47 per cent), deep partial in 55 (44 per cent), and full thickness in 18 hands (14 per cent); a total of 29 hands were grafted (15 deep partial and 14 full thickness). Escharotomies were required in 12 hands (9 per cent) (9 flame and 3 scald) and partial amputation of digits was required in 3 (2 per cent).

Follow-up was available in 46 hands from 7 to 120 months (mean 39 months). Partial thickness burns (34) healed with normal (32) or near-normal (2) hand function and developmental delay occurred in one patient. Hand function in 12 full thickness burns was normal in 9, decreased in 3 with developmental delay in 2 patients. The number of reoperations required per hand burned after hospital discharge varied with age (2 years and under 1.2 vs. over 2 years 0.6), depth (deep partial 0.4 vs. full thickness 1·6) and surface involved (palmar 1.3 vs. dorsal 0.1 vs. both 1.5), indicating that children under 2 years with full thickness palmar burns are at increased risk of developing burn scar deformities requiring surgical correction. Although 24 total reoperations were required in 25 deep partial and full thickness hand burns, residual burn scar deformities were present in only 2 hands at follow-up (1 boutonniere and I web space contacture).

It is concluded that the overall outcome of hand burns in this age-group is good and developmental delay is rare with proper acute management and prompt surgical correction of burn scar deformities.     

Trends in burn admissions in Scotland during 1970–1992

This retrospective study involved analysis of the data of the inpatients discharged with a diagnosis of burns, from various hospitals in Scotland, during the period 1970–1992. There were 51350 such inpatients all over Scotland, with an average annual rate of 2233 cases. Overall burn incidence in actual numbers was 43.7 per cent in < 15 year olds, 41.2 per cent in 15–64 year olds and 15.1 per cent in ≥ 65 year olds. Burn rates per 100 000 population were highest in < 15 year olds and lowest in 16–64 year olds.

The pattern of burn admissions has changed. Since 1987 the highest numbers of burn inpatients were the 16–64 year olds, followed by children, then the elderly. There has been a gradual but sustained fall in burns admissions in all age categories. The downward trend was statistically significant (t = 8.48, 21 d.f., P < 0.001). Though the population of the elderly (≥ 65 year olds) increased by about 13 per cent, the burn admissions and all deaths due to burns did not reveal an upward trend. The population of the old (81 + year olds) increased by 60 per cent during the same period. The incidence of burns was above average when > 80 year olds were considered separately, approaching the levels found in children. However the rate and incidence of burns in the 65–80 year olds resembled that of the younger age group (16–64 year olds).

The total number of deaths due to burns and/or smoke inhalation has declined in all age groups and the decline has been statistically significant (chi-squared = 19.62, 1 d.f., P < 0.001). Maximum number of deaths occurred in ≥ 65 year olds (44 per cent), followed closely by 16–64 year olds (43.5 per cent), and 12.5 per cent of deaths in adolescents and children. The decline was due to improved management of burns and a decrease in the number of patients having large body surface area burns.     

Tandir burns: a severe cause of burns in rural Turkey

Tandir is the name given to an oven used for baking bread in the eastern and south-eastern part of Anatolia. Tandir burn is a special kind of burns in which primarily women and small children fall in it and have deep extensive burns (TBSA %). The records of 60 patients with tandir burn who were treated in our Burn Center from September 1999 to January 2006 were reviewed. The patients consisted of 9.2% of all burned patients. The mean age was 17.10 years (1-60 years) and 61.50% of the patients were female. The mean total body surface area (TBSA) burned was 21.09% (6-58) and 88% of the patients had third-degree burns. Eight of the patients underwent amputation of an extremity, 10 had fasciotomies, and 25 partial thickness skin grafts. The mean hospitalization period was 31.64 days (3-73 days). Fifteen patients (25%) died. Tandir burn is a severe kind of burn with a higher morbidity and mortality.     

Suicide attempted by burning: a 10-year study of self-immolation deaths

In a 10-year retrospective survey of 699 admissions to the Burns Centre of Verona, 31 patients (4.4 per cent) had self-inflicted burns. No sex difference was found, the mean age was 38 years, with 58 per cent of the patients in the 20–39-year age group. The mean burned surface area (BSA) was 41 per cent, and 12 patients (38,7 per cent) died: seven within the first 24 h. The other five patients died within 40 days (mean survival: 18 days). A large number of patients had a history of previous psychiatric treatment, six patients had previously attempted suicide. Four patients were drug addicts, three of whom were affected by AIDS and one had been HIV-positive for a long time. The patients had continuous psychiatric treatment during the long hospital stay. After discharge the patients were assigned to territorial staff for psychiatric treatment. Our experience shows that these patients have a higher mortality rate and they need constant psychiatric support, which can be useful in preventing further suicide attempts.     

Management of thermal injury in pregnancy--an analysis of 16 patients.

Sixteen patients at various stages of pregnancy suffered burns covering between 10 and 80 per cent of the body surface area. This review highlights the management problems of these patients during the first, second and third trimesters. Only two mothers (both with 80 per cent TBSA burns) died. There were five fetal deaths, three of them intrauterine.     

Flame burns involving kerosene pressure stoves in India

The author has analysed 339 patients with extensive burns admitted to a teaching hospital and found them to be most common in poor socioeconomic groups with low incomes, poor housing and illiteracy. Thermal injuries afflicted 89 per cent of the patients and were generally accidental and occurred in homes with floor-level cooking: chemical and electrical burns (the remaining 11 per cent) were uncommon. Kerosene pressure stove accidents were a common cause of thermal burns and occurred in 65 per cent of the patients. These were reported in both sexes but were 3.5 times more common in females. Mishandling of kerosene pressure stoves was the commonest cause and occurred in 65.7 per cent of the patients and the next most common cause was wearing loose garments. Kerosene pressure stove accidents occurred commonly in the age group 16–35 years and were rare in other age groups. These burns were relatively more extensive, deep and carried a high mortality.     

The epidemiology of burns in a medical center in the Caribbean

A retrospective study on burns patients admitted to the Sint Elisabeth's Hospital on Curacao was conducted during the 11-year period from the years 1992 to 2002. This is the first such study performed in Curacao. Curacao does not have an established burn center, therefore severe burns cases are treated in a general hospital. Only the very severe cases are referred to burn centers abroad.Data were collected on incidence, gender, age, cause, total body surface area (TBSA burned), degree, localization, case fatality, length of hospital stay (LOS), and seasonal variation. A total of 336 burns patients were admitted. This represented an annual admission of 31 patients, and an annual cumulative incidence of 2.3 episodes per thousand persons for burns admissions. The male to female ratio was 1.6:1, and the mean age of admission was 24.3 years. Most burned patients were observed in the age group ranging from 0 to 4 years old (29.2% of all burns cases). The mean TBSA of burn was 13.6%, range 0.5–80%. The most common cause of burn was scald (47.9%) followed by flame (22.3%). The overall mean LOS and case fatality were 15.8 days and 3.3%, respectively. Second and first degree combined, and second-degree only burns were the most frequent. Most frequent localizations burned were the arms, thorax, and legs. Most burns occurred at the end and at the beginning of each year (comparable to winter and spring period in other studies), being the seasons with the most public holidays and other festivities.We conclude that the incidence, age and gender distribution, LOS and TBSA of burns on Curacao were very similar to data from other international studies from the US, Europe and Asia. Scald and fire were the major causes of burns, being preventable injuries. Especially in young children the need for a prevention program is essential. Also, there is a need to inform people from all ages on the danger of fire injuries, especially during public holidays and other festivities when the incidence is the highest.     

Management of candida septicaemia in a regional burn unit

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center.

Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14–98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients.

Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis.

Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy.

There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.     

Surgical treatment of burns in elderly patients

This study evaluates our experience with surgical treatment of burns in the elderly. Forty-two patients more than 59 years old were treated from 1982 to 1986. The mean age was 73, and the mean TBSA burned was 29%. The patients were divided into three groups. Group I had 22 patients with less than 20% TBSA burn (mean of 11%, with a mean of 6% full-thickness burns). Their survival rate was 91%. Group II had 11 patients with 21-40% TBSA burns (mean of 32%, with a mean of 17% full-thickness burns). Their survival rate was 82%. Group III had nine patients with burns greater than 40% TBSA (mean, 71%). None of these patients survived. Twenty of 29 (68%) survivors required a total of 36 operations. The mean area grafted per procedure was 8%. Each procedure required a mean of 2U packed red blood cells, and a mean of 2 1/4 hours. The complication rate was 33%, with partial graft loss (14%) being the most frequent. The average hospital stay was 27 days in Group I and 45 days in Group II. Only 25% of the patients required nursing home assistance at discharge.