Epidemiological determinants of burns in paediatric and adolescent patients from a centre in Western India

236

Epidemiological determinants of burns in paediatric and adolescent patients from a centre in Western India lP. Kumar, 2M. Sharma and 3A. Chadha Departments India

of ‘Preventive

and Social Medicine,

‘Paediatrics

A l-yearprospedive study of 112 burn patients up to 19 years of age aimed lo identify and study the de~erminanfsand rrwrtality experiencw in these burn pafienk and found flame butn.5to be the commonest, followed by scala%and ebxtric bums. Al1 burns ether than these caused by electricity were commoner in females, more so between 1s and 19 years of age. Burr~ were more frequent in winter and 85 per cent of them were domesfic. Nearly al1 burns took pkue dwing & h’me with a higher inci&nce beiween 06.00-09.00 hand 14.00-21.00 h. Thepafientfatality rare [dl. 1 per cent) was associated with total hum su&.ce area. Referral time-lag was an important debzrminant of mortality especiblly in less severe bums. As would be e+&d, hospita1 stay was signifirantly longer in swvivors.

Bums (1994)20, (3), 236-240

Introduction The study of epidemiology of bums is crucial to their prevention in target populations. Children contribute to a large proportion of bum cases’-j. Burns are the leading cause of accidental death in children* yet are largely preventable. Preadolescent and adolescent girls in India and other Eastem Asian countries are pushed early into kitchenrelated activities and therefore have a closer contact with fire5. Studies in the last decade6’ have indicated that all age groups in the population are susceptible to thermal injury. This study analyses burns in the 0-19 year-old population with emphasis on the 15-19 year olds - the latter is a unique group of mostly female victims not focused upon in the recent 1iterature’O.

and Burns Plastic Surgery, B. J. Medical College, Ahmedabad,

surface area (TBSA) was estimated from body surface charts modified from Lund and Browder” and CarvajalX2. In this study TBSA represents the percentage of surface area bumed; erythema bums have been disregarded but otherwise no attempt has been made to differentiate between superficial and deep bums.

Results During the study period 112 bum patients between 0 and 19 years old were hospitalized. These accounted for 22.5 per cent of the total of 498 admissions due to bums. Flame bums were commonest (55.5 per cent), followed by scalds and electric burns. Females (more than 10 years old) were affected more than males, the differente was most marked between 15 and 19 years of age (MF ratio 1: 2.2). Flame bums were more common in girls of 15-19 years old, scalds in children under 10 years old and electric bums in males of 10-19 years of age (Ta& 1, Figure 1). The maximum number of bums occurred in winter (48.2 per cent), largely due to an increase in flame bums and scalds. A relative increase in electrical bums was observed during the monsoon. Differences in seasonal incidence of 24

24

20

-

16

z

Materials and methods Al1 112 burn patients between 0 and 19 years of age adrnitted to the Bum and Plastic Surgery Unit (BPSU) of B. J. Medical College, Ahmedabad, from 1 January to 3 1 December 1991 were prospectively studied using a designed and pretested proforma to collect epidemiological information. The information was collected by direct interview with the patient or relative. Age and sex of patients, place of accident, type, cause of bums and temporal characteristics (season, clock hour, hospital stay, time-lag between accident and hospitalization) were recorded. Details of habitat were inquired from patients with domestic bums. Total bum 0 1994Butterworth-Heinema 03054179/94/030236-05

Ltd

2

12

5 ._ m P

a

., M F 0-4

M

F 5-9

M F 10-14

M F 15-19

Age (yr)

Figure 1. Distribution of burns according to age, sex and type of bum. M, Male; F, female; ? ,?flame; EI, scald; IJ, electric.

Kumar et al.: Bums in young people in Western India Table 1. Distibution

237

of 112 patients according to their age, sex and type of bum Type of burns

Patients studied *

Age (v) 0-4 6-9 10-14 15-19

33 18 26 35

Male to female ratio11

Flame’ _ M F 7 5 3 7

Scaldt ~ M F

3 5 10 22

9 3 3 -

1 :1.8 (55.4)

13 4 3 1

1:1.4 (32.1)

Electrid M

F

1 1 6 4

1 1 1 EO.2 (12.5)

Male to female ratio (no. of female(s) per male)

% of total patients

0.9 1.0 1.2 2.2

29.4 16.2 23.2 31.3

1.3

‘n=112.‘n=62%.fn=36.*n=14. 11 Figures in parentheses indicate percentage values.

Table Jl. Distribution of 112 bum patients according to their place and time of accident Time (h) Place

06.00-13.59

14.00-21.59

22.00-05.59

Total 96(85.7)

Domestic Living room Kitchen Bathroom Open space Outdoor Farm Others’

26 15 7 1

28 14 1 1

6 2

4 4

3 -

2”: 8 2 16(14.3) 10 6

-

112

Total (5?9)

(237,

(4Y4)

Figures in parentheses indicate percentage values. ‘Includes burns in the street, hotel, marriage hall, factories, etc.

bums were statistically significant (x” = 12.01; d.f.= 2; P
42

common in the morning (06.WO9.00 h) (Table II). A comparison between the observed and expected temporal distribution of burns showed significantly more bums (xz = 52.1; d.f. = 3; P< 0.001) occurring in the moming (06.OGO9.00 h) and in the evening (14.00-17.00 h) (7ììbleDI). Less than 20 per cent TBSA was found in 24.1 per cent of patients, less than 40 per cent in 53.6 per cent of patients, less than 60 per cent in 77.7 per cent of patients and 60-100 per cent in the remaining. Mean and median TBSA (per cent) were 40.7 f 24.9 and 40.0 respectively. Overall case fatahty rate (CFR) was 41.1 per cent, being zero when the TBSA was below 20 per cent and 100 when the TBSA was above 60 per cent. Flame burns had maximum CFR followed by scalds (TabZeAf). The delay between injury and referral time was computed for patients with less than or more than 40 per cent TBSA (TabZe V). The CFR was 9.1 per cent with less Table III. Temporal distribution of the bum events

24

% of burn incidence (n = 112)

18

Time (h)

6

Winter (Nov-Feb)

Summer (Mar-Jun)

Monsoon (Jul-Oct)

Figure 2. Distribution of bums according to their type and seasonal incidence. ?,? Flame; EI, scald; E!, electric.

06.00-09.59 10.00-13.59 14.00-17.59 18.00-21.59 22.00-01.59 02.00-05.59

Observed

Expected’

31.3 19.6 24.1 22.3

16.6 16.6 16.6 16.6

2.7

33.3

1

‘tf the 112 injuries were equally distributed between the six 4-h periods.

238

Burns (1994) Vol. 20/No.

3

Table IV. Mortalities of the burn patients according to the TBSA and type of bum Flame

Total

Electric

Scald

CFR

TBSA (W

No.

0-19 20-39 40-59 260

10 15 16 21

Total

62

CFR (%)

Expired

Expired

No.

3 9 21

10 17 6 3

33

36

53.2

4 4 3

7 1 5 1

11

14

30.6

lag Patients Referral time

(W Les than 40 (n=60) 40 or more (n=52)

CFR Studied

Expired

íw

44 16 45 7

4 3 34 5

9.1 18.8 75.6 71.4

Early

Late Early Late

Early, within 12 h. Late, after 12 h.

Table VI. Duration of hospital stay Doration of hospita/ stay (days) Parameter Median Meanfsd. Range ‘n=46.

Expired pa tien ts 6.0 5.9h6.9 1-38.0

??

Su rvivors’ 32.0 31.8*21.9 1-115.0

‘n=66.

than 40 per cent TBSA when referred within 12 h and 18.8 per cent when referred after 12 h. The CFR was 75.6 per cent with more than 40 per cent TBSA referred within 12 h and 71.4 per cent when referred after 12 h. The length of stay in hospital was significantly longer (z= 8.99, P< 0.001) in survivors than in those who died (Table Vl).

Discussion About 30 per cent of patients are aged between birth and 19 years of age; this population has not been specifically covered in recent literature“‘. After 9 years of age many more girls than boys were admitted to hospita1 in our study. An extensive reviewIj has also identified a well-marked female preponderance. Even this female dominante may underestimate the actual nurnbers because female children in India are treated and admitted to hospital less frequently than males when requiring essential medical care14 The common profile of victims in this study was of a 15to 1%year-old girl admitted with Bame bums. We attribute this to the following factors: 1.

-

14.3

Table V. Mortalities according to their TBSA and referral time-

TBSA

Expired

No.

Active, sometimes unsupervised cooking and other fire-related domestic activities by these girls. Early or teenage marriages accentuate these activities.

Expired

No. 27 33 27

1 1

25

2

112

7

:5

(%I 0 21.2 51.9 100.0

46 41 .l

Cooking while sitting on the floor is common in India. Young girls are mainly introduced to wearing the traditional ‘saree’ (long piece of cloth loosely wrapped around the lower half of body with a flowing tail over one shoulder, the tail is called ‘pallu’ and the ‘pallu’ accidentally catches on fire when they get up and it slips from the shoulder onto the stove. Use of unsafe pressure stoves is common in semiurban and rural areas. Explosive disintegration of shoddily made stoves has also been found in EgypVs Studies of thermal injuries in domestic situations usually find flame and scald bums to be the commonestz, and these accounted for 87.5 per cent of al1 burns in our study. We did not have any admissions due to chemical and friction bums as found in other studies16. In our study flame bums were the most frequent due to the inclusion of the 15 to lg-year age group. Below 15 years of age, scalds were the leading cause of thermal injury, as also reported by Lyngdorf et al.l’, Elberg et aLz, Cheng et al.18 and Gupta et al.‘O With decreasing age of the child, there is an increasing incidence of scalds”. Probably flames evoke a visual waming response in children which hot liquids do not. Preschool-aged children made up 29.4 per cent of the admissions, next only to the 15 to 1%year age group. These children are at high risk18’“0’2*due to negligence by parents or elder siblings5, their longer stay at home, their exploring and inquisitive nature and their inability to fend for themselves3. Boys and girls up to 9 years of age were admitted to our bum unit in equal numbers. After 9 years of age many more girls than boys required admission. Other studies have shown either no or only a slight male dominante in similar age groups3.5.‘o”8.19~ The hospita1 admissions with bums of patients up to the age of 14 years accounted for 15.4 per cent of the total bums admissions compared with 23.2 per cent reported by Gupta et al.‘O from the neighbouring state of Rajasthan. Many paediatric bums are mild in nature, therefore rigorous outpatient assessment and treatment can reduce the inpatient burden substantially. This is important in bum units with heavy workloads. Seasonal differences in incidence of bums are wel1 marked in North India due to the differences in the seasonal temperatures l3 . A more distinct seasonal variation reported by Gupta et al.‘O did not take into consideration different types of burns. Our study observed more flame and scald bums in winter, with a relative increase in electric bums during the monsoon. Studies from abroad do not record a well-delineated seasonal trend5*“. Domestic bums are common in children, ranging in incidence from 85 per cent (present study) and 90 per cent”

Kumar et al.: Bums in young people in Western India

to 97 per cent 3,5. This study noted that nearly 60 per cent of

the domestic burns occurred in the living room compared to 21.7 per cent observed by Gupta et al.“’ Living room burns occurred in habitats where cooking and other fire-related activities were being carried out in a single room that served al1 family purposes; 8.3 per cent of the domestic bums, mostly scalds, occurred in bathrooms. Such bums have not been reported by Gupta et al.“. A bimodal distribution (moming and evening) of injuries which correlated with peaks of human activity has been observed in this study, as wel1 as by Jamal et al3 Thus, Herd et a1.22found bums in children usually occurred during lunch times (cooking related) or evenings (bath related). Case fatality rates reflect the proportion of severe bums. Significantly different fatality rates have been observed in patients with TBSAs of more than or less than 40 per cent by Dately et a1.23.Studies with only 15-17 per cent of patients with severe bums (TBSA> 40 per cent) have reported overall CFRs of 19 and 20 per cent9,“. Such severe burns contributed to 47 per cent of our hospital admissions, and we encountered an overall CRF of 41 per cent. Patients with TBSAs of more than 60 per cent al1 died (present study and Gupta et al.‘“). Mortality in our study was nil for patients with TBSA up to 20 per cent. However Gupta et al.” reported an unexplained CFR of 6.5 per cent in patients with TBSAs of between 11 and 20 per cent. In a more advanced bum centre the earlier fatality rate of 47.2 per cent for more than 40 per cent TBSA bums was reduced to 27.1 per cent by the introduction of earlier surgical treatmentz4. The heavy workload in Indian bum centres has lead to the introduction of ‘comfort care’ rather than vigorous resuscitation13, often because these units predominantly employ conservative treatment usually due to the lack of adequate and timely availability of supportive facilities (blood, plasma, antibiotics and other drugs). The relationship between the referral time-lag and CFR has not been analysed in Indian studies so far. Early referral halved our CFR for patients with TBSA 40 per cent or less. Transportation difficulties together with lack of immediate care facilities ied to late referral in 20 per cent of our patients. Late referral has been recorded to affect between 14.4 and 36 per cent of patients elsewhereio,‘3. Severity of bums also influences hospita1 stay. Multiple surgical procedures and frequent infections led to a mean hospita1 stay of 31.8 days in our surviving patients. Less severe bums have a shorter hospital stay.3”6. Children in genera1 and girls of 15 to 19 years of age, in particular, are at a high risk for scalds and flame bums respectively. Traditional clothes and cooking activities leading to daytime, domestic flame bums with a high mortality (due to their severity and late referral) can be specifically targeted for prevention programming and containment of epidemiological risk factors. In this regard the following possible prevention methods are suggested: Inexperienced young gids should be discouraged from draping the ‘saree’ while cooking, they should wear a flame-resistant apron. Unsupervised initiation into cooking is to be strongly discouraged socially, if possible legally. The public is to be specifically educated to use only those stoves that carry the IS1 (Indian Standards Institute) mark. Primary ‘on the spot’ management and timely (i.e. early) referral of burns is to be highlighted. Tempora1 determinants of bums implicate the moming

239

hours to be of highest risk. Appropriate organization of human activities in these hours is crucial for the prevention of burns. 5. Available mass media channels are to be used to propagate the messages given above. Recently the 21.00 h commercial television slot has yielded considerable results for increasing the acceptability of immunization and family planning measures. The same could be tried for safe practices for bum prevention.

References 1

2

3

4

5 6 7 8 9 10 11 12

13 14 15 16 17

18 19 20 21

HaberaI M, Oner A, Bayraktar U et al. Epidemiology of adult and children bums in a Turkish bum center. Burm 1987; 13: 136. Elberg J, Schroeder HA, Glent-Madsen L et al. Bums: epidemiology and the effect of a prevention programme. BWYE1987; 13: 391. Jamal YS, Ardawi MSM, Ashy ARA et al. Paediatric bum injuries in the Jeddah area of Saudi Arabia: a study of 197 patients. Burns 1990; 16: 36. LaDou J and Cohen R. Disorders due to physical agents. In: eds. Schroedar SA, Tiemey LM Jr, McPhee SJ et al, Current Medical Diagtwsisana’ Treafment. Appleton Lange, Prentice Hall, p 1203. Haq A. Pattem of burn injuries at a Kenyan provincial hospital. Burm 1990; 16: 185. Ghullani KK, Tyagi NK, Narang R et al. An epidemiological study of bum injury. Ind J Public Health 1988; 32: 24. Jha S.S. Bum mortality in Bombay. BUWLS 1991; 16: 36. Sen R and Banerjee C. Survey of 1000 admissions to a burn unit SSKM Hospital, Cakutta. Burns 1981; 7: 357. Malla CN, Misgar MS, Khan M et al. Analytical study of bums in Kashmir. Bum 1982; 9: 180. Gupta Malti, Gupta OK and Goil Pradeep. Paediatric bums in Jaipur, India: an epidemiological study. Burns 1992; 18: 63. Lund CL and Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944; 79: 352. Carvajal HF. Burns in general consideration in the care of sick children - paediatric critical care. In: Behran RE, Vaughan BI BC and Nelson WE, NeLson Texf Book of Paediatrics, 13th ed. Philadelphia: Saunders, p 223. Davies JWL. The problem of Bums in India. Burm 1990; (suppl 1x 5-4. Mukherjee S. The girl child in India. Ind ] Paediafr 1991; 58: 301. Saleh S, Gadalla S, Fortney JA et al. Accidental bum deaths to Egyptian Women of reproductive age. Burvs 1986; 12: 241. Lyngdorf P. Epidemiology of scalds in smal1 children. Bwns 1986; 12: 250. Lyngdorf P, Sorenson B and Thomsen M. The total nurnber of bum injuries in a Scandinavian population - a prospective analysis. Bums 1986; 12: 567. Cheng JCY, Leung KS, Lam Z C-L et al. An analysis of 1704 bums injuries in Hong Kong children. Burm 1990; 16: 182. Rossignol AM, Locke JA and Burke JF. Paediatric bum injuries in New England, USA. Bum 1990; 16: 41. Klasen HJ and ten Duis HJ. Changing pattems in the causes of scalds in young Dutch children. Bums 1986; 12: 563. Lyngdorf P. Epidemiology of severe bum injuries. Burm 1986; 12: 491.

Bums (1994) Vol. 20/No. 3

240 22 Herd AN, Widdowson P and Tanner NSB. Scalds in the very young: prevention or cure? Bums 1986;12:46. 23 Dately S, Murthy NS and Taskar AD. A study of bum injury cases from three hospitals. Ind] Pnblic He& 1981; 25:117. 24 Benmier P, Sagi A, Gerber B et al. An analysis of mortality in patients with burns covering 40 per cent BSA or more: a retrospective review covering 24 years(1964-1988. Bt»w 1991;17:402.

25 Sharma BK, Seth KK and Dharkav Rs. Bums injuries and their prevention. ] Ind Mcd A.ssuc1978; 17: 202. Paper accepted 28 September

1993.

CorrespundenceshouJd be addressedko: Dr Anil Chadha, Department of Bums and Plastic Surgery, B. J. Medical College, Ahmedabad380016, India.

THE SIXTH CONGRESS OF THE EUROPEAN SHOCK SOCIETY STOCKHOLM, SWEDEN- SEPTEMBER 16.17,1994 Topics for discussion wil1 include: Vascular endothelium - target “organ” in sepsis How to organize clinical trails in sepsis Multiple trauma patients in the ICU For furtber information please contact: ESS, Congrex (Sweden) AB, Birger Jarlsgatan 117, P.O. Box 5619, 114 86 Stockholm, Sweden. Tel: +46 8612 6900 or Fax: +46 8612 6292 or Telex: 16949 KRECON S.

1s~ INTERNATIONALCONGRESSOF PEDIATRIC SPORTS MEDICINE VORAU,AUSTRIAIEUROPE SEPTEMBER 4-10,1994

For further infomtion

please contact: Peter H. Schober, MD Department of Pediatrie Surgery Auenbruggerplatz 34 A-8036 LKH-Graz/Austria/Europe Tel: (0) 316 385 3762 Fax: (0) 316 385 3775