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Epidemiology of burns due to domestic flammable agents
Burns (1990) 16,(2), 113-117 Prmfedin Great
Epidemiology agents
113
Britain
of burns due to domestic flammable
S. P. Pegg, L. Beecham, N. Dore, D. Hrdlicka and C. Hukins Royal Brisbane Hospital, Queensland,
Australia
ATIanalysisof the epiakmiologicd factors relating fo domesfic flammable agents has shown thaf I 7.7 per cent of admissions over a 5-year period flammableinjuries; 87.7percent of fk patients were involved in domestic were male, with 38.9per cent beingyoung maks between12and 19 years old. Petrol and diesel accounfedfor 56.8 per cent of fk burns and the average body surface area burned was 17.7per cenf. Mosf commonly fk face8 hands and limbs were burned, and the average length of stay was 18.25whys, 69.2per cent of the bums were due lo human error and were thus potentially preventable, 21.2 per cent had predisposing conditions with 8.9per cent being due to akohol. If was cons&red that fk strategies to prevent these burns injuries should be aimed patictllarly at young males.
Introduction Domestic burns comprise a major source of morbidity in Australia today. To date there are few studies dealing with this aspect of community health. Little attention has been given specifically to the epidemiology and prevention of adult bums caused by domestic flammable agents. Adults with this form of injury have been shown to comprise a significant proportion of all adult flame bums, and most of those occurring in domestic premises are preventable. This study reviewed the epidemiological factors pertaining to this type of injury. Patterns thus obtained could be incorporated into prevention strategies as although therapeutic management of burns has improved, prevention is still the most effective way of reducing physical and psychological damage caused by bums, as welJ as reducing cost to the community. No study to date has concentrated on this particular topic and while the findings of this study apply to the Brisbane area, it is hoped that it may form a basis for comparative studies in the future. Previous studies indicate a high incidence of flame bums, particularly affecting males (Gordon and Ramsey, 1983; Pegg et al., 1983; Bongard et al., 1985), and also the importance of predisposing conditions (MacLeod, 1970; Masterton et al., 1979; Pegg et al., 1979). These patients tend to have larger burns (Byron et al., 1984). More burns occur at weekends (Gordon and Ramsay, 1983) in Australia but not in Copenhagen (Lyngdorf, 1986). Flame bums are the main causative agent (Sinclair, 1977; Jurrell et al., 1984; Darko et al., 1986). while scalds are common (Jay et al., 1980; (3 1990 Butterworth & Co (Publishers) Ltd 0305-4179/90/020113~5
Bongard et al., 1985). O’Ya and Ohmori (1978) showed that nine out of 10 bums are preventable, and this study supports this.
Method This retrospective study involved the hospital records of bum patients admitted to the Bums Unit, Royal Brisbane Hospital over the s-year period between 2 July 1982 and 30 June 1987. Patients selected were over 12 years old and had received bums by inflammable agents in a domestic situation. Younger patients were excluded. Other exclusions were if the bums occurred in an occupational or industrial environment, were the result of a motor vehicle accident, or were not the result of the combustion of the agent. The Royal Brisbane Hospital admits patients from that part of the city north of the Brisbane River as well as being the major bums referral centre for Queensland.
Results During the period of investigation, 146 patients were included in this study. This number is 17.7 per cent of the total number of patients included in the Bums Unit Registry, 87.7 per cent of the subjects were male. Figure I shows the sex and age distribution in this group. The male distribution
4.5
4.0 3.5 3.0 2.5 2.c 1 1.: i 1.c 1 0.: , 0.0
12-19
20-29
30-39 Age (years
40-49
so-95
1
Figure 1. Age and sex distribution of patients.
114
Bums (1990) Vol. 16/No.
peaks at the ages of 12-19 years, as does the total age distribution because of the male preponderance. However, the female distribution peaks later at the ages of 20-39 years. There was no yearly trend over the S-year period. Average monthly admissions are represented in Fi’re~. There appears to be a relatively higher incidence of burns in the summer holiday months of December and January compared to midyear (chi-squared = 19.86, PC 0.05). As expected, the incidence of burns was relatively more common during weekends than during the week (Figure.3) (chi-squared = 6.86, P< 0.01). The incidence was greater later in the week than earlier but this was not significant (chi squared = 10.21, P> 0.10). The distribution according to time of day (Figure 4)shows a peak during the period 13.00to 20.00hours and mainly involved the patients in the age group 12-29years. Petrol and diesel are by far the most common inflammable agents that caused the burns and were involved in 56.8 per cent of all burns. Methylated spirits and liquified petroleum gas (LPG) were more common than kerosene, glue, paint, paint thinners, lighter fluid, fertilizer and turpentine. There appears to be no association between the type of inflam-
__
?? Jan
18
[7
Feb
16
Mar
14
Apr May
12
Jun
8
??Jul ??Au9
6
IS
4
?? Nov ?? Dee
10
Se@ Ott
2 0
Figure 2. Average monthly admissions.
mable agent and the age of the patient. The age group 12-29 years is responsible for between 50 and 72 per cent of bums for each type of agent except for LPG, which was involved in only 25 per cent of the patients in this age group. Nearly one-third of the burns involved no equipment other than the inflammable agent alone, and included spontaneous explosions and petrol bombs, 26.4 per cent of incidents were associated with burning-off fires or incinerators and 11.1 per cent were associated with a car, usually the result of pouring petrol into the carburettor with the engine running. All of these patients were male. Other significant equipment involved were barbecues (9.7 per cent), outdoor camping equipment (7.6 per cent) and heaters or gas stoves (7.0 per cent). Two causes of the burns are prominent - using the inflammable agent to pour onto, or light, a fire and spontaneous explosions caused approximately one-third of the burns. Twenty-two per cent of the injuries resulted from the agent being poured over a person. Sparks from other equipment such as a running motor caused 11.0 per cent of the burns. Smoking was directly responsible for 5.5 per cent of the incidents in this study. Blame was categorized into four groups: human error, mechanical error, intentional and others. From this it was determined that 69.2per cent of burns in this survey were certainly due to human error. Mechanical error, usually due to equipment failure, was responsible for only 16.4per cent of the cases. Intentional burns occurred in 10.3 per cent of cases. These were attempted murder, suicide or other, such as one patient who set fire to his hair to eliminate head lice. A number of incidents (4.2 per cent) could not be classified. The distribution of bums was roughly comparable between the sexes. The sites most commonly involved were the limbs and face, 65.8 per cent of people had one or both hands burned and 58.2 per cent had their face involved. Of all burns, 45.2 per cent involved 10 per cent or less of the body area and 76.1 per cent had 20 per cent or less body area burned with an average of 17.7 per cent, 55.5 per cent of the bums were only superficial or partial skin thickness whereas 45.5 per cent of bums had a full skin thickness component.
8-12 Sun
MOll
TU.ZS Day
Figure 3.
Days
(years): 0
,
12-29;
of week and [?,
30-39;
Wed
Thurs
Fri
Sat
of week
quency of bums. Age groups
z
13-16
17-20
21-24
Time of day(h)
Figure 4. Time of day and average frequency of injury per time period. Age groups (years): 0, 12-29; 0 30-39;
total.
Pegg et al.: Domestic
Table I. Predisposing
flammable agents in bums epidemiology
conditions Patients
Predisposing conditions Alcohol Psychiatric illness Smoking at time Suicide Pregnancy Drugs Epilepsy Diabetes
%
No.
8.9 8.9 5.5 5.5 2.1 1.4 1.4 0.7
13 13 8 8 3 2 2 1
One or more predisposing factors was recorded in 21.2 per cent of the burns studied (Table I). Alcohol intake prior to the incident was the most common predisposing factor and was mentioned in 8.9 per cent of cases. Of the 13 patients who had consumed alcohol, I I were under 40 years of age. Also, 8.9 per cent of the patients had a psychiatric illness of some sort, such as a depressive disorder. Some cases (5.5 per cent) were recorded to have been smoking at the time of the incident. Other predisposing factors included epilespy, drugs, pregnancy and diabetes. The burns were the result of a suicide attempt in 5.5 per cent of the cases. The mean length of hospital stay for patients involved in this study was 18.25 days, with a range of up to 138 days and a total period of 2665 patient-days in hospital. There appeared to be no relationship between age and length of stay. Also, there did not appear to be a correlation between length of hospital stay and type of inflammable agent.
Discussion This study looked at the epidemiological factors pertaining to adult bums in the domestic setting caused by inflammable agents. Of the adult bum patients admitted to the Royal Brisbane Hospital Bums Unit from 1 July 1982 to 30 June 1987, 17.7 per cent of the patients (146) were involved in this category of bums. Consistent with the findings of Gordon and Ramsay’s (1983) survey on thermal injuries in Australia, which found that over 85 per cent of those who suffered burns due to inflammable liquids were male, this study found that 87.7 per cent of subjects were male. The male distribution peaked between the ages of 12 and 19 years with 38.9 per cent of males being in this age group. As there was such a high preponderance of male subjects, the total age distribution also peaked at this age with the percentage of young males from the total group being 25.3 per cent. The female distribution peaked at 20-39 years of age. Since females comprised omy 12.3 per cent (18 in number) of the total number of subjects, the significance of the trends in this groups would not be statistically reliable and were thus included in the total group of subjects. The overall ratio of males to females burned in this study was 7.1: 1. This is far greater than the male to female ratio found in previous general burn studies which ranged from 1.8 : 1 (Pegg et al., 1983) to 2.72 : 1 (Bongard et al., 1985), and that found in Gordon and Ramsay’s (1983) study on flame bums which was 3.55 : 1. This study found that for the X7--40-year age group, the male to female ratio was 5.5 : I and for the 12-19-year age group was 27: 1. This far exceeded Gordon and Ramsay’s (1983) figure for the male to female ratio involved in flame burns, which was 4.75 : I. The higher number of males to females in this survey could be explained either by more females being involved in
115
occupational burns (which were not included in this study) and/or there being a higher preponderance of males, and especially young males, involved in bums due to inflammable agents in the population sampled. Most of the bums in this study were due to petrol and diesel which accounted for 56.8 per cent of all bums. Methylated spirits and LPG were each responsible for 13.6 per cent of the bums, and kerosene for 8.2 per cent. Other agents involved included glue, paint, paint thinners, lighter fluid, fertilizer and turpentine. Pegg et al. (1979) also reported that most bums were due to inflammable agents mainly petrol - and of these petrol bums, three-quarters occurred at home or during recreation. However, direct comparison is not possible. Previous studies have only dealt with the epidemiology of adult bums in general, incorporating settings such as domestic, occupational and motor vehicle accidents, thereby making it difficult to compare the findings. The average body surface area burned was 17.7 per cent. However, 76.1 per cent of all patients included in this study sustained burns of 20 per cent or less of the total body surface area. This was below that expected from previous studies reviewed. Byrom et al. (1984) found that flammable liquids were associated with a bum injury that involved an average 23 per cent of the body surface area, and these burns were deeper and of a larger body surface area. The findings in this study of a lower average body surface area burned may be the result of the exclusion of industrial burns. The sites most commonly affected in domestic adult burns due to inflammable agents are the face, hands and limbs; 58.2 per cent of patients had their face involved while 65.8 per cent of patients had one or both hands involved. Bongard et al. (1985) also found that the most commonly burned sites in their study, were the face and the hands, and these were generally flame burns. Scarring of especially the face and hands has a profound physical, functional and psychological impact on the individual and his/her lifestyle, hence the importance of trying to prevent such injuries. The average length of stay was 18.25 days, ranging up to 138 days. This correlates with Gordon and Ramsay’s (1983) findings of an average stay for flame bum patients of 1 l-20 days. The total period spent in hospital for all patients involved in our study was 2665 days and illustrates the considerable economic cost imposed on the community by bum injuries involving inflammable agents in the domestic setting. The cost to the individual and his/her family must also be considered, not only in terms of health care costs but also in the economic loss incurred from the inability to work which would not be compensated for as the burns occurred in a domestic setting as opposed to an occupational setting. Any intervention programme that could prevent or reduce the period in hospital would be thus advantageous to the general community as well as to the individual. A large variety of equipment was involved in the bum incidents. The largest proportion of these related to ‘burning off fires and incinerators which made up 30.1 per cent of such bums. Other major causes included car engines (11.1 per cent) (e.g. priming carburettor), barbecues (9.6 per cent), outdoor camping equipment (7.5 per cent) and indoor heaters and gas stoves (7.0 per cent). Of domestic adult bums due to inflammable agents (26.7 per cent) were classified as involving no equipment other than the agent itself. These were usually due to igniting clothes, linen or self doused in flammable liquids, often with cigarettes, intentionally or unintentionally, use of petrol bombs or spontaneous explosions. It is of interest to note that at least 47.2 per
116
cent of domestic adult burns due to inflammable agents involved the use of outdoor recreational equipment and fires/incinerators. Gordon and Ramsay (1983) reported that 17.6 per cent of adult flame burns are due to barbecues, incinerators and outdoor fires, with the outdoor fire being the single most common cause and of these flame burns, 42 per cent were caused by inflammable liquids. Once again the difficulties of comparing this study with others emerges. Using an inflammable agent to pour onto or to light a fire was the major cause of the adult domestic bums, accounting for 34.2per cent of such burns. The next major cause was spontaneous explosions which were related to 32.2per cent of burns. Eleven per cent of bums were associated with sparks from running motors and a further II per cent due to pouring a flammable liquid over oneself. Smoking was directly responsible for causing 5.5 per cent of adult domestic bums involving inflammable agents, and other minor causes included accidental spillage of inflammable agents and incorrect use of gas. This study has shown that 69.2 per cent of burns surveyed were due to human error and thus potentially preventable. With the remaining categories of mechanical per cent), intentional (10.3 per cent) and others of error (16.4 unclassifiable manner, infkrencing behaviour can do little to prevent these burns occurring and would therefore not be targetted in any education and behaviour change programmes. This study concluded that 21.2 per cent of subjects had one or more predisposing conditions, which compared favourably with other general retrospective bums studies which found that predisposing conditions were involved in 22-23 per cent of all burns (MacLeod, 1970;Pegg et al., 1979,1983; Gordon and Ramsay, 1983). The hospital charts indicated that 8.9per cent of patients had consumed alcohol recently before the incident. This corresponds with the results of a retrospective review which found alcohol as a predisposing condition in 6.3-13.2 per cent of bum patients (MacLeod, 1970;Pegg et al., 1979,1983;Gordon and Ramsey, 1983)as opposed to the prospective study of who reported 25.85 per cent. The Masterton et al. (1979) age group of 35 years and under accounted for 58.3per cent of those with alcohol as a predisposing factor. A similar trend was reported by Pegg et al. (1979) who found that 31.6per cent of burn patients who consumed alcohol prior to the incident were in their twenties. Other major predisposing factors were epilepsy, drug usage, pregnancy and diabetes. This indicates that effective prevention programmes should be targetted to young male drinkers in a potentially dangerous setting with respect to flammable liquids and fires and also at smoking in the proximity of inflammable agents. Cole et al. (1986)reported petrol sniffing as a precipitating cause of explosion. No such cause was detected in this series. As was found in previous general burn studies, no significant yearly trends were identified in this study. However, a significantly higher incidence of bums occurred in the summer holiday months of December and January compared with midyear months. As expected, the incidence of burns was relatively more common during the weekends than during weekdays. The most marked time of day for injury was between 13.00and 21.00h, such injuries mainly affected persons in the 12-29-year age group. Although no previous general bum studies found any significant monthly trends, several authors found that weekends figured more prominently than weekdays (Masterton et al., 1979 Gordon and Ramsay, 1983; Pegg et al., 1983), which concurs with
Burns (1990)
Vol. 16/No.2
this study. Master-ton et al. (1979) reported the daylight hours as being the most common times involved which also correlates with this study. The significant monthly, daily and hourly trends found in this study suggest a possible relationship between the Austrahan outdoor lifestyle and the incidence of domestic burns caused by flammable agents. This was also supported by the finding that nearly half of all bums in this study were associated with outdoor recreational equipment and open fires. In over two-thirds of the subjects in this survey, blame was attributed to human error. Thus, the above findings lend support to the hypothesis that the outdoor Australian way of life is associated with a large number of preventable domestic burns. The value of an epidemiological analysis of bum injuries caused by flammable agents lies in its use for prevention. The vast proportion of burns in this study (four out of five) are preventable in theory and thus susceptible to the effects of intervention. This study determined that the young male is most at risk, chiefly through the misuse of petrol and diesel, particularly pouring them onto, or lighting fires during the afternoons and weekends. Prevention is often more difficult than treatment and requires an integrated approach not oniy by doctors and other medical staff but also drawing upon the resources of politicians and other community leaders. Sorensen (1976) describes two levels of prevention, major and minor. Major prevention involves fundamental changes in cultural patterns and the way of life. The more achievable minor preventions involve alterations of rules, regulations, equipment design and habits. Ideally, strategies should be aimed at major prevention but realistically minor prevention is often oniy achievable. McLaughlin et al. (1982)reported on Project Bum Prevention, a public education programme to improve the awareness of burn hazards. She concluded that it had no effect in reducing bum incidence and severity and that education for personal responsibility alone is not enough, although it plays a crucial role in promoting community acceptance of other intervention strategies. The above interpretation of Project Bum Prevention is reinforced by MacKay and Rahman (1982). Jurrell et al. (1984) recommended three measures. First, public education highlighting the potential hazards of the misuse of the flammable agent utilizing the mass media was suggested. Secondly, clear labelling of the dangers associated with this misuse is essential. Finally, they recommended the promotion of alternative and safer substitutes to the flammable agents. An education programme in bums prevention should involve two components: community-based and schoolbased programmes. Community-based programmes involve the use of mass media with short, concise messages highlighting the dangers. A campaign involving television, posters displayed in prominent places such as railway stations and buses, and pamphlets available to the general public should be considered. Heavy emphasis should be directed on targetting the young males so that they can identify with the campaign. Use can be made of community-based organizations such as Rotary or Lions, taking advantage of access to an already assembled group of people. Schools can be recruited into this programme by the provision of audiovisual, printed or other material as well as teacher-directed group discussions as outlined in guidelines issued to teachers. Awareness generated in these school-based campaigns could be built
117
Pegg et al.: Domestic flammabie agents in bums epidemiology
”
upon in future intervention programmes. Labelling of inflammable agents should include prominent, specific and brief health warnings aimed to prevent accidents. Legislation may be required to enable a uniform standard to be applied. Examples of these messages are Not for use for starting fires’ or ‘Avoid use near naked flame’. These are short messages that can be printed boldly and visibly on the packaging. Safer alternatives to flammable agents can be promoted by both public education and labelfing messages. Fire starters are readily available and usually completely alleviate the need for the flammable agent. Bum injuries as a cause of hospitalization produce a heavy burden on the limited health resources that the community can possibly sustain. Any intervention programme that can reduce this burden on society will be of value. Benefit at the individual level would also result from a designed intervention programme with respect to preventing physical, psychological, functional and economic handicaps. The concept of prevention being better than cure is well recognized today in the area of burn injuries. Epidemiological studies such as this provide a basis upon which effective intervention programmes can be designed to reduce the mortality and morbidity resulting from bums in our community.
Acknowledgement The assistance of Mrs G. Williams in the computation analysis of the data is gratefully acknowledged,
and
References Bongard F. S., Ostrow L. B., Sacks S. T. et al. (1985) Report from the California Burn Registry -the cause of major bums. West.1,
Darko c. F., Wachtel f. L., Ward H. W. et al. (1986) Analysis of 585 bum patients hospitalized over 6 year period. Burns 12, 391. Gordon P. G. and Ramsay G. C. (1983) A survey of thermal injuries. CSIRO Rep&, December 1983, Parkville, Australia. Jay K. M. et al. (1980) Burns unit in Stockholm - a report on patients treated 1971-75 for acute bum injuries. Stand. 1. Pk. ficon5tr. surg. 14, 171. June11 G., Kjartansson J., Malm M. et al. (1984) Accidental bums with domestic fire lighting fluid. Scand. ]. Plast. R~otdr. .SUT. 18, 155. Lyngdorf P. (1986) Epidemiology of severe burn injuries. Bums 12,491. MacLeod A. (1970) Adult burns in Melbourne - a five year survey. Med. J. Aust. 2, 772. MacKay A. M. and Rahman K. J. (1982) The incidence and severity of burn injuries following Project Burn Prevention. Am. J. Public Health 72, 241. Masterton J. P., Pressley T. A. and Ramsay G. C. (1979) A survey of adults with flame bums at a Melbourne Hospital. Med. 1. Amt. 1, 332. McLouglin E., Vince C. J., Lee A. M. et al. (1982) Project Burn Prevention - outcome and implications. Am. J Public Health 72, 241. O’Ya H. and Ohmori S. (1978) Most bums are preventable. Bum 5, 8. Pegg S. and Seawright A. (1983) Burns due to cooking oils - an increasing hazard. Burns 9,362. Pegg S., Gregory J. J., Hogan P. G. et al. (1979) Epidemiological pattern of adult burn injuries. Bum 5, 326. Pegg S.. McDonald G. P., Tracey-Patte C. E. et al. (1983) Epidemiology of burns attending a Casualty Department in Brisbane. Bwns 9.416. Sinclair S. W. (1977) Barbecue bums. N.Z. Med. 1. 14, 524. Sorensen B. (1976) Prevention of burns and scalds in a developed country. 1. Trauma 16, 249.
Med. 142, 653.
Byrom R. R., Word E. L., Tewksbury C. C. et al. (1984) Epidemiology of flame bum injuries. Btlms II, I. Cole M., Hemdon D. N., Desai M. H. et al. (1986) Gasoline explosions, gasoline sniffing: an epidemic in young adolescents. 1. Bum Care Rehabil. 7, 532.
Paper accepted 26 September
1989.
Correspondenceshouti be addressed to: Dr S. P. Pegg, Royal Brisbane Hospital, Herston, Brisbane, Queensland 4029, Australia.
8th International Congress on Bum Injuries II-16 November 1990, New Delhi, India Meeting to coincide with the ISBI Silver Jubilee. Programme will include prevention; first-aid treatment, rehabilitation and research. Scientific programmes will highlight recent advances in bum care with a special reference to the needs of the Third World Countries. Further details can be obtained from: Dr M. H. Keswani, 8th International Congress on Bum Injuries 1990, PO Box 1901, GPO, Bombay 400 001, India
Epidemiology agents
113
Britain
of burns due to domestic flammable
S. P. Pegg, L. Beecham, N. Dore, D. Hrdlicka and C. Hukins Royal Brisbane Hospital, Queensland,
Australia
ATIanalysisof the epiakmiologicd factors relating fo domesfic flammable agents has shown thaf I 7.7 per cent of admissions over a 5-year period flammableinjuries; 87.7percent of fk patients were involved in domestic were male, with 38.9per cent beingyoung maks between12and 19 years old. Petrol and diesel accounfedfor 56.8 per cent of fk burns and the average body surface area burned was 17.7per cenf. Mosf commonly fk face8 hands and limbs were burned, and the average length of stay was 18.25whys, 69.2per cent of the bums were due lo human error and were thus potentially preventable, 21.2 per cent had predisposing conditions with 8.9per cent being due to akohol. If was cons&red that fk strategies to prevent these burns injuries should be aimed patictllarly at young males.
Introduction Domestic burns comprise a major source of morbidity in Australia today. To date there are few studies dealing with this aspect of community health. Little attention has been given specifically to the epidemiology and prevention of adult bums caused by domestic flammable agents. Adults with this form of injury have been shown to comprise a significant proportion of all adult flame bums, and most of those occurring in domestic premises are preventable. This study reviewed the epidemiological factors pertaining to this type of injury. Patterns thus obtained could be incorporated into prevention strategies as although therapeutic management of burns has improved, prevention is still the most effective way of reducing physical and psychological damage caused by bums, as welJ as reducing cost to the community. No study to date has concentrated on this particular topic and while the findings of this study apply to the Brisbane area, it is hoped that it may form a basis for comparative studies in the future. Previous studies indicate a high incidence of flame bums, particularly affecting males (Gordon and Ramsey, 1983; Pegg et al., 1983; Bongard et al., 1985), and also the importance of predisposing conditions (MacLeod, 1970; Masterton et al., 1979; Pegg et al., 1979). These patients tend to have larger burns (Byron et al., 1984). More burns occur at weekends (Gordon and Ramsay, 1983) in Australia but not in Copenhagen (Lyngdorf, 1986). Flame bums are the main causative agent (Sinclair, 1977; Jurrell et al., 1984; Darko et al., 1986). while scalds are common (Jay et al., 1980; (3 1990 Butterworth & Co (Publishers) Ltd 0305-4179/90/020113~5
Bongard et al., 1985). O’Ya and Ohmori (1978) showed that nine out of 10 bums are preventable, and this study supports this.
Method This retrospective study involved the hospital records of bum patients admitted to the Bums Unit, Royal Brisbane Hospital over the s-year period between 2 July 1982 and 30 June 1987. Patients selected were over 12 years old and had received bums by inflammable agents in a domestic situation. Younger patients were excluded. Other exclusions were if the bums occurred in an occupational or industrial environment, were the result of a motor vehicle accident, or were not the result of the combustion of the agent. The Royal Brisbane Hospital admits patients from that part of the city north of the Brisbane River as well as being the major bums referral centre for Queensland.
Results During the period of investigation, 146 patients were included in this study. This number is 17.7 per cent of the total number of patients included in the Bums Unit Registry, 87.7 per cent of the subjects were male. Figure I shows the sex and age distribution in this group. The male distribution
4.5
4.0 3.5 3.0 2.5 2.c 1 1.: i 1.c 1 0.: , 0.0
12-19
20-29
30-39 Age (years
40-49
so-95
1
Figure 1. Age and sex distribution of patients.
114
Bums (1990) Vol. 16/No.
peaks at the ages of 12-19 years, as does the total age distribution because of the male preponderance. However, the female distribution peaks later at the ages of 20-39 years. There was no yearly trend over the S-year period. Average monthly admissions are represented in Fi’re~. There appears to be a relatively higher incidence of burns in the summer holiday months of December and January compared to midyear (chi-squared = 19.86, PC 0.05). As expected, the incidence of burns was relatively more common during weekends than during the week (Figure.3) (chi-squared = 6.86, P< 0.01). The incidence was greater later in the week than earlier but this was not significant (chi squared = 10.21, P> 0.10). The distribution according to time of day (Figure 4)shows a peak during the period 13.00to 20.00hours and mainly involved the patients in the age group 12-29years. Petrol and diesel are by far the most common inflammable agents that caused the burns and were involved in 56.8 per cent of all burns. Methylated spirits and liquified petroleum gas (LPG) were more common than kerosene, glue, paint, paint thinners, lighter fluid, fertilizer and turpentine. There appears to be no association between the type of inflam-
__
?? Jan
18
[7
Feb
16
Mar
14
Apr May
12
Jun
8
??Jul ??Au9
6
IS
4
?? Nov ?? Dee
10
Se@ Ott
2 0
Figure 2. Average monthly admissions.
mable agent and the age of the patient. The age group 12-29 years is responsible for between 50 and 72 per cent of bums for each type of agent except for LPG, which was involved in only 25 per cent of the patients in this age group. Nearly one-third of the burns involved no equipment other than the inflammable agent alone, and included spontaneous explosions and petrol bombs, 26.4 per cent of incidents were associated with burning-off fires or incinerators and 11.1 per cent were associated with a car, usually the result of pouring petrol into the carburettor with the engine running. All of these patients were male. Other significant equipment involved were barbecues (9.7 per cent), outdoor camping equipment (7.6 per cent) and heaters or gas stoves (7.0 per cent). Two causes of the burns are prominent - using the inflammable agent to pour onto, or light, a fire and spontaneous explosions caused approximately one-third of the burns. Twenty-two per cent of the injuries resulted from the agent being poured over a person. Sparks from other equipment such as a running motor caused 11.0 per cent of the burns. Smoking was directly responsible for 5.5 per cent of the incidents in this study. Blame was categorized into four groups: human error, mechanical error, intentional and others. From this it was determined that 69.2per cent of burns in this survey were certainly due to human error. Mechanical error, usually due to equipment failure, was responsible for only 16.4per cent of the cases. Intentional burns occurred in 10.3 per cent of cases. These were attempted murder, suicide or other, such as one patient who set fire to his hair to eliminate head lice. A number of incidents (4.2 per cent) could not be classified. The distribution of bums was roughly comparable between the sexes. The sites most commonly involved were the limbs and face, 65.8 per cent of people had one or both hands burned and 58.2 per cent had their face involved. Of all burns, 45.2 per cent involved 10 per cent or less of the body area and 76.1 per cent had 20 per cent or less body area burned with an average of 17.7 per cent, 55.5 per cent of the bums were only superficial or partial skin thickness whereas 45.5 per cent of bums had a full skin thickness component.
8-12 Sun
MOll
TU.ZS Day
Figure 3.
Days
(years): 0
,
12-29;
of week and [?,
30-39;
Wed
Thurs
Fri
Sat
of week
quency of bums. Age groups
z
13-16
17-20
21-24
Time of day(h)
Figure 4. Time of day and average frequency of injury per time period. Age groups (years): 0, 12-29; 0 30-39;
total.
Pegg et al.: Domestic
Table I. Predisposing
flammable agents in bums epidemiology
conditions Patients
Predisposing conditions Alcohol Psychiatric illness Smoking at time Suicide Pregnancy Drugs Epilepsy Diabetes
%
No.
8.9 8.9 5.5 5.5 2.1 1.4 1.4 0.7
13 13 8 8 3 2 2 1
One or more predisposing factors was recorded in 21.2 per cent of the burns studied (Table I). Alcohol intake prior to the incident was the most common predisposing factor and was mentioned in 8.9 per cent of cases. Of the 13 patients who had consumed alcohol, I I were under 40 years of age. Also, 8.9 per cent of the patients had a psychiatric illness of some sort, such as a depressive disorder. Some cases (5.5 per cent) were recorded to have been smoking at the time of the incident. Other predisposing factors included epilespy, drugs, pregnancy and diabetes. The burns were the result of a suicide attempt in 5.5 per cent of the cases. The mean length of hospital stay for patients involved in this study was 18.25 days, with a range of up to 138 days and a total period of 2665 patient-days in hospital. There appeared to be no relationship between age and length of stay. Also, there did not appear to be a correlation between length of hospital stay and type of inflammable agent.
Discussion This study looked at the epidemiological factors pertaining to adult bums in the domestic setting caused by inflammable agents. Of the adult bum patients admitted to the Royal Brisbane Hospital Bums Unit from 1 July 1982 to 30 June 1987, 17.7 per cent of the patients (146) were involved in this category of bums. Consistent with the findings of Gordon and Ramsay’s (1983) survey on thermal injuries in Australia, which found that over 85 per cent of those who suffered burns due to inflammable liquids were male, this study found that 87.7 per cent of subjects were male. The male distribution peaked between the ages of 12 and 19 years with 38.9 per cent of males being in this age group. As there was such a high preponderance of male subjects, the total age distribution also peaked at this age with the percentage of young males from the total group being 25.3 per cent. The female distribution peaked at 20-39 years of age. Since females comprised omy 12.3 per cent (18 in number) of the total number of subjects, the significance of the trends in this groups would not be statistically reliable and were thus included in the total group of subjects. The overall ratio of males to females burned in this study was 7.1: 1. This is far greater than the male to female ratio found in previous general burn studies which ranged from 1.8 : 1 (Pegg et al., 1983) to 2.72 : 1 (Bongard et al., 1985), and that found in Gordon and Ramsay’s (1983) study on flame bums which was 3.55 : 1. This study found that for the X7--40-year age group, the male to female ratio was 5.5 : I and for the 12-19-year age group was 27: 1. This far exceeded Gordon and Ramsay’s (1983) figure for the male to female ratio involved in flame burns, which was 4.75 : I. The higher number of males to females in this survey could be explained either by more females being involved in
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occupational burns (which were not included in this study) and/or there being a higher preponderance of males, and especially young males, involved in bums due to inflammable agents in the population sampled. Most of the bums in this study were due to petrol and diesel which accounted for 56.8 per cent of all bums. Methylated spirits and LPG were each responsible for 13.6 per cent of the bums, and kerosene for 8.2 per cent. Other agents involved included glue, paint, paint thinners, lighter fluid, fertilizer and turpentine. Pegg et al. (1979) also reported that most bums were due to inflammable agents mainly petrol - and of these petrol bums, three-quarters occurred at home or during recreation. However, direct comparison is not possible. Previous studies have only dealt with the epidemiology of adult bums in general, incorporating settings such as domestic, occupational and motor vehicle accidents, thereby making it difficult to compare the findings. The average body surface area burned was 17.7 per cent. However, 76.1 per cent of all patients included in this study sustained burns of 20 per cent or less of the total body surface area. This was below that expected from previous studies reviewed. Byrom et al. (1984) found that flammable liquids were associated with a bum injury that involved an average 23 per cent of the body surface area, and these burns were deeper and of a larger body surface area. The findings in this study of a lower average body surface area burned may be the result of the exclusion of industrial burns. The sites most commonly affected in domestic adult burns due to inflammable agents are the face, hands and limbs; 58.2 per cent of patients had their face involved while 65.8 per cent of patients had one or both hands involved. Bongard et al. (1985) also found that the most commonly burned sites in their study, were the face and the hands, and these were generally flame burns. Scarring of especially the face and hands has a profound physical, functional and psychological impact on the individual and his/her lifestyle, hence the importance of trying to prevent such injuries. The average length of stay was 18.25 days, ranging up to 138 days. This correlates with Gordon and Ramsay’s (1983) findings of an average stay for flame bum patients of 1 l-20 days. The total period spent in hospital for all patients involved in our study was 2665 days and illustrates the considerable economic cost imposed on the community by bum injuries involving inflammable agents in the domestic setting. The cost to the individual and his/her family must also be considered, not only in terms of health care costs but also in the economic loss incurred from the inability to work which would not be compensated for as the burns occurred in a domestic setting as opposed to an occupational setting. Any intervention programme that could prevent or reduce the period in hospital would be thus advantageous to the general community as well as to the individual. A large variety of equipment was involved in the bum incidents. The largest proportion of these related to ‘burning off fires and incinerators which made up 30.1 per cent of such bums. Other major causes included car engines (11.1 per cent) (e.g. priming carburettor), barbecues (9.6 per cent), outdoor camping equipment (7.5 per cent) and indoor heaters and gas stoves (7.0 per cent). Of domestic adult bums due to inflammable agents (26.7 per cent) were classified as involving no equipment other than the agent itself. These were usually due to igniting clothes, linen or self doused in flammable liquids, often with cigarettes, intentionally or unintentionally, use of petrol bombs or spontaneous explosions. It is of interest to note that at least 47.2 per
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cent of domestic adult burns due to inflammable agents involved the use of outdoor recreational equipment and fires/incinerators. Gordon and Ramsay (1983) reported that 17.6 per cent of adult flame burns are due to barbecues, incinerators and outdoor fires, with the outdoor fire being the single most common cause and of these flame burns, 42 per cent were caused by inflammable liquids. Once again the difficulties of comparing this study with others emerges. Using an inflammable agent to pour onto or to light a fire was the major cause of the adult domestic bums, accounting for 34.2per cent of such burns. The next major cause was spontaneous explosions which were related to 32.2per cent of burns. Eleven per cent of bums were associated with sparks from running motors and a further II per cent due to pouring a flammable liquid over oneself. Smoking was directly responsible for causing 5.5 per cent of adult domestic bums involving inflammable agents, and other minor causes included accidental spillage of inflammable agents and incorrect use of gas. This study has shown that 69.2 per cent of burns surveyed were due to human error and thus potentially preventable. With the remaining categories of mechanical per cent), intentional (10.3 per cent) and others of error (16.4 unclassifiable manner, infkrencing behaviour can do little to prevent these burns occurring and would therefore not be targetted in any education and behaviour change programmes. This study concluded that 21.2 per cent of subjects had one or more predisposing conditions, which compared favourably with other general retrospective bums studies which found that predisposing conditions were involved in 22-23 per cent of all burns (MacLeod, 1970;Pegg et al., 1979,1983; Gordon and Ramsay, 1983). The hospital charts indicated that 8.9per cent of patients had consumed alcohol recently before the incident. This corresponds with the results of a retrospective review which found alcohol as a predisposing condition in 6.3-13.2 per cent of bum patients (MacLeod, 1970;Pegg et al., 1979,1983;Gordon and Ramsey, 1983)as opposed to the prospective study of who reported 25.85 per cent. The Masterton et al. (1979) age group of 35 years and under accounted for 58.3per cent of those with alcohol as a predisposing factor. A similar trend was reported by Pegg et al. (1979) who found that 31.6per cent of burn patients who consumed alcohol prior to the incident were in their twenties. Other major predisposing factors were epilepsy, drug usage, pregnancy and diabetes. This indicates that effective prevention programmes should be targetted to young male drinkers in a potentially dangerous setting with respect to flammable liquids and fires and also at smoking in the proximity of inflammable agents. Cole et al. (1986)reported petrol sniffing as a precipitating cause of explosion. No such cause was detected in this series. As was found in previous general burn studies, no significant yearly trends were identified in this study. However, a significantly higher incidence of bums occurred in the summer holiday months of December and January compared with midyear months. As expected, the incidence of burns was relatively more common during the weekends than during weekdays. The most marked time of day for injury was between 13.00and 21.00h, such injuries mainly affected persons in the 12-29-year age group. Although no previous general bum studies found any significant monthly trends, several authors found that weekends figured more prominently than weekdays (Masterton et al., 1979 Gordon and Ramsay, 1983; Pegg et al., 1983), which concurs with
Burns (1990)
Vol. 16/No.2
this study. Master-ton et al. (1979) reported the daylight hours as being the most common times involved which also correlates with this study. The significant monthly, daily and hourly trends found in this study suggest a possible relationship between the Austrahan outdoor lifestyle and the incidence of domestic burns caused by flammable agents. This was also supported by the finding that nearly half of all bums in this study were associated with outdoor recreational equipment and open fires. In over two-thirds of the subjects in this survey, blame was attributed to human error. Thus, the above findings lend support to the hypothesis that the outdoor Australian way of life is associated with a large number of preventable domestic burns. The value of an epidemiological analysis of bum injuries caused by flammable agents lies in its use for prevention. The vast proportion of burns in this study (four out of five) are preventable in theory and thus susceptible to the effects of intervention. This study determined that the young male is most at risk, chiefly through the misuse of petrol and diesel, particularly pouring them onto, or lighting fires during the afternoons and weekends. Prevention is often more difficult than treatment and requires an integrated approach not oniy by doctors and other medical staff but also drawing upon the resources of politicians and other community leaders. Sorensen (1976) describes two levels of prevention, major and minor. Major prevention involves fundamental changes in cultural patterns and the way of life. The more achievable minor preventions involve alterations of rules, regulations, equipment design and habits. Ideally, strategies should be aimed at major prevention but realistically minor prevention is often oniy achievable. McLaughlin et al. (1982)reported on Project Bum Prevention, a public education programme to improve the awareness of burn hazards. She concluded that it had no effect in reducing bum incidence and severity and that education for personal responsibility alone is not enough, although it plays a crucial role in promoting community acceptance of other intervention strategies. The above interpretation of Project Bum Prevention is reinforced by MacKay and Rahman (1982). Jurrell et al. (1984) recommended three measures. First, public education highlighting the potential hazards of the misuse of the flammable agent utilizing the mass media was suggested. Secondly, clear labelling of the dangers associated with this misuse is essential. Finally, they recommended the promotion of alternative and safer substitutes to the flammable agents. An education programme in bums prevention should involve two components: community-based and schoolbased programmes. Community-based programmes involve the use of mass media with short, concise messages highlighting the dangers. A campaign involving television, posters displayed in prominent places such as railway stations and buses, and pamphlets available to the general public should be considered. Heavy emphasis should be directed on targetting the young males so that they can identify with the campaign. Use can be made of community-based organizations such as Rotary or Lions, taking advantage of access to an already assembled group of people. Schools can be recruited into this programme by the provision of audiovisual, printed or other material as well as teacher-directed group discussions as outlined in guidelines issued to teachers. Awareness generated in these school-based campaigns could be built
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Pegg et al.: Domestic flammabie agents in bums epidemiology
”
upon in future intervention programmes. Labelling of inflammable agents should include prominent, specific and brief health warnings aimed to prevent accidents. Legislation may be required to enable a uniform standard to be applied. Examples of these messages are Not for use for starting fires’ or ‘Avoid use near naked flame’. These are short messages that can be printed boldly and visibly on the packaging. Safer alternatives to flammable agents can be promoted by both public education and labelfing messages. Fire starters are readily available and usually completely alleviate the need for the flammable agent. Bum injuries as a cause of hospitalization produce a heavy burden on the limited health resources that the community can possibly sustain. Any intervention programme that can reduce this burden on society will be of value. Benefit at the individual level would also result from a designed intervention programme with respect to preventing physical, psychological, functional and economic handicaps. The concept of prevention being better than cure is well recognized today in the area of burn injuries. Epidemiological studies such as this provide a basis upon which effective intervention programmes can be designed to reduce the mortality and morbidity resulting from bums in our community.
Acknowledgement The assistance of Mrs G. Williams in the computation analysis of the data is gratefully acknowledged,
and
References Bongard F. S., Ostrow L. B., Sacks S. T. et al. (1985) Report from the California Burn Registry -the cause of major bums. West.1,
Darko c. F., Wachtel f. L., Ward H. W. et al. (1986) Analysis of 585 bum patients hospitalized over 6 year period. Burns 12, 391. Gordon P. G. and Ramsay G. C. (1983) A survey of thermal injuries. CSIRO Rep&, December 1983, Parkville, Australia. Jay K. M. et al. (1980) Burns unit in Stockholm - a report on patients treated 1971-75 for acute bum injuries. Stand. 1. Pk. ficon5tr. surg. 14, 171. June11 G., Kjartansson J., Malm M. et al. (1984) Accidental bums with domestic fire lighting fluid. Scand. ]. Plast. R~otdr. .SUT. 18, 155. Lyngdorf P. (1986) Epidemiology of severe burn injuries. Bums 12,491. MacLeod A. (1970) Adult burns in Melbourne - a five year survey. Med. J. Aust. 2, 772. MacKay A. M. and Rahman K. J. (1982) The incidence and severity of burn injuries following Project Burn Prevention. Am. J. Public Health 72, 241. Masterton J. P., Pressley T. A. and Ramsay G. C. (1979) A survey of adults with flame bums at a Melbourne Hospital. Med. 1. Amt. 1, 332. McLouglin E., Vince C. J., Lee A. M. et al. (1982) Project Burn Prevention - outcome and implications. Am. J Public Health 72, 241. O’Ya H. and Ohmori S. (1978) Most bums are preventable. Bum 5, 8. Pegg S. and Seawright A. (1983) Burns due to cooking oils - an increasing hazard. Burns 9,362. Pegg S., Gregory J. J., Hogan P. G. et al. (1979) Epidemiological pattern of adult burn injuries. Bum 5, 326. Pegg S.. McDonald G. P., Tracey-Patte C. E. et al. (1983) Epidemiology of burns attending a Casualty Department in Brisbane. Bwns 9.416. Sinclair S. W. (1977) Barbecue bums. N.Z. Med. 1. 14, 524. Sorensen B. (1976) Prevention of burns and scalds in a developed country. 1. Trauma 16, 249.
Med. 142, 653.
Byrom R. R., Word E. L., Tewksbury C. C. et al. (1984) Epidemiology of flame bum injuries. Btlms II, I. Cole M., Hemdon D. N., Desai M. H. et al. (1986) Gasoline explosions, gasoline sniffing: an epidemic in young adolescents. 1. Bum Care Rehabil. 7, 532.
Paper accepted 26 September
1989.
Correspondenceshouti be addressed to: Dr S. P. Pegg, Royal Brisbane Hospital, Herston, Brisbane, Queensland 4029, Australia.
8th International Congress on Bum Injuries II-16 November 1990, New Delhi, India Meeting to coincide with the ISBI Silver Jubilee. Programme will include prevention; first-aid treatment, rehabilitation and research. Scientific programmes will highlight recent advances in bum care with a special reference to the needs of the Third World Countries. Further details can be obtained from: Dr M. H. Keswani, 8th International Congress on Bum Injuries 1990, PO Box 1901, GPO, Bombay 400 001, India