‎ Clinical and Demographic Features of Burn Patients in ‎Rasht ‎

Abstract

Background: Introduction: Burn is the fourth cause of trauma worldwide and as a major health ‎challenge, it is one of the most common health-related accidents in different societies. This ‎study ‎aimed at risk of mortality assessment, based on the presentations at the emergency ‎department. ‎

Method: This was a retrospective analysis of burn patients admitted to Velayat Burn ‎Hospital of ‎Rasht, Iran, from March 2019 till 2020, regarding the possible factors affecting ‎mortality. Eligible ‎records were collected for data extraction of demographics, causes of ‎burn, clinical examinations, ‎paramedical findings, and hospitalization courses. ‎

Results: Totally, 557 records of burning subjects (231 females and 326 males; mean age of ‎‎31±4.6 ‎years) were included. The most common cause of burn was fire flame (49.4%). The ‎most common ‎area of the burn was the upper limp (59.5%). Totally, 47 (8.43%) were expired ‎and 510 (91.75%) ‎were rescued. The average body surface area affected by burn was ‎‎23.41±19.17%. Most of the ‎patients (45.8%) were hospitalized for 5 to 10 days. The most common cause of death in patients ‎was a septic shock (45%). Inhalation burn injury ‎was seen in 40 patients (7.2%) and self-immolation ‎happened in 23 (4.12%) ‎patients. Mental disorders were statistically related to self-immolation, ‎based on the ‎fisher exact test (P<0.001).

Conclusion: The data summarized in this report provides the epidemiologic and clinical ‎image of ‎the burn injuries in Rasht city. ‎

Declarations:

Funding:‎

This research did not receive any specific grant from funding agencies in the public, ‎commercial, or not-for-profit sectors.‎

Conflict of interest

We do have not any relationships or support which might be perceived as constituting a conflict ‎of interest.‎

Acknowledgement:‎

We would like to thank the staff of the medical records department of the Velayat Burns ‎Hospital of Rasht for their sincere efforts and cooperation.‎

---------------------------------------------------------------------------------------------------------------------

Full Text

Introduction

Burn is the fourth cause of trauma worldwide and a major health challenge (1-3), it is ‎one of the most common health-related accidents in different societies (4). Burn is one of the ‎important causes of injury in Iran and it is responsible for 6 percent of deaths in Iran, among ‎all deaths caused by accidents (5). Based on statistics of the 2006 country report of recorded ‎accidents by the office of accident prevention of disease management of Iran Ministry of ‎Health, burn consists 5% of all accidents recorded in the country by the number of 56364 ‎persons and are one of the important causes of injury in Iran by the incidence of 1 in 1000 ‎people (5). Also, it is responsible for 6 percent of deaths in Iran, among all deaths caused by ‎accidents (5). Burn has always been notable as one of the most costly diseases and its ‎financial burden on patients, their family, and the economy of the countries (6,7). Other ‎than the expenses of burn for the patients and the health system, burn is an irreparable event ‎and has many physical mental, and social complications; but in half of the cases, this event ‎and its complications are preventable (7,8). More than 95% percent of deaths from burns have occurred in low to moderate-income countries. In Iran, burn is the 13th cause of morbidity in ‎diseases by more than 200 thousand life years annually (9). Considering that many deaths ‎occur due to burns and survived patients may also suffer from burn complications until the ‎end of life, such as vision complications, beauty problems, and defects in various organs; it ‎is necessary to identify the factors that contribute to increased mortality and morbidity ‎among burn patients. However, in Rasht city, such data has not been investigated properly, ‎and the results of this study can be effective in policies for the treatment and prevention of ‎burns. So, in this study, we aimed at evaluating the factors affecting the death of patients ‎attending the Burn ward of Velayat Hospital in Rasht in 2019-2020.‎

Material and methods

This study was a cross-sectional retrospective review of medical records of burn patients ‎in Velayat Burn Hospital of Rasht from March 2019 to 2020. Data were obtained by ‎reviewing the hospital documents of patients attending with the diagnosis of burn. The ‎records were surveyed regarding the possible factors affecting death.‎

Inclusion criteria were patients with burn, getting admitted from the emergency room to burn ‎wards of Velayat Burn Hospital of Rasht (men, women, pediatrics, Burn Intensive Care Unit ‎‎(BICU) ). Burn after trauma, incompleteness of documents, and inaccessibility to the ‎documents were the exclusion criteria.‎

Data collection:‎

Data gathering was done by the checklist and all the variables including age, gender, body percentage of burn (based on the Wallace Rule-‎of-Nines), area of the burn, length of hospital stay, external factors leading to burn and also burns ‎caused by self-immolation, underlying disease, cardiac rhythm disturbance, vital sign ‎disturbance, cause of death, electrolytes disturbance and other blood laboratory variables ‎such as complete blood count (CBC), level of blood urea nitrogen (BUN), creatinine and ‎glucose were obtained from the patients' documents and were recorded in the designed ‎checklist.‎

Statistical Analysis:‎

Data were entered in SPSS version 26. For the description of the quantitative data, average ‎and standard deviation and for the qualitative data, numbers and percentages were used. For ‎the comparison between two groups of deceased and rescued, an independent t-test was used in ‎quantitative variables and chi-square in qualitative ones. The p-value of less than 0.05 was ‎considered statistically significant.‎

Results

Total number of 557 records were surveyed in this study. Demographic and clinical ‎information of the patient is included in table 1. The average age of patients was 31±4.6 years. ‎‎326 patients (58.5%) were women and 231 patients (14.5%) were men. The Independent t-test ‎did not show a significant age difference between men and women (p>0.05). Most of the burns ‎were caused by the flame which consisted of 49.4% (N=275) of total burns. Most of the burns ‎occurred in winter and after that respectively in summer, autumn and spring (table 1).‎

Upper limb burn was reported in 59.5% (N=332) of patients, 49.1% (N=274) had lower limb, ‎‎36.7% (N=205) had head and face, 50.7% (N=283) had trunk, 13.1% (N=73) had genitalia ‎and 7.5% (N=42) had whole body burns. Therefore, the most areas of burn are respectively ‎the upper limb, trunk, lower limb, head and face, genitalia and whole body (Table 2). The ‎average percentage of burn in patients was 23.41±19.17 %. In terms of the degree of burn, ‎the most common type was the 2nd and 3rd degree together after that, 2nd, 3rd and 4th ‎degree respectively. The length of hospital stay with respect to the prevalence was 5 to 10 ‎days, 1 to 5 days, 10 to 15 days and more than 15 days. The average blood glucose, arterial ‎blood gas, and BUN are shown in table 1. ‎

Inhalation burn injury was seen in 40 patients (7.2%) and self-immolation was reported in ‎‎23 (4.12%) patients. In the case of place of burn 459 patients were at home, 61 at work ‎and 37 patients in other places. More than half of the patients had some kind of underlying ‎diseases such as hypertension (n=73), neuropsychiatric disorders (n=41), cardiovascular ‎diseases(n=31), diabetes (n=69), pulmonary diseases (n=17) and gastrointestinal disorders ‎‎(n=36) and etc. Out of 23 patients with self-immolation burns, 16 had an underlying ‎neurological and mental illness; Mental illness was statistically related to self-‎immolation (P<0.001). ‎

Mortality risk assessment: ‎

Of all the patients, 47 (8.43%) were expired and 510 (91.75%) were rescued. Chi-square had ‎shown a significant relationship between self-immolation and underlying neuropsychiatric ‎disorder (p=0.04). The most common cause of death in patients was a septic shock (45%). ‎After that, multi organ failure (31%) and respiratory failure (24%) were the causes of death. ‎One case of death also occurred in the prehospital emergency setting. ‎

In comparison to patients who died and were rescued (table 2), Chi-square analysis showed ‎a significant difference in the cause of burn type and length of hospital stay (p<0.001). In rescued ‎patients boiling burn and in expired patients fire was the most important cause of burn. Also, ‎the length of hospital stay in rescued patients was significantly higher in comparison to ‎expired patients.

The average percentage of burn in rescued patients was 44.68% and  ‎‎66.25% in expired patients, but this difference was not statistically significant (p=0.31).‎

Data survey by independent t-test showed that in biochemical variables, lower pH (p=0.00) ‎and higher BUN (p=0.04) were related to death, but no significant difference was seen in ‎serum creatinine of rescued patients in comparison to expired patients (p=0.41). ‎

Discussion:‎

Burn is one of the most destructive injuries and is one of the major concerns of global public ‎‎health (10). More than 300,000 people die of burn annually and millions of people suffer ‎‎from handicaps and social, mental and economic disabilities of burn (11, 12). Mortality rate ‎‎of burn is variable in different age groups. For example, burn caused by fire is the 6th ‎‎important cause of mortality in 5 to 14 year old people in low income countries (13).‎ Even ‎though the average age of patients in the study of Abdulwahab (14) and Kadri SS (15) ‎was ‎‎16.5 and 52.9 ±‎‏ ‏‎18.1 years respectively, our findings were more consistent with the results ‎of ‎Chorlip (16) the average age was 35.6 ±‎‏ ‏‎15.72. In our study, the average age of ‎‎patients was 31 ± 4.6 years. It seems that this age group which is the most active age group ‎‎and considered the community's workforce is more exposed to burn. Therefore,  ‎‎immunity in the work place in order to lower the burn related to different occupations could be ‎‎an effective approach to lowering the burn injuries in this age group and could be important ‎‎from an economic point of view.‎ In the study of Sharma et al., 46% of burn patients were ‎male and 54% were female (17). ‎Tabiee et al. in 2004 in Birjand surveyed the epidemiology ‎of burn in attended hospital  ‎burn ward as a descriptive cross-sectional study (18). ‎The document of 342 patients was ‎surveyed. The results of that study suggested that of total ‎burn injured patients attending  ‎the emergency ward, 55.6% were men. In our study, 231 ‎patients (58.5%) were women and ‎‎326 patients (41.5%) were men.‎ In study by Amani et al. ‎‎(19) in 2014, explosion and boiling water were introduced as the ‎most common causes of ‎burn. Statistical analysis of the study of Sharma et al. (17) ‎suggested that burn with boiling ‎water is an important risk factor for mortality. In the study ‎of Kabirzadeh et al. (20), the ‎most common external factor leading to burn (57.9%) fueled such as oil, petrol and ‎gasoline. Ibrahimian (21) suggested that most patients (32%) ‎were in the age group zero to 9 ‎years old and among them, 20.7% were burned by hot liquids ‎and 52.1% by flaming oil and ‎petrol. Moreover Berry et al. (22) suggested in their study that ‎burning with flammable ‎liquid was effective in mortality. In our study, burning with flame ‎‎(275 patients (49.4%)) ‎and hot liquids (184 patients (33.1%)) consisted of the most common ‎causes of burn. Hence, ‎necessary education of parents and children should be conducted ‎about burning with boiling ‎water which could be due to overthrow of kettle, samovar and ‎pot. Possibly, increasing the ‎safety standards in gas burning devices by production ‎companies and on the other hand, ‎increased precaution of consumers could be effective in ‎reducing the mortality from ‎explosions.‎ In the study of Bhansali et al. (23) in India, it was reported that whole-body burn ‎had a ‎significant relationship with mortality (p=0.000). Also Tarim et al. (24) 2013 ‎studied  ‎the factors influencing the mortality in burn patients attending an intrusive care ‎unit and ‎suggested that whole body burn was more common in expired patients (25). Yen et ‎al. ‎suggested in their study that patients with whole body burns and inhalation burn injury ‎have ‎a higher risk of mortality (26). Study by Kasenda et al. in 2018 suggested that higher ‎surfaces ‎of burn and burn with boiling water are consistent with higher mortality (27). In the ‎current ‎study, the most common areas of burn in patients were respectively upper limb, ‎trunk, and ‎lower limb. Head and face, genital area and whole body; in rescued patients hot ‎liquids and ‎in expired patients fire was the most common cause of burn.‎ Study by Bhansali et ‎al. (23)  suggested that the average length of hospital stay in ‎burn patients was 5 ‎days and there was a significant relationship between whole body burn ‎and duration of ‎hospital stay (p<0.001). The study of Kasenda suggested that the higher ‎duration of hospital ‎stay was correlated with higher mortality (27). By assessing the ‎electronic documents of ‎burn patients, Cheung et al. suggested that duration of hospital stay ‎was an effective factor ‎in predicting mortality (28). De Macedo et al. (1) suggested that ‎lower hospital stay was ‎consistent with lower mortality. In the current study, the duration of ‎hospital stay was 5 to ‎‎10 days, 1 to 5 days, 10 to 15 days and more than 15 days with respect to ‎prevalence.‎ William ‎et al. (29) 2019 conducted a study on mortality of burn patients and reported that ‎having ‎diabetes, pulmonary disease and cardiovascular diseases were related to higher ‎mortality ‎rates. In the current study, expired patients were diagnosed with neuropsychiatric ‎diseases, ‎hypertension, diabetes, cardiovascular diseases, pulmonary disease, ‎gastrointestinal ‎disorders, stroke and cancer. Also, a significant relationship was found ‎between self-immolation and neuropsychiatric diseases. Bolemsma et al. (30) reported in ‎their study that ‎the most common cause of death was multi-organ failure (64.9%) and septic ‎shock (45.9%). ‎In our study, the most common cause of death was respiratory failure and ‎after that cardiac ‎arrest, bradycardia, gastrointestinal bleeding, and hypotension. It can be ‎stated that with the ‎underlying disease, the resistance of the body is reduced, and the mortality ‎was increased.‎

Conclusion:‎

According to the results of the current study, the most common cause of mortality was flame ‎and the most common area of the burn was upper limb. Most burns occurred in winter and a ‎significant relationship was found between self-immolation and neuropsychiatric disorders. ‎The most common cause of mortality was respiratory arrest. Lower pH and higher BUN had ‎a signification relationship with mortality. Therefore, focusing on burn by hot liquids should ‎be a priority in any of the mentioned high-risk groups and prevention of burn and education ‎on true usage of incendiary and hot devices and safety precautions, should be noted more ‎than ever.‎