Profile of Moderate and Severe Burns: Turkish Experience In A Tertiary Care Burn Unit

Introduction

Burn injury is a universal type of trauma around the world with significant morbidity and mortality rates. It has a high cost of treatment due to prolonged hospitalization for wound and scar treatment together with rehabilitation (1). It also has adverse effects on psychology and social lives of both patients and their family members (2). Each year, nearly 6 million patients were treated for burns, and a significant portion of them was managed in outpatient services. But there are still controversies about a referral to burn units organized for specific treatment of these patients (3, 4). The predisposing factors, the demographical data and the epidemiologic coverage of the burn injuries differ between various countries and different regions. The etiological factors for burn injuries also vary among different states (5). But for everywhere, the best approach to treat a burnrelated injury is the prevention of the damage before occurrence (6).

The survival of a burn trauma individual differs due to the socioeconomic status of the region. In developed areas, an organized multidisciplinary approach including early hospitalization, proper fluid resuscitation and nutrition and infection control increases the survival (7, 8). But unfortunately, the majority of the burn traumas occur in the middle and low-income countries (9) in which low education, limited health service inhibits adequate treatment and rehabilitation for these patients (10, 11). Conse-quently, we observe higher mortality rates were in these areas.

Patients with acute burn injuries are usually brought to the nearest local hospital first. Then the primary interventions take place and finally they are stabilized followed by their transfer to the burn centers. There are various studies in the literature which were designed to evaluate the epidemiologic features of burn injuries and to determine the specific risk factors (12, 13). This study aims to analyze the demographic and epidemiologic characteristics of patients admitted to our burn center, to identify the main etiologic factors and to reveal the preventive measures for burn injuries.

Material and Method

Study design

Our study is a retrospective study including, the information of 4745 patients hospitalized in our burn center between 2009 and 2017 reviewed from a prospectively maintained database. We compared the number of patients hospitalized in burn service or burn intensive care unit according to years, the sex of patients, age, burn scars, causes of burns, days of hospitalization,occupancy rates according to years, infection rates and treatment outcomes.

Setting and sample

Kartal Dr.Lutfi Kirdar Education and Research Hospital Burns Centre is the most equipped burn center in Turkey with a multidisciplinary crew working due to the American Burn Association (ABA) criteria (14). The staff consists of general surgeons, plastic surgeons, anesthetists either in BICU or operating rooms, infectious disease doctors, pediatric surgeons, physiotherapists, psychologists, dieticians, and burn nurses. It has a helicopter landing field, and it accepts patients from every region of the country. It has six burns intensive care unit (BICU) rooms, 16 burn service beds, and two separate operating rooms all housed in one building.

All six bedrooms of our BICU were designed according to the American Burn Association (ABA) criteria with HEPA filters, laminar flows, and with cabin entrances. According to American Burn Association guidelines, the lesions of the patients treated in our burn center on an inpatient basis consisted of moderate and severe burn injuries.

Statistical analysis

We used SPSS Windows version 22.0 software for the statistical analysis. The descriptive statistics of the data were performed with proportion and frequency values. Chi-square test and Mann-Whitney U test were utilized for the study of the variables. Data were expressed as a mean ±standard deviation. P<0.05 was considered statistically significant.

Results

A total of 4745 patients admitted to our burn center during the 6-year period. 1162 (24.49%) of the severe burn patients were in intensive care unit, and 3583 (75.51%) of the moderate burn patients were hospitalized in the burn service.The mean annual admission to our burn center was 593.12, and these were 145.25 and 447.87 in burn intensive unit and burn service respectively (Table-1).

In the burn service group, the ratio of female to male was 33.4/66.6 while it was 25.1/74.9 in the intensive care group (Table-2). The male to female ratio was found to be significantly higher in the intensive care unit when compared with service (2.9 versus 1.9 respectively; p=0.003). The most common age range in the moderate burn group was 2-4.9 years with 17.38% (n: 622), but it was 20-29.9 years with 20.81% (n: 242) in the severe burn group (Table-3).

The highest rate of admission was in moderate burned patients was 49.12% (n: 1760) with a burned body surface area of 0.1-9.9%, while in the severely burned group it was 16.77% (n: 195) with a burning body surface area of 40- 49.9% (Table-4). The average percentage of burn surface area was calculated as 15.3%. The burn percentage was significantly higher in the intensive care unit (35.2±23.5%) compared to the burn service patients (10.7±8.5%) (p<0.05). When we examined the causes of moderate burns, the first order received scalding burns with 52.65% (n: 1886), and in severe burns, it was flame burns with 54.22% (n: 630) incidence (Table-5). For patients with the electrical burn and flame burn injuries, the rate of admission to the intensive care unit was significantly higher than other types of burn injuries (p<0.05). In the first eight years, the rate of burn intensive care infections was 56.04% on average, while it was 8.26% in our burn services. The incidence density of infection was 5.48% in our burn intensive care unit and 0.76% in the burn service. The most frequent infection in burn intensive care patients was blood circulation infection as 31.93%, while it was skin and soft tissue infections as 5.72% in burn service. Acinetobacter species were the most common pathogens in burn intensive care unit, and Pseudomonas species were the ones in burn service (Graphic 1, 2).

The annual average occupancy rate of the burn service was 89.39%, and the burn intensive care unit was 74.70%. The average hospitalization length was 10.09 days in burn service and 11.82 days in the intensive care unit. The duration of stay at the hospital was significantly higher in the electrical burn injuries (12.2±15.1 days) and flame burns (15.5±13.9days) compared to the other types of burn injuries (p<0.05). Our mortality rate was 7.37% (n:350) in our series(Table-6). The burn percentage was found to have a positive correlation with the mortality risk. The rate of mortality was signi-ficantly higher for electrical burn injuries (17.1% of all deceased patients)and flame burns (69.4% of all deceased patients) compared to other types of burn injuries (p<0.05).

Similarly, the patients with electrical burns and flame burn injuries had a significantly higher burn percen-tage in comparison to the patients with other types of burn injuries (23.3±19.9% and 28.6±24.5% respectively; p<0.05).

Discussion

The management of burn patients is quite tricky and an organized multidisciplinary approach is required to cope with the additional complications. So, it results in a prolonged hospitalization. Many different complications may occur during this process like extremity loss, repetitive surgical interventions, infections. The best way to the management of burn trauma is the prevention of the injury before its occurrence. First of all, a collection of data about these burn injuries in society is crucial for the production of ways of management of these burns. Our country as a developing country demands individual efforts on burn injuries; so in recent years, there are several studies about the burn epidemiology and the management of statistical data (15–17). Our study consisting of 4745 patients is one of the most extensive series presented in our country.

In our study, adult male patients constituted the majority of patients admitted to our burn center. This finding was similar to various other study results (18, 19). We can interpret this result as since women do not work in heavy industry. But in some other reports, female patients were more than males (20, 21). Our data resulted in the scalding burns as the highest percentage of burn cases. This was compatible with several other studies (22, 23), but in another study (24), flame burns constituted the majority of burn injuries. In our study scalding burns were followed by flame burns and electrical burn injuries as second and third most frequent types of burn injury. Our burn center is close to the industrial zone which explains the relatively increase frequencies of flame burns, electrical burns and contact burn injuries. Scalding burns commonly observed at home. The families with low socioeconomic status in a crowded environment may neglect their children, so these children are vulnerable to burn accidents with hot water, tea, milk or soup (25).

The highest mortality rate among our cases was in the flame burns group, followed by the electrical burn injuries. The level of burn percentage showed a direct correlation with the mortality rate. The highest burn percentage was in the flame burns group and the most prolonged duration of hospitalization in the electrical burn injuries group. Our mortality ratio was calculated to be around 7.37% which was higher than various other study results in developed countries (26–28).

In burn trauma, opportunistic infections are common due to the interruption of the skin integrity resulting from a way of penetration of microorganisms together with the suppression of the immune system. Antibiotic prophylaxis is routine for all patients under the direct control of our doctor of infectious disease and cultures fromallsites were taken.Acinetobacterspp were the most common microorganism in our results. Several studies reported different organisms as most common organisms growing in burn sites as S.aureus, Pseudomonas sp., and Klebsiella spp (19, 29, 30). Our results are different from previous findings.

In Turkey, Burn and Fire Disasters Association was established to conduct studies, education programs, national and international scientific activities on burns and fire disasters. We think that the conduction of appropriate notifications and education programs will provide significant benefits to protection from accidents.

This study revealed that the majority of burn patients in our region consisted of middle-aged male patients. The type of burn injury with the highest mortality risk was found to be the flame burns. The most common type of injury was scalding burns, and the largest group of patients experienced the burn injury while actively cooking in the evening. We believe that the traditional methods for preparing meals and tea brewing in Turkey should be re-evaluated and necessary precautions have to be undertaken.

Conclusion

Burn injuries are preventable disasters with physical and psychological scars. Thus the efforts for preventive measures and education programs should be increased. All social assistance foundations and burn associations should also work toward this goal.

Authorship Contributions

Concept: Y.Y., O.K.; Design: Y.Y., O.K..; Data collection &/or processing: Y.Y., O.K.; Analysis and interpretation: Y.Y., O.K.; Literature search: Y.Y., O.K.; Writing: Y.Y., O.K.; Critical review: Y.Y., O.K.