Burn Injuries represent one of the most important public health problems faced by both developing as well as industrialized nations today. Burn Injuries may be intentional or nonintentional but intent is sometimes difficult to determine. Burns or thermal injuries occur when hot liquids (scalds), hot solids (contact burns) or flames (flame burns) destroy some or all of the different layers of cells which form the human skin and even deeper tissues. For traditional reasons, skin injuries due to ultraviolet radiations or radioactivity, electricity and chemicals, as well as respiratory insults resulting from smoke inhalation, are considered as fire/burn injuries. Burns represent an extremely stressful experience for both the burn victims as well as their families. An extensive burn profoundly affects the patient's physique, psyche, financial situation and family. Patients suffering from extensive burn injuries frequently die while others suffer from painful and prolonged physical recovery. In different communities and countries, the etiological factors responsible for burn injuries vary considerably, hence a careful analysis of the epidemiological factors in different places is needed before the planning and implementation of a sound prevention program. This chapter highlights the history, epidemiology and prevention strategies for burns in both the developed and developing countries especially pertaining to Indian Scenario.1,2
INTRODUCTION
Burn trauma is as old as the discovery of fire in the history of mankind. Medicine is built on the best of the past. Thus, a study of ‘History of Burns’ contributes to a review of accomplishments and errors, false theories and misinformation and mistaken interpretations. The history of burns, especially in India, is very fascinating. It teaches us where we started from, where we stand today, in what direction we are marching and guides us for the future.1,2
HISTORY OF BURNS IN THE ANCIENT AGES
World History
The philosopher Santayana said; “Those who cannot remember the past are condemned to repeat it”. In an address to the Royal College of Surgeons, Churchill remarked; “The longer you look back, the further you can look forward”. In considering the history of the treatment of burn injuries, one might quote Adam MacDougall, who in 1819 stated that “It would equally exceed the bounds of convenience and utility to particularize all the remedies that have been recommended in the treatment of accidents of this kind”. Hippocrates (430 BC) used swine's semen, resin, bitumen and Oak bark solutions in the treatment of burns. Chinese (600–500 BC) used extracts of tea leaves. Smith papyrus (1500 BC Egyptians) used gum and goat's milk mixed with mother's milk and strips soaked in oil. Celsius (ancient Rome) advocated honey and bran. Glen (ancient Rome) described vinegar or wine in the treatment of burns1–3 (Table 1.1).
Indian History
Fire injuries in India have been common right from the ancient times. Suicide by fire out of insult was one of the common reasons. In Shiva Purana, it is mentioned that Lord Shiva's consort Sati had jumped into the sacred fire after being insulted by her father Daksha. Another reason for suicide by fire was ‘Sati Pratha’ a common tradition of committing suicide by widows. It is well known that Plastic Surgery originated in India in the Vedic Period about 3500 BC. Among the many distinguished names in Hindu medicine, that of Sushruta, the ‘Father of Ancient Plastic Surgery’ stands out in prominence (Fig. 1.1). Sushruta was the son of the sage Vishwamitra, contemporary of Rama of Ramayana. He compiled the surgical knowledge of his time in his classic ‘Sushruta Samhita’. It is believed that this classic was compiled between 800 BC and 400 AD. Sushruta was the first to classify burns into four degrees: Singeing, Blister, Superficial and Deep Burns.1–3
HISTORY OF BURNS IN THE MIDDLE AGES
World History
The British at the Battle of Crecy in 1346 were the first to use gunpowder and this development gave rise to many medical problems including those associated with the treatment of burns. The stimulus of the war experience initiated new and experimental types of treatment. In 1596, Clowes wrote a treatise on gun powder burns. He did not differentiate the depth of burns but rather described multiple types of treatment on different part of the body. He suggested oily dressings containing many drugs, did not open the blisters and was an advocate of bleeding. Ambroise Pare (1517–1596) described about excision and ointments. Fabricus Hildanus (1610), who wrote De Combustionibus, was the first to classify burns into three categories and also showed pictorially the early successful surgical release of hand contractures. Pare clearly described the differences between second and third degree burns that frequently developed contractures. Richard Wiseman in 1676 wrote several “chirurgical treatise” and discussed splinting to avoid contractures. He advised refrigerants or calefactive medicaments. Kentish (1797) described pressure dressings as a relief for pain and in his essay on burns promised to “rescue the healing art from empiricism and to reduce it to established laws”. David Cleghorn (1792) used vinegar and chalk poultice for burns treatment. The use of ice and ice water for analgesia and the prevention of edema was explained by H Earle (1799) in his essay “the means of lessening the effects of fire on the human body”. Syme (1827) used wool dressings. Lisfranc (1835) described calcium chloride dressings. In 1823 the Edinburgh Medical Journal published two papers on postmortem finding in two burn deaths. One patient had a gastric ulcer and another gastric congestion.
Multiple lectures at this time were describing perforation of the stomach following burn deaths and there was increased interest in studying both the pathology and treatment of thermal injuries. Cotton dressing over burns was first discussed in a Glasgow Medical Journal in 1928. Readers were told how to apply dressing and were cautioned against changing them more than once daily. Dupuytren (1832), the brilliant French surgeon, made multiple contributions to burn research, including the documentation of the degree of injury to depth and the description of the phases of the post-burns course—irritation, inflammation, suppuration, and exhaustion. Sir George Ballingall in 1833 gave one of the best description of death from burn sepsis; “sinking in a hectic state, exhausted by a profuse discharge of matter from an extensive separating surface”. In a land mark decision in 1848, the managers of the Royal Infirmary in Edinburgh designated one building for all burn cases and this became known as the burns hospital. Passavant (1858) gave concept of saline baths. In 1875 Joseph Lister recommended boric acid and carbolic acid for burn wounds in order to kill bacteria. In 1881 Tappeiner of Munich studied autopsies of burn deaths and recognized the concentration of blood, increased hemoglobin concentration and decreased blood and water volume. The appreciation by Tappeiner of burn pathology was a significant event. Thomasalis (1897) described use of salt water injection.1–3
Indian History
The history of burns in India in medieval period is that of decline in India and lull in European countries. The natural feeling of fear for operations grew and love for medicines increased. The governments prohibited and neglected the practice of surgery. The famous Buddhist scripture Mahavaggaa Jatak enjoined strict prohibition of surgery and extended the terror of hell both for the surgeon and the patient. ‘Manusmriti’ prescribed special rituals by way of purifications of surgeons, who were looked down upon as unclean. Later during the Rajput, Muslim and Maratha periods, Ayurvedic (Hindu) and Unani (Arabic) systems of medicine were practiced by Vaids and Hakims respectively. The Vaids were purely physicians and the practice of surgery was restricted only to incision of abscess, dressing of wounds and treatment of bone and joint injuries by barbers and bone-setters. Not much information is available in literature related to burn injuries.1–3
HISTORY OF BURNS IN THE MODERN AGE
World History
In 1905, Sneve noted the importance of intravenous saline for resuscitation and wrote an article in the Journal of the American Medical Association advocating early skin grafting. The understanding of burn pathology took a great leap forward when Underhill (1930) studied a group of patients burned in a theater fire in 1921. He analyzed the content of blister fluid and determined that burn shock was due to fluid loss and not toxins (a popular theory of that time). The Coconut Grove Fire in Boston in 1942 resulted in extensive studies by Cope and Moore on the diagnosis and treatment of burn shock. Controversies over the best method to treat the burn wound persist to the present day. Dressings remained popular until Wallace in 1949 advocated exposure treatment for burns of the face, buttock and perineum. Formulas gradually evolved to calculate fluid losses. Evans (1952) used burn skin surface area and weight as the principal variable. The Brooke formula was a modification of the Evans formula and utilized salt, colloid and water. Moyer and Associates (1965) recommended only Ringer's lactate solution, yielding alert, oriented patients even when the body surface area burn was large. The pattern of triage of burn patients changed dramatically in the 1960's. The US Army Research Unit was initially guided by Pulaski and Artz, who stressed patient care as well as clinical and laboratory burn related research. Critically injured patients, civilian and military, were referred to the center and the concept of the multidisciplinary burn team evolved. In 1962 the Shriners fraternal organization in the United States began development of three burn centers affiliated with universities and dedicated specifically to the care of burned children. These centers served as role models that have completely altered burn care around the world. Their superb survival statistics made others realize that patients with large burns were not automatically doomed but had a chance of survival if cared for in a specialized center. Laboratory and Clinical Research in burn injury improved other areas of trauma care as well. It became obvious that the burn patient with multi-system involvement was the perfect trauma model. The universality of the burn problems provided a reason for better international cooperation and exchange of ideas. In 1960, the first international congress on research in burns was held in Washington, DC. At the second meeting in 1963, The International Society for Burn Injuries (ISBI) was 6founded and it has been conducting meetings every four years. The American Burn Association was founded in 1968. The society's membership was unique in that it consisted of all the members of the burn team, including non-physicians (Dieticians, Physical and Occupational therapists, Nurses and Psychologists).3
Indian History
Burns became alarmingly frequent in India in the modern age of industrialization. To pour kerosene over the clothes and then set them on fire is the most common form of committing suicide or murder. There are also innumerable instances of accidental burning caused by clothes catching fire on low stoves or open gas rings; the loose flowing end of ‘saris’ and ‘dupatta’ of Indian women increases this danger enormously. Open fires in winter are an added hazard. Acid burns of the face are frequently the result of blind jealousy. Suicidal burns amongst Hindu women are usually fatal because of its extent. Practice of tradition of ‘Sati Pratha’ declined in this period. Most of the burn cases in India are treated by General Surgeons and General Practitioners in small cities and rural areas because Plastic Surgeons are few and settled mostly in Metro cities. These General Surgeons and General Practitioners have negligible facilities and have no forum to exchange, enhance or update their knowledge. The initial local treatment on admission to hospitals varies according to the area involved in the burns—face, front of chest and abdomen are routinely treated by the exposure method. Burns of extremities and fingers alone are dressed. The majority of hospitals do not have the ‘Stryker Frame’ and hence only circumferential body burns are dressed. Resistant strains of organisms have increased in recent years due to excessive use of antibiotics. Surgeons are not in favor of keeping grafts exposed from the start. Skin grafts are dressed with pressure pads for a week and then kept exposed. To keep the donor area exposed was attempted by many but were not satisfied by this method. In fact, dressing of the donor area is retained for a fortnight during which the part heals. Severe cases of contractures of the flexor creases like the neck, axilla and elbow are released and skin grafted. Free grafts are preferred to tube pedicles as the relief is quick as well as complete.4
In India many Plastic Surgeons have contributed in the development of Burns Unit and management in modern era. Dr Noshir H Antia, the 3rd generation trained Plastic Surgeon under Sir Harold Gillies was the first surgeon to start a unit at Grant medical College and associated JJ Hospital, Mumbai in 1959. In 1964, Tata Trusts provided a substantial grant to carry out two projects–one on Leprosy and other on Burns. In 1963, Safdarjung Hospital, Delhi started a department of Burns, Plastic and maxillofacial surgery with Dr JL Gupta as its head. Professor Antia felt that they should have a forum and thus, a Burn Association of India (BAI) was formed at JJ Group of hospitals, Bombay in 1972. Dr MH Keswani was the Secretary. Later under leadership of Dr Keswani the Burns Association of India (BAI) flourished with contributions like Boiled Potato Peel (BPP) dressings, prevention campaigns by way of radio and TV talks, small documentary ads, ‘School Education Program’ in burns etc. “Pour water on Burns” has received worldwide popularity. ‘AGNIVARTA’ is a quarterly publication of ‘Burns Association of India’ devoted to the problems concerning Burns. Burn injury is a disease of the poor at least in our country. Dr Keswani gave various modifications to reduce the cost of burns treatment like common home made curd (called yogurt in the US) as a de-sloughing agent, Butter Milk Diet (BMD) as cheap high calorie high protein diet, X-Plasty of Vartak as a simple operation of release of contracture, Vartak's wheel as mesh graft dermatome, cellophane dressing for donor area, simple operation cum bath trolley, etc. Dr Keswani has to his credit the setting up of the first children's burn unit in India and India's first skin bank at Bai Jerbai Wadia Hospital in Parel, Mumbai in 1975 and 1978 respectively.5–7
In 1990, Prof J L Gupta convened a meeting at Pragati Maidan, New Delhi. A very active and detailed discussions and consultations were held amongst Prof JL Gupta, Prof Mathangi Ramakrishnan, Prof J K Sinha, Prof S P Bajaj, Prof S K Bhatnagar, Prof R K Keswani, Prof Siti Roy Choudhary, Prof PK Bilwani, Prof Madhuri Gore, Prof D L N Prasad, Prof Swarna Arora and Prof Anil Chadha and many others. This historic and significant meeting led to the birth of National Academy of Burns - India (NABI). NABI mainly aims at preparing and making available a suitable appropriate and latest information relevant to all those concerned with burn care. Recognizing the services of Prof J L Gupta in the field of burns in the country, he was unanimously named as the Patron of NABI. Prof S N Sharma was the choice for the founder Presidentship. Dr S P Bajaj became the founder Secretary. The academy brought out an annual journal named ‘Indian Journal of Burns’ with Dr Rajeev B Ahuja and Dr Arun Goel as editor and assistant editor respectively. They worked for five years (1993–1997) before passing on the task to others. The first volume was 7brought out in 1993 and the journal is being regularly published. While NABI is an association of burn care professionals (doctors, nurses, therapists etc.), BAI even included persons like businessmen, old recovered burn victims, etc. who were ready to serve the cause of burns in their own way.
Dr JL Gupta gave guidelines for planning a Burns Unit.8 Subsequently many Burn Units have been developed successfully in various Institutions and Medical Colleges like Burn Unit in the Department of Plastic Surgery at Kasturba Medical College, Manipal, Karnataka, IPGME&R, Kolkata etc. Of all the existing Burns Units in India, special mention is made of Burns Unit of Safdarjung Hospital, New Delhi which is the largest burn unit in the country and which has been modernized and equipped with all modern Burn care infrastructure facilities. ‘Early Tangential Excision and skin grafting’, ‘Rescuer Burns’, ‘Policy of antibiotics in Burns’ etc. has been popularized extensively by the Burns Unit of Manipal, Karnataka.9,10
In India, Burn injuries due to fireworks on the occasion of ‘Diwali’ are very common. Safety tips related to Fireworks have been explained by Anjali Burma.11 The Government health system is not able to keep pace with population growth in recent years. Although major burn accidents are decreasing in relation to the population growth, the actual number of burn cases is on the increase. Gradually more and more teaching hospitals started separate Burn wards. Possibly about 60% of them are managed by the General Surgery services and the rest by a Burn and Plastic Surgeon. The requirement for more burn beds encouraged many non-government groups into establishing burn management centers. Many of these centers have well equipped wards, trained support staff and enthusiastic Burn Specialists. These specialists have been instrumental in maintaining the prevention and rehabilitation programs concerning burns.9,10
RECENT ADVANCES
What have been the outstanding features of burn injuries in the last twenty five years? It is the better understanding of burn pathophysiology that is the most remarkable feature of last quarter of a century. The second important feature is the realization that the care of Burns is a team effort, the leader of the team being the one, who can lead the team most inspiringly, a person with vision, with dedication and with tenacity. It would not be fair to single out any one individual for all the advances. Half a century ago, the commonest cause of death following a burn greater than 20% was surgical shock, at least in India. With a better understanding of post burn surgical shock it is possible to treat this rationally and efficiently. The mortality from this cause has reduced considerably. Generalized infection of the tissues (septicemia) is the single most common cause of death following burns, at present. Better drugs and their wide-spread availability have helped us to control infection to some extent. However, while these drugs are useful, they have many undesirable side effects, some of them lethal. Moreover, the cost of these drugs is prohibitive. They have encouraged resistant strains to develop and they have put the clock back in many instances. Post burn sequelae need correction. These have been satisfactorily corrected by reconstructive surgeons and in many instances by interested general surgeons. Early post burn rehabilitation has been encouraged, but much progress needs to be made in this direction in this country. When the hands are burned, it is a severe blow to the person's economic viability. Better methods of rehabilitation need to be developed. Unfortunately over the last 25 years, not much progress has been made in this area. It costs approximately US $1,000 per patient per day to provide satisfactory care in the Western world. This is clearly not possible in India and in many of the developing countries. Prevention of burns is the only logical solution. This is not easy and is time consuming. Easy or not, we have no option(s). We must prevent burns. Fortunately the Burns Association of India, which was formed in 1972, has been doing precisely that. Burns Prevention has to be propagated zealously by everyone who is able to do so, especially Doctors, Nurses, Paramedical workers, Social workers, teachers, surviving burns patients, and the media — in fact it should be a national responsibility. India is a country with tremendous problems-those of population explosion, education, malnutrition, unemployment and many more. Our hopes lie in a unified approach to work together and solve some if not all of these problems.12
INTRODUCTION
Epidemiology has been defined by John M. Last in 1988 as: “The study of the distribution and determinants of health-related 8states or events in specified populations and the application of this study to the control of health problems”. Epidemiology began with Adam and Eve, both trying to investigate the qualities of the “forbidden fruit”. Epidemiology is derived from the word epidemic (epi = among; demos = people; logos = study), which is a very old word dating back to the third Century BC. Burn injuries and their related morbidity, disability and mortality represent a public health problem of increasing importance in developing countries. Developing countries have a high incidence of burn injuries, creating a formidable public health problem. Epidemiological studies of burn injuries are a prerequisite for effective burn prevention programs because each population seems to have its own epidemiological characteristics and knowledge of the epidemiology of burns is needed to select target groups for preventive actions.13
BURN REGISTRY
The American Burn Association (ABA) commissioned Jeffrey T Suffle and Byron of the University of Utah Health Center, Salt Lake City, Utah, USA, to develop a computer program to assist burn units to collect data useful for patient care and prevention. The ABA graciously permitted the International Society for Burn Injuries (ISBI) to distribute a version of this program, adapted for use internationally, to ISBI members free of charge.14
USES OF BURN DATA
Burn data are useful to:
- Define the burn problem.
- Determine the most common ways that people are burned.
- Evaluate the effectiveness of medical care for burn patients.
- Identify which burn hazards should be targeted by burn prevention programs.
- Examine the economic impact of burn injuries and burn treatment.14
SOURCES OF BURN DATA
The sources of burn data vary, depending upon the severity of the burn injury:14
- For burn deaths: Collect information from hospitals and local, regional or national vital statistics registries. Many people die immediately of fire and burn injuries and do not receive medical care.
- For serious burns: Collect information from hospitals; decide whether to collect data only on burn patients admitted to the hospital, or on all patients seen at the hospital. If there are several hospitals treating burn patients from the defined population, collect data from all these hospitals. Referral patterns may distort the true profile of burns in that population.
- For less severe burns: Collect information from health clinics, doctors’ offices, visiting nurses or any other medical treatment service. A good sampling plan will make this task easier.
- For burns of all levels of severity occurring in a community: Collect information through a community survey, asking residents in face-to-face or telephonic interviews to recall circumstances of burn injuries suffered by family members. Questions about burn injuries could be added to a larger multipurpose community survey.
- For burns associated with building fires: Contact the local fire service for information about fires in which people were killed or injured. Remember, this is not a good source for clothing ignition burns, scalds, contact, electrical or chemical burns.
STANDARD CODING OF BURN INJURY DATA
Most countries use the World Health Organization's International Classification of Disease (ICD) Codes for coding data on hospital discharge records, although there are other coding schemes. For example, the Nordic countries use a coding scheme called NOMESCO. The ICD system contains two sets of codes for burn data. The first set classifies what type of fire or burn injury was sustained:14
Code | Type of Burn |
940–949 | Burn injuries |
986–987 | Smoke inhalations |
692.71 | Sunburn |
910–919 | Superficial injuries (friction burns are among these codes) |
The second set of codes is the ICD E-codes (External Cause of Injury), which classify the causes of burn. These are four-digit codes, with the fourth digit often capturing important burn information:14
Code | Cause of Burn |
E890–899 | Burns caused by fire and flames |
E923 | Accident caused by explosive material (Includes fireworks and explosive gases; not all injuries coded here are burns) |
E924 | Accident caused by hot substance or object, caustic material and steam |
E925 | Accident caused by electric current (burns or electrocution) |
E926 | Exposure to radiation |
E958.1, .2 | Suicide (by burns or scalds) |
E965–968 | Homicide and assault (965.6, 967, 968.0, 968.3 related to burns) |
E988.1, .2 | Undetermined if accidentally or purposely inflicted |
E990, 996 | War |
NATURE OF DATA NEEDED TO STUDY BURN EPIDEMIOLOGY14
How Big is our Burn Problem?
Determine the number of people who have been burned. Do not ignore burn deaths, especially those who die before coming to the hospital. Counts of non-fatal burns are made easier in areas where computerized hospital discharge records are coded using the International Classification of Disease Codes or another standard coding scheme. Count the number of patients with a burn injury diagnosis, coded using ‘type of burn’ codes.
How are our People Getting Burned?
Determine the number of people burned by specific causes of burns, such as clothing ignition or scalds. Collect information which will permit patients to be classified using ‘cause of burn’ codes. Accurate, useful coding depends upon accurate, useful information in the medical record. This includes details about the circumstances of the burning, ignition sources and other product involvement, where the event happened and the activities of the people involved and demographic information about the patient. This often requires an interview with the patient, a family member or someone present at the burn episode. Make sure that this information is written in the medical record, coded and, whenever possible, entered into computerized hospital discharge records.
How can we Prevent Burns?
Analyze data describing the common causes of burn injuries in the population to identify high risk groups such as young children and high-risk activities, such as meal preparation.
How can we Evaluate the Success of our Prevention Programs?
The precise nature of the data required depends upon the prevention program and the research design of the evaluation.
Information about Larger Populations
It is important to know certain characteristics of the defined population, whether this be a village, a region or a country. Important characteristics are: the number of people in the population and the age distribution of these people. If your country collects and publishes census data, these provide an excellent source of information to use to describe risk factors for burns in your population.
Burn Rates
Burn epidemiology uses rates of burn injury or deaths. A rate is calculated by dividing the number of burn injuries sustained during a specified time period by the number of people in a population during that same period. It is expressed, for example, as ‘burns per 100,000 populations per year’. One must use burn rates to compare the burn problem in communities or countries with different sized populations. A densely populated community may have many more burns but a relatively lower burn rate than a sparsely populated region. A lower burn rate signifies a lesser burn problem. It is important to know the age distribution of the defined population because burn risk is age-related. A population with a lower median age will have higher rates even if its adults have an equal or slightly lower risk than a population with a higher median age.
Usefulness of Burn Data from a Single Hospital
If only one hospital treats patients with serious burns in a defined population and if one is interested only in serious burns, the vital statistics registry and this hospital are the two appropriate data sources for fatal and serious burn injuries, respectively, for that population. If the hospital is one amongst many serving a single population, one cannot draw any conclusions about the population's burn problem by studying only one hospital. However, even without collaboration with other local hospitals, it can be valuable to analyze burn data from a single hospital. Individual hospitals can provide useful information about a specific circumstance 10which causes burns and can provide ‘cases’ for a ‘case-control’ study. One cannot, however, draw conclusions about the population's burn problem.
EPIDEMIOLOGY OF BURNS IN INDIA
National Burns Registry
One of the major activities of The National Academy of Burns-India (NABI) is to maintain a National Burns Registry. Various data is collected from centers engaged in management of Burns. This is, however, a voluntary effort and has so far not reached to all places. In a few years with continued efforts and support from all areas, National Burns Registry of NABI will be able to truly reflect the scene of burns problem in India.15
Extent of Problem (Mortality and Morbidity)
Over 100,000 people are affected by burns in India annually and 20,000 of them die according to rough estimates.16 In 1991, the reported deaths were 22,306. A survey of almost 3500 hospital admission over the past few years supplemented by intermittent published reports over the past 30 years indicated a mortality rate of between 25% and 49% for adults and between 6% and 20% for children (0–10 yrs old).17 Ten percent of all accidental deaths and seven percent of all suicides in India are caused by fire. Although incidence of burn trauma is on the decline in the developed nations, it is still rising in India and is second largest killer after road traffic accidents. Thousands of victims of burns are being mutilated, disfigured and handicapped every year.18 The cost of burns is both visible and invisible. In India, the cost of burns ranges from $25 to $300 a day. To this may be added the loss of wages of the patient and of those who have to be away from work to care for him or her during hospitalization. The other visible cost is in the scarring and deformity, of loss of hair and body- pigment and alterations in skin texture. There is also a loss of physical skill which leads to demotion at the place of work and makes one less fit or unfit in domestic life. The invisible cost is in the pain the patient undergoes, both physical and emotional, the emotional trauma of itching, of scarring and intolerance to heat. Neither the trauma of patient's psyche nor the imperceptible alterations of the patient's personality can be measured. And then, there is loss of time—of time lost from studies, of vanished opportunities in social life, like marriage or career promotion. And finally, one has to remember the cost to the patient's family–to the husband who loses a beloved wife, to the child who becomes motherless, to a young wife who becomes widowed and to the aged parents who loose their support. In India, society is structured differently and the cost borne by the patient's family is truly immense and immeasurable.19
Age and Sex Distribution
The age distribution revealed by various studies in India shows that more than half the cases are aged between 21–40 years. In children, the lack of coordination and unawareness of dangerous substances play an important role in the occurrence of burns. High incidence among young adults may be explained by the fact that they are generally active and exposed to hazardous situations both at home and at work.20–22 Male predominance in the younger age group (5–10 years) might be explained by the inquisitive and exploring nature of boys of this age. As regards sex distribution, the female preponderance in the age group 20–40 years concurs with reports from other developing countries and might be explained by the involvement of females in domestic activities and dowry deaths too. However, figures from industrialized countries are clearly lower than those reported from developing countries. This may be due to the relatively lower percentage of occupational and recreational burns or due to better home safety with safer cooking and heating devices in industrialized countries.23–25
Sociocultural Factors
Sociocultural factors are among the major causes of different age and sex predisposition of developing countries like India compared to other developed nations. The majority of the patients belong to low socioeconomic status (69.6%), while 21.8% are from middle and only 8.6% are of high socioeconomic status. 42.6% belong to an urban area while the rest are from rural areas. Arrival time to hospital after the incidence is variable, only few patients (9.7%) arrive within six hours of the incidence. The majority (61.8%) reached the hospital between 6 and 24 hours; those reaching the hospital after 24 hours contribute about 28.5%.26–28
Etiology
An extensive study was done by the department of Burns, Plastic and Maxillofacial Surgery, Safdarjang Hospital, New Delhi.29 Analysis of the causes of 9927 burn cases is given in Table 1.2.
|
It is seen that the vast majority in these are dry burns, by direct contact with either flash or flame. The second most common are scalds. This is because of conditions which are peculiar to the villages in our country. Most of the cooking is done at the floor level with open fire. Stoves, coal and wood are commonly used. Often large families live and cook in the same room. If there is a kitchen, it is small, crowded and ill-designed. The storage shelves lie above the chulla/angithi (a kind of open oven used in India) or stove, so that while getting up to pick up an article from the shelf, any loose garment can easily catch fire. The lamps used for illumination are made of an ordinary glass bottle or tin can, with cotton wick and kerosene oil. They are either kept on the floor or on any shelf. They can be easily upset and result in an oil fire. The majority of the population lives in villages in thatched houses which easily catch fire. Accidents at home form the major bulk and the common causes are:
- Loose clothing like ‘sari’ and ‘dupatta’, mostly made of synthetic, inflammable material.
- Spilling and spraying of kerosene oil from pressure stove is more common than actual bursting of it. The jet of oil under pressure catches fire immediately.
- Hot food stuff and liquids carry a constant danger to children and infants, particularly in over crowded rooms. They often fall in the steaming food, cooking utensils and hot water buckets and tubs.
- It is common to heat water in a tin with its lid in position. As the lid is handled, the steam under pressure inflicts severe scalds of face, neck and upper chest wall.
After flame and scalds, electrical burn is the third most common cause of burns in India. The electric appliances used are substandard and are used without any regard to safety measures. Electrical burns while flying kite is very common in India especially in young children.
Circumstances of the Injury
There has been a change in the pattern of burn injuries as far as circumstances of the burn injury are concerned. Recent study shows that majority of burn injuries, i.e. more than 85% occurs in homes. Kitchen-related activities are most often responsible for burns in domestic setup. Flames represent the most common agent of burn injuries (75.1%). Among the flame burns, kerosene pressure stove is the most common source. Chimney and Liquid petroleum gas (LPG) burns rank the second most common source of flame injuries. Most of the burn injuries are accidental (67.7%), followed by homicidal (13.4%) and suicidal (18.9 %).30
Epidemiology of Pediatric Burns
Pediatric burns differ from adult burn injuries in many aspects and need separate consideration. Only few pediatric burn units exist in India. Most of the children with burns are treated in a common burns unit. Epidemiological studies on childhood burn injuries in India are very scant. Information on the exact magnitude of burn injuries has not been well documented. It is known, however, that burn hazards are present in the daily life of children. Household activities, including cooking are expected of girls early in their lives. According to one of the epidemiological study of pediatric burns, various risk factors attributed to burn injuries in children are low socioeconomic conditions, poor living conditions, illiteracy, overcrowding and floor level cooking, on either kerosene pressure stove or an open fire. These pressure stoves are sometimes of shoddy construction and commonly malfunction leading to explosive disintegration. The overcrowded conditions cause young children to play in the vicinity of the cooking area leading to scalds from spilled hot fluids or foods. Pre-existing diseases and malnutrition afflict a considerable number of patients, particularly children injured in slum areas, thereby ensuring that patients have a reduced ability to compensate for the physiological stress inherent in a severe burn. The ridiculous first aid measures like application of ink, cow dung, hen's blood, haldi (turmeric), honey and other home made remedies, surprisingly, are still frequently used. Delay in transportation and initiation of treatment due to lack of education, lack of transportation facilities and lack of economic support are still prevalent.31 According to the recent study of 500 pediatric burns, majority (24%) of burns occur in children between one and two years age group. 12Male to female sex ratio was 1.38:1. Burn injury occurred predominantly during winter. Most common type of burn was scalds which occurred mainly in domestic circumstances. Mortality rate was 10.4%. Mortality rate was high in patients having more than 40% TBSA involvement. Parental occupation, family size and the first aid did not affect the mortality rate.32
INTRODUCTION
Burn injuries are universal and incidence is on the increase with the complexities of modern living and industrialization. As most of the burns occur either at home or at the place of work, it becomes important to know about Burn Prevention. In order to bring down the incidence of burn, education programs are oriented to bring the changes of culture pattern, change in the way of life, change of rules and regulations at work place, change in dangerous substandard gadgets and change of habits. Prevention does not mean only to reduce the incidence but also to reduce the depth and severity of the burn.33
RISK FACTORS
Before preventive measures are discussed it is important to know about the risk factors especially in Indian scenario. Various risk factors are as follows:34
At Home
In India most of the burn injuries occur at home, especially in the kitchen. Various risk factors are floor level cooking, substandard kerosene pressure stove, loosely worn garments (saris and dupatta), low level electric plug points, long over hanging flex of kettle, overhanging table cloth over which hot food or beverages are kept, carelessly kept match boxes within reach of children, substandard pressure cookers, etc.
At Work
Inadequate safety measures, overwork and fatigue are common risk factors at work place.
At Play
During Diwali, Indians play with fire crackers and celebrate the festival with lights. Inferior quality of crackers and carelessness during their bursting are important risk factors.
RESEARCH DESIGNS FOR BURN PREVENTION
Given below are the broad outlines of four research designs which may be helpful in planning and implementing burn prevention programs and their evaluation.35,36
Nonexperimental Descriptive Study
Purpose
To determine dimensions of a serious burn problem in a defined population.
Tasks
- Define the population of interest, determine numbers and age distribution, if possible.
- Decide on a time period. Include at least one year, since in most locations, burn injuries have seasonal variations.
- Decide on the level of burn severity. Include all deaths and people hospitalized for a burn injury and may be those treated and released from hospital or clinic.
- Identify all hospitals treating burn patients in the defined population. Request permission to review medical records or request hospital staff's help to provide data.
- Use a standardized burn form to collect all available information. Record as much information as is available on the circumstances surrounding the burn episode. The ISBI Burn Registry computer software is a useful tool for collecting and recording burn data.
- Prepare report to include rates:
- Death rates [(no. of deaths/no. in population) × 1000,000], expressed as deaths per million persons
- Injury rates [(no. of injuries/no. in population) × 1000,000], expressed as injuries per million persons.
Calculate rates for the following categories:- Age groups
- Gender
- Type of burn (flame, scald, other)
- Severity (depth and extent of burn).
- Plan a prevention program to address these problems. A review of literature may reveal which strategies have been effective.
Preexperimental Design: One Group Pretest-Posttest Design
Purpose
To document change associated with a prevention program.
Cautions
There is no control for natural time trends, societal forces and factors other than the intervention which influence burn rates.
Tasks
- Conduct the descriptive study to determine the burn problem in a defined population. Determine rates for those types of burn injuries and those age groups expected to be affected by the program.
- Design or adapt a burn prevention program which addresses a significant burn problem.
- Repeat the descriptive study and compare burn-type and age-specific rates before and after the intervention.
Note: If the prevention intervention has already been instituted, as it often is with safety standards or regulations, the descriptive studies of burns before and after implementation are retrospective and may be conducted simultaneously. Burns are relatively rare occurrence and are known to have yearly fluctuations. For this reason, it is well to collect data for several years before and after intervention.
Quasi-experimental Design: Non-equivalent Control Group Design
Purpose
To measure the effectiveness of a burn prevention program.
Tasks
- Conduct the descriptive study to determine the burn problem in two communities. These communities should be comparable in size, age distribution and socioeconomic variables.
- Select a burn prevention program, proven to be effective in other locations, which addresses a burn problem shared by both defined communities.
- Randomly select one community as experimental and one as control. Conduct the prevention program in the experimental community.
- Repeat the descriptive study in both populations and compare burn-type and age-specific rates. A successful program would be indicated by significantly lower burn rates in the experimental community with rates essentially unchanged in the control community.
Experimental Design: A Case-control Study
Purpose
To measure the effectiveness of a burn prevention program, for example, whether a new inexpensive kerosene stove, recently introduced into a community, has reduced the likelihood that someone will be burned.
Tasks
- Identify ‘cases’, that is, patients treated for burn injuries caused by stoves.
- Interview the patient or family member to determine the type of stove used by the patient. Determine fuel source, whether or not stove is the ‘new design’.
- Select appropriate ‘control’ for each case. This is the most difficult task of a case-control study, to find persons comparable to the case in all things except the type of stove used in the home. It is well to find multiple controls for each case, drawn from different categories. For instance, a hospital ‘control’ could be a person admitted to the hospital the same day for an illness rather than an injury, who is the same gender, same socioeconomic status and in the same age group as the burn patient. A neighborhood ‘control’ could be a person living on the same road, within a certain number of houses, who is the same gender, same socioeconomic status and in the same age group as the burn patient.
- Interview each ‘control’ to determine the type of stove used. Determine fuel source, whether or not stove is the ‘new design’.
- Analyze data using simple 2 × 2 table, categorizing subjects along two axes: positive or negative for burn injuries associated with stoves and positive or negative for exposure to ‘new stove’. Success would be achieved if those using the new stove were significantly less likely to be in the burn category.14
EVIDENCE THAT BURN PREVENTION CAN SUCCEED
- Throughout history, whole cities have burned down, cities like Rome, London and Chicago, to name but a few. Today, such massive fires are rare; when they do occur, they are associated with war and natural disasters. There are many reasons why whole cities do not burn down: More fire-safe construction methods and materials, fire-safety-related building codes and standards, professional fire services and water delivery systems.
- Fewer children are being burned when their clothes catch fire. There are many reasons: sleepwear flammability standards, the introduction of new, less flammable fibers and fabrics and more close-fitting designs for girls’ clothing. This pattern has not been seen in all countries, particularly not in those countries like India where girls and women commonly wear flowing dresses (saris) made of cotton and rayon.
- Fewer people in the USA are dying in residential fires, due in part to the widespread adoption of smoke detectors which warn residents of deadly smoke.
- Electrical burns of the mouth were all but eliminated in Denmark when a defective electrical cord for a popular vacuum cleaner was recalled and replaced.37
COMMON ELEMENT IN SUCCESSFUL BURN PREVENTION PROGRAMS
A consumer product or the environment is made safer for everyone by using prevention programs. Although it might seem easier to teach people to act safely in an unsafe environment, it does not usually work that way. Put your energy into making a safer environment. Burns can happen to anyone, but some groups are at greater risk: the very young or very old, the poor and people with disabilities or who are impaired by drugs or alcohol. These groups are the hardest to reach with educational messages or are less able to adopt safe practices, even if they hear the educational messages.37
BASIC PRINCIPLE UNDERLYING BURN PREVENTION STRATEGIES
Keep people separated from excessive heat. This may appear simplistic, but it is fundamental. A person cannot be burned unless a person and a heat source come into contact.37
- Separate with a barrier: For example, insulate the outer surfaces of stoves and heaters to prevent contact burns; install fences to keep trespassers away from electrical power stations; use sun block creams, umbrellas and roofs to protect people from sunburn.
- Separate by location: For example, keep children out of the kitchen or away from the cooking area.
- Separate by time: For example, permit trucks carrying volatile fuel to be driven through tunnels only during hours of low traffic volume.
SEQUENCE OF TASKS FOR BURN PREVENTION PROGRAMS
There are six major tasks within a burn prevention program:37
- Document the problem.
- Set goals.
- Consider possible strategies.
- Design the intervention.
- Implement program.
- Evaluate program.
Above tasks can be exemplified by study program conducted in India by Injury Prevention Workers to protect the people of India from burns caused by fireworks; a secondary success was increasing the use of cool water as first aid for burns.
Document the Problem
Determine the size and nature of the burn problem in your community. Make sure you get good information about what causes these burns and what products and circumstances are involved e.g., in India, researchers found out that the ‘cone fountain’ fireworks were involved in most of the injuries sustained during Diwali, the festival of lights.38
Set Goals
Decide what you want to accomplish in your prevention program. Have single and specific goals, not multiple and broad ones, e.g. in India, researchers decided to prevent injuries caused by ‘cone fountain’ fireworks.
Consider Possible Strategies
Use the ‘public health model’, following the example of public health specialists who consider three factors (Agent, Host and Environment) when trying to eradicate diseases. Energy (be it thermal, electrical, chemical or ultraviolet 15radiant energy) is the ‘agent’ for the burn injury. Host is person at risk. Environment includes both social and physical environment. Here is an example how planners in India have addressed host, agent and environmental factors when designing their programs:
Host (person at risk) | Teach proper use of fireworks |
Agent (energy source) | Redesign ‘cone fountain’ fireworks or ban them |
Environment (social and physical) | Restrict sale of these fireworks to professionals and/or restrict locations where they can be used |
Design the Intervention
Decide how your goal will be accomplished. Be specific about what is to be done, who is to do it, in what time frame, with what resources, e.g. in India, researchers decided to mount a media campaign during Diwali, to teach people to handle ‘cone fountain’ fireworks safely and to pour water on burn.
Implement Program
Gather the necessary resources to implement your program and get to work. This means finding financial support if necessary and hiring people or finding volunteers to perform appointed tasks and to monitor progress. It means regular review of progress and brainstorming on how to correct elements of the program that are not working. It means hard work. In India, researchers got financial support and technical expertise from a local insurance company and advertising firm which made television spots about safe handling of ‘cone fountain’ fireworks and about cool water as first aid for burns. Television spots, print advertisements and brochures were prepared. The television ran the spots just before and during Diwali.
Evaluate Program
Evaluation is the key to progress. This is true of surgical procedures, infection control, skin replacements and prevention practices. It indicates what is effective and what is not, what should be duplicated, what should be redesigned and what should be dropped. Evaluation is complex, but easier when the goals of the program are very clear. The bottom line is fewer burn injuries. Evaluators try to determine if there are fewer burns after the program, linked to measurable changes in behaviors, products or the environment. In India, researchers found no significant difference in the number of people injured by ‘cone fountain’ fireworks during Diwali after the media program. However, they found significant increases in the number of patients who used cool water for first aid for burns. Thus, this program had mixed results.38
GENERAL GUIDELINES FOR POTENTIALLY EFFECTIVE BURN PREVENTION ACTIVITIES
Burn prevention efforts must be tailored to the characteristics of specific burn risks. It is not possible to prevent all burns simultaneously. Burn prevention specialists must be patient and systematic, addressing one type of burn at a time. The best strategy to prevent scald burns will not reduce the number of flame or chemical burns.
Kerosene Lamps and Stoves
In homes throughout the lower income nations, the most common flame burn risk is associated with kerosene lamps and stoves. These two appliances are in constant use for cooking and lighting. Burns occur when these appliances malfunction and kerosene sprays out while people attempt to clean and fix them. One study from India reported that a kerosene stove was involved in 80 percent of the flame burn injuries treated at a burn unit. Customary cooking at floor level was cited as an additional risk factor. Flame burns would be reduced dramatically worldwide if people used efficient, safe, inexpensive kerosene lamps and stoves placed above floor level. Keep children out of kitchen. Avoid storing cooking material across the stove. Avoid bending over the flame to put out fire. Avoid keeping stove near gas cylinder.39
Flammable Fabrics
In many higher income countries, clothing ignition burns have become quite rare and those which do occur are often linked with flammable liquids. Reasons for this reduction include: flammability standards for children's nightwear, a trend toward closer-fitting garments for women and girls and the redesign of ignition sources, such as space heaters. However, clothing ignition is a major problem in countries where women's traditional dress is loosely draped (saris) and made of cotton or rayon. The beauty of these garments and pride in the traditional dress has made it unlikely that reductions seen elsewhere will occur. These garments combined with floor-level cooking, place women at very high risk. Research is needed in the development of inexpensive flame-resistant materials that can be used in the manufacture of saris and other traditional women's 16clothing. While cooking, the women should be encouraged to wear only those designs of traditional dress which fit closer to the body and are thus, less likely to catch fire at the stove. Avoid using ‘sari’ or ‘dupatta’ to handle hot vessels.39
Cigarette
Lighted tobacco products, primarily cigarettes, are the major cause of fire deaths in higher income countries, for example, approximately 50%in Sweden,40 33% in Canada and 25% in USA.41 In Japan, smoking materials cause 14% of fire-deaths, second only to incendiary suicide (23 %).42 In the USA, the Center for Fire Research at the National Institute for Standards and Technology has developed a test method to measure compliance with a performance standard to reduce cigarette ignition propensity. Once this standard is adopted, death and injury from cigarette-ignited fires should drop dramatically around the world. It is necessary that all cigarettes manufactured, imported or exported, and/or sold within a country meet the performance standard for reduced cigarette ignition propensity. Home owners must install smoke detectors in all owner-occupied and rented homes. Educate people not to smoke in bed or under influence of alcohol and drugs. Extinguish all cigarettes before throwing. Redesign cigarette to make them fire safe. Ban use of cigarette at places like petrol pump.
Hot Liquids
Do not keep hot liquids/foods near the edge of table. Keep them out of the reach of children. The temperature of the hot water heater should be set at 124° F. Check temperature of water before bathing children. Never leave a child unattended in the bathroom. Avoid leaving unattended hot liquids. Do not use loose pressure cooker rubber (casket). Do not carry hot water on a slippery floor. Avoid carrying hot liquids when children are around. Do not pour water in an empty hot car radiator, wait to cool or keep the face away from the radiator while pouring water.42
Liquid Petroleum Gas (LPG) Leak
Windows and door should be kept open. Do not light a match or switch on the electric light. Call Gas Company or Fire Department.42
Fire Works/Fire Crackers
Fire crackers should be ignited from a distance and those which fail to burst should not be inspected from close distance because it can burst at any time. Do not wear easily flammable fabrics while playing with fire crackers. Do not leave children to play with firecrackers unsupervised. Redesign fire crackers with safety measures. Ban dangerous fire crackers. Use fire works in the open ground only.42
Crowded Places (Theater)
Heat and smoke detectors should be installed. A well designed fire escape plan should be available. Fire brigade and police telephone numbers should be kept near phone. Fire extinguishers, water and sand should be available readily.42
Electric Burn
Educate children not to touch wires and electrical appliances. Do not handle electric appliances with wet hands and bare feet. Unplug electric appliances when not in use. Use standard company electric appliances. Plug point should be placed at higher level out of the reach of children and it should be covered with a cap. There should be no dangling cords. All flawed cords should be replaced with redesigned cords. Keep electric appliances away from the water. Hot iron should not be left unattended within reach of children. Avoid open plug point. Avoid open bathrooms if immersion rod is used to heat water. The rescuer must be careful so that he does not become a part of the electrical circuit in attempting to free a person still in contact with a live wire. Use dry wood and push the patient away from current source.
When flying a kite, it is important to remember the 3 C's of kite safety: Caution, Courtesy and Common Sense. By keeping these three items in mind at all times, you will make your recreational time more enjoyable, and safer43.
Here are some extra tips for making your kite outing a safe one:
- Choose a flying site at least 3 miles (5 km) away from airfields; also stay away from roads and railway lines.
- Never fly your kite near electrical pylons, overhead power cables or overhead lines of any kind.
- If your kite becomes entangled, do not attempt to free it yourself. Seek help from your local authorities.
- Do not fly your kite in electrical storms. The kite will act as a lightning conductor, causing injury and even death.
- Be aware of casual observers. They could be unaware of the potential dangers involved in kite flying.
- Flying kites on larger lines can cause line burns on your hands, so be sure to wear gloves.
- Always be aware of who or what is behind you as well as in front of you.
- Know your skill level, limitations and strength. Do not fly anything too large for the conditions or try any complicated moves in crowded areas.44
SUMMARY
Burn injuries in a developing nation like India are still a major problem. Poverty, illiteracy, lack of funds and lack of burn education, etc. are the major hurdles in solving the problem of burns in India. The only answer is Burn Prevention. It is not quick, cheap or easy. If it were, the burn problem would have been eliminated long ago. Be prepared to make long-term plans to gather public support for safer product designs and for codes and regulations which are often necessary for effective burn prevention. Be prepared to rethink strategies halfway through a project. Be prepared for a struggle. But know that burns are preventable.
A final word: ‘Prevention takes time, energy and money but ultimately, it is the solution to the world's burn problem’. ‘Vision is nothing but a dream that's backed by the drive to achieve it’.
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