BURN INJURIES IN BENGHAZI: EIGHT YEARS STUDY

El-Gallal A.R.S., Yousef S.M., Toweir A.A.

Burn Unit, Aljala Hospital, Benghazi, Libya

SUMMARY. This study evaluates thermal injuries in the region of Benghazi, Libya. From January 1990 to December 1997, 6797 patients were treated in the Burn Unit at A1jala Hospital, Benghazi. The frequency of burns increased every year, being more frequent in the cold season. All serious burned patients from hospitals outside Benghazi (25.7%) were referred to our unit. Young adults (48.9%) were the most commonly involved, followed by infants and children (35.9%), while elderly patients with burns were infrequent (1.5%). Overall, scald accidents were the commonest cause of thermal injuries (47.2%), followed by flame burns (34.9%). Scalding was the also the main cause of burns in infants and children, while among adults burns were mostly caused by flame. The male to female ratio was 1: 1. 1. Home accidents accounted for 68.3 % of our patients, of whom 69.8 % were females. Work accidents were responsible for only 21.2% of the injuries. Suicide attempts were generally infrequent (0.6%) but were relatively more frequent among females. The mean BSA was 23.8% (12.7%) and the overall mortality was 19%. Non-Libyan patients (mostly adult males) accounted for 9.6% of the cases. Diabetes was the commonest associated medical condition found in our patients (10.7%). The data obtained in our study are discussed and compared those of similar studies carried out elsewhere.

As in many fast-developing countries, burn epidemiology in Libya is still at an early stage of development and few studies are available to date. The aim of this hospital-record based study was to make a recent estimate of thermal injuries in the region of Benghazi and surrounding towns. Our study was carried out at the main referral hospital in the region.
Our burn unit is based in A1jala Hospital, Benghazi, which serves the city as well as the eastern part of the country (population over two million). The unit consists of 40 beds for paediatric and adult females, and 12 separate beds for adult males. Severely burned patients are accommodated initially in the intensive care unit.

Methods

This study started in January 1990 and ended in December 1997. All the required data were recorded on special cyclostyled forms. The data included the age, sex, residence and nationality of the patients, causes, date and extent of the burn, place, type and nature of the injury, and concomitant medical condition.
For the purposes of the study the patients were grouped according to age into five groups (less than 5 yr, 6-12 yr, 13-40 yr, 41-65 yr, and more than 65 yr). The patients were also grouped according to their burned surface area (% BSA) in 10 categories, ranging from I to 100%. The nature of the injury was defined in this study as either accidental or suicidal.
As per the existing policy of our unit, the Evans formula was used for fluid replacement. Locally, povidone-iodine (Betadine) was used as a standard treatment, as also silver sulphadiazine cream (Flamazinel). Autografting was the only skin grafting procedure used in our unit.

Results

Over a period of eight years, 6797 patients presented to our Unit. The annual frequencies of our patients during the years under review are shown as a histogram in Fig. 1.

Fig. 1 - Annual and seasonal frequencies. Fig. 2 - Geographical distribution of patients.

The histogram shows that more than 50% of the annual number of accidents occurred in the cold season (OctoberMarch).
Of our patients, 25.7% (1744 / 6797) were referred from various peripheral hospitals outside the city of Benghazi (Fig. 2). These patients were mostly seriously injured.
Table I shows age distribution and the causes of the burns, also in relation to the age group. Patients aged between 13 and 40 yr constituted 48.9% of the total number (3324 / 6797), while patients under 13 yr accounted for 35.9% (2440 / 6797).
Admission of patients over the age of 65 years was infrequent, representing only 1.5% (102 / Table 1 - Relationship between cause of burn and age of patients 6797). The youngest patient was a new-born male two days old, while the eldest was a female of 83 years. The mean SD) age was 24 yr (± 18.4).
Overall, scald accidents accounted for 47.2% of thermal injuries (3208 / 6797), with 15.6%, 12.4%, 10.6% and 8.6% of scalds being caused respectively by boiling water, hot food or oil, tea or coffee, and hot milk. Flame burns were found to be the second commonest cause of injury, accounting for 34.9% of cases (2371 / 6797). Of these flame burns, 13.8%, 11.2% and 9.9% were caused respectively clothes by catching fire, cooking-gas explosions, and direct exposure to flame. Scalding accounted for 84.9% of thermal injuries (1091 / 1285) in preschool children, and of these injuries 55.1% (636 / 1155) involved children aged between 6 and 12 yr. Flame burns predominated over other causes of burns that affected both adults and the elderly age groups, being responsible for 44.2% and 40.2% of their thermal injuries respectively (1880 / 4255 and 41 / 102).
Although 51% of the patients aged 13-65 yr were males (2222 / 4357), females (3536 / 6797) overall outnumbered males (3261 / 6797) (male to female ratio, I / 1. 1 (Fig. 3).
Among our patients 68.3% (4642 / 6797) sustained their injuries at home, and of these patients 69.8% were females (3240 / 4642). Overall, 31.7% of the total number (2155 / 6797), mostly adult males, suffered their accidents outside the home, of which 21.2% (1442 / 2155) occurred at the place of work (Fig. 4).
The nature of the injury was accidental in 99.4% of the patients (6756 / 6797). Suicide attempts accounted for only 0.6% of the case (25 females and 16 males), of whom nineteen (7 females and 12 males) were known to be undergoing psychiatric treatment (Table II).

Fig. 3 - Distribution of patients by sex. Fig. 4 - Distribution of patients by place of accident.

The mean BSA (±) SD in our patients was 23.8% 12.7%) (range, 1-100%). There were no deaths among patients who sustained burns of less than 7% BSA, while there was a 100% death rate in patients,with a BSA exceedino, 70%.
There were no survivals among infants and children under the age of 4 years and the elderly over 65 years who had a BSA of more than 50% (Table III). The overall mortality rate was 19% (1290 / 6797), and among the deceased patients 81% (1045 / 1229) died between 12 and 24 days post-burn.

Among our patients 9.6% (652 / 6797) were nonLibyans, the majority being adult: males (Table IV).
The concomitant medical conditions reported during the years under review are shown in Table V.

Discussion

The pattern and frequency of burns in various parts of the world seem to have wide variations. Also, the lack of uniformity between methodologies, in addition to the existence of a plethora of variables and differences in the periods of study, makes any comparison with other studies difficult.
The annual rate of thermal injuries in our area has increased gradually every year. This could be attributed to an increasing incidence of scalds among children and adult females and to an increase of flame burns among adult males.
The seasonal peak that has been observed in the cold months of the year could be explained by the occurrence of accidental burns related partly to the improper use of gas and kerosene for heating purposes and partly to the widespread custom of preparing hot drinks in the sittingroom. Of our patients 84.8% (5764 / 6797) were aged less than 41 yr, with 48.9% and 35.9% of the total number occurring in adults aged 13-40 yr and children below 13 yr, respectively. This means that the order of frequency of thermal injuries affecting different age groups is not consistent with that reported by other researchers.` This could be attributed to the high proportion of young adult females who sustained burns at home. In addition, most of our patients burned outside the home were young adults.
The infrequency of elderly burned patients in our society (1.5%) is similar to that observed in Kuwait,' but contrasts with that found in England and Wales' and France,` where patients over 60 and 65 yr presented a high frequency respectively of 11% and 13%. This disparity could be explained by differences in population structure and by the fact that most of our elderly population are sedentary and cared for by other family members, and thus kept away from potential hazards.
Scalding was the leading cause of thermal injury in our society, being responsible for 47.2% (3208 / 6797) of the total number of injuries. Of these, 53.8% (1727 / 3208) occurred in children under the age of 13 yr. The frequencies of scalding in each of the age groups (84.9%, 55.1%, 34. 1 % and 30.4%) were higher than the figures found in comparable age groups elsewhere (64%, 34%, 17% and 21 %).
With regard to flame-burned patients, in the different age groups, the opposite was true, since our cases presented a low frequency (5.1%, 33.3%, 44.2% and 40.2%) as compared with that observed in comparable age groups (18%, 58%, 58% and 72%) in the abovementioned study.
A female predominance was encountered in our study, consistently with reports from Algeria" and Kashmir.` This is however in contrast with results from other areas like Jordan,`Japart, 14 Australia` and Virginia.` To a large extent, we can attribute this finding to a high female presence among in our domestic burn patients (69.8% = 3240 4642).
Nevertheless, the frequency of domestic injuries (68.3%) was', relatively low as compared with other studies, in which it ranged between 71 and ~0%.
Only 41 patients (0.6%) were managed as attempted suicide cases~and, of these, nineteen were known to be under psychiatric care. Although statistically insignificant, it is interesting to note that the male/female ratio among patients without any psychiatric disorders was 4/18.
It was found that the BSA of most infants and children ranged between 1 and 10%, while that of most adults ranged between 11 and 20%. This could be attributed to differences in the main causes of burn, since scalds in children, which were frequently caused by hot drinks, usually affected relatively limited surface areas compared with those caused by flame burns in adults and the elderly. Also, our mean percentage BSA (23.8 ± 12.7%) is relatively high compared with the 15% found by French authors. This could be explained by the presence in our patient population of a significant proportion of referred cases (25.7%) with an extensive BSA.
The overall mortality was 19% (1290 / 6797). Although this was higher than the mortality rates ranging from 7.2 to 9.5% reported'by others, we consider that our finding is proportional to the relatively high number of patients who were referred to our unit either in late stages of their illness or with serious injuries. Eighty-one per cent of deaths were attributed mainly to burn wound sepsis and its consequences. The contributing factors in the remaining 19% were inhalation injuries, acute renal failure, cardiac arrest, and the presence of concomitant serious illness.
The non-Libyans who accounted for 9.6% of our cases were mostly labourers and technicians from various countries. Many nationalities were involved in this group of patients but expatriates from Egypt, Sudan, Palestine and Chad were those most commonly afflicted. This could be attributed to their relatively high presence in our community. As said, they were mostly manual labourers, and their living standards were far below average, with work safety precautions that were far from ideal.
It is noteworthy that diabetes was observed in 10.7% of our patients, which contributed considerably to morbidity levels, while other medical conditions were less common. The frequency of psychiatric disorders (0.8%) in our study was not comparable with the 7% reported by French authors.
On the other hand, the number of our epileptic patients (27) was certainly high, in spite of their low representation (0.4%), as compared with the 14 epileptic patients Address correspondence to: Dr A.R.S. EI-Gallal, Burn Unit, Aljala Hospital, Benghazi, Libya. reported by others` over a much longer period of 16 years. Although it is desirable to perform epidemiological studies in developing countries like ours on a nation-wide basis, we believe that the data we present here provide a fair idea of the pattern of thermal injuries that occur in this region of our country.

RESUME. Les Auteurs se proposent d'évaluer les brûlures dans la région de Benghazi (Libye). Pendant la période janvier 1990décembre 1997 6797 patients ont été traités à l'Unité des Brûlures de l'Hôpital Aljala, Benghazi. La fréquence des brûlures a augmenté tous les ans, avec une fréquence majeure dans la saison froide. Tous les brûlés graves non résidents à Benghazi atteints de graves brûlures (25,7%) ont été hospitalisés dans notre Unité. En général, les patients les plus fréquemment atteints étaient les jeunes adultes (48,9%), suivis par les enfants (35,9%). Les patients âgés étaient rarement atteints (1,5%). La cause la plus fréquente des brûlures était l'ébouillantement (47,2%), suivie par la flamme (34,9%). Chez les enfants Fébouillantement était la cause principale, et chez les adultes elle était la flamme. Le rapport mâle/femelle était 1 : 1,1. Les accidents domestiques constituaient 68,3% des cas, dont 69,8% fémelles. Les accidents professionnels constituaient seulement 21,2% du numéro total. Les tentatives de suicide étaient rares (0,6%). La surface moyenne brûlée était 23,8% (+12,7%) et la mortalité complessive 19%. Les patients non libyens, pour la plupart des patients adultes mâles, constituaient 9,6% du numéro total. La pathologie la plus fréquente était le diabète (10.7%). Les Auteurs en conclusion discutent leurs résultats et les comparent avec des études similaires effectuées ailleurs.

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