% vol = 14 number = 3 prevlink = 111 nextlink = 119 titolo = "ACID BURNS IN BANGLADESH" volromano = "XIV" data_pubblicazione = "september 2001" header titolo %>
SUMMARY.The distribution is documented of burn injuries treated during the period December 1996/July 2000 in the burn unit of Dhaka Medical College Hospital and City Hospital (Bangladesh). Acid burns constituted 8.76% of all the burn cases treated. In Bangladesh most such cases were of intentional origin (attempts to disfigure the face, eyes, nose, genital organ). Young girls were common victims. The incidence was greater in rural than in urban areas.
Acid burn injuries represent a special type of burn injury, with a pathophysiology depending on the type of acid, concentration, strength, quality, duration of contact, and penetration power.1,2 Both acid and alkali can cause burn. In Bangladesh common causative agents are sulphuric acid, nitric acid, hydrochloric acid, tannic acid, and formic acid. These are most commonly used in jewellery workshops, sales and service centres of automobile battery manufacturers, dyeing industries, and tanneries. Chemical burns from alkalis are almost nil in Bangladesh.
Although accurate statistics regarding the incidence of such cases are not available in Bangladesh, at present Dhaka Medical College Hospital (DMCH) and City Hospital are the only recognized burn hospitals and ultimately most burn cases therefore reach them. The data presented can thus give a rough guide to the incidence of acid burns (8.76%) in Bangladesh. More than 3000 deaths attributable to chemical burns are reported in the United States each year.3 In the burn unit of the University Hospital at Varanasi,4 in India, chemical burns constituted 4.9% of all burns.
When acid comes into contact with the body it feels like water. It wets the body and a burning sensation begins that gradually increases in intensity. The patients cry in agony until the chemical is washed away or is neutralized. The affected skin becomes black and leather-like. The chemical also leaves its mark on the healthy skin it trickles over (Figs. 1a,b).
|<% Immagine "Fig. 1a","gr0000009.jpg","28-yr-old man, victim of acid burn due to personal enmity. Acid leaves pathway through which it trickles down.",230 %>||<% Immagine "Fig. 1b","gr0000010.jpg","Victim of acid burn: 32-yr-old male, day 4 post-burn before colonization of bacteria",230 %>|
Usually good-looking girls were the victims. Males were relatively less affected. Common causes were love affairs, enmity over land properties, and personal reasons. Children were also affected - they are the victims of circumstance (Tables I-III).<% createTable "Table I","Distribution of patients by sex",";Sex;Number;Percentage;Mean Age (yr)@;Male;43;27.22%;25.03@;Female;115;72.78%;21.62@;Total;158;-;22.82","",4,300,true %> <% createTable "Table II","Distribution of patients by age and sex","§2§Age (yr)§1,2§#Male§1,2§#Female@;#No.;#%;#No.;#%@;0-10;3;1.90;8;5.06@;11-20;9;5.70;68;43.03@;21-30;21;13.29;23;14.56@;31-40;5;3.16;8;5.06@;41-50;5;3.16;5;3.16@;51-60;0;0;1;0.63@;61 and above;0;0;2;1.27","",4,450,true %> <% createTable "Table III","Reasons for acid burns","§2§Reason§1,2§#Male§1,2§#Female§2§#Total§2§#%@;#No.;#%;#No.;#%@;Love affair and refusal of indecent proposal;2;1.26;68;43.03;70;44.30@;Political;1;0.63;0;0;1;0.63@;Enmities;30; 18.98;18;11.39;48;30.37@;Accidental;1;0.63;6;3.8;7;4.48@;Industrial;8;5.06;5;3.16;13;8.22@;Other;1;0,63;18;11.39;19;12.03","",4,450,true %>
Acid was commonly thrown over the face, neck, and upper part of the body (Figs. 2, 3, 4a,b,c) through a window at night-time, when the victims were asleep or engaged in study, or over the lower part of the trunk, buttocks, perineal region, and genitalia after refusal of an indecent proposal (Figs. 4d,e,f,g). Sometimes the chemical was thrown from a rapidly moving motor cycle, or the perpetrator threw acid at the victim and then ran away. The home, street, educational institutes, and occupational sites were the places of incidence. In industries, machine operators or factory workers were the usual victims of chemical burn, when a chemical accidentally came into contact with their bodies (Table IVa,b).
|<% Immagine "Fig. 2","gr0000011.jpg","22-yr-old girl, victim of acid burn due to refusal of love affair. Loss of vision in both eyes",230 %>||<% Immagine "Fig. 3","gr0000012.jpg","23-yr-old girl, victim of acid burn due to refusal of love affair. Patient came late width infected wounds",230 %>|
|<% Immagine "Fig. 4a","gr0000013.jpg","Girl of 21 yr, victim of acid burn, due to refusal of incident proposal. Acid burn over chest and breast",230 %>||<% Immagine "Fig. 4b","gr0000014.jpg","Early excision and split-thickness skin graft over chest with reconstruction of breast",230 %>|
|<% Immagine "Fig. 4c","gr0000015.jpg","Follow-up after two weeks (chest and breast)",230 %>||<% Immagine "Fig. 4d","gr0000016.jpg","Acid burn over back, buttock, and thighs",230 %>|
|<% Immagine "Fig. 4e","gr0000017.jpg","Burn of perineal region and genitalia",230 %>||<% Immagine "Fig. 4f","gr0000018.jpg","Early excision and split-thickness skin graft over perineal and genitalia",230 %>|
|<% Immagine "Fig. 4g","gr0000019.jpg","Follow-up after two weeks (perineal region and genitalia)",230 %>|
The outstanding features of acid burns are the prolonged duration of tissue destruction that continues until all the acid is either inactivated or neutralized, for instance by irrigation of water. Superficial burns can occur after only 5 sec of contact and full-thickness burns after 30 sec.5 Acids cause coagulation necrosis of the tissue with thrombus formation in the microvasculature of lesion. There is a rapid reduction in the collagen and acid mucopolysaccharide content with loss of one-third of dermal collagen within the first 8 h owing to collagenolysis.6 Acids like tannic acid, formic acid, and picric acid are absorbed quickly and produce systemic effects, which may cause metabolic acidosis, haemolysis, and renal failure.1,2
The study was conducted among patients admitted to the burn unit of DMCH and City Hospital during the period December 1996 to July 2000. The total number of burn patients was 1803, of whom 158 had acid burns (Figs. 5a,b).
|<% Immagine "Fig. 5a","gr0000020.jpg","Distribution of patients by sex and mean age",230 %>||<% Immagine "Fig. 5b","gr0000021.jpg","Comparison of acid burns and total number of burns",230 %>|
The patients admitted to hospital were managed according to our protocol. All details regarding name, age, sex, date, time and place of incidence, and depth of burn were recorded on a standard form, and the results were analysed.
As prescribed by our protocol, we irrigated the wound with copious pouring of water and resuscitated patients with oral or i.v. fluid. We used morphine to relieve pain.
The patients were divided in two groups. Group A consisted of patients who presented immediately after their burn and whose wounds were not yet colonized by bacteria (Fig. 1b).
Group B consisted of patients whose wounds were grossly infected and in whom the slough remained adherent (Fig. 3) and healthy granulation tissue had not yet formed (Table V).<% createTable "Table V","Admission to hospital","§2§#Sex§1,2§#Early Group A§1,2§#Late Group B§2§Average time of delay@;#No.;#%;#No.;#%@;Male;14;8.86;29;18.35;7.5 days@;Female;31;19.62;84;53.16;9 days","",4,450,true %>
In group A cases our intention was to excise the burn eschar with a diathermy knife or scalpel between days 3 and 5 post-burn and to cover the wound with a split-thickness autoskin graft. However, we also used full-thickness skin graft, particularly on the eyelids and lips.
In group B cases, desloughing was gradually performed during the course of cleaning and dressing. Once granulation tissue was formed, we covered the wound with a split-thickness skin graft.
During the course of follow-up, some patients developed ectropion of the eyelid, distortion of the angle of the mouth, post-burn contractures, hypertrophic scars, and keloids (Table VIa,b). These problems were treated accordingly.<% createTable "Table VIa","Immediate effect of burn","§2§~§1,2§#Disfigurement face§1,2§#Loss of vision§1,3§#Disfigurement of pinna§1,3§#Distortion of lip§1,2§#Distortion of genitalia and angle of mouth§1,2§#Distortion of nose§1,2§#Death@;#No.;#%;#S;#B;#%;#S;#B;#%;#No.;#%;#No.;#%;#No.;#%;#No.;#%@;Male;33;20.89;13;1;8.86;5;1;3.8;17;10.76;0;0;12;17.59;0;0@;Female;84;53.16;23;4;17.09;21;4;15.82;51;32.28;2;2.17;25;15.82;2;1.26","S = single, B = both",17,450,true %> <% createTable "Table VIb","Late effect of burn","§2§~§1,2§#Disfigurement of breast§1,2§Ectropion§1,2§#Hypertrophic scar§1,2§#Keloid§1,2§#Psychological effect@;#No.;#%;#No.;#%;#No.;#%;#No.;#%;#No.;#%@;Male;0;0;18;11.39;25;15.82;5;3.16;17;10.76@;Female;15;9.49;37;23.41;78;49.36;16;10.12;51;32.28","",17,450,true %>
The total number of patients treated was 158, of whom 43 were male (27.22%) and 115 female (72.78%) (Table I). The age range was from 0 to 70 yr (mean age, 22.82 yr (Tables I,II). Common causes of acid burns were love affairs (44.30%) and property and personal disputes (30.37% (Table III).
The total percentage of body surface area burn (BSA) ranged between 2 and 60% (mean, 10.84%). Other findings were: loss of vision in one eye, 36 patients (22.78%); loss of vision in both eyes, 5 (3.16%); disfigurement of nose, 37 (23.42%); disfigurement of one pinna, 26 (16.46%); disfigurement of both pinnae, 5 (3.16%) (Table VIa). The total number of patients presenting immediately after burn was 45 (28.48%) (Table V) and the total numbers coming late was 113 (71.52%). Complications developing after the post-burn period were ectropion of the eye in 55 patients (34.81%), hypertrophic scars in 103 (65.19%), keloids in 21 (13.29%), and distortion of the angle of the mouth and lip in 68 (43.04%).
In this series two patients died, aged 28 and 32 yr. Respectively, they presented burns in 60 and 30% TBSA and died on days 4 and 14 post-burn, probably because of irreversible shock and septicaemia.
Acid burn injuries represent a special type of lesion in which disability is high and aesthetic sequelae are very important. The strategic management of acid burn injury can be both challenging and complex. The challenge begins at the moment of injury and continues throughout the rehabilitation period.
The complex aspects of management are the complications that occur, mostly due to damaged soft tissue, eyes, eyelids, nose, ears, lips, breasts, and genitalia. In our series the facial disfigurement rate was 20.89% in males and 53.16% in females. The victims became socially isolated owing to their facial disfigurements, mentally depressed, and sometimes physiophrenic. The increase in the incidence of acid burns may be due to lengthy judiciary procedures, political shelter of the criminals, and a deterioration in general law and order.
Acid burns represent a small percentage of total burns but complications and morbidity are high. All such injuries are preventable.
RESUME.Les Auteurs considèrent la typologie des brûlures traitées dans l’Unité des Brûlures de l’Hôpital du Medical College de Dhaka et du City Hospital (Bangladesh) pendant la période décembre 1996-juillet 2000. Les brûlures causées par l’acide constituaient 8,76% de tous les cas traités. En Bangladesh la plupart des cas de ce type de lésion sont volontaires, c’est-à-dire des tentatives de défigurer le visage, les yeux, le nez et l’organe génital. Communément les victimes sont des jeunes filles. L’incidence est plus élevée dans les zones rurales que dans les zones urbaines.