Subrahmanyam M., Joshi A.V.

Department of Surgery, Government Medical College, Miraj and General Hospital, Sangli, Maharashtra, India

SUMMARY. A total number of 254 burn patients treated during the period July 2001-June 2002 were analysed. Of these, 158 were female and 96 male. The age of the patients ranged from 3 to 60 yr. The monthly admission rate ranged from 12 to 33, with the lowest number in July and the highest in October. One hundred and thirty admissions occurred between midnight and 4 a.m., and 13 patients were admitted 48 h post-burn. The extent of the burns ranged from 3 to 100% TBSA. The causes of the burns were flame in 228 cases (88.9%), scalds in 11 (4.3%), electricity and chemicals in six each, plus other causes in three instances. The burns were accidental in 210 cases (82.6%), suicidal in 38 (15.0%), and homicidal in six (2.4%). Altogether there were 174 deaths, with a mortality rate of 68.5%. There were 79 deaths in the first 48 h, 82 in the first week, 10 in the second week, one in the third week, and two after 6 weeks. The mortality rate was 100% in burns above 60% TBSA, 69% in 41-60% burns, and 12% in burns of less than 40%

Introduction

Burns constitute a major health problem in India. A very high mortality in major burns was noted two decades ago. However, owing to recent advances in fluid and electrolyte maintenance and burn wound care and to the availability of more specific systemic topical medications, survival rates have greatly improved in specialized burn centres in India.1 However, India is a vast country with a diverse cultural and ethnic background, and more than 75% of the population live below the poverty line. Burn patients come from all over areas in towns and villages, but not all of them are fortunate enough to reach hospitals where recent information has been made available. Exact mortality figures for India are not available owing to the lack of any proper burn registry. The projected figures suggest an annual mortality rate of 100,000 to 140,000. This staggering incidence is largely due to illiteracy, poor living conditions, neglect of children, and certain social customs that are unique to India.1 As the majority of burn patients are still treated in district hospital health centres, the exact picture will never be available, as such hospitals do not report their results. In the present study, conducted in a district hospital in Western India located 350 km south-west of Mumbai, all patients admitted to the burn unit in Sangli General Hospital during the one-year period July 2001-June 2002 were analysed and the results are reported.

Patients and methods

The records of all burn patients admitted to the General Hospital, Sangli, Maharashtra, India between July 2001 and June 2002 were studied. The information collected included the age and sex of the patient, cause of burn, extent of burn (percentage total body surface area), time required for the patient to report to the hospital, place of burn, treatment given, patients deceased, and patients discharged after recovery.

Results

During the period from July 2001 to June 2002, a total number of 254 patients were admitted to the burn ward in Sangli General Hospital, which is similar to the other wards in the hospital with a 20-bed capacity. Of these patients, 96 were male and 158 female. The age of the patients ranged from 3 to 60 yr (mean, 38 yr).

The monthly admissions ranged between 12 and 33 (mean, 21.1). Table I presents the monthly admissions during the period of study.

Of the 254 patients, 204 were admitted within 8 h of the injury, of whom 130 within only 4 h. Table II shows the time interval between the burn and admission to the hospital.

Fifty per cent of the patients had more than 60% TBSA burns and 77 (30.0%) had burns of between 81 and 100%. Out of the 254 patients, 228 (88.9%) had burns due to flame, 11 had scalds (4.3%), six had respectively electrical and chemical burns, and three presented other causes.

Out of the total number, 210 patients had burns due to accidental injury (82.6%), 38 to attempted suicide (15.0%), and six to attempted homicide (2.4%). The mortality rate in patients with over 60% TBSA was 100%, compared with 69% in burns between 40 and 60% TBSA and 12% below 40% TBSA (Table III).

Of the 96 males admitted 55 died, while of the 158 females 119 died (Table IV).

Seventy-nine deaths occurred within the first 48 h after admission to the burns ward, 82 in the first week, ten in the second week, one in the third week, and one after one and a half months. Ninety-two patients had inhalation injury.

The patients’ response to initial treatment was poor in 101 cases, good in 89, and average in 62. The patients were given fluids according to the Parkland formula and local coverage of the wounds was by silver sulphadiazine 1% or honey dressing.

Discussion

This analysis of burn patients concerned 254 patients admitted during a one-year period to the burn ward of a district general hospital at Sangli in Maharashtra, India.

Age incidence. In this study, the incidence of children below 10 yr was 7.8%, which was lower than that reported by Subrahmanyam2 and Gupta et al.3 The incidence of age between 11 and 40 yr was 74%, which was lower than in these studies, while the incidence of age above 40 yr was 18.2%, which was higher than in these studies.

Sex incidence. The overall male-to-female ratio was 0.6:1. In children, the male-to-female ratio was 2.2:1. Kumar et al.4 reported a 1:1 ratio of males to females below 10 yr and 1:1.2 between 10 and 14 yr.

Monthly admissions. The maximum number of admissions was in October and the minimum number in July, which is similar to the findings of Kumar et al.4.

Time interval between burn injury and admission to our hospital. Ninety-three per cent of the admissions occurred within the first 24 h, which was much higher than in previously reported series.2,3

Burn extent. Nearly half the patients (49.5%) had more than 60% TBSA burns, and 30.3% had more than 80% TBSA burns, compared with the results of Gupta et al.,3 who reported a rate of 15.7% of patients with burns exceeding 80% TBSA burns, most patients presenting burns in less than 20% TBSA.

Cause of burns. Flame was responsible for the majority of burns (88.9%), which was similar to other studies,2,3 while scalds (4.3% ) and electrical burns (2.3%) were much lower than the rates reported in those studies. Accidental burn injuries accounted for 81.9% of cases, a similar rate to other studies,2,3 while suicidal burns amounted to 14.8% of cases, which was less than in these reports.

Mortality in relation to body surface area burned. This seems to be the most significant factor, as all patients with above 60% TBSA burns died, with an overall mortality rate of 68.5%, which was much higher than in other studies.2,3 The higher mortality in this study may be due to the large number of patients (49.5%) presenting a high percentage of TBSA burns, i.e. above 60%. Below 40% TBSA, mortality was 12.4%, which was higher than the rate reported in previous studies.2,3 The high mortality in our series could be due to the absence of effective barrier nursing of the patients, since each room in the ward contained three or four patients, which resulted in cross-infection and septicaemia. Most such deaths occurred in the second and third weeks. This report indicates that although the majority of patients reported to the hospital within 4 h post-burn, the outcome did not reflect early attention to the patient. This is because of cross-infection, resulting in septicaemia and death. Effective barrier nursing, immediate skin covering, and meticulous care would help to reduce mortality. Such facilities must be made available in district general hospitals and rural health centres, where most patients are still treated. Considering the vastness of our country and the fact that facilities for treating burn patients are restricted to a few specialized centres, the problem of burns in India will remain.

The high incidence of burns could be reduced by proper education of people as regards common causes of burns and their prevention.

Effective control of infection is not achieved, owing to the lack of isolation of patients, which is due to the deficiency of infrastructure facilities and the cost of expensive antibiotics and local antibiotic applications.

Conclusion

In developing countries like India, cheap and efficient technologies for immediate skin coverage facilities and effective indigenous local therapies may offer some solutions.5 Research in this direction seems to be the need of the hour.

RESUME. Les Auteurs ont analysé 254 cas de brûlures traités pendant la période juillet 2001-juin 2002. De ces patients, 158 étaient femelles et 96 étaient mâles. L’âge des patients variait de 3 à 60 ans. Le numéro mensuel des patients hospitalisés variait de 12 à 33, le minimum en juillet et le maximum en octobre. Cent trente patients ont été hospitalisés entre minuit et 4 heures du matin, et 13 patients 48 heures après la brûlure. L’extension des brûlures variait de 3 à 100% de la surface corporelle. Les causes des brûlures étaient les flammes en 228 cases (88,9%), les ébouillantements en 11 cas (4,3%), l’électricité et les substances chimiques en six cas respectivement et d’autres causes en trois cas. Les brûlures étaient d’origine accidentelle en 210 cas (81,9%), suicide en 38 cas (14,8%) et homicide en six cas (2,3%). Globalement il y a eu 174 décès, avec un taux de mortalité de 68,5%. Les décès se sont vérifiés dans les premières 48 heures en 79 cas, dans la première semaine en 82 cas, dans la deuxième semaine en 10 cas, dans la troisième semaine en un cas et après six semaines en deux cas. Le taux de mortalité était 100% dans les patients atteints de brûlures en plus de 60% de la surface corporelle, 69% dans les brûlures de 41-60% et 12% dans les brûlures de moins de 40%

Bibliography

1. Bharat R.: Then and now: Burns in India. Burns in India 1974-1999. Burns, 26: 63-81, 2000.
2. Subrahmanyam M.: Epidemiology of burns in a district hospital in India. Burns, 22: 439-42, 1996.
3. Gupta M., Gupta C.K.,Yaduwanshi R.K. et al.: Burn epidemiology: The pink city scene. Burns, 19: 47-51, 1993.
4. Kumar P., Sharma M., Chadha A.: Epidemiological determinants of burns in paediatric and adolescent patients from a centre in Western India. Burns, 20: 236-40, 1994.
5. Subrahmanyam M.: Topical application of honey in the treatment of burns. Br. J. Surg., 78: 497-8, 1991.