SUMMARY. Cement is now widely used in the field of both civil and rural area engineering and in the construction industry in China. Cement powder-related burns have rarely been reported previously. We performed a retrospective study on cement powder-related burns treated in the 148th Hospital of PLA in China from April 1997 to March 2002. Twenty-six victims were analysed with special regard to common modes of injury, localization of cement exposure, preventive measures taken, and treatment, with complete records. Cement powder burns are injuries concerning professionals at the workplace as well as amateurs during do-it-yourself work. In all patients, no attempt had been made to protect the skin and 22 patients with inhalation injury had not received adequate respiratory protection. Full-thickness burns were reported in all cases. Surgery had to be performed to remove dead skin, and skin grafting was necessary for these patients. Eleven patients died of severe inhalation injury. Cement powder burns can be avoided by adequate skin protection and especially by respiratory protection. Although acute cement injuries may seem rare, prospective studies should be carried out for the correct estimation of prevalence. Product education and proper protection appear to be the best preventive measures.
More than three thousand million tons of cement are processed in China each year, and cement-related burn injuries have been rapidly increasing in the Chinese construction industry in recent years. Burns caused by prolonged contact of wet cement with skin have been widely reported.1-6 However, cement powder-related burns are only rarely reported, particularly if we consider the extensive skin exposure and the high frequency of use. Such burns may lead to severe illness, needing intensive therapy, as well as significant loss of working time. We report 26 cases of cement burns in order to identify risk profiles and to reflect on the preventive measures that should be taken to avoid these injuries.
The skin, eye, and respiratory tract are the organ systems most prone to damage by ready-mixed cement or cement dust. Damage to the respiratory epithelium may become life-threatening and a leading cause of post-burn death.7 The skin lesions induced are classified in degree according to the depth of the damage. Explosions in cement plants may principally also cause emission of hot cement powder.7 The severe results of hot cement powder-related burns, and especially inhalation injury, prompted us to perform a retrospective case-study series, as cement-related burn injury has been rapidly increasing in recent years in China. Our purpose was to prevent, or at least reduce, cement-related burn injury and to improve the patients’ quality of life.
Twenty-six patients with burns caused by high-temperature cement powder were admitted to the 148th Military Hospital of PLA in Shang-dong Province of China from April 1997 to March 2002. The clinical notes of the 26 patients were available for review, and only these patients were included in the study. Data analysis from the case notes included sex, age, mechanism of injury, time of injury, depth and extent of the burn, treatment, and mortality. All data were entered into a computer database and analysed.
The 26 patients were all burned by high-temperature cement powder following accidents. All the patients were cement plant workers.
Sex, age, and social status
As just said, the 26 patients were burned by high-temperature cement powder following accidents. All the patients were male farm factory workers aged 22 to 43 yr (mean age, 30.5 ± 8.2 yr).
Mechanism of injury, percentage of total body surface area burned, and full-thickness burn
All the cases were accidental, occurring when explosions in cement plants caused the emission of hot cement powder. The percentage of total body surface area (TBSA) burned ranged from 20 to 100% (mean, 65 ± 31%). All patients had full-thickness burn wounds. The mean percentage of full-thickness burns was 53 ± 32% TBSA (range, 5-88%). Of these victims, 22 patients had inhalation injury, with 17 suffering moderately severe or severe inhalation injury.
Admission time, treatment, mortality, and prognosis
One hundred per cent of the patients were admitted immediately to our hospital. The average time interval from burn injury to admission was 30 min (from 15 to 60 min). All patients received debridement immediately, and the 17 patients with moderately severe and severe inhalation injury were given tracheotomy after admission. Monitoring of the blood gas and ventilation mode was also important for these patients. Fluid resuscitation was performed immediately, and the amount of resuscitation liquid was adequately increased according to the severity of the inhalation injury. Full-thickness burns were treated by surgery and early skin autograft after the patients went through the shock phase from 3 to 7 days post-burn. Eleven patients died of adult respiratory distress syndrome (ARDS) due to severe inhalation injury. Fifteen patients recovered and were discharged, but these patients developed blisters in the healed burn wounds and mild itching in healed areas. From the viewpoint of cosmetology, 15 patients were dissatisfied with the appearance of their burn scars, pigmentation, or other abnormalities such as hypertrophic scars. Five patients had post-burn contracture of the knee joint.
Burns caused by cement have been widely reported.1-6 The high alkalinity of wet cement and its tiny content of water-soluble chromate can cause occupational skin diseases and also burn injury.1 High-temperature cement powder-related burns have rarely been reported in China, which may prompt speculation of a low prevalence rate of such injuries in the past years; however, in the last twenty years, the number of these cases has increased with the rapidly developing construction industry in China.
In the cases we report, the burns were not induced by contact with wet cement - they were all related to accidents involving an explosion in a cement plant and exposure to high-temperature cement powder, resulting in burns, and especially in the inhalation of high-temperature cement powder causing inhalation injury. Each accident caused burn injury in 3 to 6 workers. Seventeen patients out of the overall 26 suffered moderately severe or severe inhalation injury, and 11 died of ARDS due to severe inhalation injury.
The localization of injuries peaked in the head, and in particular in the face, which is consistent with the mode of the accidents. All the patients had full-thickness burn wounds. Fluid resuscitation was given to all the patients, and 17 patients with moderately severe or severe inhalation injury received tracheotomy immediately after admission. It is clear that skin grafting was necessary for patients with full-thickness burn wounds after they went through a shock phase.
Conservative therapy for superficial burn wounds, including local or systemic antibiotics and dressings, was sufficient. Information on the mean duration of the healing process was available in 15 patients - this lasted 6 months. Sequelae were assessed in individual cases only and usually consisted of hypertrophic scar formation, sometimes associated with hypersensitivity and contractures.
This study reveals some interesting factors related to burns caused by high-temperature cement powder, including the mechanism of the injuries, the victims’ social status, the percentage of total body surface area burned, full-thickness burns, and especially severe inhalation injury. Seventeen patients (65%) suffered moderately severe or severe inhalation injury due to the lack of adequate protective measures, especially respiratory tract protective measures. Cement burns are avoidable by means of adequate protective measures, such as suitable gloves and work clothes and proper protective boots, and especially a good protective mask, as well as immediate first aid.
For prevention of such injuries, information and training in risk management are recommended for employees and apprentices in the construction industry. Adequate hazard notification and information are especially important if accidents are to be avoided during do-it-yourself work, which seems to be over-represented in the case reports we evaluated.
RESUME. En Chine, le ciment est employé sur grande échelle dans le champ de l’ingénierie dans les aires civiles et rurales comme aussi dans l’industrie de la construction. Les brûlures dues à la poudre de ciment ont été rarement décrites. Les Auteurs ont effectué une étude rétrospective sur les brûlures liées à la poudre de ciment traitées dans la période avril 1997-mars 2002 dans le 148ème hôpital de PLA en Chine. Vingt-six victimes ont été analysées, et en particulier les modalités communes des accidents, la localisation et l’exposition au ciment, les mesures préventives observées et le traitement, avec un examen de toutes les données. Les brûlures causées par la poudre de ciment constituent des accidents qui touchent les professionnels au travail comme aussi les amateurs occupés au bricolage. Dans tous les patients, aucune tentative n’avait été faite pour protéger la peau, et 22 patients atteints de lésions par inhalation n’avaient pas reçu une protection respiratoire adéquate. Tous les patients présentaient des brûlures à toute épaisseur. Il fallait effectuer une opération chirurgicale pour éliminer la peau morte et dans ces patients une greffe cutanée s’est révélée nécessaire. Onze patients sont morts à cause de lésions sévères par inhalation. Il est possible d’éviter les brûlures causées par la poudre de ciment moyennant la protection adéquate de la peau et en particulier la protection respiratoire. Bien que les lésions aiguës dues au ciment puissent paraître rares, il faudrait effectuer des études prospectives pour évaluer correctement leur prévalence. L’éducation pour ce qui concerne l’emploi des produits intéressés et la protection appropriée semblent être les meilleures mesures de prévention.