Ann. Medit. Burns Club - vol. VIII - n. 1 - March 1995

BURN INJURY ADMISSIONS TO A NEW BURNS UNIT IN BURAIDAH, QASSIM, SAUDI ARABIA - A STUDY OF 218 CASES

Fadaak R*, AI-Kurashi N.**, Mahaluxmivala S.*, Mathur A.*, Borkar K*, Ibrahim E*

* Department of Plastic Surgery and Burn Unit, King Fahd Specialist Hospital, Buraidah, Saudi Arabia
** College of Medicine and Medical Sciences, King Faisal University, Al-Khobar, Saudi Arabia

SUMMARY. A 10-bed "state of the arC burns unit was commissioned at King Fahd Hospital, Buraidah Ad-Qassim, Saudi Arabia, and the first 218 cases admitted to the Unit over a 42-month period were analysed. The mean age (ISD) of the patients was 8.2 years (range 6 months - 75 years); 56.9% were males and 43. 1 % females; 60.6% were children under 12 years, of whom 78.8% were qnder five years of age. Only four patients were aged over 60 years. Scalds and flames accounted for 75.2% of-the aetiological factors. Domestic bums constituted the majority of the cases (160/218; 73.4%), and the majority of patients were admitted within the first 24 hours (79.4%). Admission was either direct or through a general hospital or a health centre. The mean (± SE) total body surface area (TBSA) burned was 26% (± 2.4), with a range of 1-98%. The mean hospital stay of the entire group was 19.2 days. The in-hospital mortality rate was 15 patients (6.9%). The TBSA burned was found to be the main factor influencing mortality. The study highlights the important factors that affect the outcome in this Unit and others in Saudi Arabia. Factors that can improve the morbidity and mortality rates are identified. The study reveals certain patterns and aetiological patterns in the Qassim, region. Education for prevention through a national campaign remains the keystone for the reduction of the incidence of burns, particularly in children, and for the maximization of resources.

Burns remain a major health problem all over the world and their impact on community resources is great. Health care in Saudi Arabia has developed considerably in the last 15 years and specialized burns units have only recently been opened in several major regional hospitals. Hence, full data based on a nationwide study regarding the exact incidence and the magnitude of the problem in Saudi Arabia are not easily available. Few papers have been published that reflect the importance that these units have had insignificantly reducing mortality (1, 2).
The end points in burn care are survival, functional recovery and good cosmetic results, and only specialized burns units can achieve these goals. As in the past, in some hospitals in Saudi Arabia burns are still treated in the surgical wards of big hospitals, with a high mortality rate mainly due to sepsis. The paucity of data on burn injuries in Saudi Arabia has given us an impetus to report our findings on patients admitted to a dedicated Burns Unit at a tertiary care hospital in Qassim Province in Saudi Arabia.

The King Fahd Specialist Hospital at Buraidah AlQassim is a 540~bed tertiary care hospital serving the Province of APQassim, the agricultural heartland of the Kingdom, with a population of 0.5 million inhabitants.
A 10~bed "state of the art" burns unit was opened in early 1989, consisting of one emergency resuscitation room with two beds, eight isolated air~controlled rooms, two clinitron beds, one circle bed and three automated Hubbard tanks. All the rooms are fully self-contained with all dressing materials. Every room has central oxygen supply, suction and a monitor connected to a central monitor at the nursing station.
A record of the first 218 cases admitted to the Unit over a 42-month period was analysed retrospectively for aetiological factors, treatment modalities and outcome.
Patients were admitted either directly or referred from a general hospital or a primary health centre. The farthest point of reference was the AI-Rass Hospital, situated 100 km away.
A computerized data entry form was designed to take 101 information elements for each patient and grouped under demographic characteristics, aetiopathology, investigations, treatment and outcome. A personal computer was used and a structural base was designed to enter data. For the identification of the independent factors that have adversely affected in-hospital mortality, the Cox proportional hazards model was used. Describe and continuous variables were entered in stepwise fashion. For all data analysis the BM13P statistical software program was used (3).

Of the first 218 cases analysed, 124 were males (56.9%) and 94 were females (43%). The mean age (ISD) was 8.2 years (range six months to 75 years); 132 (60.6%) were children (<12 years), of whom 104 (78.8%) were under the age of five years (Table 1); 86 patients (39.4%) were adults between 13 and 75 years of age.

Analysis of the aetiological factors (Table I1) shows that scalds and flame burns represented the major aetiological factors (75.2%). Most burns (160) were domestic (73.4%); 36 were industrial accidents (16.5%). The cornmonest aetiological case in children was scalding. directly to the hospital constituted the majority of the total admissions, i.e. 137 (62.8%).
In an attempt to evaluate the quality of care given to the patients by the referral hospitals and health centres prior to referral to our unit, the basic burn care management lines were considered - topical and dressing care, resuscitation, investigation, estimate of T13SA burned, and care of other injuries. A grade out of ten was given for each of these factors (Table IV). The results from the Table show that the initial care offered by the general hospital was considered to be satisfactory compared to that given by health centres
The mean (± SE) of the T13SA burned was 26% (± 2.4%) with a range of 1 - 98%. The standard criteria for admission to a burns unit were adhered to, including burns to critical body areas (face, hands, feet, perineum) irrespective of T13SA. This accounts for the 1% T13SA admissions, which were mainly deep hand burns.
Cutdown for venous access was performed in 29 patients, and a CV line was required in nine cases. Fortytwo patients were discharged against medical advice and were treated in hospitals nearer their place of residence.
The mean hospital stay of the entire group was 19.2 days. Out of the 218 patients, 15 (6.9%) died during hospitalizadon. The deaths were attributed to critical burns and their complications.
The TBSA burned in the 15 deceased patients ranged between 50 and 99%. Eleven died in the first week (six in the first 48 hours). The TBSA in these six patients ranged between 85 and 95%; inhalation burns also occurred in this group.
Two of the deceased patients died of high-voltage electrical burn after four days, and the other four died between day 10 and 27 post-admission as a result of burn wound sepsis and its consequences.
Of the various factors considered for their independent influence on in-hospital mortality, using the proportional hazard model, only the TI1SA burned percentage was found to have an independent effect on the probability of survival, patients with extensive burn injuries experiencing higher mortality (model P-value <0.00001).

Burns remain a serious problem in both developed and developing countries. The paucity of data on burn injuries in Saudi Arabia led us to report on the experience we have gained at a newly opened burns unit in the Province of Qassim. A retrospective study was designed to analyse the pattern of burn injuries in the region and to study the impact of the care provided in burn units on the final outcome. Our data regarding 218 admissions showed that more than half the patients (60.6%) were children under the age of 12 years, of whom 78.8% were under the age of five years. This observation is similar to that found in other developing countries (4, 5, 6). Only four patients were aged over 60 years, and this low incidence in the elderly has also been observed in a recent Kuwaiti study (4), in which only 1% of the patients were over 60. This is in sharp contrast with data from the western world - in one study conducted in England and Wales 11 % of the patients were over the age of 65 years (7).
Flames and scalds represented the major aetiological factors, accounting for 75.2% of all the burn injuries, 73.4% being domestic burns. This is in keeping with other studies which showed the incidence of domestic burns as 75% in Eastern Province, Saudi Arabia (1), 79% in Kuwait (4) and 71% in Nigeria (8). When studies involving children only were undertaken, the incidence of domestic burns was even larger: 95% in Jeddah (2) and 88% in China (9). Scalds were common in children in all the above studies, as also in the present study.
The sex distribution in our series showed an almost identical incidence for either sex. In a study from Alexandria, Egypt (5), the incidence of flame burns was 46.9% in females, which was almost twice the incidence in males. The explanation given for the high female figure was the higher number of suicide attempts in the female group. There were no cases of suicide attempts in our series.
In Zaria, Nigeria (10), 85% of scald burns occurred in women, and nearly half of these were due to puerperium hot baths, axitual not practised in Saudi Arabia, where most women are now delivered in hospital, or at home by trained midwives.
In the majority of cases the kitchen was the place of flame and scald injuries. The high incidence among children under the age of five years may be due to their relatively large number in the same household, combined with unsupervised free movement and easy access to the kitchen.
In our series 79.3% of the cases were admitted within the first 24 hours and 4.6% after more than 48 hours. The cases that arrived early and direct to the burn unit showed a better outcome. The evaluation of cases referred from other general hospitals and primary health centres indicates the need for a protocol for referring health facilities to adhere to, with regard to immediate local and systemic therapy and prompt evaluation of burn severity.
The average hospital stay in our series was 19.2 days, which is shorter than that reprted by,other centres.
Early excision in the management of deep burns might further reduce the average hospital stay period. After adoption of early excision, the University of Washington Burn Center showed in a comparative study that the average hospital stay dropped from 32 to 16 days (11). Survival rates have also significantly improved in recent years owing to a better understanding of burns pathophysiology, as also to improved laboratory facilities, more adequate nutritional support, infection control and early wound closure.
The mortality rate in the reported series ranges from a low of 4.4% (2) to a high of 25% (12), depending on the prevalence of a variety of prognostic factors. These figures vary considerably, some being quite high, e.g. Alexandria 21.1% (5) and Zaria 22% (10). In our study the overall inhospital mortality of 6.9% may reflect the advantages of specialized Burn Units that have been opened in many Saudi Arabian hospitals. Mortality was recorded as 8% in APKhobar, Eastern Province (1), 4% in Jeddah, Western Province (2) and 7.2% in Kuwait (4).
Our low mortality rate can be attributed to several factors. First, treatment is provided in a well-equipped unit with unlimited access to all investigative facilities, ade~quate nutritional and parenteral support, and strict measures for infection control. Second, good communication facilities lead to early admission, which has an important bearing on survival in criti~ cal bums. Third, there is a high percentage of young patients.The main contributing and significant factor in the 15 deaths was burn extent. Inhalation injury was an enhancing factor in six cases. Septicaemia, which is a leading cause of death in many centres, contributed to the death of only four patients. In many centres, since the 1970s, early excision in the management of bums has been thought to improve survival. Wolfe (13) compared data from 11 centres and found somewhat better survival rates in patients who had early excision and grafting. Early excision was not adopted as a routine in our centre for a number of reasons, such as non-availability of large quantities of blood and resistance of the patient's family to early surgery, which they thought could be avoided.
The probability of burn injury has been found to decrease as the individual's economic status rises (14). The overall economic status in Saudi Arabia has vastly improved but the incidence of burns remains the same. Further prospective studies are needed to estimate the overall incidence pattern and aetiological factors in AI-Qassim Province and other regions of the Kingdom.
Educational efforts for prevention should be the keystone for the reduction of the incidence of burns. Plans to maximize hospital resources should also be realized. A detailed analysis of all the cases shows unequivocally that the majority of burns in children are preventable if basic safety measures are adopted in the household.
Educating the people is the only way to minimize the suffering and tragedy of burns. This must cover the following points:

1. Education of the public regarding the danger of thermal injuries and the type of injuries that can be sustained.
2. Domestic appliances and industrial equipment should be designed to meet accepted safety standards.
3. Elements of burn prevention should be taught at school, and there should be posters and displays for the general public.
4. Children under the age of five years should not be allowed free access to the kitchen.

RESUME. Les auteurs décrivent leur expérience pendant une période de 42 mois dans un nouveau Service de Brûlures fourni de dix lits a l'Hôpital Spécialiste Roi Fahd, Buraidah AI-Qassirn, Arabie Saoudite. Ils ont analysé les premiers 218 patients (56,9% mâles, 43,10/0 femelles) qui ont été hospitalisés. L'âge moyen était 8,2 (± 1,5) ~ans, avec une variation de six mois jusqu'à 75 ans. Les enfants (moins de 12 ans) représentaient 60,6% des cas, desquels 78,8% étaient âg~.s moins de 5 ans. Seulement quatre patients étaient âgés plus de 60 ans. Les facteurs étiologiques étaient les ébouillantements et les flammes dans 75,2% des cas. Les brûlures domestiques constituaient la majorité des cas (160/218; 73,4%) et la plupart des patients (79,417o) ont été hospitalisés dans les premières 24 heures. L'hospitalisation était ou directe ou à travers un centre hospitalier ou un centre sanitaire. La surface corporelle totale brûlée (TBSA) moyenne était 26% (± 2.4) et variait entre 1 et 981/o. La période moyenne de l'hospitalisation de tous les patients était 19,2 jours. La mortalité hospitalière était de 15 patients (6,9%). Les auteurs ont trouvé que la TBSA était le facteur principal qui déterminait la mortalité. Cette étude souligne tous les facteurs importants qui ont influencé les résultats obtenus dans le Service et dans d'autres services saoudiens. Les auteurs mettent en lumière les facteurs qui peuvent améliorer les taux de morbidité et de mortalité dans les patients brûlés. L'étude révèle certaines tendances et facteurs étiologiques dans la région de Qassim. L'éducation pour la prévention au moyen d'une campagne nationale reste la clef de voûte pour réduire la fréquence des accidents, en particulier pour ce qui concerne les enfants, et pour maximiser les ressources.

BIBLIOGRAPHY

1. Hegazi M., Ibrahim E.: The pattern and outcome of bum injuries at a Burn Unit in Saudi Arabia: retrospective analysis of 501 consecutive patients. Annals of Saudi Medicine, 11 (3): 1991.
2. Jamal Y.S., Ardawi M.S.M., Asly A.R.A,, Shaik S.A.: Paediatric injuries in the Jeddah area of Saudi Arabia: a study of 197 patients. Bums, 16:34-40,1990.
3. Dixon W.J. et al.: BMDP statistical software. Berkeley: University of California Press, 1990.
4. Bang R.L., Mosbah K.M.: Epidemiology of Burns in Kuwait. Burns, 14: 194-200, 1988.
5. Mostafa M.F., Burhan A., Abdullah A.F., Beheri A.S., Abdul-Hassan H.S.: A retrospective study of 5505 burned patients admitted to Alexandria Burn Unit. Annals Medit. Bums Club, 3: 269-72, 1990.
6. Sowemimo G.O.A.: Bum injuries in Lagos. Bums, 9: 280,1983.
7. Muir I.F.K., Barclay T.: "Burns and their treatment" (3rd ed.).Butterworth, 1987.
8. Charosia AR.: Mortality from burns in developing countries. Burns, 9:184,1982.
9. Zhi-Xiangzhu, Hua Yang, Fan-Zhi Meng: The epidemiology of childhood bums in Jiarnusi, China. Burns, 14: 394-6, 1988.
10. Mabogunje O.A., Lawrie J.H.: Burns in adults in Zaria, Nigeria. Bums, 14: 308-12, 1988.
11. Heimbach D.M.: Early bum excision and grafting. Surg. Clin. N. Am., 67 (1): 1987.
12. Rittenbury M., Maddox R., Schmidt F.: Probit analysis with burn mortality in 1831 patients: comparison with other large series. Ann. Surgery., 334: 1966.
13. Wolfe R.A., Lawrence D.R., Flora J.D. et al.: Mortality differences and speedy wound closure among specialised burn facilities. JAMA, 250: 763-6, 1983.
14. Edlich R.F., Glasheen W., AtteDger E.O. et al.: Epidemiology of serious burn injuries. Surg. Gynecol. Obstet., 154: 505, 1982.
15. Akhtar M., Gand R.K.: Epidemiology of bums in Benghazi, Libya. Burns, 7: 351, 1981,
16. Langley J., Silva P.A.: Childhood accidents involving the electricjug - options for prevention. Bums, 7: 288, 1981.
17. McDowak A.: A seven-year survey of a Bums Unit for children 1954-1960. Brit. J. Plast. Surg., 18: 1535, 1965.