Annals of Burns and Fire Disasters - vol. IX - n. 2 - June 1996

ADMISSION AND PATTERN OF BURN INJURIES AT A NEW BURN UNIT AT UNAYZAH, QASSIM, SAUDI ARABIA

* College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia and King Fahd Hospital of the University, AlKhobar, Saudi Arabia
** Division of Plastic Surgery and Burn Unit, King Saud Hospital, Unayzah, Oassim

SUMMARY. Over a 3-year period (1991-94) 116 patients were admitted to the 5-bed bum unit at King Saud Hospital, Unayzah, Qassirn (Saudi Arabia). Eighty-seven (75.0%) were males, the majority of them non-Saudi workers in the age group 18 to 60 yr. Forty (34.5%) were children under the age of 5 yr, and eight patients (6.9%) were aged 5-18 yr. The mean age was 13 yr (range 2 months-75 yr); only one patient over the age of 60 was admitted. Flame burns were present in 55 patients (47.4%), scalds in 48 (41.4%), electrical burns in 15 (12.9%) and chemical burns in two (1.7%). Saudi patients were involved more in domestic fires (57.8%), while fire at work was more common (36.2%) in the non-Saudi group. No significant seasonal variation was found. Burned TBSA ranged from 2 to 80%, the majority of patients (74 = 63.8%) presenting less than 10%. Hospital stay ranged from one to 338 days, with a mean of 31 days. Twenty-five patients were discharged against medical advice. There were 29 different complications in 22 patients due to burn injuries, with wound infection in 6 patients. Three patients (2.6%) died. This survey stresses the importance of prevention programmes. Also stressed is the need to establish bum clinics and to train staff in the management of minor burns, in order to reduce hospital admissions with added cost burdens. The need for bum units and their better utilization is also discussed.

Health care has developed fast in Saudi Arabia in the last 20 years. Many new hospitals have opened throughout the country, as well as specialized burn units in major regional hospitals. Fortunately nowadays, especially in the larger cities, we do not see so many severe post-bum cornplications due to contracture and deformity as we did 20 years ago. This is a reflection of progress in health care in general and of the correct treatment Provided by these hum units, from isolation and minimization of wound infection to early surgical invention when indicated. The burn mortality rate has dropped in Saudi Arabia" and our figures are now comparable with those of many developed countides.
Every country has the goal of burn prevention, in order to minimize the impact on community resources and the cost of hospital management and rehabilitation. It is a complex aim that is never easy to achieve, but the prevention of the physical and psychological sequelae of bums is worth every effort. Scalding is recognized worldwide as the main cause of burns in children under the age of five years, yet it still remains an on-going problem, even if most such accidents can be prevented through close observation of children and better general watchfulness.
The data on burn injuries in Saudi Arabia are incomplete, and the exact incidence and magnitude of the problem nationwide are not known. This retrospective study is intended to add to the contributions of the few papers that have appeared in the literature` and to focus on the problem of burns and burn trends in our country, with a view to prevention.

The records of the 116 burned patients admitted to the burn unit at King Saud Hospital, Unayzah, between the opening of the unit in October 1991 and October 1994 were retrospectively studied using a specially designed and pre-tested form for the collection of epidemiological information. The following were recorded: age, sex, nationality, place of accident, type and cause of burn, location, time lag between accident and hospitalization, complications, and treatment.
Total burned body surface area was estimated using Lund and Brower charts. Our burn unit has five beds, isolated self-contained air-controlled rooms with all necessary dressing material, and one automated Hubbard tank.
Unayzah is the second city in the region of Al-Qassim in central Saudi Arabia. It is only 25 km from Buraidah, the capital of the area, where there is the King Fahd Specialist Hospital with a 10-bed burn unit serving Buraidah and the whole area of Al-Qassim.1 At-Qassim is mainly an agricultural area and there are many non-Saudi workers among our patients.
The criteria for admission to the unit followed the American Burn Association policy, with a certain flexibility due to local norms of social privacy.
The Parkland formula was used as a guide for infusion therapy, adjusted when necessary on the basis of clinical observation and urine output. Povidone iodine (Betadine) was mainly used for wound dressing; when indicated, Flamazine was used in deep, deep dermal, and exposed areas. Early tangential excision and skin grafting was not routinely performed in the unit. In the first year of its activity the unit used antibiotics as a prophylactic measure; this policy was then changed, and antibiotics were given only as indicated - mainly in deep major bums, compromised children, and prior to surgery.

Results

An analysis of the 116 patients admitted shows that males were in the majority (87 = 75.0%), compared to 29 females (25.0%). There were 61 Saudis (52.6%) and 55 non-Saudis (47.4%). The mean age was 13 years (range 2 months to 75 yr); there were 40 children under the age of 5 years (34.5%), eight aged 5-14 years (6.9%), and none in the age group 14-18 yr. The age group 18-60 years constituted the majority of patients (67 = 57.8%); only one patient was aged over 60 yr (Table I).

Flame was the cause of bums in the largest group of patients (51 = 44.0%), followed by scalds (48 = 41.4%), electricity (15 = 12.9%), and chemicals (2 = 1.7%). Scalding was the commonest cause of burns in children aged under 5 yr (30 cases out of 40) (Table II). Details of causative agents are shown in Table III.

The home was the commonest site of bum accidents (67 = 57.8%). Saudis were more often involved in domestic burns, while bums at work were more common in nonSaudis (42 = 36.2%). Bums outdoors and in open spaces accounted for 7 cases (6.0%). In domestic burns the kitchen was the commonest site (36 = 31.0%), followed by the living-room (22 = 19.0%) and the bathroom (9 = 7.8%).
The age group 18-60 years old presented the majority of patients (67 = 57.8%), of whom 34 (50.7%) had flame burns. The fifteen patients (all non-Saudi males except one) with electrical burns belonged to this group; all the electrical accidents happened at work (Table I). No significant seasonal variation was found: in the summer period there were 26 patients with flame burns and 29 with scalds, compared to 25 and 19 respectively in the winter period.
With regard to the time interval between the burn accident and admission to hospital, the majority patients were seen and admitted in the first 6 hr (9380.2%); nine patients were admitted after 6-24 hr an 14 patients after more than 24 hr. All were direct admissions except for 11 patients referred from other hospitals.
Regarding burn severity, the burned TBSA ranged from 2 to 80%, the majority of patients (74 = 63.8%) presenting less than 10%. The burned TBSA exceeded 40% in only six patients (5.2%). Nearly all body areas were involved, especially the upper limbs and hands. The perineum was less frequently involved.
Pseudomonas and E. coli (Table VII). In eight patients there was a history of 18 associated diseases, including diabetes mellitus, hypertension, ischaemic heart disease, bronchial asthma, epilepsy, and others. Surgical procedures were required in 21 patients, skin graft in 44, debridement in 26, escharotomy in 2, skin flap in 3, as well as amputation of gangrenous fingers.'
Hospital stay ranged from one to 338 days, with a mean of 31 days. Only four patients had a stay of more than 110 days, the longest (338 days) being that of a 5year-old girl admitted with 60% deep bums. This young patient had various complications, including bum wound 'sepsis, urinary incontinence, and chest complications, and there was further delay in her discharge owing to social reasons. A good number of patients discharged themselves against medical advice (25 patients, all Saudi except one).
Analysis of morbidity and mortality shows that 22 patients developed 29 different complications due to bum injury, of which bum wound infection was the commonest (six patients); the main organisms involved.
Three of the 116 patients admitted died (2.9%). The first was a 21-year-old woman, admitted in the first week after the opening of the burn unit, suffering from a 50% deep flame burn caused by the explosion of an air conditioner. She also had inhalation burns, and she died 48 hours later. The second was a 75-year-old woman (the only patient admitted in the over-60 years age group) with 70% mixed flame burns due to ignition of clothes in the kitchen; she died after 10 days. The third patient was a 45-year-old male with 80% deep burns, also caused by ignition of clothes in the kitchen. The patient suffered from diabetes mellitus, bronchial asthma, ischaemic heart disease, and hypertension; he was also a heavy smoker and was known to have psychological disorders. He died 17 days later.

We have reported before on the experience of a 10bed unit in King Fahd Specialist Hospital at Buraidah, Qassim province, which is the agricultural heart land of the kingdom of Saudi Arabia, with a population of approximately 0.5 million inhabitants. The average admission for the unit is 62 patients per year.
Unayzah City is only 25 kin from Buraidah, and the average number of admissions to the burn unit is 38 patients per year. This number does not reflect the whole scope of burn injuries in the area, since many cases treated in the emergency department do not meet the criteria for admission, while others are treated in health care centres distributed throughout the area, and other patients fail to present early to hospital and are seen only some days later in clinics.
Analysis of the 116 cases admitted to the burn unit over the 3-year period shows that domestic burns were the commmonest (57.8%). This incidence was however lower than in Buraidah (73.4%) and other Saudi cities, e.g. Jeddah (84.6%)' and Gizan, which was reported to be the higheSt.3 Domestic burns are also high in some neighbouring Arab countries (Jordan, 88%; Kuwait, 78.6%; Assiut, Egypt, 94.3%).
Burns at work were seen relatively more often in the area of Al-Qassim. This may be due to the presence of untrained workers on farms and in other work sites with inadequate safety measures.
The incidence of electrical bums also seems high. In this study the 15 patients (12.9%) who had burn accidents at work were all non-Saudi except for one. In Buraidah electrical burns were also relatively high (9.2%), compared to a lower incidence in surrounding areas: Jeddah (1.3%); Gizan, (5.4%); Kuwait (4.3%), Jordan (3.8%) and Assiut, Egypt (1.2%).
In domestic fires the kitchen was the place of highest risk for both flame and scald burns, representing 53.7% of domestic burns, followed by the living-room (28.0%). These accidents were mainly scald burns caused by hot tea or coffee in unsupervised children. This compares with an incidence of 60% in living-rooms in a recent study in India 6 where cooking and other fire-related activities were carried out in a single room that served all family purposes.
Flame and scald burns constituted the majority of all burn accidents. There was a variable pattern of causes for burns at home and at work (Table III). Gas explosions represented I I% of flame fires. The problem was more serious in Jeddah, where about one-third of all flame burns were caused by a gas cylinder explosion, as a result of careless handling.
Two cases of deep dermal burns in children were caused by contact with hot henna, which is a powder mixed with hot water to make a paste commonly used in the Arabian Gulf area for the decoration of hands and feet.
Children below the age of 5 years were the main victims (34.5%). There were only 8 patients in the age group 5-14 years (6.9%), and none in the age group 15-18 years. In Buraidah 60.6% of the patients were children below the age of 12 years, and the majority of these (78.0%) were aged less than 5 years.
The age group 18-60 years constituted the majority of patients admitted (57.8%). This can be explained by the fact that non-Saudi workers in the area represented 47.4% of our admissions. In Buraidah this age group constituted 31.6% of admissions.
A significant constant finding was the low incidence of bums in the over-60 years age group - there was only one patient in our study. Buraidah, with 4 patients (1.8%), Kuwait (1%), Jeddah (1.5%) and Gizan also reported low incidences compared to data from the western world. In one study conducted in England and Wales 11 % of the patients were aged over 65 years .7 It would seem that in our community, while we tend to neglect children under the age of 5 years, at the other age extreme older people are well looked after and given better care.
The majority of patients (80.2%) were seen and admitted in the first 6 hours post-burn. Admission within the first 24 hours represented 88.0%, compared to 79.3% in Buraidah 79.3%, where there were many delayed referrals. In this study only 11 cases were referrals from other hospitals.
Hospital stay presents -a concern for many hospitals and burn units because of its impact on costs. The mean hospital stay was 31 days, which is comparable to other studies in Kuwait and Alexandria, but longer than in Buraidah (19.2 days). The length of stay in our present study could perhaps be lower, as most of the burns were less than 10% BSA, and it would also be lower if surgical excision were performed earlier. Experience however shows that some families, especially Saudi families, resist early surgery. Problems related to the availability of blood and donations also add to the surgeon's reluctance.
Discharge against medical advice (DAMA) was high: 25 patients (21.6%), compared to 19.3% in Buraidah and 17.5% in Gizan. These patients were nearly all Saudi and mainly children, with an attendant mother in a hurry to return home to look after her other children. In Gizan' DAMA was a source of concern for the treating doctors, as some children left so early that their lives were still in danger, while others had defects that will heal with unstable scars and contractures. The explanation for DAMA is the lack of communication with attendant family members, usually the mother who has an important function in caring for her sick child. We are of the opinion that the custom of allowing attendant family members into the burn unit should be stopped. Their presence complicates matters father than facilitating them, they misunderstand instructions by staff for general discipline in the unit, they complain, and in the end they ask for the patient's discharge. This observation has also been made in Gizan.
The severity of bums and the distribution in different body areas showed a high percentage of burns in critical areas (hands, feet, face, and perineum), and this partially explains the majority of admissions of patients with less than 10% burned BSA (63.8%). Major life-threatening burns were fortunately few, only 6 patients being admitted with more than 40% TBSA.
Mortality is related to burn severity, which depends on TBSA burned, degree of depth, and age. The burn mortality rate is decreasing nowadays in many burn centres, owing to better understanding of pathophysiology, isolation, and early surgery. Mortality however remains high in some developing countries, with inhalation burns and sepsis remaining important causes. In Assuit, Egypt, where flame burns represented 67.9% of admissions, the mortality rate was 33.5%, compared to Gizan (16%), Jeddah (9.4%), and Buraidah (6.9%).
The mortality rate in this study was 2.9%. This low rate was due to the reduced number of major burns (only 6 patients had burns in more than 50% TBSA). The main contributing factor in the three deaths was the burn extent (50% and over). Among burn-related complications, wound infection remained low, although it was at the top of the list (6 patients); no death was related to sepsis. Gastrointestinal disorders in the form of prolonged ileus and distension were encountered in three cases, but without bleeding.
An important observation is that in this study, and also in Buraidah, no attempted suicide cases were admitted. This contrasts with Jordan,' where 13.5% of burn deaths were suicides, and Alexandria, Egypt,' where flame bums were higher in females, a finding related to the higher incidence of suicide attempts among the female population.
In conclusion, burns remain a problem in our area. Patients at risk must be recognized and prevention programs are always worth the effort. Fortunately, major bums seem less common, and most cases admitted are mild in nature. To reduce the cost of in-patient care, and to maximize benefits from such sophisticated specialized burn units, we should be more selective and strict about admission, without reducing all the necessary care for minor burns. This can best be achieved by using bum clinics, rather than by opening new bum units. Nursing staff with specific training in bum treatment can provide assistance and adequate medication in burn clinics rather than working in emergency rooms, as happens in many hospitals. This would obviate the need for many unnecessary admissions.

RESUME. Pendant une période de trois ans (1991-94) 116 patients ont été hospitalisés dans l'unité de brûlures (5 lits) à l'Hôpital Roi Saud, Unayzah, Qassirn (Arabie Saoudite). Quatre-vingt-sept patients (75,0%) étaient mâles, et la plupart était ouvriers non-saoudiens dans la tranche d'âge de 18 à 60 ans. Quarante patients (34,5%) étaient des enfants âgés moins de 5 ans; huit patients étaient dans la tranche d'âge de 5 à 18 ans. L'âge moyen était 13 ans (limites inférieur et supérieur 2 mois-75 ans); un seul patient âgé plus de 60 ans a été hospitalisé. Les brûlures par flamme étaient présentes dans 55 patients (47,4%), les ébouillantements dans 48 (41,4%), les brûlures électriques dans 15 (12,9%) et les brûlures chimiques dans deux (1,7%). Les patients saoudiens étaient impliqués de plus dans les accidents domestiques (57,8%), tandis que les brûlures au lieu de travail étaient plus communs dans le groupe non-saoudien. Les auteurs n'ont pas observé aucune variation saisonnière. La surface totale corporelle brûlée variait de 2 à 80%; la plupart des patients (74 = 63,8%) présentaient moins de 10%. La période d'hospitalisation variait d'un jour à 338 jours (valeur moyenne 31 jours). Vingt-cinq patients ont été renvoyé à la maison contre les conseils des médecins. Les auteurs ont observé 29 complications différentes chez 22 patients dues aux brûlures, avec l'infection de la lésion chez 6 patients. Trois patients (2,6%) sont morts. Ces résultats, selon les auteurs, soulignent l'importance des programmes de prévention et la nécessité de créer des cliniques de brûlés et d'instruire le personnel dans la gestion des brûlures mineures, pour réduire le numéro d'hospitalisations et les coûts. Les auteurs discutent aussi la nécessité de créer des unités de brûlures et l'importance de leur bonne gestion.

BIBLIOGRAPHY

1. Fadaak H., Al-Kurashi N., Mahaluxmivala S., Mathur A., Borkar A., Ibrahim E.: Burn injury admission to a new burns unit in Buraidah, Qassim, Saudi Arabia - a study of 218 cases. Ann. Medit. Burns Club, 8: 4-7, 1995.
2. Jamal Y.S., Aradwi 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. Larsen J., Got Murthry, Ghali M.T., Hall KN.L.: Admission to a new burn unit in Gizan, Saudi Arabia. Burns, 13: 286-9, 1987.
4. Hegazi M., Ibrahim E.: The pattern and outcome of bum injuries at a burn unit in Saudi Arabia: retrospective analysis of 501 consecutive patients. Ann. Saudi Medicine, 11 (3): 199 1.
5. Bang R.L., Mosbah K.M.: Epidemiology of bums in Kuwait. Bums, 14: 194-200, 1988.
6. Kumar P., Sharma M.S., Chadha A.: Epidemiological determinants of burns in paediatric and adolescent patients from a centre in western India. Burns, 20 (3): 1994.
7. Muir I.F.K., Barclay T.: "Burns and their treatment" (3rd ed.), Butterworth, London, 1987.
8. El-Sonbaty M.A., El-Oteify M.: Epidemiology of Bums in Assiut Province, Egypt, during the last two years. Ann. Medit. Bums Club, 4: 22-4. 1991.
9. Mostafa M.F., Burhan A., Abdullah A.F., Beheri A.S., AbdulHassan H.S.L.: A retrospective study of 5505 burned patients admitted to Alexandria Burn Unit. Ann. Medit. Bums Club, 3: 269-72, 1990.
10. Hussam EI-Muthaseb, Salah Qaryote, Sameeh Abu Ragheb: Burn injuries in Jordan: a study of 338 cases. Bums, 10: 116-20, 1983.

11. Sameeh Abu Ragheb, Salah Qaryote, Hussam El-Muhtaseb:Mortality of bum injuries in Jordan. Bums, 10: 439-43, 1984.