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Innovation and clinical specialities: burns
Burn management
ARTICLE BY M DAVEY AND B AYENI (PICTURED)
McMaster University, Hamilton, Ontario, Canada
Y YING AND MJ DUNCAN
Department of Plastic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
Pepita, 6 years old, was thrown into a fire by another child two years earlier and sustained an 8% burn of her
lower back. The burn was initially thought to be superficial, but, months later, the wound is still open and has
never been grafted. Pepita cannot stand upright because she has flexion contractures of both hips and one
knee. Instead, she has to crawl. Her groin was not burned, and the burn on her knee was only a minor one.
Her contractures are the result of failing to ensure that she used her unburnt and minimally burnt limbs
during the acute stage of her injury. She has now been abandoned by her family 1 .
The devastating effects of burns are long lasting at both an
individual and societal level. These impacts are
compounded in resource-poor settings, where the human
and material resources necessary to deal with this complex public
health problem are lacking. Developing nations are
disproportionately affected – 95% of the 322,000 global firerelated
deaths in 2002 occurred in low to middle-resource
countries. 2 A structured and comprehensive approach to burn
care must be applied to resource-poor settings in order to improve
outcomes.
A combination of improved management and prevention
strategies has resulted in important declines in morbidity and
mortality in the developed world. A recent US study demonstrated
a 50% decline in burn-related mortality and hospital admissions
over a 20 year period. 3 Patients are frequently surviving even the
most devastating burns due to advances in infection control,
antimicrobial and biologic wound coverings, as well as a better
understanding of resuscitation and the systemic effects of burn
physiology and associated lung injury in burn patients. However,
a stark contrast is seen when comparing the burn related mortality
rates in high and low-income countries. For example, the WHO
Global Burden of disease database has reported an over 10 fold
difference between mortality rates in South East Asia and Europe
(11.6 vs 0.7 per 100 000 population respectively). 2
Unfortunately, without adequate resources in first-aid, acute
surgical management and rehabilitation facilities, patients that do
survive their burn injuries in developing countries often have poor,
disfiguring and disabling long term outcomes. A Ghanaian study
found that 18 % of childhood burns patients had suffered a
physical impairment or disability. 4
As surgeons working in or supporting those who work in
resource-poor countries, it is imperative that we understand the
region-specific risk factors associated with burns, support
preventative measures and provide rapid and appropriate
resuscitation, surgical treatment and rehabilitation.
Etiology and epidemiology
In order to understand and overcome the challenges in the
management and prevention of burns in low-income countries, a
close look at the epidemiology and causal factors involved is
required. It is also necessary to understand the local economic
constraints and the available healthcare infrastructure.
There exist numerous hospital or clinic-based studies describing
epidemiological characteristics of their burn population. Forjuoh
has published a review of 117 articles from 34 low and middleincome
countries. 5 The majority of these studies dealt with the
pediatric population, with the highest incidence of burns occurring
in infants and toddlers (ages 0-4 years) who are dependant on
others for their care. In a study from Angola which looked at all age
groups, the pediatric population accounted for as much as one
third of all burn victims. 6 A comprehensive population-based study
in Ghana identified and calculated the strength of specific risk
factors found in childhood burns; the presence of a pre-existing
impairment such as epilepsy was associated with 6.7 greater odds
of a burn, a finding supported by many other studies. 7 Other risk
factors identified in case-control studies include history of a burn
or burn-death in a sibling, low income, illiteracy, poor living
conditions (overcrowding, lack of water supply) and careless
7, 8, 9, 10
practices (cooking equipment within reach of children). All
these reflect the importance of identifying and developing
prevention strategies that reach marginalized populations.
In many countries in Africa and Asia, young women are also at
particular risk. A reversal of gender distribution is seen compared
to most other injury mechanisms. Women in East Asia account for
26% of the burn deaths worldwide, the highest burn mortality
rates of any population (16.9 per 100 000 population per year) 5, 11 .
This risk is attributed to the domestic role of women cooking in the
home, using unsafe ground-level stoves oil-lanterns or open-fires
and frequently wearing highly flammable (yet inexpensive)
synthetic, loose clothing 12 . Some authors have found that violence
against women is a frequent underlying causal factor in fatal burns,
54 Hospital and Healthcare Innovation Book 2009/2010