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The Pattern and Outcome of Burn Injuries at a Burn Unit in Saudi Arabia: Retrospective Analysis of Consecutive 501 Patients

1991; King Faisal Specialist Hospital and Research Centre; Volume: 11; Issue: 3 Linguagem: Inglês

10.5144/0256-4947.1991.255

0975-4466

Mohammed M. Hegazy, Ezzeldin M. Ibrahim,

Pressure Ulcer Prevention and Management

Original ArticlesThe Pattern and Outcome of Burn Injuries at a Burn Unit in Saudi Arabia: Retrospective Analysis of Consecutive 501 Patients Mohammed M. Hegazy and FRCS Ezzeldin M. IbrahimMRCP, FRCPI Mohammed M. Hegazy Address reprint requests and correspondence to Dr. Hegazy: Plastic Surgery Unit, Department of Surgery, King Fahd Hospital of the University, P.O. Box 40004, Al-Khobar 31952, Saudi Arabia. From the Department of Surgery, College of Medicine and Medical Sciences, King Faisal University, Al-Khobar Search for more papers by this author and Ezzeldin M. Ibrahim From the Plastic Surgery Unit and Department of Medicine, College of Medicine and Medical Sciences, King Faisal University, Al-Khobar Search for more papers by this author Published Online::1 May 1991https://doi.org/10.5144/0256-4947.1991.255SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractWe retrospectively reviewed the cases of 501 consecutive patients with burn injuries who were seen between June 1983 and December 1988. The population consisted predominantly of young patients under 20 years of age (53%); 65% were males and 72% were Saudi nationals. Most burn injuries were the result of domestic accidents (75%) and scald burns were the cause in 55% of patients. There was an inhospital mortality of 8% during first hospitalizations. Multivariate analysis identified several independent adverse prognostic factors: increased total burn surface area, inhalation injury, thrombophlebitis, documented septicemia, and deep circumferential burn over the extremities. Using these poor prognostic factors, we were able to stratify patients into three risk categories, each representing a significant difference in the probability of survival. Our analysis yielded data about the pattern of burn injuries, prognostic factors, and outcome at a dedicated burn unit in Saudi Arabia.IntroductionDeath due to burn injuries ranks second only to traffic accidents among all unnatural causes of death[1]. Morbidity and mortality statistics about burn injuries in developing countries are not adequately documented in the English literature, and the only data available for the Kingdom of Saudi Arabia has only recently been reported[2]. This lack of adequate data prompted us to analyze the local experience in the management of burn patients, using material from a five-year period.MATERIAL AND METHODSA 10-bed critical care burn unit was opened in June 1983 at King Fahd Hospital of the University, and was designated to receive primarily all burn patients living in the Eastern Province who would have previously gone untreated. This made possible the study of a concentrated group of patients with burn injuries. The study population included all consecutive patients with burn injuries admitted to the burn unit between June 1983 and December 1988.Patient care was standardized according to the type and extent of injury. Patients with deep burns that involved the face or neck, those with burns incurred in a closed space, and those with burns that affected the nasal vibrissae routinely underwent direct laryngoscopy to determine possible upper respiratory tract injury. The presence of extensive laryngeal edema was considered an indication for elective intubation.A burn surface area of greater than 15% in children and 20% in adults was considered an indication for use of the modified Baxter's formula[3]. Prophylactic systemic antibiotic coverage was not used routinely, except perioperatively when major burn wound excision was necessary. Large surface area wounds were managed surgically by staged excision and autografting, usually done 5 to 7 days after the burn injury.A computerized data base was constructed using a personal computer. Several variables were tested for their unadjusted association with survival using the chi-square test. Covariates with P ≤ 0.10 were included in the all-possible subset regression analysis to identify the “best” subset of predictor variables for survival. The “best” subset was selected using Mallow's Cp (coefficient) criteria, in which the “best” was defined as the smallest Cp[4].Survival during hospitalization was estimated using the Kaplan-Meier method and was calculated from the date of admission to date of discharge or death[5]. The log-rank test of Mantel-Cox was used to compare the unadjusted differences in survival[6].In all data analysis, P ≤ 0.05 (two-tailed) was considered significant. Data analysis was carried out using P4F and P9R programs of the BMDP Statistical Software package[7].RESULTSAll 501 patients seen during the designated time period were evaluable for occurrence of complications and for survival. Mean age was 16.5 years. Patients data are summarized in Table 1. Patients under 20 years of age constituted the majority (53%); 65% were male and 72% were Saudi nationals. The mean hospital stay was 3.89 weeks (range, 0.1–14).Table 1. Clinical characteristics and outcome of 501 burn patients.Forty-one patients (8%) died during hospitalization as the result of their burns. The unadjusted effects of various variables on the probability of survival during hospitalization were examined. As shown in Table 1, the significant adverse prognostic factors were: older age, extensive burn, type of burn, and inhalation injury, as well as the occurrence of any of the following complications—thrombophlebitis, renal failure, documented septicemia, and deep circumferential burns of the extremities requiring escharotomy and hematemesis. Figure 1 demonstrates the survival probability plotted against the total burn surface area.Figure 1. Survival proportions plotted against the extent of the burned surface area.Download FigureAll unadjusted variables with P ≤ 0.1 were included as explanatory variables in the all-possible subset regression analysis. The dependent variable was death versus survival during hospitalization. Increased total percentage of burn surface area, inhalation injury, thrombophlebitis, documented septicemia, and deep circumferential burn over the extremities were associated with a decreased likelihood of survival (Table 2). The resultant explanatory variables accounted for 63% of the variance in survival probability (R2). The Mallow's Cp of the model was 6.09 with an F statistic of 171.89 (df, 495 and 5).Table 2. The adjusted regression analysis of outcome (all-possible subset regression analysis)Based on these derived models, patients were categorized into three risk strata. The following variables were deemed of equal weight in classifying patients: extensive burn (> 30%), inhalation injury, thrombophlebitis, deep circumferential burn over the extremities, and documented septicemia. Patients with none of the factors represented the low-risk group; those with one or two, the intermediate; and those with three to four, the high-risk group. Death occurred in one of the 380 patients considered a low-risk group (0.26%), 3 of 58 regarded as intermediate risk (5.2%), and 37 of the 63 high-risk patients (58.7%). Figure 2 shows the survival curves of the patients in the three risk categories. The difference between the three survival curves was estimated using the log-rank test and was highly significant at P < 0.00001.Figure 2. Kaplan-Meier survival curves for the three risk strata (low, intermediate, and high).Download FigureDISCUSSIONBurn injuries represent a serious worldwide problem, as they account for considerable morbidity and mortality[1]. Accurate statistics on the incidence of burn injuries in the population of Saudi Arabia are not known because of a lack of regional or national burn registration.Our data showed that the majority of our population (53%) were younger than 20 years and 44% were younger than 5 years. The mean age of the entire population was 16.5 years. The dominance of children and young adults in our series is comparable to that observed for burn units from other developing countries[8,9]; however, it differs from that reported for England and Wales[10]. The high prevalence of burns in males was also comparable to those from Cuba and Mauritius[11], but contrasts with that reported for Egypt[9].The high incidence of domestic burn accidents (75%) is similar to the 71% and 79% reported from Nigeria and Kuwait, respectively[11,12]. Scald injuries were responsible for 55% of all accidents, and this high rate contrasts with those reported for Egypt[9], England and Wales[10], and Libya[13], where flame burns were the most common type of injury.Survival analysis revealed that 8% of the patients died during hospitalization. The mortality reported from various studies of burn injuries varies considerably, from 5.2 to 25%, and depends on the nature of the study population and whether the data were derived from a dedicated burn unit or a general surgical ward[8–16]. The survival pattern in our patients (Figure 1) is comparable to those reported from other series[17–19]. The low mortality in our population could be attributed to several factors: (1) the dominance of young patients; (2) referral of all patients within hours of the accident; (3) treatment of all patients by trained staff in a specialized burn unit rather than in general surgical wards; and (4) a total burn surface area of less than 15% in 66% of all patients (330 of 501). The error inherent in assessing prognosis based on independent examination of variables rather than in combination has been previously emphasized[20,21].The inverse relationship between the extent of burn and survival probability shown in our series is a well-established observation[22,23].The negative effect of inhalation injury, proved by multivariate analysis, also agrees with data published from other centers[24,25]. The high mortality rate (73%) in patients with inhalation injuries is expected, due to the known deleterious influence of smoke inhalation on respiratory airways, microvascular permeability, and myocardial contractility[20].None of the previously published studies identified thrombophlebitis as a negative prognostic feature, but in our study it may have become evident because those patients with extensive burns and with resulting lack of venous access who required cut-down procedures were made highly susceptible to suppurative thrombophlebitis. The use of intravenous plastic cannulas has also been linked with an increased risk of colonization by invasive microorganisms[27], and this was also true in our patients. Furthermore, suppurative thrombophlebitis often manifests itself only after systemic symptoms of sepsis arise, as dark discolored eschar can hide the early manifestations of thrombophlebitis.A high incidence (15%) of deep circumferential burns over the extremities was noted in our series and this was associated with high mortality (49%). Deep circumferential burns of the extremities can cause severe ischemia in underlying muscle by producing compartmental compression syndrome[28].Use of the prognostic factors identified in our series has been successful in categorizing the patient population into different risk strata, but our data should be validated in a prospective study.Our data provide an epidemiological foundation concerning the pattern of burn injuries in a burn unit located in the Kingdom of Saudi Arabia. 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