burns 41 (2015) 582–589
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
A population-based study of the epidemiology of acute adult burns in Ecuador from 2005 to 2014 Esteban Ortiz-Prado a,b,c,*, Luciana Armijos c, Ana Lucia Iturralde d a
Faculty of Medicine, Universidad de las Ame´ricas, Quito, Ecuador Centro Internacional de Neurociencias, Quito, Ecuador c Universidad Yachay, Urcuqui, Ecuador d Universidad Tecnolo´gica Equinoccial, Quito, Ecuador b
article info
abstract
Article history:
Objectives: To describe the demographic, risk factor, occupational, and morbidity and
Accepted 18 August 2014
mortality characteristics of burns in adults in Ecuador using national data. These data
Keywords:
Methods: The National Institute of Statistics and Census provided data from the burn unit of
are from the only specialized public hospital in Ecuador that has a 12-bed burn unit. Burns
the Hospital Eugenio Espejo, in Quito. Three different datasets pertaining to burn deaths,
Ecuador
burn unit inpatient admissions, and hospital discharge were analyzed. Patients who died or
Alcohol burns
were discharged before entering the burn unit were not included in this analysis.
Electrical burns
Results: During the 10-year period, 1106 patients were admitted to the burn unit, men
Tissue bank
represent 69.37% with 768 cases and women represent 30.62% with 337 patients; the number
Quito
of patients per year was on average 123 cases; the average age was 33–34 years old, with a range between 16 and 96 years old. Heat (thermal) burns represent 65.78% followed by electrical with 30.53%, friction burns with 2.06%, and chemical burns with 1.62%. Domestic methane gas was the most frequent agent causing thermal burns and the most affected occupational groups are construction workers and people who stay at home. The overall mortality is 10.2% and the average length of stay was 23 days. Conclusions: Thermal burns are more frequent than any other cause of burns. Electrical burns are more frequent in Ecuador than anywhere else according to our research, meaning that control and prevention of workplace safety, urban planning, and home safety are scarce. The most affected groups are those dedicated to labor work. Finally, mortality in hospitalized patient is higher when compared with developed countries. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns represent one of the leading causes of death worldwide, placing these injuries as the fourth cause of mortality in 2004, representing a higher incidence than tuberculosis and HIV put
together [1]. Patients that suffer from burns can have physical, emotional, socioeconomic, and functional consequences that, in many cases, can be devastating. The worldwide incidence of fire-related burns was estimated to be 1.1 per 100,000 population, Southeast Asia being the most affected and America the least [1].
* Corresponding author at: Faculty of Medicine, Universidad de las Ame´ricas, Quito, Ecuador. Tel.: +59 3995760693. E-mail addresses: [email protected], [email protected] (E. Ortiz-Prado). http://dx.doi.org/10.1016/j.burns.2014.08.012 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 582–589
The importance of keeping track of the epidemiology of burns in a country comes from the need to find better public health policies focused mainly in workplace safety and home prevention. Additionally, by gaining an understanding of the epidemiology of burns, especially in developing countries, several strategies can be implemented in order to improve the efficiency of specialized health care for our patients. The number of burns in a population reflects socioeconomical aspects such as current labor conditions and inadequate urban planning. Data from several countries worldwide have shown that poverty and poor education are correlated with more severe burns [2,3]. Despite the fact that burn epidemiology has been described around the world, in South America, those reports are scarce and the data usually need to be extrapolated from other regions, including developed countries [2,4–9]. Current statistics show that in the United States around 400,000 patients require hospitalization in a burn unit every year, of which 3% die due to post-burn complications, compared to 20–30% mortality reported in the 1980s [10–12]. A European systematic review of 76 publications concluded that about 186,500 patients get burns per year in Europe [13], with a mortality rate between 1.4 and 18%, depending on the country. In global statistics, around 90% of mortality caused by burns originated in developing countries, which continue having a high mortality rate due to the lack of adequate prehospital and hospital care, smaller access to expensive treatments, lack of skin substitutes, and absent or nonfunctional tissue banks [14–19]. In Ecuador, there is no official record of burn epidemiology in adults. However, in 2005, Vernimmen et al. [20] published the demographic description of electrical burns in Hospital Luis Vernaza in Guayaquil, Ecuador; they specifically describe the risk factors of electrical burns, excluding all other types of burns. In 2007, Da´valos et al. published statistics of burns in pediatric patients hospitalized in one of the major hospitals in the country [21]. Da´valos et al. compared data from 2007 with those records reported in 2005, finding a reduction in mortality due to burns from 17% to 4.25% in the last report [21]. The lack of information about the incidence of burns in adults in Ecuador and deeper analysis of national mobility, mortality, and risk factors, lead us to collect this data, allowing us to describe the epidemiology, demographics, and socioeconomic factors involved with burns in Ecuador. The data collected in this study refer to patients hospitalized in the only specialized public hospital in Ecuador, its burn unit, and all the available data from all over the country from 2005 to 2014.
2.
Methods
This cross-sectional study was done using registered data from the National Institute of Statistics and the biggest government and public-funded burn unit. Data were collected from January 2005 to January 2014 at the Eugenio Espejo Hospital, this being the only specialized public hospital in Ecuador, which serves not only the city of Quito but also all the surrounding regions including part of the Amazon rainforest and the north part of the coast. This hospital has a burn unit
583
made up of 12 beds, of which only one is equipped for intermediate care. This hospital has a tissue bank, unlike any other public hospital in the country; however, it is not currently functioning due to the lack of capabilities.
2.1.
Selection and description of patients
The data used in this study are collected from patients that meet the admission criteria for the burn unit, which are the same criteria used for the American Burn Association [22–24]. The patients are adults or adolescents over 16 years old, which have suffered some kind of burn. These burns can be accidental, occupational, or self-injuries caused by heat, electrical, physical, or chemical sources. Patients with burns that did not require hospitalization were excluded as well as the patients who died in the emergency room or the intensive care unit without having entered the burn unit. Beside the data collected directly from the hospital, national statistics were used in order to have a broader approach, especially for the demographic data. The variables included in the study are age, sex, occupation, characteristics of the burn lesion (etiology, type, deepness, body part affected, and extension), arrival condition, date of release, and final condition.
2.2.
Technical information
All of the data of the patients included in the study were collected from their respective medical records and from the statistical files of the unit. These data were stored both manually and electronically. The nurses in charge of the burn unit collected each patient’s data, starting with the admission to the burn unit and including medical records, laboratory exams, images, and complementary studies. Each patient and their family members completed any missing information.
2.3.
Statistics
Considering this is the first analysis of its kind made in Ecuador, some of the statistical comparisons are made based on other countries and their populations. The information from the Ecuadorian National Institute of Statistics and Census is also taken into consideration, as well as the epidemiological data from the Eugenio Espejo Hospital. The statistical analysis includes a detailed description of the data to obtain the total distribution, calculating a series of measures of central tendency, the correlation between variables using Pearson correlation method and multiple ttest to show differences among groups. Graphics have been designed to help visualize the distribution, including pie charts, bar charts, as well as scatter plots, and linear models, in which the relationship between certain variables and morbidity and mortality is calculated, using linear regressions. The data were stored on a spread sheet in an XLS format from Microsoft1 Office. The statistics and graphics were analyzed and created, respectively, with SPSS17 software and Sigmaplot version 10. All of the bibliographic references and the full text have been retrieved through the Ovid, Pubmed, Scopus, and Google
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burns 41 (2015) 582–589
Fig. 1 – Age distribution of burned patients.
scholar databases search engines. References and citations were organized and managed with the Zotero software version 4.0.11.
3.
Results
The population included in this study is made up of 1106 patients, acquired over the period of time between 2005 and 2014. Of this population, men represent 69.37% of the people hospitalized in the burn unit with 768 cases and women represent 30.62% with 337 patients. The incidence of burns registered at the Eugenio Espejo Hospital is practically stable with a media of 123 cases per year. The relationship between man and woman is in average 2:1, respectively.
3.1.
Age
The average age of the patients admitted to the burn unit was between 33 and 34 years old, with a range between 16 and 96 years old. The age group most affected is the one most economically active (Fig. 1).
3.1.1.
Etiology
Considering the type of burn and its cause, the distribution is as expected according to the reviewed bibliography. The burns caused by flame are the most frequent, representing 65.78% followed by those caused by electricity that represent 30.53%. Burns caused by physical sources (100% caused by friction) represent 2.06%, and chemical burns 1.62% (Fig. 2). The data reveal the most frequent causes of the different types of burns are thermal. Within these groups, the most
Fig. 2 – Burns distribution according to its etiology.
burns 41 (2015) 582–589
585
Fig. 3 – Etiology of thermal burns.
frequent cause are those caused by domestic methane gas with 37.2% of cases, followed by gasoline with 24.2%, hot liquids with 20.09%, and open flames with around 8.40%. Alcohol caused 4.20% of the thermal burns, being risky ‘‘shamans’’ practices, the only cause reported (see Discussion Section) and a smaller percentage of burns caused by gunpowder, which according to our experience has been reduced when compared with years prior 2000 (Fig. 3). For electrical burns, direct contact makes up 65% of the causes (including three cases of lightening) while the rest were caused by an electrical arc, regarding chemical burns, 92% were caused by acid, and 100% of the physical burns were caused by friction causing ‘‘road rash’’ deep enough to require specialized attention.
3.1.2.
the results mentioned, it was curious to find that 1.2% of the patients suffered from burn lesions also presented a convulsive episode at the moment of the accident, relation that was not studied any further.
3.1.4.
Total Body Surface Area
The total body surface area (TBSA) burned or affected on average is 20%, the range that encloses the majority of burns is between 11% and 20% of TBSA, followed by TBSA of less than 10%. The third and fourth most frequent ranges of TBSA affected were 21–40% and 41–60%, respectively. The ones with the highest mortality rate were those with higher body surface burned (r = 0.11).
Body Part Burned
The burns reported are more likely to affect more than two regions at the same time representing 33.3% of the locations of the lesions. Burns affecting the head and neck affect 13%, hands and arms 17.5%, legs and feet together 21.2%, and inguinal region with less than 0.5% by itself (Fig. 4).
3.1.3.
Occupational Group
The patients that suffer from burn lesions treated at the Eugenio Espejo Hospital come from different social backgrounds, nevertheless, the more likely to be burned were those who perform labor jobs while ‘‘white collar’’ workers were the least likely to be burned. The most affected occupational groups are construction workers and people who stay at home, followed by industrial mechanical workers, and electricians (Figs. 5–7). Regarding the severity of the burns, people with whitecollar jobs and those who have an academic degree are those with less severe burns and shorter hospitals stays. It is interesting to point out that electrical burns are less frequently found among electricians, probably due to safety reasons and better work hazardous awareness. On the other hand, those who stay at home occupy 23.5% of the total number of burns, most of them affected by thermal burns, which are less severe than other types. In addition to
Fig. 4 – Burns distribution by body part affected.
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burns 41 (2015) 582–589
Fig. 5 – Burns distribution by patient’s activity.
3.1.5.
Hospitalization
The average amount of hospitalization for the patients in the burn unit during the period studied is of 23 days. Most of the patients that survived had a longer hospitalization period, mostly due to the gravity of those who died in the first days. The longest hospital stay was 180 days and the shortest stay was less than a day. The correlation between hospital stay and mortality was not calculated since the patients who died in the first 24 h were those with more severe burns. However, a relationship between hospitalization length and total body surface area affected is displayed (Fig. 8).
3.1.6.
were men and 32 were women, showing a mortality rate of 10.8% for men and 9.49% for women. The average age of the patients who died was 41 years old with a standard deviation of 21 years. Based on this data, the total mortality rate of our study is 10.38%. The mortality is directly proportional to the TBSA affected, the greater the surface the highest is the mortality. We also found that age is correlated with mortality, the patients who died were older than those who survived ( p = 0.005).
4.
Discussion
Mortality
Of all the patients registered in the burn unit over the 10 years period, 115 died during the hospitalization period, 83 of them
The epidemiological factors observed in the burn unit at Eugenio Espejo Hospital reflect the reality of our country. The
Fig. 6 – Distribution of electrical burns by patient’s activity.
burns 41 (2015) 582–589
587
Fig. 7 – Mortality versus total body surface area burned.
conditions of the burn unit and the outcome of the patients show that there is a need for improvement in order to lower the risk of morbidity, mortality, and the length of hospitalization. The patients who were admitted to the burn unit were those who met the American Burn Association criteria; however, we have not included those patients who died without entering the burn unit. We do not have the data at this moment, although we estimate that at least 50 patients died before even reaching the burn unit every year and another 100 patients are discharged directly from the E.R due to uncomplicated burns.
In Ecuador, males are twice as likely to get burned compared to females; this relationship 2.3:1 seems to be within the range described worldwide [4,14,15,25]. The conditions of the burn unit and the outcome of the patients show that mortality rates are a lot higher than in developed countries [3,22]. The data showed that lower income patients, according to the type of job, are more likely to be affected by burns and that these injuries tend to be deeper and more severe than those found in patients with ‘‘white collar jobs’’ [26,27]. This can prove that the system is not being as efficient as it should be. We also have to take into consideration the risk
Fig. 8 – Hospitalization length versus total body surface area burned.
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burns 41 (2015) 582–589
factors that the patients are exposed to. Most of the accidents that occur are preventable, considering many of them occur because of the lack of safety regulations. For this reason, it is important to focus on the etiology of the burn lesions to identify possible changes that could help prevent them like changing certain regulations of work safety in the country. Other studies have demonstrated that the affected population, when dividing by gender, differs depending on the country. In Iran, the ratio between men and women is 10:1 [28,29]. As many other report, there is a much larger proportion of men affected by burns than women. Since most injuries occur at the work place, the data show a direct relationship between the jobs that are more frequently occupied by men and the amount of burns. The average age shown in this study is comparable to the average age in studies done in different countries; however, for a developing country having a higher incidence of burns among the more economically active population can be devastating for their families, excluding the consequences in the patient’s wellbeing. In our environment, thermal burns are the most frequent, representing 65.78% of all the burn lesions. Thermal burns are more common than the other types of burn lesions due to the proximity of the population to many thermal sources, either at home or at work. Another important source of flame causing thermal lesions in our cohort was high concentrated ethylic alcohol used by medicine men also called ‘‘shamans’’ or ‘‘yachas.’’ We reported that 4.20% of the thermal lesions provoked by flames were caused by untrained ‘‘shamans’’ blowing alcohol (and smoking herbs) in front of a patient, in order to ‘‘scare away’’ the bad spirits. In our study, we found that electrical injuries are very high in comparison with other analysis worldwide [4,7,22,30–33]. For example, Ghaffar et al. [34] found a 16% incidence of electrical injuries in India in 2002; another study in Turkey [35] found a 21% incidence. The results are alarming; a very high incidence of electrical burns could demonstrate the absence of an organized urban structure puts people at risk due to the proximity of the high-tension cables to the ground, a situation that is uncommon in developed countries where electrical burns range from 1% to 6% of the total causes of burns [22,30,36,37]. Poor pre-hospital care, poor access to wide spectrum antibiotic, plasma replacements, expensive dressings, as well as the lack of tissue banks make the hospitalization less efficient and raises its cost. In the hospitals in the country that have a tissue bank, the procedure of choice is an escharectomy, followed by an immediate cover with autologous skin grafts to avoid infection and loss of extracellular fluids until full definite cutaneous coverage with artificial skin or that of the actual patient is achieved. This kind of procedures increase survival rate dramatically [38,39]. The cost of having a patient in the burn unit for 24 h is approximately $300 USD and 24 h of intensive care cost approximately $1000 USD [40]. These prices are considerably low when compared to the cost of these same units in other countries. Nevertheless, in Ecuador, the cost of treating a burn victim is much higher than it could be by implementing more
efficient treatments and hospital equipment. The change of work regulations to avoid many burns and an adequate training program for paramedics, physicians,and nurses working in rural areas functional and well-equipped burn units could help increase survival rates, decrease hospitalization, and save the country approximately $1,000,000 USD per year just by decreasing hospitalization in 50% [38,39,41]. The mortality rate in this study is of 10.8% and this number is reflected in the highest mortality rate once the TBSA reaches 50% or more.
5.
Conclusions
To our knowledge, this is the first and only long-term population-based study of burns performed in Ecuador. The data analyzed in this study provide important information regarding the socioeconomic factors related to a higher incidence of burns, the severity of those injuries, and the population groups that are the most affected. We concluded that despite the fact that burns are an important public health issue in Ecuador, there is also a considerable deficit regarding information of workplace safety regulations. Heat injuries are the most common type of burns followed by electrical lesions. The place where the accident occurred and the reason (accidentally, self-inflected, or intentionally) were not analyzed; however, accidents occurring at home among people who stay at home, cooks, or even students are alarming. Electrical burns are more frequent in Ecuador than anywhere else according to our research, meaning that control and prevention of workplace safety, urban planning, and home safety are scarce. Finally, the high mortality among severely burned patients compared with other regions, countries, and settings might be attributable to the lack of functioning tissue banks.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
A population-based study of the epidemiology of acute adult burns in Ecuador from 2005 to 2014 Esteban Ortiz-Prado a,b,c,*, Luciana Armijos c, Ana Lucia Iturralde d a
Faculty of Medicine, Universidad de las Ame´ricas, Quito, Ecuador Centro Internacional de Neurociencias, Quito, Ecuador c Universidad Yachay, Urcuqui, Ecuador d Universidad Tecnolo´gica Equinoccial, Quito, Ecuador b
article info
abstract
Article history:
Objectives: To describe the demographic, risk factor, occupational, and morbidity and
Accepted 18 August 2014
mortality characteristics of burns in adults in Ecuador using national data. These data
Keywords:
Methods: The National Institute of Statistics and Census provided data from the burn unit of
are from the only specialized public hospital in Ecuador that has a 12-bed burn unit. Burns
the Hospital Eugenio Espejo, in Quito. Three different datasets pertaining to burn deaths,
Ecuador
burn unit inpatient admissions, and hospital discharge were analyzed. Patients who died or
Alcohol burns
were discharged before entering the burn unit were not included in this analysis.
Electrical burns
Results: During the 10-year period, 1106 patients were admitted to the burn unit, men
Tissue bank
represent 69.37% with 768 cases and women represent 30.62% with 337 patients; the number
Quito
of patients per year was on average 123 cases; the average age was 33–34 years old, with a range between 16 and 96 years old. Heat (thermal) burns represent 65.78% followed by electrical with 30.53%, friction burns with 2.06%, and chemical burns with 1.62%. Domestic methane gas was the most frequent agent causing thermal burns and the most affected occupational groups are construction workers and people who stay at home. The overall mortality is 10.2% and the average length of stay was 23 days. Conclusions: Thermal burns are more frequent than any other cause of burns. Electrical burns are more frequent in Ecuador than anywhere else according to our research, meaning that control and prevention of workplace safety, urban planning, and home safety are scarce. The most affected groups are those dedicated to labor work. Finally, mortality in hospitalized patient is higher when compared with developed countries. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns represent one of the leading causes of death worldwide, placing these injuries as the fourth cause of mortality in 2004, representing a higher incidence than tuberculosis and HIV put
together [1]. Patients that suffer from burns can have physical, emotional, socioeconomic, and functional consequences that, in many cases, can be devastating. The worldwide incidence of fire-related burns was estimated to be 1.1 per 100,000 population, Southeast Asia being the most affected and America the least [1].
* Corresponding author at: Faculty of Medicine, Universidad de las Ame´ricas, Quito, Ecuador. Tel.: +59 3995760693. E-mail addresses: [email protected], [email protected] (E. Ortiz-Prado). http://dx.doi.org/10.1016/j.burns.2014.08.012 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 582–589
The importance of keeping track of the epidemiology of burns in a country comes from the need to find better public health policies focused mainly in workplace safety and home prevention. Additionally, by gaining an understanding of the epidemiology of burns, especially in developing countries, several strategies can be implemented in order to improve the efficiency of specialized health care for our patients. The number of burns in a population reflects socioeconomical aspects such as current labor conditions and inadequate urban planning. Data from several countries worldwide have shown that poverty and poor education are correlated with more severe burns [2,3]. Despite the fact that burn epidemiology has been described around the world, in South America, those reports are scarce and the data usually need to be extrapolated from other regions, including developed countries [2,4–9]. Current statistics show that in the United States around 400,000 patients require hospitalization in a burn unit every year, of which 3% die due to post-burn complications, compared to 20–30% mortality reported in the 1980s [10–12]. A European systematic review of 76 publications concluded that about 186,500 patients get burns per year in Europe [13], with a mortality rate between 1.4 and 18%, depending on the country. In global statistics, around 90% of mortality caused by burns originated in developing countries, which continue having a high mortality rate due to the lack of adequate prehospital and hospital care, smaller access to expensive treatments, lack of skin substitutes, and absent or nonfunctional tissue banks [14–19]. In Ecuador, there is no official record of burn epidemiology in adults. However, in 2005, Vernimmen et al. [20] published the demographic description of electrical burns in Hospital Luis Vernaza in Guayaquil, Ecuador; they specifically describe the risk factors of electrical burns, excluding all other types of burns. In 2007, Da´valos et al. published statistics of burns in pediatric patients hospitalized in one of the major hospitals in the country [21]. Da´valos et al. compared data from 2007 with those records reported in 2005, finding a reduction in mortality due to burns from 17% to 4.25% in the last report [21]. The lack of information about the incidence of burns in adults in Ecuador and deeper analysis of national mobility, mortality, and risk factors, lead us to collect this data, allowing us to describe the epidemiology, demographics, and socioeconomic factors involved with burns in Ecuador. The data collected in this study refer to patients hospitalized in the only specialized public hospital in Ecuador, its burn unit, and all the available data from all over the country from 2005 to 2014.
2.
Methods
This cross-sectional study was done using registered data from the National Institute of Statistics and the biggest government and public-funded burn unit. Data were collected from January 2005 to January 2014 at the Eugenio Espejo Hospital, this being the only specialized public hospital in Ecuador, which serves not only the city of Quito but also all the surrounding regions including part of the Amazon rainforest and the north part of the coast. This hospital has a burn unit
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made up of 12 beds, of which only one is equipped for intermediate care. This hospital has a tissue bank, unlike any other public hospital in the country; however, it is not currently functioning due to the lack of capabilities.
2.1.
Selection and description of patients
The data used in this study are collected from patients that meet the admission criteria for the burn unit, which are the same criteria used for the American Burn Association [22–24]. The patients are adults or adolescents over 16 years old, which have suffered some kind of burn. These burns can be accidental, occupational, or self-injuries caused by heat, electrical, physical, or chemical sources. Patients with burns that did not require hospitalization were excluded as well as the patients who died in the emergency room or the intensive care unit without having entered the burn unit. Beside the data collected directly from the hospital, national statistics were used in order to have a broader approach, especially for the demographic data. The variables included in the study are age, sex, occupation, characteristics of the burn lesion (etiology, type, deepness, body part affected, and extension), arrival condition, date of release, and final condition.
2.2.
Technical information
All of the data of the patients included in the study were collected from their respective medical records and from the statistical files of the unit. These data were stored both manually and electronically. The nurses in charge of the burn unit collected each patient’s data, starting with the admission to the burn unit and including medical records, laboratory exams, images, and complementary studies. Each patient and their family members completed any missing information.
2.3.
Statistics
Considering this is the first analysis of its kind made in Ecuador, some of the statistical comparisons are made based on other countries and their populations. The information from the Ecuadorian National Institute of Statistics and Census is also taken into consideration, as well as the epidemiological data from the Eugenio Espejo Hospital. The statistical analysis includes a detailed description of the data to obtain the total distribution, calculating a series of measures of central tendency, the correlation between variables using Pearson correlation method and multiple ttest to show differences among groups. Graphics have been designed to help visualize the distribution, including pie charts, bar charts, as well as scatter plots, and linear models, in which the relationship between certain variables and morbidity and mortality is calculated, using linear regressions. The data were stored on a spread sheet in an XLS format from Microsoft1 Office. The statistics and graphics were analyzed and created, respectively, with SPSS17 software and Sigmaplot version 10. All of the bibliographic references and the full text have been retrieved through the Ovid, Pubmed, Scopus, and Google
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Fig. 1 – Age distribution of burned patients.
scholar databases search engines. References and citations were organized and managed with the Zotero software version 4.0.11.
3.
Results
The population included in this study is made up of 1106 patients, acquired over the period of time between 2005 and 2014. Of this population, men represent 69.37% of the people hospitalized in the burn unit with 768 cases and women represent 30.62% with 337 patients. The incidence of burns registered at the Eugenio Espejo Hospital is practically stable with a media of 123 cases per year. The relationship between man and woman is in average 2:1, respectively.
3.1.
Age
The average age of the patients admitted to the burn unit was between 33 and 34 years old, with a range between 16 and 96 years old. The age group most affected is the one most economically active (Fig. 1).
3.1.1.
Etiology
Considering the type of burn and its cause, the distribution is as expected according to the reviewed bibliography. The burns caused by flame are the most frequent, representing 65.78% followed by those caused by electricity that represent 30.53%. Burns caused by physical sources (100% caused by friction) represent 2.06%, and chemical burns 1.62% (Fig. 2). The data reveal the most frequent causes of the different types of burns are thermal. Within these groups, the most
Fig. 2 – Burns distribution according to its etiology.
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Fig. 3 – Etiology of thermal burns.
frequent cause are those caused by domestic methane gas with 37.2% of cases, followed by gasoline with 24.2%, hot liquids with 20.09%, and open flames with around 8.40%. Alcohol caused 4.20% of the thermal burns, being risky ‘‘shamans’’ practices, the only cause reported (see Discussion Section) and a smaller percentage of burns caused by gunpowder, which according to our experience has been reduced when compared with years prior 2000 (Fig. 3). For electrical burns, direct contact makes up 65% of the causes (including three cases of lightening) while the rest were caused by an electrical arc, regarding chemical burns, 92% were caused by acid, and 100% of the physical burns were caused by friction causing ‘‘road rash’’ deep enough to require specialized attention.
3.1.2.
the results mentioned, it was curious to find that 1.2% of the patients suffered from burn lesions also presented a convulsive episode at the moment of the accident, relation that was not studied any further.
3.1.4.
Total Body Surface Area
The total body surface area (TBSA) burned or affected on average is 20%, the range that encloses the majority of burns is between 11% and 20% of TBSA, followed by TBSA of less than 10%. The third and fourth most frequent ranges of TBSA affected were 21–40% and 41–60%, respectively. The ones with the highest mortality rate were those with higher body surface burned (r = 0.11).
Body Part Burned
The burns reported are more likely to affect more than two regions at the same time representing 33.3% of the locations of the lesions. Burns affecting the head and neck affect 13%, hands and arms 17.5%, legs and feet together 21.2%, and inguinal region with less than 0.5% by itself (Fig. 4).
3.1.3.
Occupational Group
The patients that suffer from burn lesions treated at the Eugenio Espejo Hospital come from different social backgrounds, nevertheless, the more likely to be burned were those who perform labor jobs while ‘‘white collar’’ workers were the least likely to be burned. The most affected occupational groups are construction workers and people who stay at home, followed by industrial mechanical workers, and electricians (Figs. 5–7). Regarding the severity of the burns, people with whitecollar jobs and those who have an academic degree are those with less severe burns and shorter hospitals stays. It is interesting to point out that electrical burns are less frequently found among electricians, probably due to safety reasons and better work hazardous awareness. On the other hand, those who stay at home occupy 23.5% of the total number of burns, most of them affected by thermal burns, which are less severe than other types. In addition to
Fig. 4 – Burns distribution by body part affected.
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Fig. 5 – Burns distribution by patient’s activity.
3.1.5.
Hospitalization
The average amount of hospitalization for the patients in the burn unit during the period studied is of 23 days. Most of the patients that survived had a longer hospitalization period, mostly due to the gravity of those who died in the first days. The longest hospital stay was 180 days and the shortest stay was less than a day. The correlation between hospital stay and mortality was not calculated since the patients who died in the first 24 h were those with more severe burns. However, a relationship between hospitalization length and total body surface area affected is displayed (Fig. 8).
3.1.6.
were men and 32 were women, showing a mortality rate of 10.8% for men and 9.49% for women. The average age of the patients who died was 41 years old with a standard deviation of 21 years. Based on this data, the total mortality rate of our study is 10.38%. The mortality is directly proportional to the TBSA affected, the greater the surface the highest is the mortality. We also found that age is correlated with mortality, the patients who died were older than those who survived ( p = 0.005).
4.
Discussion
Mortality
Of all the patients registered in the burn unit over the 10 years period, 115 died during the hospitalization period, 83 of them
The epidemiological factors observed in the burn unit at Eugenio Espejo Hospital reflect the reality of our country. The
Fig. 6 – Distribution of electrical burns by patient’s activity.
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Fig. 7 – Mortality versus total body surface area burned.
conditions of the burn unit and the outcome of the patients show that there is a need for improvement in order to lower the risk of morbidity, mortality, and the length of hospitalization. The patients who were admitted to the burn unit were those who met the American Burn Association criteria; however, we have not included those patients who died without entering the burn unit. We do not have the data at this moment, although we estimate that at least 50 patients died before even reaching the burn unit every year and another 100 patients are discharged directly from the E.R due to uncomplicated burns.
In Ecuador, males are twice as likely to get burned compared to females; this relationship 2.3:1 seems to be within the range described worldwide [4,14,15,25]. The conditions of the burn unit and the outcome of the patients show that mortality rates are a lot higher than in developed countries [3,22]. The data showed that lower income patients, according to the type of job, are more likely to be affected by burns and that these injuries tend to be deeper and more severe than those found in patients with ‘‘white collar jobs’’ [26,27]. This can prove that the system is not being as efficient as it should be. We also have to take into consideration the risk
Fig. 8 – Hospitalization length versus total body surface area burned.
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factors that the patients are exposed to. Most of the accidents that occur are preventable, considering many of them occur because of the lack of safety regulations. For this reason, it is important to focus on the etiology of the burn lesions to identify possible changes that could help prevent them like changing certain regulations of work safety in the country. Other studies have demonstrated that the affected population, when dividing by gender, differs depending on the country. In Iran, the ratio between men and women is 10:1 [28,29]. As many other report, there is a much larger proportion of men affected by burns than women. Since most injuries occur at the work place, the data show a direct relationship between the jobs that are more frequently occupied by men and the amount of burns. The average age shown in this study is comparable to the average age in studies done in different countries; however, for a developing country having a higher incidence of burns among the more economically active population can be devastating for their families, excluding the consequences in the patient’s wellbeing. In our environment, thermal burns are the most frequent, representing 65.78% of all the burn lesions. Thermal burns are more common than the other types of burn lesions due to the proximity of the population to many thermal sources, either at home or at work. Another important source of flame causing thermal lesions in our cohort was high concentrated ethylic alcohol used by medicine men also called ‘‘shamans’’ or ‘‘yachas.’’ We reported that 4.20% of the thermal lesions provoked by flames were caused by untrained ‘‘shamans’’ blowing alcohol (and smoking herbs) in front of a patient, in order to ‘‘scare away’’ the bad spirits. In our study, we found that electrical injuries are very high in comparison with other analysis worldwide [4,7,22,30–33]. For example, Ghaffar et al. [34] found a 16% incidence of electrical injuries in India in 2002; another study in Turkey [35] found a 21% incidence. The results are alarming; a very high incidence of electrical burns could demonstrate the absence of an organized urban structure puts people at risk due to the proximity of the high-tension cables to the ground, a situation that is uncommon in developed countries where electrical burns range from 1% to 6% of the total causes of burns [22,30,36,37]. Poor pre-hospital care, poor access to wide spectrum antibiotic, plasma replacements, expensive dressings, as well as the lack of tissue banks make the hospitalization less efficient and raises its cost. In the hospitals in the country that have a tissue bank, the procedure of choice is an escharectomy, followed by an immediate cover with autologous skin grafts to avoid infection and loss of extracellular fluids until full definite cutaneous coverage with artificial skin or that of the actual patient is achieved. This kind of procedures increase survival rate dramatically [38,39]. The cost of having a patient in the burn unit for 24 h is approximately $300 USD and 24 h of intensive care cost approximately $1000 USD [40]. These prices are considerably low when compared to the cost of these same units in other countries. Nevertheless, in Ecuador, the cost of treating a burn victim is much higher than it could be by implementing more
efficient treatments and hospital equipment. The change of work regulations to avoid many burns and an adequate training program for paramedics, physicians,and nurses working in rural areas functional and well-equipped burn units could help increase survival rates, decrease hospitalization, and save the country approximately $1,000,000 USD per year just by decreasing hospitalization in 50% [38,39,41]. The mortality rate in this study is of 10.8% and this number is reflected in the highest mortality rate once the TBSA reaches 50% or more.
5.
Conclusions
To our knowledge, this is the first and only long-term population-based study of burns performed in Ecuador. The data analyzed in this study provide important information regarding the socioeconomic factors related to a higher incidence of burns, the severity of those injuries, and the population groups that are the most affected. We concluded that despite the fact that burns are an important public health issue in Ecuador, there is also a considerable deficit regarding information of workplace safety regulations. Heat injuries are the most common type of burns followed by electrical lesions. The place where the accident occurred and the reason (accidentally, self-inflected, or intentionally) were not analyzed; however, accidents occurring at home among people who stay at home, cooks, or even students are alarming. Electrical burns are more frequent in Ecuador than anywhere else according to our research, meaning that control and prevention of workplace safety, urban planning, and home safety are scarce. Finally, the high mortality among severely burned patients compared with other regions, countries, and settings might be attributable to the lack of functioning tissue banks.
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