Flame Burn Injury in Yichang of China:the Trends,Complications,and Risk Factor Analysis

Lixia WEN,Weimin WU,* ,Yunbo JIN ,Bo ZHOU ,Lei WU ,Yapeng LIU ,Ying HU

ABSTRACT Background A flame burn is an injury of body tissues,including respiratory tract damage,due to exposure to a flame or its dense smoke.Flame burns cause some of the most physically and psychologically devastating forms of trauma.Compared to scald burns,flame burn patients have a higher mortality rate and a higher frequency of multiorgan failure.The purpose of this research was to investigate the trends,complications,and mortality risk factors of flame burns at the Department of Plastic and Burn Surgery (DPBS)of the People’s Hospital of China Three Gorges University (PHCTGU).Methods A retrospective analysis of 48 flame burn patients — accounting for 8.3% of the 576 burn victims admitted for burns at the PHCTGU from February 1,2010,to September 30,2019— was performed after collecting information from the Burns Registry of the said hospital.Results The proportion of patients with flame burns was 8.3% (n=48).The mean total body surface area (TBSA) affected was 27.6%.The mean duration of hospitalization was 32.5 days.The etiologies of the flame burns were as follows:gas explosions (21,43.8%),ethanol (8,16.7%),charcoal fire (7,14.6%),petrol explosions (4,8.3%),wooden houses(4,8.3%),and others,including dust,cigarette lighter,and burning incense,accounting for 8.3% of cases (4).Finally,42 (87.5%) patients were treated and discharged,and 6(12.5%) patients died.Complications included scarring in 38 (90.5%) patients,severe scar contractures on different parts of the body in 25 (60.0%) patients,scar ulcer in 6(14.3%) patients,keloids in 3 (7.1%) patients,and scar cancer in 1 (2.4%) patient.Multiple complications occurred in the same patient.The only risk factor for mortality that was identified was TBSA (P=0.043).Conclusions Our study revealed that a small population (8.3%) was injured by flame burns,but 6 deaths were recorded.Society must continually enhance safeguard procedures to flames and strengthen education to protect life and avoid severe complications.

KEY WORDS Flame burn;Trend;Complications;Mortality risk factors

INTRODUCTION

A flame burn is an injury of the body tissue caused by exposure to a flame,which often leads to deep burns.At the same time,inhalation burn injury might occur,especially in large-scale fires[1-2],which greatly increases the associated morbidity and mortality,especially in patients with severe burns[3].Scald burns often occur in children,while flame burns occur more frequently in adults[4-5].Generally speaking,poor accommodation is recognized as a risk factor for flame burns,although there are different risk factors in different countries because of the different cultures and customs[6].

The clinical features are diverse depending on the surroundings of the flame,the route of escape,the site of the body injured,the time of exposure to the flame and the TBSA affected.Timely rescue can reduce injury.Since more than 300 000 people die of flame burns annually and more deaths are a result of burns for other reasons,such as hot liquid scalds and electrical and chemical burns,the World Health Organization (WHO) recognizes burns as a major public health problem worldwide[7].With the improvement of education and the popularization of medical protection knowledge in China,the incidence of burn injuries is decreasing year by year.However,the incidence of flame burns caused by gas is increasing.Most flame accidents are preventable,and over 90% of burn-related deaths occur in the low-income and povertystricken areas in China.According to the severity of the burns,the patients may have to undergo plastic restoration and reconstruction to improve deformities and functions caused by scar contractures or other complications.Many survivors may be disabled or disfigured in their entire lives,suffer from adverse physical and psychological effects,and are usually discriminated against by others[6].

In the present study,we aimed to analyze the trends,complications,and mortality risk factors of flame burn patients in the eastern region of the Three Gorges who were admitted to the PHCTGU.

MATERIALS AND METHODS

Research Background

The PHCTGU,located in Yichang,Hubei Province,currently operates with 1 700 beds.The DPBS of the PHCTGU is the only provincial key clinical specialty on burns in the eastern region of the Three Gorges,which burdens the treatment of burn victims from Yichang,Enshi,Shennongjia,and the eastern area of Chongqing.All hospitalized burn victims receiving active treatment were included in this study.However,outpatients and 11 inpatients who were transferred to another hospital after immediate care were excluded.Ethical clearance for this study was obtained from the ethics committee of the PHCTGU.

Data Collection

The Burns Registry at the DPBS of the PHCTGU,containing information on patients who were admitted for flame burns from February 1,2010,to September 30,2019,was consulted.Data on age,sex,etiology,profession,anatomical sites,TBSA,type of reconstruction,complications,and functional outcomes were obtained from the registry.

Data Analysis

Data were analyzed using SPSS version 21.0.Descriptive statistics were used to display information,and logistic regression analysis was used to analyze the risk factors for mortality.

RESULTS

There were 48 flame burn patients,accounting for 8.3% of the total 576 burn victims in the DPBS of the PHCTGU from February 1,2010,to September 30,2019.The mean TBSA was 27.6%,ranging from 0.5% to 98%.The mean duration of hospital stay in DPBS was 32.5 days.Basic data on the cases of flame burns in this study are presented in Table 1.

Table 1 General data on flame burn patients in this study

Some pictures of the cases are shown in Figs.1-4.The mean age of the patients with flame burns was 39.0 years(range,1-74 years).The study participants included 31 men (64.6%) and 17 women (35.4%).Most of the people burned by fire were between 40 and 49 years old (Fig.5).The etiologies of the flame burns were as follows (Fig.6):gas explosions (21,43.8%),ethanol (8,16.7%),charcoal fire (7,14.6%),petrol explosions (4,8.3%),wooden houses (4,8.3%),and other reasons,including dust,cigarette lighter,burning incense,etc.,accounting for 8.3% (4).For the other patients with non-flame burn injury (n=528),there were 438 scald patients,61 electrical burn patients,and 29 chemical burn patients.The professions referring to the occurrence of flame burns were 24 farmers,9 laborers,5 housewives,5 preschool children,3 students,and 2 chefs (Fig.7).The sites where the flame burn damage occurred were workplaces (24,50%),homes (15,31.3%),restaurants (6,12.5%),and beauty salons (3,6.3%)(Fig.8).The affected area of the burned body included the whole body (10),head (5),face (18),neck (17),trunk (5),upper limbs (14),lower limbs (8),hip (3),and genitalia (2) (Fig.9).A tracheotomy was performed on 8 patients with extensive burns,with 5 of them receiving mechanical ventilation.The survivors did not show any respiratory complications.Finally,42 (87.5%)patients were discharged,while 6 (12.5%) patients died(Fig.10).

Fig.1 98% TBSA burned by a gas flame

Fig.2 95% TBSA burned by a charcoal flame

Fig.3 Photographs of a male patient with deep burns of the left shoulder from a gas flame.(A) Deep burn of the left shoulder due to a gas flame.(B) Two weeks after debridement (C) Free skin grafting during the surgery.(D) Ten days after surgery,the grafted skin survived.

Fig.4 Photographs of a female patient with neck scar contracture from alcohol flame.(A-B) Neck scar contracture caused by an alcohol flame.(C-D) Two weeks after surgery (contracture release and full-thickness skin grafting).

Fig.5 Age distribution and flame burns

Fig.6 Flame burn sources (n=48)

Fig.7 Occupation and flame burns

Fig.8 Sites of flame burns

Fig.9 Anatomical sites of the flame burn patients

Fig.10 Outcomes of the flame burn patients

Mortality Risk Factors

Logistic regression analysis was used to analyze the risk factors for mortality.“Deaths (functional outcome)”were used as the dependent variable,while all the demographic features of the participants were used as the independent variables;these included age,sex,etiology,occupation,site,TBSA,type of reconstruction,and complications.The threshold for statistical significance was set atP＜0.05.The TBSA was associated with mortality(P＜0.05),the odds ratio of the TBSA was 1.095,and the 95% confidence interval was 1.003-1.196 (Table 2).

Table 2 Logistic regression of the mortality risk factors

DISCUSSION

Fire plays an important role in daily life.However,severe complications and even death could be caused by fire burns.The skin is the organ most vulnerable to damage,while internal burn damage could also be caused by inhalation impairment[6].Complications in our study included scar,scar contracture,scar ulcer,keloid,and scar cancer,which is consistent with many other reports[8-17].Patients with scars and contractures after burns often cannot completely recover their entire life.Limited extension of the burnt neck,elbow,wrist,ankle joint,or other joint movements,even claw-hand or claw-foot deformity,may be caused by scar contracture,which has been reported by other authors[10-17].Scar contracture after ocular burns often results in the periocular area and eyelid ectropion[18].More seriously,Istek et al.[19]demonstrated that a 2-yearold boy was blind in both eyes as a result of a severe flame burn.Burn recovery is usually an arduous,costly,lengthy,and endless process associated with physical and psychological challenges[20].Unlike developed countries that possess relatively perfect measures for burn prevention,developing countries do not have enough epidemiological surveys in many regions and safeguard procedures[21].Some reasons,such as ignorance and poverty,are thought to be associated with the high incidence of burns in developing countries[22].In the present study,we aimed to explore the characteristics of fire burns in the eastern part of the Three Gorges region and the factors influencing the consequences,and summarize the defensive measures.

Our data showed that men were more likely to suffer fire burns than women,with a ratio of 1.82:1.Most of the patients (29.2%) in our study were between 40 and 49 years old,followed by those aged 30-39 years and those aged more than 60 years.People aged 30-49 years were more likely to be exposed to flames because of their work requirements.Runyan et al.[23]reported that the rate of mortality and non-fatal injury due to fire burns are higher among children (＜ 5 years) and older adults (＞ 60 years).Older people (＞ 60 years) also had higher rates of flame burns (14.6%) in our study;this finding was different from that of Ben et al.,who reported that only a small proportion of older people (＜ 5%) suffer fire burns on the ship[24].This could be attributed to the fact that older people with cold intolerance are more likely to be exposed to flames because of warming from wood or charcoal in winter.It is remarkable in the eastern mountains of the Three Gorges,where villagers like to warm themselves with huge fire pits,which is different from many other regions in China.However,certain people basking themselves,such as those doing so after drinking,those with syncope,and those with epilepsy,are at greater risk of falling into the fire pit,which often causes severe and deep fire burns.

Farmers and laborers were the most vulnerable groups in this study.This was because,in this area,they were often the breadwinners of poor families and sometimes were helplessly engaged in jobs without security.Flame burns were most common in the workplace (50%) and at home (31.3%) in our study.Song et al.[25]demonstrated a 9.5% decrease in occupation-related burns because of an improvement in fire prevention and management in the industrial sector.Legislation on safeguards for industrial sectors should be strengthened,and dangerous operations must be prohibited.In the United States,fire accidents in homes account for over three-quarters of fire-related fatalities and injuries.In the present study,flame burns at home were often caused by gas pipe explosions during cooking or warm by fire pits.Flame burns also occurred due to accidents in unattended preschool children playing with cigarette lighters and incense.The most effective way to reduce home fires and burn damage is to use smoke alarms,which can reduce the mortality from home fires by at least 50%[26].Automatic fire sprinklers are also protective measures that can reduce fire impairments and deaths[26].Studies have shown that the mortality rate is reduced by 93% when using automatic fire sprinklers and smoke alarms at the same time,and no deaths have been reported in single-family homes in British Columbia,Canada[26].In addition,we should strengthen the regular maintenance of natural gas pipelines and closely supervise the elderly and children.

In addition to homes and work-related places,gas explosions also occurred twice on hotpot tables at poorlyequipped restaurants,causing group burn injuries.Therefore,gas was the most common source of fire in our study.This category of injuries is caused by a combination of blunt trauma and burns[27-28].It is very important to regularly overhaul gas pipelines to maintain civil safety.Alcohol was the second most common source of fire in the present study,which is consistent with the results of other research[29].

In the current study,the most frequent anatomical sites of damage were the face and neck,followed by the upper limbs.This could be because these parts of the body are often exposed to the etiology of the burn.Al-Shamsi et al.[30]reported that the mortality risk factors of burns were TBSA and suicidal tendencies.Zheng Y et al.[31]reported that in southwest China,the major risk factors for burnrelated death included burns resulting from explosions,shock,age (aged 0-1 or ≥ 50 years),greater TBSA,and full-thickness burn area.Mortality is associated with the TBSA and the occurrence of inhalation injury in different categories of burned children[32],which is consistent with the findings of our study only on flame burns.

CONCLUSIONS

Flame burns are responsible for deaths.Complications of flame burns include scars,scar contractures,scar ulcers,keloids,and scar cancer;thus,skin flaps or free skin grafting might be required for reconstruction.In particular,severe scar contracture caused by flame burns could lead to a limited extension of different joints,causing different types of dysfunction.Long-term scar ulcers can lead to malignant changes.Mortality is associated with TBSA and inhalation injuries.Preventive measures and citizen education should be intensified to minimize the occurrence of flame burns.

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

This study received ethical approval from the Ethics Committee of the People’s Hospital of the Three Gorges University.All participants provided written informed consent before study enrollment.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare no conflicts of interest.The authors state that the views expressed in the article are their own and not the official position of the institution or funder.