Comparison of mortality and mean hospital stay between patients with burns in upper and lower extremities in Southern Iran
Subgroup: Volume 9, Issue 4
Date: October 2007
Type: Original Article
Start Page: 201
End Page: 204
- M Amini Assistant Professor of Department of Surgery,Faghihi Hospital,Shiraz University of Medical Sciences, Shiraz, fars, Iran
- M Kherad Registered nurse,Faghihi Hospital,Shiraz,ran, Shiraz, Fars, Iran
- R Sadeghimehr of nursing,Office of Vice Chancellor for Clinical Affairs,Shiraz University of Medical Sciences, Shiraz, Fars, Iran
- AA Mohammadi Department of Surgery,Faghihi Hospital,School of Medicine, Shiraz, Fars, Iran
City, Province: Shiraz, fars
Tel: 98 9171121917
Background: Burn injury according to severity, extent and organ involvement leads to different mortalities and morbidities. Considering burn injuries of similar extent, the mortality related to lower extremity seems to be higher than that of upper extremity. This study was performed to compare the mortality and mean hospital stay between two groups of burn patients with upper and lower extremities admitted to Ghotbeddin Hospital during a two years period.
Methods: The present retrospective study encompassed 322 patients aged from 15-40 years with 45% females and 55% males and burns of 15%-40% during a two years period. Depending on 2/3 or more of total burns; they were divided into two groups with burns in the upper and lower extremities.
Results: Upon comparison of the mean hospital stay and mortality rate, it was shown that the mean hospital stay in those with burns of lower extremity was two weeks, which was longer than that in patients with upper extremity burns. Mortality in lower extremity burns was about 10% more than that of upper extremity.
Conclusion: It seems that treatment of lower extremity burns along with appropriate planning for intensive care of this organ would help reduce mortality, save time and lower costs.
Keywords: Hospital stay; Mortality; Lower extremity; Upper extremity; Burns
Burn causes different complications with various mortality rates based on the severity and the organs involved.1 Although hands constitute only 3% of the total body surface area (TBSA), more than 70% of treatments belong to hand burns which occur more frequently among workers and at work places.2 According to a study including 1705 burn patients during a 10 yeans period, the incidence of hand burn was 54% of the total burn of upper extremities with a mean of 15% of TBSA.3 Foot burns involve a specialized area of function and although they comprise a small TBSA (3.5%), they can cause a significant degree of morbidity. This is caused by the fact that foot burns often require prolonged bed rest. Time lost from work along with the length of hospitalization and high risk of complications result in a high financial as well as emotional cost to the individual.4,5 Treatment of foot burns depends on the depth of injury. The data concerning pain control of burns with superficial partial thickness, early bed rest and elevation for up to 3 days to manage edema, multiple daily dressings with frequent observation, splinting of the foot, as well as commonly used topical antibiotics, usually used as part of the dressings and commonly prophylactic systemic antibiotics,4 and.6 The aggressive management of superficial partial thickness foot burns to prevent infection may prevent progression of a superficial partial thickness burn into a deep partial thickness burn which is known to occur with infection.5 Treatment of a full thickness burn is usually by eschar excision and wound coverage by a skin graft,5 Early complications such as infection, cellulitis, delayed wound healing, graft loss and late complications such as dryness, pruritis, hyperkeratosis, ulceration, keloid and hypertrophic scarring, scar contractures, decreased range of movement, altered gait patterns and complex regional pain syndrome were documented in the literature.4,6-8 In regard to lower extremity burns, admission to a hospital is usually needed, because they involve a larger surface of the body. Hospitalization of subjects with burn in lower extremity includes 5 to 10% of all hospital admissions. Boiling water, hot oil, and chemical or electric shock usually causes burn in this organ. The mean age of patients affected by burn of lower extremity was reported to be 25 years.9 It seems that morbidity due to burns in lower extremities will result in a higher mortality compared to those of upper extremities with the same degree of severity. In view of the foregoing and with respect to subsequent complications of pulmonary burn, this study was conducted to compare the mortality and mean hospital stay of patients, admitted to Ghotbeddin Hospital, with burns in upper to those involving lower extremities, undergoing the same treatment and rehabilitation during a two years period.
Materials and Methods
The present study comprised 322 patients, 45% females and 55% males, and aged from 15-40 years (31±8 SD) with burn degrees of 15%-40% admitted to Ghotbeddin Hospital affiliated to Shiraz University of Medical Sciences from April 2003 to April 2004. Patients with pulmonary burn or background diseases such as diabetes, cardiovascular disorders, asthma, epilepsy and those who were discharged with their own consent were excluded from the study. The data were collected during the study in relation to age, extent of burn, duration and stage of burn in different parts of the body and the ultimate condition of patients (dead or discharged). Depending on 2/3 or more of total burns; the patients were divided into two groups with burns in the upper and lower extremities. Also, considering the extent of burn (15%-25%, 26%-35% and more), data were collected with regard to the age of patients (15-25 and 26-40 years-old). The wound site was cleansed by sterile saline solution and povidin iodine and then covered by Silvadin ointment and sterile dressing that were changed twice daily. This protocol is used in Iran and other developing countries as a preferable method for burn treatment. A routine physiotherapy procedure is routinely carried out for rehabilitation of burn patients. The duration of stay and mortality rates of the patients in both groups were compared in relation to the age. Children aged less than 15 years due to their lack of cooperation and patients older than 40 years because of their debilitating diseases, including possible cardiovascular disorders and diabetes were excluded from the study. The reason for considering the extent of 15-40% burns in present study was the zero mortality in relation to burns of less than 15% and increasing fatality due to burns of more than 40%. Independent t test was used for comparison of MHS in subgroups with different age and varying burn extent. Chi Square and Fisher Exact tests were employed for comparing mortality rates whenever appropriate.
The mean hospital stay (MHS) in patients aged less than 25 years with 15-25% burns, and more than 2/3 of
burns in their lower extremities were 26±2.6 days. However, under similar conditions, MHS for patients with burns
in their upper extremities was 11±1.2 days (P=0.001). On the other hand, MHS in relation to 26-40% burns,
with more than 2/3 of burns being in lower extremities, was 31±3.1 days, whereas under the same condition,
MHS in patients with burns in their upper extremities was 21±4.3 days (P=0.005). The MHS in 40% or higher
of the patients suffering from burns in lower extremities was 41±3.8 days against 21±2.3 days (P=0.001), in
those with similar burns of upper extremity. MHS in subjects older than 26 years and with 15 to 25% burns was
21±3.8 days, while 2/3 of burns being in their lower extremities, against 14±2.8 days for those with burns of the
same extent in their upper extremities (P=0.001). MHS in patients with 26-40% burns and more than 2/3 of burns
being in their lower extremities was 28±4.1 days in contrast to 20 days±3.5 days for patients with burns of similar extent
in the upper extremities (P=0.003). As for the group with more than 40% of burn in their lower extremities, the MHS was 24±3.5 days
against 18±2.8 days for patients with burn in the upper extremities (P<0.001). The mortality rates in patients younger and older than 25 years
with more than 2/3 of burns in upper and lower extremities and in regard to 15%-25%, 26%-40% and more than 40% burns. However, no mortality
was observed in patients suffering from 15-25% burn in their upper and lower extremities and aged less than 25 years. A mortality rate of 17.5% and 14%
occurred in patients with 25-40% burn in the lower and upper extremities respectively (P=0.6). Respective mortality rates of 29% and 8% were observed in
patients with 40% burns in the lower and upper extremities (P=0.005). A zero mortality rate was noted in patients older than 25 years with 15%-25% burns in the
upper and lower extremities, but in regard to 25%-40% burns, the corresponding mortalities for lower and upper extremities were 27% and 12% (P=0.008). In patients
with more than 40% burn, mortality associated with lower extremities was 45% against 25% in connection with upper extremity (P=0.005).
The pathological changes produced by thermal injury to the hands have a multifactorial origin. After thermal injury, progressive loss of hand function may result from the direct effect of heat, being secondary to immobilization, disuse atrophy, soft-tissue loss, contracture formation, bacterial wound colonization, decreased circulation, inappropriate splint, or the formation of edema in connective tissues. The treatment of hand burn is important due to the activity and beauty of the organ and the effect on the patient's morale.10 The treatment of burn in lower extremities is usually associated with some problems causing long term mortality and is often associated with complications, such as cellulitis, organ rejection, chronic pain, prolonged hospitalization and loss of motion. Patients with large total body surface area (TBSA) burns and involvement of the lower extremities frequently sustain injuries to the dorsum of the lower extremity. Early dressing of the lower extremity burn injuries allows faster ambulation and rehabilitation. Pressure garments, splints, and physical therapy are the first line of therapy to assist in wound recovery, improved range of motion and prevention of burn scar contractures.11 The long-term rehabilitation in lower extremity burns is difficult to achieve, because of being refractory to treatment, chronic and long term swelling and severe adhesiveness, injury to tendons and ligaments, peripheral neuropathy and the abnormality in bone shapes. The final result of patients’ treatment depended on the depth and extent of burn, the involved organ, the patients’ health before burn and their age.12 Foot burns are often colonized by microorganisms from the surrounding skin, which reflects the presence of multiple organisms. Prophylactic systemic antibiotics were given to most of our cases with foot burns, treated either as in or out patients, a practice accounting for lower infection rate.13 In our center, systemic antibiotics were given to treat all burn patients as documented by other studies,4,6 but local antibiotics were only used as prophylactic treatment. Depending on the burn, a variety of dressings, including Aqaucel Ag, were used for adults to reduce pain, and frequent changes of dressings allowed earlier mobilization and decreased inpatient stay.14 We used Silvadin ointment and sterile dressing which were changed twice daily. The length of hospitalization varied from 1 to 70 days, with MHS of 7 days in patients with isolated foot burn.13 In our study, MHS in different groups varied from 21 to 41 days. Therefore, especial attention should be paid to this organ in addition to routine measures for treatment of burn in other areas of body particularly with respect to reducing MHS and mortality. There is no difference between treatments of burns in lower extremities and other organs in our setting. Thus, using elastic bandage, the patients should be given bed rest with their feet elevated as well as passive physiotherapy in order to prevent edema and leakage of fluid and protein from the wound.15 Also priority given to early debridment and graft for the lower extremity,16 helped treat such patients. Our results showed that MHS of patients with various burn extents in lower extremities was approximately two weeks longer compared to those admitted due to burn of the same extent in the upper extremities. As for the mortality rate in these patients, no difference was observed between subjects less than 25 years and older age group with less than 25% burn. In regard to burns of more than 25%, the mortality rate corresponding to lower extremity was approximately 10% higher than those of upper extremity. Burn injury usually involves multiple organs with various functions in activity and survival and demanding different treatment protocol. As some organs are more susceptible to infections, which spread faster to other sites, inappropriate treatments may cause partial or complete loss of organ activity or lead to patient’s death. A fast rehabilitation may lead to decreasing disability or mortality and increasing patients' self-esteem, improving their morale and cooperation in addition to a short MHS and cost- effectiveness. The following factors could help decrease burn complications: 1) Adjustment of joint position during immobilization after graft. 2) To decrease immobilization period after graft. 3) To increase daily frequency of physiotherapy and to customize it according to patient's condition.10 It seems that treatment of lower extremity burns along with appropriate planning for intensive care of this organ would help reduce mortality, save time and lower costs.
The authors would like to thank Dr. D. Mehrabani at Center for Development of Clinical Studies of Nemazee Hospital for editorial assistance.
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