Burn injuries are a significant cause of morbidity and mortality throughout the world. Burn injuries perhaps represent the widest spectrum of any form of trauma. Burns occur in all age groups and may range in severity, from very minor requiring no treatment to extremely severe requiring highest level of intensive treatment. Burn is a public health problem, accounting for an estimated 180,000 deaths annually worldwide. The burden of burn is unevenly distributed throughout the world. The majority of these deaths occur in low- and middle-income countries (LMICs), and almost half occur in the Southeast Asian region, including Nepal. Burns are among the leading causes of disability adjusted life-years lost in LMICs. Burns are the third most common cause of injury in Nepal, followed by fall injuries and road traffic accidents.
Burn injuries result in lifelong physical and psychological scarring, causing pain and influencing mental health and quality of life. The injuries can be caused by friction, cold, heat, radiation, chemical, or electric sources, but the majority of burn injuries are caused by heat from hot liquids, solids, or fire. Although all burn injuries involve tissue destruction due to energy transfer, different causes can be associated with different physiological and pathophysiological responses. The particular cause of a burn injury determines the treatment approach. For example, although deep thermal burns are operated on immediately, the same approach would be an error in frostbite, in which the therapy of choice is moist re-warming, possible thrombolysis, and watchful waiting. Although information on burn epidemiology is essential for resource allocation and prevention, the available data is variable and inconsistent. An epidemiological study is a prerequisite for planning and implementing prevention programs in communities. Different strategic planning is required, based on the cultural and socio-economic status of the region.
Mr. Hemanta Dhoj Joshi
Q&A with an expert
Here, in this issue, we reached out to burn expert Mr. Hemanta Dhoj Joshi, who is the chief coordinator of ReSurge International Surgical Outreach Program (RISOP), Phect Nepal-Kirtipur Hospital, to ask about burn-related issues and their treatment available in Nepal.
What are the common causes of burn and scald?
Flame burns are the commonest cause of burns. Falling of children into pots containing hot liquid is the commonest cause of scalding.
Which age groups are more prone to burn injuries?
Women and children are the largest groups.
What are the things that you would like to share regarding burn injuries and awareness that would save lives?
We should focus on prevention. Pouring running room temperature water just after a burn injury for half-an-hour is very important to limit the extent and depth of burn injury. After that, they should call a toll-free number for help and guidance in treatment—16 60 01 1 51000 from NTC number or 9851051749, 9851061490, 9841295062 from any number for help.
Are burn injuries and acid incidents similar?
Both cause burns, but the number of people who suffer from these two different kinds of burns are very different. Only a few cases of acid burns are seen, compared to thousands of flame burns. Acid burns are usually inflicted by others, while flame burns are mostly accidental.
What are the degrees of burn and chances of recovery?
Burns can be first degree, second degree, third degree, or even fourth degree, depending upon how deep it is. First degree is very superficial, just like a sun burn. Second degree burns cause blisters. Third degree burn causes damage of the whole thickness of skin, while fourth degree burns are deep and expose bones and joints, or through the full thickness of abdomen and chest wall. Chances of recovery depend upon many factors, but most important ones are how extensive or how deep the injury is. Any deep burns involving more than 40% total body surface area (TBSA) has very high mortality, especially in places where there is no skin substitute or cadaveric skin available for treatment. Patients at the extreme of ages also do not do as good. Patients who already had some other health issues, such as diabetes, respiratory problems, or concomitant injuries also do not do well. Chances of recovery are also very low if patients with major burns (20% or more TBSA burns in adults and 10% or more in children) do not receive resuscitative fluid, either through mouth or via intravenous route for the first 24 hours uniformly have very high mortality rates. This is the main reason why we cannot save many of our patients who have major burns and are coming from far away, since our ambulances do not have any paramedic to continue the IV or oral fluid resuscitation. It is very important to keep these patients in the same peripheral hospitals for the first 24 hours of injury for fluid resuscitation, which every doctor knows how to do. A call at 16 60 01 1 51000 will connect us with the patient and treating medical team, so that we can guide the treatment from Kathmandu. With the use of smartphones, we can see the patients, estimate the extent and depth of burn, and institute fluid resuscitation plan as well as wound care till the patient gets transferred to a burn center.
What are the physiological and psychological complications in a patient?
Patients with major burns have effects of burns in the whole body, rather than just over the burned area. The fluid from our blood vessels leaks out, causing very little fluid to be available in the blood vessels for circulation, which delivers oxygen and other nutrients all over the body. The patient will be in shock if not treated properly within the first 24 hours. Fluid resuscitation should be started as soon as the patient receives running water on the burn areas for half an hour. Jeevan Jal could be an alternative to intravenous fluid in situations where IV cannot be given. The volume of the resuscitation fluid is calculated according to the body weight of the patient and extent of burn (TBSA). Physiological complications are the reason for the death of many of burn injuries patients. Patients also need psychological support throughout the treatment, and even afterwards.
What is reconstructive surgery?
Reconstructive surgery is the branch of surgery that reconstructs the body parts damaged by diseases or injury. It is also used for reconstructing deformed parts of the body at birth. Injuries lead to deformities and disabilities, but reconstructive surgeries will restore normal or near-normal function of the body parts. Public Health Concern Trust-Nepal has been providing this service free-of-cost to poor people in Kirtipur Hospital and in five outreach centers (Biratnagar, Butwal, Chitwan, Pokhara, and Nepalgunj) with help from ReSurge International.
What are the available and advanced surgical procedures?
These surgical procedures are performed by trained plastic and reconstructive surgeons who are very few in Nepal. Phect Nepal has put together a team of 14 such highly-trained reconstructive surgeons who provide these services at Kirtipur Hospital as well as five outreach centers. Advanced surgical procedures, such as microsurgical free tissue transfer, skin banking, etc. are available at Kirtipur Hospital.
Everybody should know that running water should be poured onto the burned areas as soon as possible for half an hour. Then the toll free number should be called immediately—16 60 01 1 51000 (sora saathi sunna ek, ekaunna hazar) for further help.