Outcome of burn injury and associated factor among patient visited at Addis Ababa burn, emergency and trauma hospital: a two years hospital-based cross-sectional study

Human skin and other underlying organs can be destroyed or damaged by burns [1] and categorized according to extent of damage to the body part [1]. Timely adequate resuscitation decrease both mortality and nonfatal complications associated with burn injury [1‐3]. According to a WHO report of 2018, over 200-300,000 people die from fire-related burns annually, disproportionately in low and middle-income countries of African and Asian countries [4‐6]. 90% of burn occurs in low and middle-income countries [7]. And also WHO 2018 report shows that around 265,000 burn-related deaths occur annually. Most of them occur in low and middle-income African and Asian countries accounting for more than 90% of death [8‐11]. Death by burn injury in low- and middle-income countries (LMICs) is estimated to be eleven times higher than in high-income countries as the World Health Organization (WHO) estimated that 43,000 people die of burns in Africa every year with a rate of 6.1 per 100,000 [12]. In the USA, one million people seek medical care for burns annually, with an estimated mortality rate of 3 – 5% [13]. Most burns occur at home, causes being due to scald and flame [14]. Different studies reported that children are most at risk for burn injuries [15‐21]. Most studies highlight younger males and older females as most at risk for burn injuries [15‐19, 22], although some showed no clear differences between the sexes [21, 23]. Scald and contact injuries appear to be the most common [15‐17, 22, 23], often as a result of bathing or cooking, however, flame injuries, as well as electrical and chemical burns, are common in some areas [21]. In the studies describing the location of the burn injuries, the extremities – particularly the upper extremities – are the most common locations for suffering burn injuries, especially in scald and contact burns. The lower extremities are more commonly affected by flame injuries [17, 21, 23]. Many studies highlight the home, particularly the kitchen, as the most common location for sustaining burn injuries [15‐18, 22]. Children under the age of five who sustained burn injuries were 69% and over 70% of burns are sustained at home [24, 25]. Even if the trend of burning is decreasing in most developed nations, the problem is still on a rise in most developing countries including Ethiopia [4, 8, 26]. Mortality and morbidity are burdened more in developing countries [8‐10, 26]. Each year approximately about 11 million peoples suffer from burns making almost 30,000 new burn injuries per day with an annual mortality rate of around 200,000 to 300,000 per year [8, 13]. The rate of burn-related deaths has been declining in many high-income nations, whereas it is currently nearly 7 times greater in low- and middle-income countries than in high-income ones for children [4, 13]. Non-fatal burn injuries are also a leading cause of morbidity including prolonged hospitalization, disfigurement, and disability often resulting in stigma and rejection [4, 11, 27]. In Europe, the in-hospital crude mortality ranges from 1.4% to 18% and is mostly influenced by regional economic conditions and variations in the case mix (TBSA percent) [2]. America, Eastern Medetrinian, and the Western Pacific regions, which are grouped as underdeveloped countries, account for 1.3, 0.02, and 0.6%, not even 2% combined of global mortality due to fires related death, respectively [8]. A study from a major burn center in Southwest China shows improvement from time to time as early intervention and prevention were applied. The mortality rate from the research result was 0.9 % [26]. In sub-Saharan African countries the severity and mortality rate is different in a different country with an average mortality rate of 17%, a death of one for every five burn victim [5]. In some African countries, the Mortality rate exceeds the average one. E.g. Togo 24.6% [28], Malawi 27% [29].

The outcome of the burn depends on the age and sex of the patient, burn surface area, depth of burn, burn site, type of burn, time of arrival to the hospital, getting appropriate resuscitation, presence of comorbidities as well as presence of rehabilitative center with the trained practitioner [11, 26, 30‐32]. Inhalational injury is an independent risk factor for death [31, 33]. The commonest age of burn injury is 5 -14 years with the highest mortality rate in children less than 5 years and elderly greater than 70 years [10]. A study done in Taiwan reported that those aged over 65 years constitute 13- 20% of admissions to burn units n [34]. Females in South-East Asia have the highest fire-related burn mortality rates worldwide, followed by males in Africa and females in the Eastern Mediterranean [10, 34]. Burns greater than 15% in an adult and greater than 10% in a child have a poor prognosis [4, 11]. The mortality rate is higher for those that have higher TBSA%, third rather than second-degree burn, and inhalational injury [8, 34, 35]. Developing nations show low engagement rate than developed countries, probably because other competing diseases need to be controlled [8]. Advances in critical care (fluid resuscitation, nutritional assistance, and antibiotic treatment), as well as the adoption of early burn wound excision, play a substantial role in this improved survival rate [2]. Mortality and non-fatal injuries depend on several factors including age, sex, place of residency, economic status, involved site, depth, TBSA % involved, co-morbidity, time arrival to the emergency department, pre-hospital care, and presence of trained staff in giving the appropriate level of care [1, 4, 34]. A community-based study in Northern Ethiopia showed that the most commonly affected age group were children less than 10 years of age, and scald burn and domestic settings are the predominant causes and settings responsible for burns in the pediatric population, respectively [36, 37]. Different studies showed that the majority of burn patients were discharged without complication [14, 36, 38, 39]. In Ethiopia burn accounts for 1.5% to 9% of injuries in all age groups and between 4% and 15% of injuries in the pediatric population with an estimated mortality rate of 11.6% [8, 40]. The mortality rate according to a study conducted in Addis Ababa, Ethiopia was 11.6% [41]. In a rural community survey in Ethiopia, burns were the second most common injury to children under 15 years of age [13]. Research done at Bahir-dar, Ethiopia showed that 0.46% of pediatric female populations were more affected than males [42]. In Ethiopia, there is little research conducted related to burn injury and they focused on pattern and causative factors mainly, not the outcome of burn injury. The available information’s also somewhat incomplete [43]. After burn injuries were raised as a major health problem in the country, AaBET hospital was established to give care to burn and trauma victims 6 years ago. Since then, the hospital continued to give care to such victims. Since its establishment however published data on the outcome of burn injuries is not yet available. Therefore the significance of this study will be to assess the outcome of burn injury and its associated factor among burn patients who visited the hospital. This study is to analyze the outcome of burn injury and its associated factor among patients who visited AaBET Hospital from April 1, 2019, to march 30, 202.

The outcome of burn injury is affected by different factors. These factors are divided into four groups. The Conceptual framework shown in the figure below helps to summarize the relationship between outcomes of burn injury with its associated factor (Fig. 1).

Our study conducted a review for two consecutive years (from April 1, 2019, to March 31, 2021) on the outcome of burn injury, Most burn victims were Adults whose age range is from 15 to 60 years, which accounts for about 54.7% of the study population. This is comparable to a study done by S.Triphate & S.J.Basenet, Nepal, India which accounts for about 65.4% [46]Predominance of adult age is also described in South Africa and Singapore. The predominance can be explained by the fact that they are the most active groups and are exposed to hazardous environments both at home and at the workplace. In this study males also predominate females with a male-to-female ratio of 1.23:1. The result is consistent with the study of N.A. Forbinake, Cameroon, which consists of 68.3% [47]. The reason may be males are more participants in hazardous workplaces like industries with faulty electrical wires Adults and boys are more active than girls in the pediatric age group. Since the workplace and events during the accident were difficult to access due to the nature of the study and not assessed in this study, we couldn’t conclude specifically. A contemporary, study done by Tesfaye Mulat, Yekatit 12, Addis Ababa, Ethiopia shows female predominance which consists 64.5 % [48]as well by S.Triphate & S.J.Basenet, Nepal which accounts for 55.6 % [46]. This study is explained by the fact that females are predominantly involved in household activities that strongly correlate with fire and hot liquids like cooking and baking. On top of that, they usually handle fire in relatively open spaces [46, 49].

The most frequent cause of injury is scald which accounts for 39% followed by Flame, Electrical and chemical burn (33.6%, 26.8%, and 0.8% respectively). This result was also shown in a study by Tesfaye Mulat, Yekatit 12 hospital but according to S.J.Basenet, Nepal, India Flame was the commonest cause [46, 48, 50]. The variety could be due to population distribution and cultural variation. Scald burn is the number one cause in the pediatric population but adults are affected more by electrical and flame burns. Electrical burn currently shifts epidemiology from previous studies [51]. Usually Male is more affected than a female with a male-to-female ratio of 6.1:1 and adults are more prone than pediatrics with a ratio of 6.7:1. The children’s attitude in playing (stay) at home or in the kitchen with their mother or guardians where drinks and liquid foods are being prepared with inadequate supervision and inability to protect themselves may explain why scald commonest in children. Electrical burn as described earlier, work area exposed male adults are most commonly affected [46, 47, 49, 52]. Moreover, flame burn injuries were the second most common (33.6%) frequent cause of burn injury in this study. It accounts for 75% of elderly’s burns and is the most common cause of burn-in in Female patients with a ratio of females to males of 2.3:1. Asa described earlier working environment will explain it well [6, 53].

The median TBSA% was 10.5% with a mean of 15.49%, SD of 13.78%, and a range from 1- 64%. It is slightly lower than the study done by Tesfaye Mulat, Yekatit 12 Hospital, Addis Ababa, in which the mean was 17.2% [48]. TBSA %< 10 % is the most common accounting almost for half of the cases (49.4%) and higher than the study of Frehiwot Girma, Bahirdar Ethiopia, in which total body surface area was mean of 12.56 and SD OF 8.91% [49, 52]. Higher TBSA% (>20%) is more observed on flame burn than others [49]. This may be due to the nature of the offending agent and the duration of contact with it. A study by Aditya Wardhana, Indonesia shows that the mean TBSA% was 26.7% (range from 0.5% to 100%). This could be due to most patients' sustained flame burn (50%) [54]. The most observed degree of burn is superficial second-degree burn accounting for 39.4%. Pediatric age groups encountered more superficial second-degree burns while adults and the elderly commonly full thickness burns. This could be due to cause of the degree of burn, in which, scald more cause first-degree burn and second-degree superficial while flame and electrical burn cause full thickness & Second degree burn [40, 43, 53, 55].

The upper extremity is the most affected body part and is involved in 63.1% of followed by the Lower extremity (56%), anterior trunk (45.6%), face (24.5%), posterior trunk (21.6%), neck (17.8%), Head (12.4%) and Genitalia (5%). In 73% of the case, there is the involvement of two or more body parts involvement. This is higher but consistent in part involved from a study done in another region of Ethiopia like 43.3% in a study of Frehiwot Girma, Bahirdar, Ethiopia [49] and 45.4% in a study Sielu Alemayehu, Ayder, Mekele, Ethiopia [3]. This could be due to the nature of an offending agent and personal response to the circumstance of events. Twelve burn victims (5 %) had associated injuries in which 3 people (1.2 %) had blunt chest trauma with hemothorax, 3 people (1.2%) had extremity fractures (1 femoral shaft and 2 clavicular fracture) and 6 (2.5%) had a mild head injury(1 victim had minimal subdural hematoma). 7.5% of all burn victims had comorbidity epilepsy prevalent in 13 patients (5.4%). Other comorbidities include pregnancy (3, 1.2%), hypertension (2, 0.8%), psychiatric illness (2, 0.8%), diabetes mellitus, and retroviral infection (1, 0.4% each). Epilepsy is mentioned in various types of research as the commonest comorbidity in 5.6% in a study of S.Triphate & S.J.Basenet, Nepal, 4.1% in a study of Aditya Wardhana, Indonesia, and 7.8 % in frehiwot Girma, Bahirdar, Ethiopia [46, 49, 54]. This could be due risky nature of the disease to end up with a fall at an unsafe place including on causative agents of burn.

Most of the patients come to this hospital by referral system. Among them, 75.6% of patients received some sort of treatment which include, Resuscitation fluid, analgesia, wound care, oxygen administration, fasciotomy, or a combination of them. Gaps are observed in handling the patient, starting available appropriate treatment, and documentation as well as delays in the referral system. This could affect most unstable patients in getting definite management. A similar problem is faced in other countries like Indonesia (according to Aditya Wardhana study), in which, patients wait for a longer time to get a referral to a territory center where the subspecialists are available [54]. This is due to the scarcity of facilities as well as equipment and manpower faced by most developing countries.

In our hospital, all patients had been given necessary routine care but 50% of them needed advanced care including endotracheal intubation and other surgical intervention. According to endotracheal intubation (8, 3.3%), skin graft (106, 44 %), wound debridement (44, 17.1%), tissue flap (17, 7.1%), contracture release (15, 6.2%) and fasciotomy (5. 2.1%) had been done. When comparing to the study of Tesfaye Mulat, Yekatit 12 hospital, Addis Ababa, a surgical operation done here was low. According to this study, 74.7% of patients had delayed splint skin grafts. This may be due to the low sample size (121), the nature of the burn, or improvement in the care of the patient in our hospital [48].

Thirty six point one (36.1%) of burn victims develop at least one early complication while staying in this hospital. The top complication was burn wound site infection (30.7%) and Burn wound sepsis (22%) followed by Anemia of hemoglobin less than 10 g/dl ( 26.1%), hospital-acquired pneumonia HAP (10%), Septic shock (6.2%), CAUTI (4.6%), respiratory failure (4.1%), hospital-acquired infection of unknown origin (1.7%), arrhythmia (1.7%), COVID 19 infection (1.7%) and Bedsore (1.2%). hyponatremia in 37.5 %, Hypokalemia in 18.4%, hyperkalemia in 8.2%, and hypernatremia in 10.1% are the most encountered electrolyte abnormality. 6.2% had a Creatinine of > 1.2g/dl which possibly suggests acute kidney injury. This result is consistent with the study done by N.A. Forbinake in Cameroon [47].

After all, 241 burn patients 189(78.4%) were discharged without complications, 36(14.9%) were Discharged with complications and 16(6.6%) died. The commonest long-term complication is amputation of the extremity (19, 7.9%) followed by contracture (14, 5.8%) and hypertrophic Scar of skin graft or wound (3, 1.2%). The death rate is improved from Tesfaye Mulat study in Yekatit 12, which was 11.6% as well in most African countries like Cameroon (N.A. Forbinake study, 23.4%) [47], Malawi (G. Virich study, 26.4%) [56, 57], Nigeria(A.O. Olandele and J.K Olabanji study, 26%) [58] and some Asian country like Indonesia (Aditya Wardhana study, 24%) [54] and Nepal (S.Triphate & S.J.Basenet study, 25.4%) [46]. Of all death, septic shock was identified as the immediate cause of death in 8 patients (50%) followed by multi-organ dysfunction (MOD) in 4 patients (25%), respiratory failure in 3 patients (18.8%), and arrhythmia in 1 patient (6.3%). There is agreed data from Nepal and Cameroon with the commonest cause of death as septicemia with septic shock followed by MOD, acute respiratory distress syndrome (ARDS) as well acute renal failure, and severe anemia [46, 47].

In General, in this study, of 241 burn patients 189(78.4%) were discharged without complications, 36(14.9%) were discharged with complications and 16(6.6%) died. This is comparable with those conducted in East Africa (7.1%) [59], and Mekele (6.0%) [60]. However, it is higher than studies conducted in the USA at 0.85% [61], Nigeria at 3.8% [39], Egypt at 2.5% [62], Iraq (4.7 %) [63], Dutch (3.2%) [64], Turkey (3.8%) [65], and Pakistan 2.35% [66]. The discrepancy might be explained by the lack of infrastructure, ambulance service, and health facilities in our study setting. This discrepancy might also be due to the lack of burn unit centers in our study setting, and the lack of trained and experienced health professionals dedicated to the care of burn patients compared to the mentioned studies [65]. The finding in this study is lower than a study conducted in Ghana (21.3%) [67], and Tanzania (11.7%) [68]. This discrepancy might be due to the difference in socio-demographic characteristics, and due to the reason that studies in mentioned countries were conducted in tertiary hospitals which are prone to have overflows of burn patients throughout their country and increases the rate of mortality in the hospitals [67, 69, 70]. On the other hand, in our study-setting complex and complicated burn cases are referred to in another area, which might decrease the mortality rate in the study setting.

According to this study in multivariable logistic regression analysis, age > 60 years and TBSA% greater than 30% were significantly associated with burn mortality. The odds of mortality among burn patients were 2.206 times higher among burn patients aged> 60 years than those aged < 15 years [AOR=2.206 (95% CI, 1.323-3.69)]. This study is similar to different studies which showed that the mortality risk was higher in older patients [71, 72]. Natural age advancement impairs wound healing significantly and makes aged burn patients more prone to infections and associated complications and worsens the clinical outcome [73]. Older persons are affected by burns and the resources required to meet their needs may be higher due to their long periods of hospitalization [74].

Regarding the extent of burn injury, the risk of mortality among burn patients was 8.72 times higher in burn patients who had TBSA% greater than 30 than those who had TBSA<10% [AOR=8.72 (95% CI, 1.32-57.33)]. The bigger the burn, the greater the risk of the subsequent burn wound and systemic infections, which are directly associated with increased morbidity and mortality [75, 76]. In this study total body surface area, greater than 30% of burn was times more likely (AOR 8.72; 95% CI 1.32–57.33) to die compared to less than 10% burn area. This study is consistent with the study done in South Gondar zone government hospitals [77], and Bahir Dar, Ethiopia [78]. This is supported by the scientific evidence of those who have a larger body surface area of burn are prone to complex fluid shifts, including system-wide extravasation of fluids into unburned tissues. This results in resultant intravascular hypervolemia which can produce ischemia to body organs, lactic acidosis, and eventual cardiovascular collapse [79, 80], which increases the risk of mortality and complications.

The commonest cause of burn was scald burn. Electrical burns and flame burns are more common in adult and elderly age groups. Extremities were by far, the commonest affected body parts. The mortality rate decreased significantly from previous studies. But, disability up on discharge remains high. The extent of burn injury and the age of the patient independently predict the mortality of the patient. Therefore, timely identification and monitoring of burn injury should be necessary to prevent the mortality of burn victims, and it is highly recommended to give priority to preventive measures and improve pre-hospital care service.

Overall the mortality rate shows a decrement from previous studies as compared to a study done at another site. But burning is still a burden for our countries. To decrease mortality and morbidity, we recommend the following;