- •Preface
- •List of contributers
- •History, epidemiology, prevention and education
- •A history of burn care
- •“Black sheep in surgical wards”
- •Toxaemia, plasmarrhea, or infection?
- •The Guinea Pig Club
- •Burns and sulfa drugs at Pearl Harbor
- •Burn center concept
- •Shock and resuscitation
- •Wound care and infection
- •Burn surgery
- •Inhalation injury and pulmonary care
- •Nutrition and the “Universal Trauma Model”
- •Rehabilitation
- •Conclusions
- •References
- •Epidemiology and prevention of burns throughout the world
- •Introduction
- •Epidemiology
- •The inequitable distribution of burns
- •Cost by age
- •Cost by mechanism
- •Limitations of data
- •Risk factors
- •Socioeconomic factors
- •Race and ethnicity
- •Age-related factors: children
- •Age-related factors: the elderly
- •Regional factors
- •Gender-related factors
- •Intent
- •Comorbidity
- •Agents
- •Non-electric domestic appliances
- •War, mass casualties, and terrorism
- •Interventions
- •Smoke detectors
- •Residential sprinklers
- •Hot water temperature regulation
- •Lamps and stoves
- •Fireworks legislation
- •Fire-safe cigarettes
- •Children’s sleepwear
- •Acid assaults
- •Burn care systems
- •Role of the World Health Organization
- •Conclusions and recommendations
- •Surveillance
- •Smoke alarms
- •Gender inequality
- •Community surveys
- •Acknowledgements
- •References
- •Prevention of burn injuries
- •Introduction
- •Burns prevalence and relevance
- •Burn injury risk factors
- •WHERE?
- •Burn prevention types
- •Burn prevention: The basics to design a plan
- •Flame burns
- •Prevention of scald burns
- •Conclusions
- •References
- •Burns associated with wars and disasters
- •Introduction
- •Wartime burns
- •Epidemiology of burns sustained during combat operations
- •Fluid resuscitation and initial burn care in theater
- •Evacuation of thermally-injured combat casualties
- •Care of host-nation burn patients
- •Disaster-related burns
- •Epidemiology
- •Treatment of disaster-related burns
- •The American Burn Association (ABA) disaster management plan
- •Summary
- •References
- •Education in burns
- •Introduction
- •Surgical education
- •Background
- •Simulation
- •Education in the internet era
- •Rotations as courses
- •Mentorship
- •Peer mentorship
- •Hierarchical mentorship
- •What is a mentor
- •Implementation
- •Interprofessional education
- •What is interprofessional education
- •Approaches to interprofessional education
- •References
- •European practice guidelines for burn care: Minimum level of burn care provision in Europe
- •Foreword
- •Background
- •Introduction
- •Burn injury and burn care in general
- •Conclusion
- •References
- •Pre-hospital and initial management of burns
- •Introduction
- •Modern care
- •Early management
- •At the accident
- •At a local hospital – stabilization prior to transport to the Burn Center
- •Transportation
- •References
- •Medical documentation of burn injuries
- •Introduction
- •Medical documentation of burn injuries
- •Contents of an up-to-date burns registry
- •Shortcomings in existing documentation systems designs
- •Burn depth
- •Burn depth as a dynamic process
- •Non-clinical methods to classify burn depth
- •Burn extent
- •Basic principles of determining the burn extent
- •Methods to determine burn extent
- •Computer aided three-dimensional documentation systems
- •Methods used by BurnCase 3D
- •Creating a comparable international database
- •Results
- •Conclusion
- •Financing and accomplishment
- •References
- •Pathophysiology of burn injury
- •Introduction
- •Local changes
- •Burn depth
- •Burn size
- •Systemic changes
- •Hypovolemia and rapid edema formation
- •Altered cellular membranes and cellular edema
- •Mediators of burn injury
- •Hemodynamic consequences of acute burns
- •Hypermetabolic response to burn injury
- •Glucose metabolism
- •Myocardial dysfunction
- •Effects on the renal system
- •Effects on the gastrointestinal system
- •Effects on the immune system
- •Summary and conclusion
- •References
- •Anesthesia for patients with acute burn injuries
- •Introduction
- •Preoperative evaluation
- •Monitors
- •Pharmacology
- •Postoperative care
- •References
- •Diagnosis and management of inhalation injury
- •Introduction
- •Effects of inhaled gases
- •Carbon monoxide
- •Cyanide toxicity
- •Upper airway injury
- •Lower airway injury
- •Diagnosis
- •Resuscitation after inhalation injury
- •Other treatment issues
- •Prognosis
- •Conclusions
- •References
- •Respiratory management
- •Airway management
- •(a) Endotracheal intubation
- •(b) Elective tracheostomy
- •Chest escharotomy
- •Conventional mechanical ventilation
- •Introduction
- •Pathophysiological principles
- •Low tidal volume and limited plateau pressure approaches
- •Permissive hypercapnia
- •The open-lung approach
- •PEEP
- •Lung recruitment maneuvers
- •Unconventional mechanical ventilation strategies
- •High-frequency percussive ventilation (HFPV)
- •High-frequency oscillatory ventilation
- •Airway pressure release ventilation (APRV)
- •Ventilator associated pneumonia (VAP)
- •(a) Prevention
- •(b) Treatment
- •References
- •Organ responses and organ support
- •Introduction
- •Burn shock and resuscitation
- •Post-burn hypermetabolism
- •Individual organ systems
- •Central nervous system
- •Peripheral nervous system
- •Pulmonary
- •Cardiovascular
- •Renal
- •Gastrointestinal tract
- •Conclusion
- •References
- •Critical care of thermally injured patient
- •Introduction
- •Oxidative stress control strategies
- •Fluid and cardiovascular management beyond 24 hours
- •Other organ function/dysfunction and support
- •The nervous system
- •Respiratory system and inhalation injury
- •Renal failure and renal replacement therapy
- •Gastro-intestinal system
- •Glucose control
- •Endocrine changes
- •Stress response (Fig. 2)
- •Low T3 syndrome
- •Gonadal depression
- •Thermal regulation
- •Metabolic modulation
- •Propranolol
- •Oxandrolone
- •Recombinant human growth hormone
- •Insulin
- •Electrolyte disorders
- •Sodium
- •Chloride
- •Calcium, phosphate and magnesium
- •Calcium
- •Bone demineralization and osteoporosis
- •Micronutrients and antioxidants
- •Thrombosis prophylaxis
- •Conclusion
- •References
- •Treatment of infection in burns
- •Introduction
- •Clinical management strategies
- •Pathophysiology of the burn wound
- •Burn wound infection
- •Cellulitis
- •Impetigo
- •Catheter related infections
- •Urinary tract infection
- •Tracheobronchitis
- •Pneumonia
- •Sepsis in the burn patient
- •The microbiology of burn wound infection
- •Sources of organisms
- •Gram-positive organisms
- •Gram-negative organisms
- •Infection control
- •Pharmacological considerations in the treatment of burn infections
- •Topical antimicrobial treatment
- •Systemic antimicrobial treatment (Table 3)
- •Gram-positive bacterial infections
- •Enterococcal bacterial infections
- •Gram-negative bacterial infections
- •Treatment of yeast and fungal infections
- •The Polyenes (Amphotericin B)
- •Azole antifungals
- •Echinocandin antifungals
- •Nucleoside analog antifungal (Flucytosine)
- •Conclusion
- •References
- •Acute treatment of severely burned pediatric patients
- •Introduction
- •Initial management of the burned child
- •Fluid resuscitation
- •Sepsis
- •Inhalation injury
- •Burn wound excision
- •Burn wound coverage
- •Metabolic response and nutritional support
- •Modulation of the hormonal and endocrine response
- •Recombinant human growth hormone
- •Insulin-like growth factor
- •Oxandrolone
- •Propranolol
- •Glucose control
- •Insulin
- •Metformin
- •Novel therapeutic options
- •Long-term responses
- •Conclusion
- •References
- •Adult burn management
- •Introduction
- •Epidemiology and aetiology
- •Pathophysiology
- •Assessment of the burn wound
- •Depth of burn
- •Size of the burn
- •Initial management of the burn wound
- •First aid
- •Burn blisters
- •Escharotomy
- •General care of the adult burn patient
- •Biological/Semi biological dressings
- •Topical antimicrobials
- •Biological dressings
- •Other dressings
- •Exposure
- •Deep partial thickness wound
- •Total wound excision
- •Serial wound excision and conservative management
- •Full thickness burns
- •Excision and autografting
- •Topical antimicrobials
- •Large full thickness burns
- •Serial excision
- •Mixed depth burn
- •Donor sites
- •Techniques of wound excision
- •Blood loss
- •Antibiotics
- •Anatomical considerations
- •Skin replacement
- •Autograft
- •Allograft
- •Other skin replacements
- •Cultured skin substitutes
- •Skin graft take
- •Rehabilitation and outcome
- •Future care
- •References
- •Burns in older adults
- •Introduction
- •Burn injury epidemiology
- •Pathophysiologic changes and implications for burn therapy
- •Aging
- •Comorbidities
- •Acute management challenges
- •Fluid resuscitation
- •Burn excision
- •Pain and sedation
- •End of life decisions
- •Summary of key points and recommendations
- •References
- •Acute management of facial burns
- •Introduction
- •Anatomy and pathophysiology
- •Management
- •General approach
- •Airway management
- •Facial burn wound management
- •Initial wound care
- •Topical agents
- •Biological dressings
- •Surgical burn wound excision of the face
- •Wound closure
- •Special areas and adjacent of the face
- •Eyelids
- •Nose and ears
- •Lips
- •Scalp
- •The neck
- •Catastrophic injury
- •Post healing rehabilitation and scar management
- •Outcome and reconstruction
- •Summary
- •References
- •Hand burns
- •Introduction
- •Initial evaluation and history
- •Initial wound management
- •Escharotomy and fasciotomy
- •Surgical management: Early excision and grafting
- •Skin substitutes
- •Amputation
- •Hand therapy
- •Secondary reconstruction
- •References
- •Treatment of burns – established and novel technology
- •Introduction
- •Partial thickness burns
- •Biological membranes – amnion and others
- •Xenograft
- •Full thickness burns
- •Dermal analogs
- •Keratinocyte coverage
- •Facial transplantation
- •Tissue engineering and stem cells
- •Gene therapy and growth factors
- •Conclusion
- •References
- •Wound healing
- •History of wound care
- •Types of wounds
- •Mechanisms of wound healing
- •Hemostasis
- •Proliferation
- •Epithelialization
- •Remodeling
- •Fetal wound healing
- •Stem cells
- •Abnormal wound healing
- •Impaired wound healing
- •Hypertrophic scars and keloids
- •Chronic non-healing wounds
- •Conclusions
- •References
- •Pain management after burn trauma
- •Introduction
- •Pathophysiology of pain after burn injuries
- •Nociceptive pain
- •Neuropathic pain
- •Sympathetically Maintained Pain (SMP)
- •Pain rating and documentation
- •Pain management and analgesics
- •Pharmacokinetics in severe burns
- •Form of administration [21]
- •Non-opioids (Table 1)
- •Paracetamol
- •Metamizole
- •Non-steroidal antirheumatics (NSAID)
- •Selective cyclooxygenasis-2-inhibitors
- •Opioids (Table 2)
- •Weak opioids
- •Strong opioids
- •Other analgesics
- •Ketamine (see also intensive care unit and analgosedation)
- •Anticonvulsants (Gabapentin and Pregabalin)
- •Antidepressants with analgesic effects
- •Regional anesthesia
- •Pain management without analgesics
- •Adequate communication
- •Psychological techniques [65]
- •Transcutaneous electrical nerve stimulation (TENS)
- •Particularities of burn pain
- •Wound pain
- •Breakthrough pain
- •Intervention-induced pain
- •Necrosectomy and skin grafting
- •Dressing change of large burn wounds and removal of clamps in skin grafts
- •Dressing change in smaller burn wounds, baths and physical therapy
- •Postoperative pain
- •Mental aspects
- •Intensive care unit
- •Opioid-induced hyperalgesia and opioid tolerance
- •Hypermetabolism
- •Psychic stress factors
- •Risk of infection
- •Monitoring [92]
- •Sedation monitoring
- •Analgesia monitoring (see Fig. 2)
- •Analgosedation (Table 3)
- •Sedation
- •Analgesia
- •References
- •Nutrition support for the burn patient
- •Background
- •Case presentation
- •Patient selection: Timing and route of nutritional support
- •Determining nutritional demands
- •What is an appropriate initial nutrition plan for this patient?
- •Formulations for nutritional support
- •Monitoring nutrition support
- •Optimal monitoring of nutritional status
- •Problems and complications of nutritional support
- •Conclusion
- •References
- •HBO and burns
- •Historical development
- •Contraindications for the use of HBO
- •Conclusion
- •References
- •Nursing management of the burn-injured person
- •Introduction
- •Incidence
- •Prevention
- •Pathophysiology
- •Severity factors
- •Local damage
- •Fluid and electrolyte shifts
- •Cardiovascular, gastrointestinal and renal system manifestations
- •Types of burn injuries
- •Thermal
- •Chemical
- •Electrical
- •Smoke and inhalation injury
- •Clinical manifestations
- •Subjective symptoms
- •Possible complications
- •Clinical management
- •Non-surgical care
- •Surgical care
- •Coordination of care: Burn nursing’s unique role
- •Nursing interventions: Emergent phase
- •Nursing interventions: Acute phase
- •Nursing interventions: Rehabilitative phase
- •Ongoing care
- •Infection prevention and control
- •Rehabilitation medicine
- •Nutrition
- •Pharmacology
- •Conclusion
- •References
- •Outpatient burn care
- •Introduction
- •Epidemiology
- •Accident causes
- •Care structures
- •Indications for inpatient treatment
- •Patient age
- •Total burned body surface area (TBSA)
- •Depth of the burn
- •Pre-existing conditions
- •Accompanying injuries
- •Special injuries
- •Treatment
- •Initial treatment
- •Pain therapy
- •Local treatment
- •Course of treatment
- •Complications
- •Infections
- •Follow-up care
- •References
- •Non-thermal burns
- •Electrical injury
- •Introduction
- •Pathophysiology
- •Initial assessment and acute care
- •Wound care
- •Diagnosis
- •Low voltage injuries
- •Lightning injuries
- •Complications
- •References
- •Symptoms, diagnosis and treatment of chemical burns
- •Chemical burns
- •Decontamination
- •Affection of different organ systems
- •Respiratory tract
- •Gastrointestinal tract
- •Hematological signs
- •Nephrologic symptoms
- •Skin
- •Nitric acid
- •Sulfuric acid
- •Caustic soda
- •Phenol
- •Summary
- •References
- •Necrotizing and exfoliative diseases of the skin
- •Introduction
- •Necrotizing diseases of the skin
- •Cellulitis
- •Staphylococcal scalded skin syndrome
- •Autoimmune blistering diseases
- •Epidermolysis bullosa acquisita
- •Necrotizing fasciitis
- •Purpura fulminans
- •Exfoliative diseases of the skin
- •Stevens-Johnson syndrome
- •Toxic epidermal necrolysis
- •Conclusion
- •References
- •Frostbite
- •Mechanism
- •Risk factors
- •Causes
- •Diagnosis
- •Treatment
- •Rewarming
- •Surgery
- •Sympathectomy
- •Vasodilators
- •Escharotomy and fasciotomy
- •Prognosis
- •Research
- •References
- •Subject index
M. D. Peck
dents, falls, and interpersonal violence – this is higher than the combined incidence of tuberculosis and HIV infections, and just slightly less than the incidence of all malignant neoplasms. Burns under 20 % of the body surface area occur to 153 per 100,000 population of children aged 0–15 years, making them the fifth most common cause of non-fatal childhood injuries after intracranial injury, open wounds, poisoning, and forearm fractures [232]. Five percent of disabilities at all ages in Nepal are due to burns and scalds [213].
When confronted with the story of a burn survivor, the first picture that comes to mind is that of the agonizing open wounds, followed by resolution into undeniably obvious burn scars. But the thickened, non-compliant skin tells only part of the story. Much of the impact of burns is emotional, psychological and spiritual. Studies of recovery from burn injury in the US show clearly that the ability to adjust following injury is less dependent on the physical characteristics of the burn (such as burn size, burn depth or location), and more on pre-in- jury adjustment. Coping skills, family and community support, and general psychological health have more impact on recovery from burns than the burn itself [39].
In HIC, this means that burn survivors from struggling family backgrounds are likely to have problems reassimilating into school and community. In LMIC, the consequences are direr, with isolation from or even abandonment by the family, social segregation, unemployment and extreme poverty. Although burn victims from affluent families in LIC have a chance of recuperation, the vast majority of burn survivors will start from living situations that deny them the opportunity to recover from even a small burn.
Additionally, the sequelae of non-fatal burn injuries are often severe enough to cause permanent disability. In the Global Childhood Unintentional Injury Surveillance pilot study done among children (0–12 years of age) in Bangladesh, Colombia, Egypt and Pakistan, 17 % of survivors had long term (greater than six weeks) temporary disability, and 8 % had permanent disability [167]. The incidence of longterm temporary disability was highest in children surviving burns and traffic injuries. Only neardrowning victims had a higher rate of permanent
disability. Permanent disability was eight times more common in burn survivors than in those children recovering from falls.
Thus comes the wisdom of one of the founding fathers of burn care in India, Dr. M. H. Keswani: “The challenge of burns lies not in the successful treatment of a 100 % burn, but in the 100 % prevention of all burn injuries.” [112]
Epidemiology
Although burns and fires account for over 300,000 deaths each year throughout the world, the vast majority of burn injuries are fortunately not fatal [232]. In 2008 there were 410,149 non-fatal burn injuries in the US, giving an age-adjusted rate of 136 per 100,000 each year [47]. A higher estimate comes from data collected from the National Hospital Ambulatory Medical Care Survey during the period of 1993 to 2004 in the US, in which the average annual emergency department visit rate for treatment of burns was 220 per 100,000 population [73]. The vast majority of these burns were treated and released from the emergency department; only 5 % were hospitalized or transferred. In comparison, only 45 % of non-fatal firearm injuries and near-drowning were treated and released, suggesting that the severity of most burns requiring medical treatment is low compared to other types of injury [47].
Epidemiological studies from LIC lend insight into the true impact burns have in communities. A cross sectional survey of nearly 1400 households in Tigray, Ethiopia, showed that 1.2 % of the population is burned each year. Over 80 % of these burns occurred at home, and 90 % healed without any complications. Only 1 % of the burn victims died [148]. A populationbased survey of over 170,000 households representing nearly 350,000 children and 470,000 adults during 2003 in Bangladesh showed that the overall incidence of non-fatal burn injuries was 166 per 100,000, and that about 173,000 Bangladeshi children suffer moderate to severe burns each year, which is an annual rate of 288 burns per 100,000 children. Similar to the study in Ethiopia, 90 % of the burns occurred at home. The rate of permanent disability due to burns in childhood was 5.7 per 100,000, and the mortality rate was 0.6 per 100,000 [126, 127, 129].
20
Epidemiology and prevention of burns
Other studies confirm the relative infrequency with which burn patients require hospitalization. In a recent study of patients treated for burns at emergency departments in North Carolina in a recent study, 4 % were admitted and only 4 % were transferred to burn centers [57]. Based on the incidence of burns treated at emergency departments and the proportion of those patients requiring admission, it appears that anywhere from 5 to 16 burn patients per 100,000 population require admission for treatment of their injuries. In Pennsylvania in 1994, the rate of hospitalizations for treatment of burn injuries was 26.3 per 100,000, based on hospital discharge records [78].
Global data are even more elusive, but an estimate of the frequency with which children are hospitalized throughout the world for treatment of burns is a rate of 8 per 100,000 [44]. In a rural community survey in Ethiopia, burns were the second most common injury to children under 15 years of age. The annual incidence of burns severe enough to restrict activity for one or more days was 80 per 1000 children [58]. Burns were therefore the leading cause of admission for injury to pediatric hospitals in Ethiopia, and ranked third as a source of outpatient visits [210, 212].
There has been a decrease in emergency department visits for burn injury in the US from 1993 to 2004 [47]. The absolute number of burn injuries in the US may be declining, or the severity of those injuries decreasing, or both [43]. Fortunately a similar trend is being observed overseas. For example, the number of burn patients admitted annually to the Burn Unit of Lok Nayak Hospital and Maulana Azad Medical College, New Delhi, India, from 1993 to 2007 has declined from 1276 to 724 patients [7].
In parallel with the decline in emergency department visits and hospitalizations for burns, there has been a decline in mortality due to fire and flames across the world. The two decades from 1982 to 2002 have witnessed a decrease in fire and burn mortality in many countries. During this period of time, for instance, fire and burn mortality in Australian men declined from 1.5 to 0.7 per 100,000. Similarly the fire death rate in Brazilian women went from 1.1 to 0.5 per 100,000. Other countries observing reduction in fire and burn mortality from 1982 to 2002 include
Canada, France, Mexico, Panama, Thailand, the United Kingdom, and Venezuela [233]. In the US, the age-adjusted death rate from fire and burns has dropped from 2.99 per 100,000 in 1981 to 1.2 per 100,000 in 2006 [47]. Even in just the brief period of time between 2000 and 2004, the Global Burden of Disease Project noted a 6 % decline worldwide in fire and burn deaths from 5.1 to 4.8 per 100,000 (GBD 2008).
Yet not all countries have experienced a simple linear decline in the incidence of burn deaths during the last three decades. Significant political and economic upheaval in the nations which used to belong to the Union of Soviet Socialist Republics (USSR) has left its mark on trends in fire and burn deaths. Following a gentle decline through the early 1980’s, fire and burn deaths began to rise before and just after the dissolution of the USSR in 1991. By the late 1990’s, as capitalism and democracy began to replace communism, deaths rates again began to decline [164]. National variations in injury-related mortality may be related to individual factors, such as alcohol consumption and risk-taking behavior, as well as alterations in social, political and environmental factors [154].
The inequitable distribution of burns
As noted by Mock and associates in a recent editorial in the Bulletin of the World Health Organization, injuries and violence cause disability and death to tens of millions of people across the globe each year, and this burden is unfairly borne primarily by those in LMIC where prevention programs are uncommon and the quality of acute care is inconsistent [142]. Burn injuries are dramatic examples of the inequity of injury.
The majority of burn deaths (90 %) occur in lower middle or low income countries. Slightly more than 7 % occur in high middle-income countries. Only 3 % of burn deaths across the world occur in HIC (Fig. 1; [232]). The rate of child injury death from fire and flames is nearly 11 times higher in LIC than in HIC (Table 1; [232]). Although in HIC the death rate in children from fire and flames is only 3 % of the overall rate of death from unintentional injuries of all kinds, it is over 10 % the death rate of all unintentional injuries in LIC [232]. In ab-
21
M. D. Peck
Fig. 1. Low-income countries (LIC) disproportionately suffer the impact of fire deaths and burn injuries throughout the world, according to statistics from the Global Burden of Disease project [232]. In this figure, blue represents males and red represents females
solute numbers, the proportion of childhood deaths due to fire and flames in LIC is twice that in HIC (Table 2).
Even in HIC’s, burn injuries disproportionately occur to racial and ethnic minorities in which socioeconomic status – more than cultural or educational
factors – account for most of the increased susceptibility to burns. In the Republic of Korea (South Korea), for instance, the severity of burn injury is highest in the lowest socioeconomic groups [161]. For another example, the proportion of AfricanAmerican infants requiring hospitalization at US
Table 1. Unintentional injury death rates per 100,000 children (0–20 years of age) by cause and country income level [232]
|
Road traffic |
Drowning |
Fire & Burns |
Falls |
Poisoning |
Other |
Total |
HIC |
7.0 |
1.2 |
0.4 |
0.4 |
0.5 |
2.6 |
12.2 |
LMIC |
11.1 |
7.8 |
4.3 |
2.1 |
2.0 |
14.4 |
41.7 |
World |
10.7 |
7.2 |
3.9 |
1.9 |
1.8 |
13.3 |
38.8 |
22
Epidemiology and prevention of burns
Table 2. Unintentional injury deaths (in millions) in children (0–14 years of age) by cause and country income level [232]
|
Road traffic |
Drowning |
Fire & Burns |
Falls |
Poisoning |
Other |
Total |
HIC |
6 |
2 |
1 |
1 |
0 |
5 |
14 |
MIC |
53 |
71 |
10 |
11 |
9 |
137 |
292 |
LIC |
108 |
62 |
62 |
23 |
23 |
120 |
399 |
burn centers for treatment is double the proportion of African-Americans in the general population [16]. Similarly, the standardized mortality ratio for fire deaths in 1981–1982 among aboriginals in Manitoba was 4.3 times that of the population of the entire province [79]. Indeed, in many aboriginal communities in North America and Greenland, the third most common cause of unintentional fatal injury is house fires [38, 145].
At the time of burn injury, all patients – young and old – experience shock, horror, pain and anxiety. The events that follow the injury may confuse the victims, and lead them to believe (sometimes correctly) that their death is imminent. Because few burn victims in LMIC receive appropriate first aid or immediate acute care, the medical mismanagement of the burn is likely to lead the survivor to the hopeless conclusion that little or nothing can be done to sooth the pain and relieve suffering. As a result, burn survivors become emotionally overwhelmed and typically withdraw. They lose interest in food and activity, and retreat to dark corners where they may lay motionless for hours. Unfortunately, this lack of activity compounds the speed with which the healing burn wound causes wound contractures to occur, and heightens the survivor’s disability. For these reasons, the distribution of burn morbidity is also imbalanced. The prevalence of moderate and severe disability due to unintentional injuries in people under 60 years of age is 35.4 million in LMIC, 12.5 times higher than in HIC [232].
Cost of fires and burns
A variety of features characteristic to burns lead to prolonged and expensive hospital stays. In addition to pain management and wound care, burn patients
require attention to nutritional deficiencies, to the consequences of suppression of the immune system, and to rehabilitation therapy. In the US, the average hospital charge for care of a child (age 5–16 yrs) with extensive third degree burns requiring skin grafting is over US$140,000 [16]. In one state alone in 1994, hospital charges for treatment of burn injuries were over $93 million [78]. Yet in spite of this lavish medical care, many burned children leave hospitals in the US with permanent physical and psychological scars.
During the decade from 1999–2008, patients at burn centers in the US stayed a mean of 10 days in the hospital. The dominant predictors of hospital stay in burn patients are burn size and burn depth [162, 201]. Patients in US burn centers from 1999–2008 accumulated an average hospital charge of just over $58,000 per patient-stay. However, the charges for patients who died were nearly three times that for survivors. Hospital charges per day were over $4000 for survivors and nearly $12,000 for fatal cases.
Loss from burns and fires includes not only health care expenditures and property damage, but destruction of human resources as well. In 2006 there were nearly 70,000 years of potential life lost in the US because of burn fatalities [47]. The indirect costs of such loss of productive years of life arise from absence of useful employees from the workplace and lack of wage earners in families.
Cost by age
When charges are viewed as a surrogate for intensity of care, certain trends are apparent. The presence of comorbid medical conditions typical in the elderly increases the need for more complex services and longer hospitalizations. Thus whereas the mean hospital charge per day for survivors was
23