How Westernised Burns Management Can Influence Paediatric Burns Management in
Africa
Kris Owden Bsc (Hons) year 5 MBBS candidate
Correspondence to: [email protected]
Abstract
Globally, the highest incidence of hospitalised paediatric burns patients is in Africa. Worldwide, burns account
for over 300,000 deaths, although most are non-fatal. Burns are the 5th most common cause of non-fatal injuries
in the world, with the world-wide incidence of ≤20% Total Body Surface Area (TBSA) occurring to 153:100,000
of the paediatric population (between the ages of 0 and 15).
Burn care could be further developed using sustainable protocols. This would reduce hospital admission length
by circa 35% and further reduce mortality by circa 30%.
This prospective cohort study identified 14 paediatric burn patients (<18 years of age) throughout July 2013 at
the Coast Provincial General Hospital, Mombasa, Kenya burns unit. All paediatric patients were included, unless
their parents objected. The primary outcome measure was to identify how an African burns unit manages their
patients, and compare it to Westernised burns management.
All bar one patient had the “standard” management regimen (1% Dermazine cream and dressing, which was
changed every 2/3 days, followed by wound exposure). In contrast, Westernised management first identifies the
burn classification which then dictates the management outcome, with an emphasis on surgery to reduce
complications.
Westernised burns management can greatly influence how African paediatric burns unit treat manage their
patients.
Aim
Paediatric burn epidemiology and prevention is widely
discussed1-8 yet practical, cost-effective and sustainable
burn management protocols have been less widely
studied. The World Health Organisation (WHO)
proposed a 10 year agreement in 2008 to develop burn
interventions in the resource-poor setting5. This study
paves a way for these countries to develop sustainable
burn management strategies.
Epidemiology
Globally, highest incidence of hospitalised paediatric
burns patients is in Africa (incidence per year = 0.0108 n
= 96,444, and increasing6), with the lowest in the
Americas (incidence per year = 0.0044 n = 38,148),
according to extrapolated data1. Worldwide, burns
account for over 300,000 deaths, although most are nonfatal1,5,8. Burns are the 5th most common cause of nonfatal injuries in the world, with the world-wide incidence
of ≤20% Total Body Surface Area (TBSA) occurring to
153:100,000 of the paediatric population between the
ages of 0 and 15 4. Burns ≥20% TBSA is the most
common condition causing disability and has been said
by Date et al5 that the prevalence of burns is
approximately four times the prevalence of HIV/AIDS.
Increased burn susceptibility has been suggested by2,4 to
include a low socio-economic status, race, age, ethnicity
and gender. Children have been shown to be
predominately affected in Low-and Middle-Income
Countries (LMICs)3,5 with a Tanzanian study showing
82.9% (n = 253) were children from a low socioeconomic group3. Albertyn et al6 further suggest that
parent(s) from low socio-economic groups may not be
supervising their children as they are away from the
home seeking employment. Males are predominately
affected more5 at a ratio of 2:12-3, although female
incidence rises through adolescence due to them being
more active in household chores6. Illiteracy, urban
migration, shantytown and slum area development have
been suggested to be contributing factors to the rise in
incidence of burns over the last decade6. The reported
figures are from hospitalised paediatric burns patients,
and thus community treated patient numbers are
unknown and unexplored6, affecting epidemiological
data. Although exact epidemiology figures are unclear,
what is clear is that burn incidence is rising in Africa and
there is a lack of uniform management protocols6.
Efficient and effective burn management could reduce
hospital admission length by circa 35% and further
reduce mortality by circa 30%6.
Burns background
Severity of burns stems from a mild inconvenience to
death, with a spectrum of physical (visible) and
psychological (invisible) co-morbidities2,9. The upper
extremity has been predominantly shown to be at the
highest risk of burns, with the majority of burns
occurring in the home2-6. Forjuoh2 undertook an
international literature review between 1974 and 2003
which showed that the highest reported burn age range
was between 0 and 4 (additionally supported by6), the
mean average TBSA was <10% and the mean average
mortality was 9.9%. Burns can occur due to underlying
co-morbidities such as hearing loss, impaired vision,
polio lameness and epilepsy2. Febrile convulsions add to
the co-morbidity risk6. Scalds have been shown to be the
most common type of burn, followed by flame burns2-3, 5,
9
, although Albertyn et al6 state that flame burns are the
most common, followed by scalds. Hot milk scalds cause
significantly deeper burns than water (p<0.001)10.
Chemical burns, although not discussed in this study (due
to their rarity in paediatrics), are paradoxically on the
rise6.
Burn pathophysiology
A burn occurs when tissue is subjected to an energy that
exceeds physiological tolerance4. A burn area can be
characterised by pathophysiological zones:
1. The centre of a burn is the ‘zone of stasis’, in
which tissue perfusion is decreased. Although
these cells are injured, they have the ability to
recover11
2. The area surrounding the ‘zone of stasis’ is the
‘zone of coagulation’ in which the tissue is
unsalvageable due to irreversible coagulation of
tissue proteins from the burn11
3. The ‘zone of hyperaemia’, which envelopes the
above zones, has salvageable tissue due to
hyperperfusion from the acute inflammatory
response11. This zone is only threatened if other
factors, such as a superadded infection, occurs 13
An acute systemic response can emerge if the TBSA
reaches a critical level; Lawton et al12 advocate that
≥25% TBSA initiates the response, whereas Ghandi et
al13 suggest it is ≥30%. This is due to an influx of
inflammatory mediators, which can affect the renal,
cardiovascular, respiratory, immunological, metabolic
and the gastrointestinal systems13. The mediators include
chemokines and cytokines: serotonin, bradykinin,
histamine, nitrous oxide, interleukins and tumour
necrosis factor (TNF). The permeability of the
microvasculature increases, which causes fluid
sequestion and localised burn oedema (plasma with less
protein)11, 12. Until a balance between extravascular and
intravascular compartments befalls, the oedema remains.
The haemocrit will progressively rise in major untreated
burns to between 60% and 70%, suggesting a third of the
patients’ blood will be lost, with burns shock
ensuing11.Burns shock supervenes from plasma loss from
the general circulation, causing burn oedema and reduced
haemeoconcentration (raising the haemocrit). This
systematically decreases capillary blood flow from
peripheral and splanchnic vasoconstriction, which leads
to inadequate tissue perfusion; cellular hypoxia and
hyponatraemia then follows11. Systemic Inflammatory
Response Syndrome (SIRS) can occur when there is an
exaggerated immune response to inflammation. SIRS
causes further tissue damage and increases the risk of
Multiple Organ Dysfunction (MODS) and sepsis11. The
patients’ adapted and innate immune system becomes
suppressed, although it is unclear why12.Perfusion
changes and the inflammatory response impacts the
severity of the burn13.
Wound healing
 Superficial burns: Adnexal and/or periphery
epidermal cells re-epithelise the wound.
 Deeper burns: Adnexal structures are annihilated
from the burn insult and thus the wound cannot
re-epithelise. Contraction eventually reduces the
surface area of the wound and the epithelial cells
eventually meet, but contractures may occur11.
Burn classification
Appendix A characterises burns as this influences
treatment and suggests the prognosis as superficial
wounds should heal <2 weeks, whereas deeper wounds
require tangential excision and skin grafting14-15.
The Lund and Browder chart has the dynamic ability to
take into account the change of TBSA in paediatric
patients, albeit subjective, as there is a 60-80%
concurrence15.
Management
A large study in Ghana reported that over a five year
period (2001 – 2006) 826 patients (60% male, 40%
female) were admitted14. Although not purely committed
to paediatrics, the mean age was 10.5+/-5. The TBSA
mean was 11-20% with 94% having a TBSA of ≤ 60%.
64% had wound dressings and 21% had tangential
excision and split-thickness skin
grafting (SSG).
Mortality reduced over the 5 years (20.4% to 7.4%) with
appropriate patient management (including education)
and more healthcare professionals contributing to this
improvement. Burn management in developing countries
is problematic at varying stages of treatment, including
poor equipment, inadequate aseptic technique and staff
shortages14. Due to stretched resources, burn
management needs to be cost effective and sustainable14.
Below, paediatric burn management is discussed and
summarised in a protocol in Appendix B11, 14-15
Pre-hospital burn care:
1. 20 minutes of intradermal cooling using cool
water (not too cold, as this could worsen
ischemia)11, 15
2. Clingfilm wrapping of the burn(avoiding
circumferential
wrapping
which
causes
14-15
vasoconstriction)
Peri-hospital burn care:
1. Where possible, attempt to gain a history and any
information regarding the burn
2. Airway and C-Spine protection (using nasotracheal intubation, where appropriate)
3. Oxygen (between 12-15L/min of humidified
oxygen)
4. Observations: respiratory rate, heart rate and
blood pressure (checked every 15mins)
5. An electrocardiogram monitor should be set up
6. If the patient has a low GCS or TBSA ≥ 10%,
then insert a self-retaining catheter and collect a
sample for analysis. Record fluid loss on a chart
to aid fluid resuscitation
7. Acquire blood samples, and cannulate if
necessary (if needed, insert two wide bore
cannulas): (full blood count, group and save,
blood
glucose,
urea
and
electrolytes,
carboxyhaemagolbin – in suspicion of an
inhalation injury and amylase if there has been
abdominal trauma)11
8. TBSA is calculated using the Lund and Browder
chart14-16 If TBSA <10%TBSA oral fluids can be
give, if TBSA ≥ 10% IV fluids should be
initiated for over 48hours 11
9. Pain relief
10. Antibiotic use is subjective, A study in Ghana14
described antibiotics being administered to all
patients (predominately Ceftazidime) although it
has been suggested that the use of systemic
antibiotics (in all cases) will encourage resistant
organisms and does not prevent sepsis11.
11. Provide tetanus prophylaxis11
12.
20mg omeprazole, once daily for at least 14 days
can be given to prevent Curling’s Ulcers,
although not supported by many studies15
13. Nutrition should be adequately provided
14. Escharotomy consideration12,15 should be done if
there is circumferential full thickness burns (to
avoid vascular compromise)15
15. Wounds care +/- surgical intervention11,14-15
A series of management phases has been described, to
include: rescue, resuscitate, retrieve, resurface,
rehabilitate, reconstruct and review9.
Fluid resuscitation
Fluid resuscitation is a vital part of the management plan
to prevent thermal necrosis (reducing burn depth in the
‘zone of stasis’) and to maintain organ perfusion20. If
TBSA ≥ 10% (paediatrics), the Parkland formula11,13,15
calculates fluid requirements: 4 x TBSA x kg = ml/24hrs
using Ringer’s lactate14, although any crystalloid fluid
can be used 15 with Hartmann’s solution being suggested
as an alternative11. The protocol for colloid use, however,
is ambiguous15. The fluid requirements should be
calculated from the time of the injury and not time of
admission/examination, thus fluid compensation may be
required. Early fluid resuscitation has been shown to
reduce the incidence of renal failure, sepsis and
mortality15. Urine output has been used to monitor fluid
resuscitation, but its use has been challenged, with the
use of invasive/non-invasive monitoring unclear15.
Pain control
Poor pain control can lead to poor adherence to patient
therapy, causing prolonged healing and potentially a
longer stay in hospital or risk of infection13. Procedural,
maintenance and chronic pain management is thus
critical, proposes 13, with paracetamol, NSAIDS and
opioids being titrated appropriately. Morphine has been
recommended to be used for severe burns, diclofenac for
less severe and paracetamol for paediatric patients,
although the precise definition of ‘severity’ remain
uncertain14. Qualified and experienced prescribers
together with drug availability are known obstacles to
appropriate pain control14-15.
Nutrition
Nutrition has been shown to be critical for burn
modulation. Basal metabolic rate (BMR) can increase up
to 40% after a significant burn whilst surgical
interventions can increase energy expenditure by
between 50 and 70%13. This means nutritional status and
therapy is dynamic and requires specialist input within 12
hours15.
Protein requirements can be calculated using the
following formula: 3g/kg + 1g x %TBSA burned. Calorie
requirements can be calculated using these guidelines:
 Normal basal requirements +:
o ≤9kg = 15kcal x %TBSA burned
o 10 – 13kg = 20kcal x %TBSA burned
o 14 = 30kg = 30 kcal x %TBSA burned11
Escharotomies
An eschar is an area of dead tissue that sheds17.
Escharotomies (division of the eschar) should be done if
there are circumferential full thickness burns (to avoid
vascular compromise)12,15. Compartment syndrome
should be treated using limb decompression12. Failure to
undertake these procedures could lead to reduced tissue
perfusion, and consequently tissue necrosis12. The gold
standard escharotomy procedure is unclear; however it
has been suggested that the incisions down the long axis
of the limb through the mid medial (or lateral) lines
through the dermis (which should extend through
unburned tissue and through joints) shows successful
results12. Ideally, the procedure should be conducted in
theatre, aseptically12. Post operatively; the affected limb
should be raised11.
Wound care
1% Dermazine (silver sulfadiazine) was only given to
6.3% of patients (facial wounds) in a study by
Agbenorku et al14, who further suggest that silver
sulfadiazine should be used on only deep and extensive
burns. The National Institute of Clinical Excellence
(NICE) recommends that superficial dermal burns
shouldn’t be treated using silver sulfadiazine
creams/ointments18. Silver sulfadiazine can be applied to
provide a barrier to bacteria11. Dermazine should be
applied in a 2 to 4mm thick layer, twice a day (and then
dressed in a sterile gauze) and only used if the TBSA
>20%19. The British National Formulary (BNF) states
that 1% silver sulfadiazine cream is priced at £2.91 for
20g20. Dermazine can cause haemolysis and this should
not be used in new-born and premature infants to prevent
kernicterus or patients with inborn deficiency of glucose6-phosphate dehydrogenase19.
For superficial and superficial dermal burns,
polyurethane and hydrocolloid dressing can be used6,11, 1415
. The BNF states that a paraffin gauze dressing is priced
at 25p for a 10cm by 10cm dressing21
An exposure method has been described which is of
specific use in tropic climates6. Perineum, axillae, groin,
neck and face burn wounds were treated using this
method, with silver sulphadiazine cream applied after
cleansing and debridement.
Wounds are re-assessed at 24 and 72 hours after the
initial injury as infections and poor wound care could
increase the depth of the wound15. Dressings were
removed between 3 and 5 days (every 24hours if there
are signs of infection or if the wound is deep dermal)
until the eschar has lifted and there is clear reepithelisation15.
Dressings, however, have been
recommended to be changed one to two days11.
Debridement and tangential excision with skin
auto/homograft’s have been shown to be effective for
large burns, by reducing infections and increasing
healing time12, 14-15. Early surgical intervention reduced
hospital stay to <10 days14. Atiyeh et al22 confirms this
study, further signifying mortality, morbidity and
septicaemia; costs of treatment and hospital stay are
reduced with early skin excision.
Psychology
Throughout the early resuscitative, acute and
rehabilitation phase, depression and post-traumatic stress
disorder can occur in up to 60% and 30% respectively 15.
Complications of burns
Paediatric burn morbidity deteriorates by longer hospital
admission length with skin grafts (if done), often
delayed6. A survey reported that 23% (n = 620) of
paediatric burns patients suffered complications, such as
contractures,
keyloid
scar
formation
and
depigmentation6. Long -term complications include
hypertrophic scars and cosmetic disfigurements as well
as short-term complications, such as septicaemia,
infection, hypovolaemia, impaired renal function,
pulmonary oedema from over-transfusion and
haemochromogenuria2,11. Hyponatramia can also occur
which could lead to burn encephaly11. Contractures are
especially concerning as they increase the risk of
squamous cell carcinoma5-6. Patients have been shown to
present
chronically
for
contracture
5
release/reconstruction . It is unclear if these patients
failed to present acutely or were not given appropriate
treatment early on. Hypovolaemia was the main reason
for mortality, followed by septicaemia6. The lack of
barrier nursing with extensive burns was suggested as
being a major contributor to wound infections. Mortality
in paediatric burns is higher than expected as patients
with over 45% TBSA of burns infrequently survive and
younger patients with 20% TBSA rarely survive6.
African burn management
Burn management, discussed by6 is dependent on
equipment, expertise and resource allocation. Varying
ratios of traditional and western burn care is currently in
operation. Despite improving acute care, outpatient care
and follow-ups are non-existent6.
Tradition burn care treatments to vary from a concoction
of urine, mud, cow dung, eggs, to simple wound bathing
in cool water2. A traditional rural Kenyan burn treatment
recipe comprises of: oil/butter (47%), raw egg yolk
(39%), milk (5%), salt (2%), cow dung (4%) and soil
(7%)6. Traditional herbal remedies are used in rural
Africa to reduce pain and include coriander, lantana,
bitter orange and grapefruit6. The above remedies,
however much believed, can delay professional treatment
causing an increase in complications and co-morbidities6.
Papaya has been advocated to prevent wound infections
by de-sloughing necrotic tissue23.
In 1995, the Coast Provincial General Hospital,
Mombasa, Kenya could only afford an expenditure of £3
for the entire treatment of the burn injury, with a shortage
of medication and personnel attributing to the problem.
Ethiopian hospitals followed a similar fate as paediatric
burn patients had a total budget of £2 for their entire care.
Very few specialist burns units exist in Africa, and even
if one exists, patients may struggle to get there and thus
suffer sub-optimal care in the community or local
hospital. Despite this, most district and community
hospitals can provide immediate emergency care, IV
fluids, antibiotics and topic preparations. Larger hospitals
may be able to provide physiotherapy and specialist
nursing care. Debridement, tangential excisions and skin
grafting interventions are scarce, if not impossible to
undertake, due to a lack of knowledge, experience,
anaesthetists and blood products6. Despite this, Forjuoh2
showed from 139 studies between 1974 and 2003 that
some LMICs do utilise tangential excision, skin grafting
and escharotomies, albeit constrained by inadequate
resources and appropriate personnel.
Methods
Data collection was conducted prospectively at Coast
Provincial General Hospital Kisauni Rd, P.O. Box 90231
Mombasa, Kenya burns unit in paediatrics during July
2013. Paediatric histories were difficult to acquire due to
the age of the children and language barriers. Histories
were predominantly acquired from the child’s parent(s).
A student nurse often provided translation.
Results
Throughout July 2013, 18 paediatric (<18 years of age)
patients were admitted with 14 willing parents prepared
to discuss their child’s condition and be photographed.
Informed verbal consent was obtained prior to the
consultation and subsequent photography. Attempts have
been made to anonymise the imagery, with eyes distorted
using Adobe Photoshop Elements 10©.
The hospital policy is as follows:
SORT: remove unused items out on ward surfaces to
reduce clutter
SET: Organise everything in proper order for easy
operation
SHINE: Maintain high levels of cleanliness
STANDARDISE: set up the above 3 S’s as routine in
every section of work
SUSTAIN: train and maintain discipline
Burn management
Patients were assessed and acutely managed initially in
the emergency department and then referred to the burns
unit where a non-specialist doctor/nurse assessed the
patient. TBSA % was assessed using the Lund and
Browder chart. Patients with ≥10% TBSA or ≥5% TBSA
along a joint were admitted. If the TBSA ≥ 10% ,then
fluid resuscitation was started using either Ringers
lactate, saline or Hartmann’s solution, depending on
availability. Fluid amount was calculated using the
Parkland formula and prescribed by a non-specialist
doctor. This would be the main input from a doctor, as
nurses and sisters undertook the rest of the burn care.
Furthermore, student nurses have a large input in burns
care. Paracetamol or ibuprofen was given to the majority
of patients for acute and chronic pain, with morphine
being restricted to severe burn injuries, although burn
severity was inconsistently determined. Antibiotics were
given in the presence of infection, predominately
Flucloxacillin, and weren’t given prophylactically. All
patients were treated with antibacterial 1% silver
sulfadiazine (Dermazine) cream. Once the wound
becomes dry and less sloughy, exposure wound care was
given. A nurse changed dressings every 2/3 days, with
crepe bandaging being the main dressing applied.
Surgical interventions were rarely used due to lack of
expertise. Patient age and burn severity were taken into
account when deciding to operate, yet this was subjective
depending on which surgeon, if any, was available.
Nutrition
Nutrition was provided in the following order as per a
daily nutritional regime:
1. Porridge
a. +/- fruit
2. Milk (around 10am)
3. Lunch
4. Super
If the patient was unable to tolerate feeding, a nasogastric
(NG) tube was inserted; porridge and milk were the
constituents of the feed.
There was no psychological or psychotherapy input,
unless the patient attempted to commit suicide. Most
patients/parents were unsure of HIV status but not all
patients were tested, as tests were dependent on lab
capability for that week.
Patient burn injuries are shown in Table 1, below. The
mean hospital admission length at the time of
consultation was 17.6 days (S.D 7.28 to 2 d.p.), the mean
age was 6 years, 2 months and 2 weeks (67% between 0
and 4 years old) with male:female ratio of 2:1. Scalds
predominated the mechanism of injury to flame burns at
a ratio of 5:1, with porridge water being the main cause
of injury. Conjointly, the most common body parts
affected were the anterior trunk and legs, followed
conjointly by the face and genitals. The mean average
TBSA was 17.3%. All bar one patient had the “standard”
(1% Dermazine cream and dressing, which was changed
every 2/3 days, followed by wound exposure)
management regime. Not all patients were followed up
due to a lack of interpreter, availability of the patients’
parents, or because they had been discharged.
Retrospective analysis was impossible due to the lack of
records kept at the hospital, as the patients took home
their notes in a notebook. Additionally, outpatient followup and complications were not documented. Throughout
July 2013, there were no burn fatalities.
No.
Length of
stay
1
12 days
Age
7 months
Mechanism of
injury
Fluid lamp
Before**
No.
2
Length of
stay
2 weeks
Burn description
Partial facial, anterior
trunk and genitalia
TBSA (%)
Breast milk, water,
Standard*
19
Before**
Age
2 years 3
months
Before**
Mechanism of
injury
Porridge
Burn description
Lower anterior trunk,
proximal thighs and
genitalia
Management
After***
TBSA (%)
Management
Standard* and then
exposed method,
ibuprofen three times a
day, amoxicillin, oral
fluids
10
After***
No.
3
No.
Length of
stay
3 weeks
Before**
Length of
stay
4
2 weeks
No.
Length of
stay
5
1 month
Age
Mechanism of
injury
Burn description
4 years
Playing in the
garden and fell
in fire pit
Posterior right hand,
bilateral lower legs
TBSA (%)
12.5
Before**
Age
17 years
Age
12 years
Mechanism of
injury
Fell onto hot
water
Mechanism of
injury
Fell into house
fire from
epileptic
seizure
Burn description
L arm, R shoulder,
posterior neck
extending to sacral
spine (left laterally)
Burn description
Left lower arm and
elbow, left thigh to
distal femur
Management
Immediate: 4 pints of
water , paracetamol,
Augmentin, standard*
After***
TBSA (%)
19
TBSA (%)
12.5
Management
Oral fluids,
paracetamol, standard*
Management
Standard*
No.
6
No.
7
Length of
stay
2.5 weeks
Age
3 years
Before**
Length of
stay
2 weeks
Mechanism of
injury
Tea
Burn description
Partial face and neck
partial anterior trunk,
partial left upper
anterior arm and partial
right shoulder and arm
TBSA (%)
13
Before**
Age
1 year
Mechanism of
injury
Tea
Burn description
Trunk
Management
Standard*
After***
TBSA (%)
25
Management
Standard*
No.
Length of
stay
8
1 week
No.
Length of
stay
9
3 weeks
No.
Length of
stay
10
11 months
Age
14 years
Age
7 months
Age
10 months
Mechanism of
injury
Hot water
Mechanism of
injury
Fluid lamp
Mechanism of
injury
Hot porridge
Burn description
Left posterior thigh,
buttock and partial
posterior leg
Burn description
Partial lower face,
anterior trunk, genitalia
and bilateral proximal
thigh
Burn description
Anterior trunk,
genitalia, anterior
proximal right thigh
and left anterior thigh
TBSA (%)
10
TBSA (%)
18
TBSA (%)
22
Management
Standard*
Management
Standard*
Management
Standard*
No.
Length of
stay
Age
14 years
Mechanism of
injury
Stove
Burn description
Partial face, anterior
trunk, genitalia and
upper thigh
11
3 weeks
No.
Length of
stay
Age
Mechanism of
injury
Burn description
12
4 weeks
14 months
Porridge water
Posterior trunk and left
shoulder
TBSA (%)
33
TBSA (%)
14
Management
Standard*, with IV
fluids, antibiotics and
paracetamol.
Management
Standard*
Table 1: depicts patients seen at the Coast Provincial General Hospital burns unit through July 2013.
Standard*: 1% Dermazine cream and dressing, which was changed every 2/3 days, followed by wound exposure
Before**: 10 days prior to after images
After***:10 days after before images taken
Discussion:
Patients were acutely managed, assessed (using the Lund
and Browder chart) and provided with fluid resuscitation
(using the Parkland Formula) as per current research
recommendations11,15. The male:female ratio of burns
patients in this study supports the results of2,3,5. Thermal
burns were by far the most common mechanism of
injury, supported by Forjuoh2 and Albertyn et al6. The
mean age is two years higher over the highest range
reported by Forjuoh at al2, but the majority of patients
(67%) were between 0 and 4 years old. Percentage TBSA
was 1.73 times higher in this study than Forjuoh2 reports
but this will vary greatly depending on the mechanism of
injury, and amount of porridge water per serving, for
example. This study showed an inconsistency Forjuoh2
and Albertyn et al6 regards to the most common parts of
the body affected, but this may reflect the small sample
size. Only one of the patients had a co-morbidity of
epilepsy. It is unclear whether the burns were a result of
the patient touching a heat source during a seizure, or a
consequence of the traditional belief –based action of
burning a fitting patient to end the seizure2. HIV status
was unknown in the majority of patients and further
investigation was inhibited by laboratory capabilities; it
is therefore unknown if immunosuppression modulated
the burn injury. Burns were not classified, thus
management regimes were not targeted to specific burn
classifications, and all patients received the standard care
of 1% Dermazine cream, crepe bandaging and exposure,
with the latter being supported by Albertyn et al6.
Dermazine, as agreed by Agbenorku et al14 and Pape et
al11 should only be prescribed for deep and extensive
burns, and superficial burns do not require this level of
treatment18. It was seen that these types of burns were
treated using Dermazine during this study, perhaps due to
a lack of understanding, education, simplicity of
treatment or medication stock levels. Dressing changes
are consistent with studies11,15 but as Dermazine is being
used, it should be applied twice a day in thick (between 2
and 4mm) layers19. Dermazine should only be used if the
TBSA >20% 19, yet only 25% (n = 3) of the paediatric
patients were treated using this guideline, as 75% (n =9)
patients were given Dermazine with <20% TBSA. Thus
this African hospital is over-using Dermazine, and underapplying it when it is used. Surgical interventions were
not carried out during this study, yet studies12, 14-15
suggest that surgery would not only reduce infections and
increase healing time, but also reduce hospital stay,
mortality, morbidity and complications. Likewise,
Escharotomies were not undertaken, despite research
stating the procedure avoids vascular compromise12,15.
Surgery was not undertaken due to a lack of expertise.
Surgical candidates were not identified using a burns
classification due to a lack of a surgeon and knowledge.
Educating health care members on burn classifications
will help to identify patients who need a lighter wound
dressing (polyurethane and hydrocolloid) and those who
either require surgery or Dermazine. Superficial and
superficial dermal wound dressings have been stated by
the BNF at costing 25p for a 10cm by 10cm dressing
compared to £2.91 for 20g of Dermazine20-21. Although
lighter dressings are individually cheaper, the Dermazine
cream can be used on more than one occasion. Wound
exposure has been demonstrated and discussed to be an
accepted form of management and utilised at the studies
hospital6. The ‘zone of stasis’ and ‘zone of hyperaemia’
could be recovered (from good wound care)11. With the
latter only threatened by superadded infection, which this
hospital is good at managing (using Flucloxacillin). Pain
control was poor and is not supported by evidence13 as
opioids should be titrated in severe cases. This is due to
resource allocation as paracetamol and ibuprofen are the
only pain relief available. Nutrition is given generally,
and not given as per individual requirements, which may
inhibit
wound
healing11,13.
There
was
no
psychological/psychotherapy input, unless a suicide was
attempted, despite high stress and distress levels
reported15. Complications were not seen and reportedly
not managed, despite 23% of burns patients suffering
complications6, this was due to a lack of expertise and
time.
The general theme emerging is that this hospital uses
some proven burn management strategies, but could
improve the care they give to patients using appendix 1
and 2. Using a burn classification system will allow the
hospital to categorise those patients needing
polyurethane/ hydrocolloid dressings and those needing
Dermazine or surgical intervention. Although the hospital
has a standard policy, a further ‘S’ could be added:
Subsist; which encapsulates management protocols as
proposed in this study.
Limitations of the study
Results from the hospital were acquired only if an
interpreter was available, and/or the patient’s parents
were willing to discuss their child’s case. Although basic
burn management is discussed, a surgical intervention
protocol (albeit mentioned) is not fully discussed as this
goes beyond the scope of this study.
Conclusion
Understanding the pathophysiology of burns (including
the salvageable tissue zones), along with the systemic
(such as SIRS) and local consequences (such as
contractures) focuses one’s mind to treat the burn
effectively to prevent morbidity (including the
preventable complications of burns) and mortality.
Deeper burns require specific management to prevent
contractures from ineffective wound healing. Early
surgical interventions have been shown to be the most
effective management strategy to prevent further
complications. Polyurethane or hydrocolloid dressings
have been shown to be an efficient and cost effective for
superficial and superficial dermal burns. This study
suggests that Westernised burns management can
influence paediatric burns management in Africa.
Developing these effective and sustainable management
strategies could reduce hospital admission length by circa
35% and further reduce mortality by circa 30%.
Ethical considerations:
Patient details were anonymised with no personal
information collected. Full verbal consent was acquired
using a translator.
Acknowledgements and conflicts of interest
I would like to thank The Healing Foundation, the British
Association of Dermatologists, Children’s Burns Trust
and the Sir Philip Reckitt Educational Trust for providing
financial support to enable this study to be completed.
Appendix A: Burn classification15
Appendix B: Paediatric burn management protocol6,11-12,13-15,22,24
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