Prevention of burn injuries

Table 4. Vectors leading to burns related to cultural and social traditions or festivities

1.Tanning

2.Aesthetic skin branding

3.Steel chopsticks use (Korea)

4.Barbecues, flambé food, fondues

5.Primus stoves

6.Kerosene oil for lighting

7.Sandal burns (heating device)

8.Ember or “brasas” (Mediterranean countries)

9.“Kangari” burns

10.“Dowry” and “sati” burns (India)

11.Drug abuse or use

12.The “street soccer” game.

13.“Shabbes” burns (Jewish orthodox children)

14.“Friday” mass and pilgrimage to Mecca and extremely hot temperatures and barefeet

15.“Camphor” burns of the plam (India)

16.Garlic burns (traditional medicine practice)

17.Self-mutilation by burning (Buddhist community)

18.Fireworks

19.Halloweeen “Egyptian mummy” burn (United Kingdom).

20.Chinese mid-autumn festival burns

21.Cupping (Middle East)

22.The Turkish “flying toy balloon” burn

23.Coining (Vietnam)

Adapted from: Al-Quattan MM, Al-Zahrani K (2009)

A review of burns related to traditions, social habits, religious activities, festivals and traditional medical practices. Burns 35: 476–481 [2]

cide or suicide attempts. Self-inflicted burns tend to be more extensive and have 14 times higher mortality than accidental burns due to the use of accelerants. In the developing world, some flame-related burns are the result of social traditions and religious rituals (Table 4).

Burn prevention types

We can classify burn prevention in two ways:

A) Primary, secondary and tertiary prevention

Focusing on the time elapsed since injury; this classification is similar to the one published by Haddon in 1968, with the phases pre-event (primary prevention), actual event (secondary prevention) and postevent (tertiary prevention) and the nine-cells matrix combination (Table 5).

A1) Primary burn prevention aims to avoid the injury from occurring at all. Primary burn prevention strategies include automatic protection, legislation/regulation and education.

A1. 1) Automatic protection represents the most effective primary preventive strategy. It involves elimination of environmental hazards or more accurate product design.

A2. 2) Legislation/regulation: Community, state, national or international governmental regulations and laws are in place to reduce injury. For instance, local ordinances that require apartment buildings to have working smoke detectors or installation of antiscald devices; regulation of exits and fire escapes from buildings where people work or congregate, as well as laws, not only for the installation but more importantly for the maintenance of equipment for fire control; regulations of fire drills in educational institutions; regulations of handling and disposition of any kind of flammable materials, etc.

A2. 3) Education: Educational programs focus on providing information about an identified area of concern and seek to make the public aware of the

Table 5. The Haddon matrix for burn control

	Agent or vector	Host		Environment
			Physical	Social
PRE-event	Fire-safe cigarette	Control seizure	Non-slip	Legislation: factory preset
			tub surface	water heater thermostats
EVENT	Sprinklers,	Flame-retardant clothes	Fire escapes	Fire drill education
	smoke detectors
POST-event	Water	First aid antibiotics	Emergency	Emergency and
			Medical Services	rehabilitation services

From: Hunt JL, Arnoldo BD, Purdue GF (2007) Prevention of burn injuries. In: Herndon DN (ed) Total burn care. Saunders Elsevier, Galveston, pp 33–39

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dangers and to teach appropriate preventive strategies. They also inform people about the medical and social consequences of burn injuries; i. e. parents are taught to insert plastic plugs to cover the electrical outlets to prevent electrical burns in small children.

While burn prevention educational campaigns have reduced the incidence of burn injuries, they have not eliminated the injuries entirely. Education may increase knowledge, but does not always lead to behavioural and/or lifestyle change needed to diminish or eliminate incidence or severity of burn injuries.

Probable causes of failure of burn education primary prevention programmes may be the brevity of the campaign, multiplicity of messages and separation of the interventions. It has been postulated that the prevention program needs to be repeated several times to be effective. In some US states, burns education in public schools is mandated by law. In fact, school children constitute the largest high-risk group to suffer burn injuries. Although similar prevention methods may be used to reach both children and adults, it has been shown that the amount of time required to adequately convey a burn injury prevention curriculum is agedependent, and that extracurricular school activities are very important. For children 6 –12 years of age, games would be an effective educational prevention tool. Family education is also crucial. Posters, mass media and multimedia strategies are effective means of disseminating the burn prevention message in general.

A2) Secondary burn prevention seeks to minimize the already-produced injury and consists of teaching early injury detection and treatment. For example, an individual whose shirt catches fire is taught to STOP, DROP to the ground and ROLL to extinguish the flames; other examples include “apply cool water to a burn” or “crawl under smoke” (see Table 6).

A3) Tertiary burn prevention involves avoiding impairment and maximizing functionality during the phase of rehabilitation after a burn. Indeed, not only secondary, but also tertiary burn prevention strategies aim at limiting the alreadyproduced damage.

Table 6. First aid counselling after a burn (secondary prevention)

If your clothing catches fire:

–STOP (don’t run!)

–DROP to the ground

–ROLL to put the fire out

If a burn occur: COOL

–Immediately pour cool water – not ice – on the burn

–Cover burn with a clean sheet and seek medical attention

B)Active versus passive prevention

Focusing on the three aspects of injury prevention: agent, environment and host.

B1) Active burn prevention: Active prevention requires individual effort. Education is the only active primary burn prevention strategy. For instance, teaching people to lower their tap water temperature through educational campaigns. Active prevention is the least effective and most difficult strategy to maintain, especially over a long period of time.

B2) Passive burn prevention includes legislation/regulation and product design/environmental change. Passive prevention strategies don’t require “correct behaviour” by the individual and appear to be more successful than active prevention strategies. However, many of the more effective burn prevention programs contain both active and passive measures. Among the passive prevention methods, legislation appears to play a major role.

To sum up (Table 7), burn prevention involves not only physicians, nurses and other health careproviders but also engineers, legislators and inspectors.

Table 7. Strategies to reduce severity injury and parameters of injury occurrence

ACTIVE (Education)

– Agent + Host + Environment

PASSIVE

–Product engineering + Environmental change + Legislation

–Agent + Environment

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Prevention of burn injuries

Burn prevention: The basics to design a plan

Any injury prevention campaign should consider the following ABCDE steps:

A = Analyze the data. B = Build a coalition.

C = Communicate the problem. D = Develop the interventions. E = Evaluate the program.

Efforts at burn prevention should target the population groups most at risk and should aim at minimizing the effects of specific risk factors and harmful actions. To achieve success, it is necessary for a leader, who has strong knowledge about the epidemiology, care and recovery of burn patients to guide colleagues, who are also well-informed and culturally sensitive to the specific population where the prevention is going to be conducted.

That is to say, that every burn prevention programme has to be population-specific and differ, depending on the country/ individual characteristics (education, socioeconomic status, geography, traditions, cultural or religious beliefs and social habits . . .); in other words, the who, where, when and how burns happen must be taken into consideration. For instance, in India, the task of educating students appears to be more worthy because they are more receptive and spread easily the educational messages to their parents and friends.

In conclusion, knowing the general risk factors –the vector or energy source, the host or victim and the environmentis essential for preventing and controlling any injury.

Any injury prevention plan is not valid until the results of its application are evaluated (Table 8). If a prevention plan fails to have success, possible solutions may be to:

a)change the technique to measure the burn incidence reduction. Mortality and, more importantly, morbidity data must be used for outcome measures.

b)modify the prevention program design to a more appropriate one.

Regarding this problem, however, some researchers found that patients who sustain burn injury use burn prevention strategies at similar rates, when compared with those who do not. They defend that those individuals with lower education and in-

Table 8. Autosurvey to evaluate oneself’s burn prevention tools

–Do you put handles stick out from the stove?

–Do you leave children alone in the kitchen while food is cooking?

–Do your children play in the kitchen while you are cooking?

–Are appliance cords hang down from counters or tables?

–Do you rush to fix breakfast or dinner?

–Do you check for children before carrying hot liquid?

–Is hot coffee or tea left on the table when no adult is there?

–Are children alone in the bathroom when the tub is being filled?

–Do you forget to test the temperature of your child’s bath water?

–Do you have long hair and wear it loose while cooking?

–Are matches and cigarette lighters lying around where children can find them?

–Are flammable liquids stored on a high, cool shelf, away from open flame in tightly sealed containers?

–Do you store children’s snacks over the stove?

–Do you pour charcoal lighter fluid on coals after they have started burning?

–Do you smoke near gasoline?

–Do you wear a bathrobe while cooking?

–Do you spill lighter fluid on your clothes?

–Do you usually fall asleep while smoking?

come, remain more susceptible to burn injury, independently of the prevention strategy used.

Target-specific burn prevention strategies

Flame burns

Prevention of burns from residential fires

The use of smoke alarms has had the greatest impact in decreasing fire deaths in the US, but they have to be maintained –not only installedto be really effective.

On the other hand, fire sprinklers complement smoke detectors and are the most effective tool to prevent the spread of fires in their early stages. In 1993, the National Fire Protection Association (NFPA) estimated smoke alarms alone could reduce fire deaths by 52%; sprinklers alone could decrease fire deaths by 69% and the combined use of them by 82%.

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House fires account for most of the major burn injuries. Causes of injuries and burn prevention tips include:

a)Careless cigarette smoking: Canada was the first country to pass fire-safe cigarette legislation in 2004. People must be aware of practising safe behaviour while using any flammable materials. It is also recommended that one practice EDITH (Exit Drills in the Home), so that everyone will know the meeting place and how to escape in case of a fire.

A cigarette left unattended can burn for as long as 30 minutes. In 1993, 40% of residential fire deaths were caused by the careless use of cigarettes. Most smoking fires started in the bedroom or living room. Some severe COPD (Chronic Obstructive Pulmonary Disease) patients use home oxygen and then, at the same time, they go to light a cigarette, leading to facial burns. Furthermore, alcohol is often combined with cigarette smoking or other substance abuse, with the victim falling asleep. In fact, statistics have shown that it is quite common for burn patients to have higher blood alcohol levels.

b)Heating equipment: Never leave small children unattended next to a heat source. Also don’t leave candles unattended.

In middle Asia, the “sandal” is an ancient heating device responsible for a high number of third degree foot burns in small children in Uzbekistan. The “sandal” is a table, around which people sit which has a hole in the floor underneath, where lit coals are placed. Unsupervised toddlers crawl and fall into the coals leading to severe burns.

During winters in Kashmir, people charcoal braziers, known as “kangari”, between their legs to keep warm. Repeated exposure results in erythema to the inner thighs and lower abdomen and may also promote skin cancer.

c)Electrical equipment malfunction: You should install not only smoke, but also CO (carbon monoxide) detectors.

Whereas smoke alarms are now present in almost 100% of homes, CO detectors are largely absent, but they should also be present. CO inhalation is the main cause of fatal poisoning in the industrialized world and CO intoxication is present in flame injuries, especially those sustained indoors. CO is produced by open flames, whenever a carbon-based fuel, gas, oil, wood or charcoal is burned. Products

Table 9. Prevention tips for home burns in developing countries

1.Cooking should be done only on a platform, not on the floor.

2.Don’t use a pressure stove.

3.Do not pour kerosene into a burning stove or lamp.

4.Do not adjust a rack for storing materials just above the cooking range.

5.Do not allow younger children to play with matchsticks, candles and electric switches.

include charcoal grills, gas water heaters, stoves and lanterns. Carbon monoxide-generating appliances, such as stoves, are often used during power outages or for financial reasons in low-income households. If the heating source is either used improperly or ventilation is inadequate, CO levels can become toxic and have fatal consequences.

d)Cooking: You should be very careful when cooking, avoid wearing loose clothing that could catch on fire, avoiding cooking when naked (especially in the summer and hot weather countries) and install smoke detectors and automatic sprinklers in the home and restaurants.

In many developing countries, cooking is still done using primus stoves, which are an important cause of burns, due to the presence of kerosene. Apart from the kitchen, Kerosene is also used as a nightly light source and contained in home-made chimneys, located in the living rooms or bedrooms in houses in the developing world (Table 9).

e)Children playing with matches and lighters: Matches and lighters must be kept out of the reach of children. Children should be taught, at an early age, that matches and lighters are tools and not toys.

Prevention of outdoors flame-burns

In many dry and warm-climate countries, especially during the summer, forest fires caused by unattended fallen cigarettes or intentionally by individuals with psychiatric disorders who enjoy provoking fires. In some rural areas of Spain, farmers burn olive trees or timber to produce embers or “brasas”, which leave incandescent residue. These residues remain alight and undergo slow combustion and, hence, are used for heating, but they may also produce flame burns.

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Prevention of burn injuries

Outdoor barbeques are commonly held in many countries during summer months. Instead of using an authorized carbon source of heat, some people use gasoline or alcohol to make the flames grow, causing flame burns. Other cooking-related burns involve the making of fondues flambéed food.

Outdoor, recreational fires are also a normal practice during the warmer months of the year and may cause severe burns. They involve mostly the hands, with a mean TBSA (Total Body Surface Area) of 3.5%, and the main mechanism is falling into the fire. Parents can play an important role in educating their children about campfire safety and the hazards of both active and extinguished fires.

In India, marital traditions are associated with “dowry” and “sati” burns, which both have high mortality rates. After marriage, if the gifts (known as “dowry”) are not considered enough, the wife is put on fire (usually after pouring kerosene on her body) and this is known as “dowry burns”. In “sati burns”, the wife throws herself on the burning body of the deceased husband. Although the government has made efforts to prevent these burns by writing legislation and including it under the Penal Code, these type of injuries still occur and some families lie and report “dowry burns” as kitchen accidents.

In a similar manner, in the developing world, some religious activities involve self-inflicted ritual burns (especially in the Buddhist community) or promote unintentional burning (e. g. foot burns in Muslims who leave mosques barefoot where temperatures exceed 50 °C).

Also in India, a special type of fire-related burn (jaggery) causes severe and deadly pediatric burns. Jaggery is the non-industrial refinement of sugar cane into a sugar product and represents an important source of income and significant role in cooking and cultural rituals in rural India. Legislation aimed at improving dangerous work environments, establishing minimum age requirements and maximum hours of work, as well as with engineering or product design safety improvements, would be effective in reducing these types of injuries.

Fireworks are an important cause of burns in many countries around the world, due to its use during national holidays, traditional festivals or special events, such as New Year’s Eve or other celebrations, such as the Olympic games, Independence day (US),

Guy Fawkes Night (Commonwealth), Fallas (Valencia, Spain), Hari raya (Malaysia), Mawlid and Eid al-Adha (Muslim countries), Charshanbe-Soori (Iran) or Purim (jewish festivity). Contact hand burns from holding the fireworks, are most frequently seen accounted for largely by boys 10–14 years of age. However, in approximately 50% of the cases bystanders are injured. Eyes are affected in 18% of cases. Flame burns may also occur when the clothes catch fire. Complete firework bans are found in Hungary, Ireland, Australia and the northeast USA, at the present time.

A specific type of outdoor burn is seen during war. Combat-related thermal injuries generally affect the hands and head, mainly through improvised explosive devices, causing blast injuries and polytrauma. They generally involve less than 20% TBSA and have relatively low mortality rates (4% of all war deaths and 5–20% of all war-injuries). Preventive measures against war-related burn injuries include improvement in predeployment education to reduce noncombat injuries, flame retardant military clothing and decreased combat episodes.

Prevention of clothing-ignition burns

Clothing burns result from a combination of 3 factors: flammability, the behaviour of the wearer and the heat source. In the 1940s, many children in the US suffered leg burns as a result of the ignition of a particular cowboy suit or chaps, made of highly flammable brushed rayon. This initiated research interest in clothing flammability, leading to the following findings:

a)Wool: Burns very slowly and does not ignite. It melts with a red glow and finally extinguishes itself.

b)Cotton: Burns like a torch and is completely destroyed in a matter of seconds. Cotton combined with wool burns less than either by itself.

c)Rayon: Ignates easily, but not as intensely as cotton.

d)Raised cut materials: Are very flammable.

e)Silk: Produces a red glow but usually extinguishes quickly.

f)Nylon: Melts but clings to the underlying surface.

Apart from the materials, what has been shown to be very important in terms of preventing clothing-igni-

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