MORTALITY FROM BURN: AN AUTOPSY BASED STUDY FROM NEPAL

1* 2 Madan Prasad Baral , Sidarth Timsinha Baral MP et al Received : 29 March, 2021 Accepted : 23 July, 2021 Published : 04 November 2021 1496 ISSN: 2542-2758 (Print) 2542-2804 (Online) Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Original Research Ar cle


Introduc on
In developing countries like Nepal burn deaths are a major public health problem due to their increased mortality, morbidity and long-term disability. A few clinical studies on burns have been reported from Nepal however, autopsy based studies on burns are limited.

Objec ves
To study the socio-demographic characteris cs of vic ms of burns and evaluate the cause and magnitude of fatal burn injuries retrospec vely.

Methodology
A two years retrospec ve analysis of burn deaths brought for autopsy was conducted from January 2017 to December 2018 in a central level hospital of Nepal.

Result
Out of 775 total cases autopsied 38 (4.90%) cases were burn related deaths. The majority of the deaths 17(44.70%) occurred in the age group 21-30 years with a preponderance in females 22(57.89%). Majority of the vic ms were married females 25(65.78%) and most of them were housewives 14(36.84%). Flame burn 23(60.52%) was the most common cause of all burns. The Total Body Surface Area (TBSA) Burn between 50-69% was observed in majority of the cases 27(71.05%).Most of the vic ms 15(39.47%) survived over 10 days post injury. Burn incidents were mainly accidental 33(86.84%) in nature followed by suicidal burns 5(13.15%). The main cause of burn death was sep cemic shock 16(42.10%) followed by neurogenic shock 10(26.31%).

Conclusion
The results of this study show that burns injuries are mostly accidental in nature; therefore, the risks of burn injuries should be rightly addressed and appropriate burn preven on strategies should be developed to reduce the frequency and burn related deaths.

INTRODUCTION
Burns are one of the highly destruc ve injuries, causing not only deaths but also major economic, psychological, and 1 long-term consequences. There is around 300,000 deaths worldwide due to burns each year. Of these, 95% happen in developing countries with Southeast Asia recording about 2 57% of deaths due to burns. The Annual Report from the Department of Health and Popula on for Nepal, including the fiscal year 2016-2017, recorded 55,090 burn or scald 3 injuries na onally. A na on-wise household survey in 15 districts in Nepal reported an incidence of 55 burns from 1350 households. The majority of cases (60.4%) were due to 4 hot liquid and/or hot objects. Deaths from burns are normally accidental in nature however; it might be of suicidal or homicidal origin. Suicidal burning is rela vely uncommon. Homicidal burning is unusual, yet it is found in situa ons where paraffin or some other inflammable material is 5 thrown over vic ms and their apparel and then ignited. It is common for an offender to try to discard the body of the vic m by the fireplace to hide the crime. At mes, some people might cause burn injuries on a dead body and a er ward produce it before the police to assist a misleading allega on of homicide against foe. In each case, care is to be taken to iden fy ante mortem and post mortem burns to 6 point that vic m was alive or not during fire. In Nepal few clinical studies on burns have been reported on burn vic ms [7][8][9] however, autopsy based studies are limited. In this region postmortem study of burn cases from a medicolegal viewpoint has not been conducted ll date. Therefore, the present study is conducted to analyze the epidemiology, ae ology, causes and manner of death in autopsied burn cases in Morgue of Western Regional Hospital of Pokhara Academy of Health Sciences (PAHS) which is one of the central level hospitals in Nepal.

METHODOLOGY
A retrospec ve review of autopsy report on burn deaths from January 2017 to December 2018 was carried out at Western Regional Hospital of Pokhara Academy of Health Sciences (PAHS). The study was approved by the Hospital administra on as ins tu onal ethical commi ee. A total number of 775 cases were autopsied in morgue of Forensic medicine department during the study period. Out of these 38 cases were related to burns. The details of these 38 cases were collected and thoroughly reviewed. Data was related to corpse and not harmful for living human beings; privacy of data was maintained while collec ng the data. The collected data included age, sex, marital status, percentage of burn, hospitaliza on and survival me, cause of death and manner of death. The Total Body Surface Area (TBSA) burn was es mated by the rule of nine for all the cases. Further the police inquest was also reviewed to gather addi onal informa on regarding crime scene and statements of rela ves. All the informa on was noted in a pre-structured Pro forma. The data was then entered and analysed using Microso Excel 2014.  Table 2 shows that in majority 22(57.89%) of cases total body surface area burn was between 50-69 % with a higher incidence 16(42.10%) cases in the age group 21-30 years. Table 3 illustrates the rela on between the percentage of TBSA burn and the period of survival. Out of 38 cases, 27(71.05%) cases suffered 50-69% TBSA burn. Only 2 (5.26%) cases were brought dead cases with 70-79% TBSA burn. Out of 27 cases, 13 cases (28.93%) survived for 1-8 days, 5 cases (13.15%) survived for 9-10 days and 9 (23.68%) cases survived for more than 10 days post-injury.   Flame burn 23(60.52%) was the most common cause of all burns followed by scalds 6(15.78%) and electric burn 5(13.15%). Flame burn affected more females 16 (72.72%) than males7 (43.75%) while electrical burn affected more males 4(25.00%) than females 1(4.54%). Scalds, lightening, and chemical burn affected both the sexes equally. In maximum cases, burns were accidental 33(86.84%) in nature followed by suicidal burns 5(13.15%). Suicidal burns were more common in female 4(80.00%) than male 1(20.00%). We did not find any case of homicidal burn in this study. Sep cemia 16(42.10%) was the major cause of burn death in our study.

RESULTS
As per history, dying declara on of vic m (ante mortem), police inves ga ons and post-mortem report, it was observed that in majority of the burn vic ms, the manner of burn was accidental.

DISCUSSION
In this study, the age group 21-30 years (44.7%) was mainly 10 involved in burns. Chakraborty Set al also observed majority of the burn vic ms in the age group of 20-39 years (56.6%). This finding is also comparable to an Indian study in 11 which (59.6 %) of burn vic ms were between 15-30 years. This age group is both produc ve and ac ve in terms of earning a living, which exposes individuals to a variety of injuries, including burns. Our study showed that burns were common in females (57.89%) than males (42.10%). Also, burns were observed more in married females (65.78%) and among housewives (56.0%). Our finding is in agreement to a study conducted in Nepal, where burns were common in 12 females accoun ng 79% and among married females 84%. LiuE Het al also observed burns common in females (52.8 %) 13 than males (47.2 %). In contrast burns were more in males (58.0%) than females (42.0%) with male: female ra o of 14 1.3:1 in a Nepalese study. The female preponderance is perhaps because females are regularly exposed to fire sources as they cook on regular basis as compared to males especially a er marriage. In our study maximum cases reported from Kaski district (68.42%) of Gandaki Province of Nepal. Our study site is located in same district and it is most established and largest one thereby covering large number of cases. It is very certain that the deaths are directly propor onal to percentage of burns. In the present study, majority of the subjects sustained over 50% TBSA burn with mortality rate of (57.89%). This indicates the incompa bility with life even at a ter ary care centre. In a study from 15 Angola majority of the vic ms sustained over 40% TBSA burn with (100%) mortality. Similarly, over 40-50% TBSA burn has been reported from other studies with (80%) 16,17 mortality rate.
In our study, flame burn accounted for (60.52%) of burns. Similar, findings were observed in a Nepalese study where flame burn (64%) was the main cause 7 18 of burn injuries. However, Poudel K et al observed burns due to contact with hot liquid and steam (53%) was the most common This indicates the presence of social problems among married females, who have all household responsibili es even in urban se ng like ours. Another element that may contribute to burn incidents among females is the loose flammable clothes they wear like sari and shawls that can easily catch fire exposing them to burn injuries. In the current study, maximum (28.93%) cases died within a week a er hospitaliza on, indica ng that burns are highly fatal. 20 Vilasco B and BondurandA reported (40%) burn deaths between 3 and 7 days of the incident. Correspondingly, 21 Kumar V et al also reported death from burns within a week in (60.8%) vic ms. In this study, soot par cles were found in trachea in (18.42%) cases. Similar findings where soot par cles in trachea was no ceable in (18.05%) cases was 22 reported in an Indian study. Almost, all the vic ms in our study died in the hospital a er receiving treatment. This could be the reason of absence of soot par cles in the trachea. It is very challenging to opine that a burn injury is accidental, suicidal or homicidal in nature. According to history, dying declara on, police inves ga ons and postmortem report (86.84%) of deaths in our study was due to accidental burns. Similar observa on was made by Vidhate 23 SG et al where, majority (65.14%) of deaths were due to 10 accidental burns. Chakraborty S et al also reported in his study that out of 83 cases most of the cases were due to accidental burns (61.4%). This might be due to regular contact with fire and kerosene while cooking, as well as a lack of awareness of burn safety measures among females. In most of the cases the common cause of death was sep caemia (42.10%). This finding is comparable with an Indian study where majority of death (55%) was due to 24 sep caemia. Also, in a study on 352 pa ents with burns, sep caemia was the leading cause of death in 10 pa ents 25 out of 16 fatali es.

CONCLUSION
The epidemiological components for burn injuries vary from country to country. In present study more than half of the vic ms died were married women who were ac vely involved in house hold ac vity including cooking. Accidental burn occurred in most of the cases with just a few cases being suicidal in nature. In the current study, there was no Baral MP et al incidence of homicidal burns. Sep cemia was the leading cause of death among burn vic ms.

RECOMMENDATION
As majority of burn incidence occurred from preventable causes, it is impera ve to educate the common people about burns preven on and safety measures. Crea ng awareness in the family especially the housewives and parents and also in male concerning risk in work loca ons, would be certainly produc ve. Also, se ng regula ons to develop safer cooking appliances, promo ng less inflammable fabrics to be worn at home and educa ng the community especially women on safer first aid prac ces would be highly beneficial. Therefore, married female housewives can be the target group for awareness regarding safety measure for burn injury to reduce the number of burn injury cases in future from this par cular region of Gandaki Province Nepal.

LIMITATIONS OF THE STUDY
This study was conducted in a single loca on. There are other districts in Gandaki Province where autopsies are performed, so the current study cannot reflect the actual burden of burn deaths from Kaski district despite the fact the current loca on is a ter ary centre where complicated burn cases are referred from other districts.