Frequency of Burn-Trauma Patients in an Urban Setting

Background  Burn-trauma patient encounters constitute 5% of the emergency department population.

Hypothesis  A large urban hospital will treat twice as many (ie, 10%) burn-trauma patients.

Design  Retrospective 44-month study.

Setting  Metropolitan county hospital.

Patients  Population-based sample of burn-only (n = 1102), burn-trauma (n = 120), and assault burn–trauma (n = 43) patients.

Main Outcome Measures  Frequency and demographics.

Results  Just under 10% (n = 120) of the burn population had burn-trauma injuries. The mean ± SD Injury Severity Score was 12 ± 12 in these burn-trauma patients: 4 ± 2 in outpatients and 14 ± 13 in inpatients. The burn-only and burn-trauma groups had similar age ranges, ethnic distribution, frequency of inhalation injury, substance abuse, malnutrition, sepsis, pneumonia, diabetes mellitus, percentage total burn surface area, number of procedures, grafted areas, and mortality. Forty-three burn-trauma patients (35.8%) sustained injuries due to assault, compared with 123 (11.2%) in the burn-only group (P<.001). Burn-trauma patients who were assaulted had a mean ± SD Injury Severity Score of 11 ± 10. There was a significantly increased male-female ratio among the assault burn–trauma patients (6:1) compared with the burn-trauma (3:1) and burn-only (2.3:1) groups (P<.04). Most of these injuries were caused by an unknown assailant, in connection with an automobile, a motorcycle, a bicycle, or pedestrians intentionally struck by moving vehicles, or by child abuse. The main mechanism of injury was contact in 57 burn-trauma patients (47.5%), compared with 127 (11.5%) in the burn-only group (P<.001).

Conclusions  A large urban population will have an increased frequency (2-fold in our center) of burn-trauma injuries. Assault and child abuse are significant contributory factors to burn-trauma injuries in this population.

APPROXIMATELY 5% of patients who are seen in trauma departments have sustained multiple modes of trauma, including bone fractures and soft tissue injury such as burns, lacerations, gunshot wounds, and contusions.^1-7 The most common causes or mechanisms of injury are motor vehicle crashes (MVCs) and falls (work-related such as electrocutions, roofing, or escape from structural fires).^1,2 There have been reports in the literature detailing the management complications of burn-trauma patients, especially if the burned area overlies a fracture. In 1989, Purdue and Hunt⁸ found that 5% of the Dallas, Tex, trauma population had burn-trauma injuries; assault was a factor in 12.5% of these cases. In 1990, Cesare et al⁹ reviewed 900 trauma admissions, but they listed burns and assault injuries as separate categories of trauma. None of these reports addressed the demographic characteristics of burn-trauma patients as an entity. The purpose of this study was to determine burn-trauma frequency and demographics in a busy metropolitan county hospital and to compare them with a concurrent burn-only patient population.

A 44-month (March 1, 1999, to November 30, 2002) retrospective review of patients seen in the department of trauma identified 17 531 patients, of whom 1419 (8.1%) were seen in the burn center, 1222 (7.0%) sustained thermal injury, and a subset of the burn population (120 patients [9.8%]) were burn-trauma patients. One hundred ninety-seven patients seen for other conditions such as inhalation injury only, intravenous infiltrations, wounds, ulcers, and other skin disorders were removed from the statistical analysis database. The severity of injury and percentage total burn surface area (TBSA) determined the service to which the patient was admitted. Patients received emergency services as required by their injury, with the most acute needs taking precedence. Resuscitative fluids were administered as needed for all injuries. The trauma and burn services made joint patient care decisions daily. The burn team saw all burn patients as outpatients, in-house consults, or burn center admissions. Among 120 burn-trauma patients, 21 (17.5%) were seen in the trauma, adult, or pediatric emergency department or were transferred from another hospital and were treated and sent home. Twenty-three (19.2%) were seen as in-house consults on different services. If they required burn surgery, they were transferred to the burn unit. Seventy-six (63.3%) were admitted directly to the burn service. The study was approved by the institutional review board of the John H. Stroger, Jr Hospital of Cook County.

Burn-trauma patients sustained a thermal injury and fractures or soft tissue injuries such as lacerations, abrasions, road burn, knife wounds, gunshot wounds, hematomas, bruises, or sprains. Some patients in the burn-trauma category with fracture also had a soft tissue injury. Patients in the burn-trauma category with soft tissue injury did not have fractures. In some cases, patients had a thermal burn, fracture, and soft tissue injury (they were included only in the burn-trauma with fracture category).

Assault burn–trauma was defined as intentional injury or harm by physical force, weapons, neglect, or substances perpetrated by another individual. Categories identified were MVCs, domestic violence (relative or friend), intimate partner violence (spouse or mate of opposite or same sex), gang-related, and unspecified (assailant was unknown to the victim). Injuries resulted in a burn with fracture or soft tissue injury.

Contact injury resulted from hot irons, curling irons, radiators, space heaters, or the heat of the engine or the undersurface of a car.

Road burns were defined as traumatic debridement or degloving of epidermis and dermis on body areas in friction contact with asphalt, gravel, ground, or earth, resulting in a partial- or full-thickness burn.

Statistical analyses were performed using Statistica (STATSOFT, Tulsa, Okla) for descriptive and basic statistics. Summary descriptive statistics were obtained, including means, SDs, χ² 2 × 2 summary frequencies (Pearson product moment correlation, maximum likelihood χ² test, McNemar test, and Fisher exact test), and 1-way analysis of variance, with the Tukey test for unequal numbers. Statistical analyses compared burn-trauma with burn-only and assault burn–trauma patients by age, ethnic distribution, frequency of malnutrition, sepsis, pneumonia, urinary tract infections, diabetes mellitus, percentage TBSA, inhalation injury, number of procedures, grafted areas, and mortality. Additional analyses compared the different types of assault. The data were normally distributed when categorized by age or percentage TBSA in raw or log linear analysis. P<.05 was considered significant.

A retrospective study of patient encounters at the Sumner L. Koch Burn Center of the John H. Stroger, Jr Hospital of Cook County during 44 months identified 120 burn-trauma patients and compared them with 1102 burn-only patients and with 43 assault-related burn-trauma patients. As depicted in Table 1, the 3 groups generally had similar age ranges, percentage TBSA, inhalation injury, hospital length of stay, burn intensive care unit and step-down days, mortality, number of procedures, grafted areas, ethnic distribution, frequency of malnutrition, diabetes mellitus, sepsis, urinary tract infection, pneumonia, substance abuse, and flame as a mechanism of injury. Although not statistically significant, there was a trend toward longer hospitalization in the assault burn–trauma category (P<.14 compared with control and P<.17 compared with the burn-trauma only group). Sex distribution among the 3 groups identified a 6:1 male-female ratio in the assault burn–trauma category, compared with 3:1 in the burn-trauma group and 2.3:1 in the burn-only group (P<.04). There were 770 males and 332 females in the burn-only group, 92 males and 28 females in the burn-trauma group, and 37 males and 6 females in the assault burn–trauma group. The mean ± SD Injury Severity Score¹⁰ was 12 ± 12 in the burn-trauma patients: 4 ± 2 in outpatients and 14 ± 13 in inpatients. There was also a significant seasonal variation in the occurrence of the burn-trauma injuries. Eighty-two (68.3%) of the burn-trauma patients had their injury in the summer and spring; the burn-only group had injuries throughout the year: 314 (28.5%) in summer, 301 (27.3%) in spring, 244 (22.1%) in fall, and 243 (22.1%) in winter (P<.001).

As seen in Figure 1, most of the burn-trauma patients were adults, with few patients older than 55 years (senior) and about a fifth who were younger than 14 years (mainly the 1-month-old to 8-year-old range). Figure 2 demonstrates that the burn-trauma patients reflected the ethnicity of the burn-only patients. The major mechanism of injury was contact in 57 burn-trauma patients (47.5%), compared with 127 (11.5%) in the burn-only group (P<.001, Figure 3). In contrast to the burn-only population, in whom scald and flame were the major mechanisms of injury, burn-trauma patients were more likely to be injured by contact and flame. Nine patients (7.5%) in the burn-trauma group had road burn injury.

Sixty-three patients (52.5%) had multiple areas of skin involvement, 16 (13.3%) had upper extremity involvement, and 15 (12.5%) had lower extremity involvement in the burn-trauma group, compared with 433 (39.3%) with multiple areas, 222 (20.1%) with upper extremity, and 189 (17.2%) with lower extremity involvement in the burn-only group. Forty-three (35.8%) in the burn-trauma group required skin grafting, compared with 288 (26.1%) in the burn-only group. In the burn-trauma group, 60 patients (50.0%) had a thermal injury, 39 (32.5%) had road burn, 3 (2.5%) had thermal and road burn injury, and 3 (2.5%) had a gunshot wound. Fractures, such as those of the spine, ribs, clavicle, face, scapula, and extremities, were present in 47 burn-trauma patients (39.2%); some of these patients also had soft tissue injury and a burn wound. Fourteen (11.7%) of 120 burn-trauma patients had blunt head trauma.

Both groups had an 8.3% rate of inhalation injury (10 in the burn-trauma group and 91 in the burn-only group). Twenty-three (19.2%) of the burn-trauma patients were substance abusers; likewise, 193 (17.5%) of 1102 burn-only patients were substance abusers. Wound cellulitis was present on admission in 119 (10.8%) in the burn-only group and in 9 (7.5%) in the burn-trauma group. Sixty (50%) of the 120 burn-trauma cases were of high or moderate complexity (requiring burn intensive care unit admission), compared with 407 (36.9%) in the burn-only group and 20 (46.5%) of 43 in the assault burn–trauma group. There were 2 deaths (1.7%) in the burn-trauma group and 22 deaths (2.0%) in the burn-only group. Statistical analysis was also performed to determine the types of assault seen in the burn-trauma population.

Forty-three (35.8%) of 120 burn-trauma patients sustained injuries due to assault, compared with 123 (11.2%) of 1102 in the burn-only group (P<.001). Burn-trauma patients who were assaulted had a mean ± SD Injury Severity Score of 11 ± 10, compared with 12 ± 12 in the burn-trauma group. Figure 4 compares the assault rate in the general burn center population with that in the burn-trauma group. While the burn-trauma patients comprised only 7.1% of the burn population in 1999, that figure rose to 10.5% in 2002. The frequency of assault-related burn-trauma injury increased from 20% in 1999 to 26.2% in 2002.

Table 2 shows the demographic characteristics of the different types of assault seen in the burn-trauma group: unknown assailant, MVC, child abuse, domestic violence, partner violence, and gang-related. The 2 largest categories were unspecified assailant and MVC, comprising 58.1% of the assault burn–trauma category. Most of these injuries were sustained in connection with an automobile, a motorcycle, or pedestrians intentionally struck by moving vehicles. Of the 75 MVC cases, 18 (24%) involved pedestrians. There were 54 MVC cases in the burn-trauma group and 21 MVC cases in the burn-only group. Five (27.7%) of 18 pedestrians were intentionally injured on the street. In most cases, the assailants were unknown to the burn-trauma patients or the incidents were gang-related. The pedestrians were standing on the street corner or crossing the street when they were run over or dragged by the vehicles. Most sustained fractures, and many required skin grafting for third- to fifth-degree burns or road burn. Twelve (27.9%) of 43 assault perpetrators used motor vehicles as weapons (7 assault cases did not involve pedestrians). There were 7 motorcycle-associated injuries in the burn-trauma group; 1 was assault-related. The motorcyclist was riding immediately behind a van when a cinder block, thrown from an overpass, struck the van, causing the driver to lose control, and the van burst into flames. Four individuals were hospitalized for burns; the motorcyclist also sustained a lower extremity fracture. Six of the assault burn–trauma patients were child abuse cases.

Of 104 pediatric cases investigated by the Department of Child and Family Services for child abuse and neglect, 39 were cleared. Sixty-five (62.5%) were confirmed as child abuse cases, and 11 (16.9%) of these children had traumatic injuries in addition to the burn injuries. An additional pediatric patient was in the burn-trauma group because of multiple injuries sustained in a hit-and-run accident. There was a 2-fold increase in child abuse cases in the burn plus fracture group compared with the burn-only or burn plus soft tissue injury groups. Although the numbers were small, these burn-trauma patients had a lower mean percentage TBSA than patients in the unknown assailant, MVC, or domestic violence groups, as seen in Table 2. Most of these children sustained a flame or scald injury.

Most burn-trauma publications cite a 5% frequency of burn-trauma patients and usually concentrate on the management of fractures in patients with burns and the complications that may ensue.^1-7,11-13 Most occur after MVCs or structural fires.^7-9,11 Because burn-trauma is a rare occurrence outside of a major conflict or disaster, most centers reported 2 to 5 cases yearly during 5 to 7 years.⁷ In contrast, we saw 120 cases in the span of 44 months, approximately 3 cases per month and 10 cases per year, a 2-fold increase compared with the other reports in the literature. While MVCs can result in fracture, soft tissue, and thermal injury, unique to this burn-trauma population was that the MVC injury was frequently a result of assault (Figure 4). Of the frequencies reported in the literature,^8,14 none match the frequency of assault in our burn-trauma population. Road rage, defined as intentional injury of motorists, joyriding, and sensation-seeking activity has also been a component for injuries in the urban burn-trauma patients.¹⁴ In our urban center, pedestrians have been victims of joyriding activity. In addition, there is a subset of children who have been abused by burning and by blunt or penetrating trauma.

The literature mainly provides descriptions of types of burns and fractures characteristic of abuse and asserts the necessity for a complete history and physical examination and total body radiographs to document old, healing, or current fractures.^15-18 The frequency of confirmed child abuse in our center (10.6%) corresponds to that reported in the literature: 12%¹⁷ and 9%.¹⁸ By definition, child abuse falls into the burn-trauma category.⁹ It is possible that because of the sexual, emotional, and psychological abuse and neglect these patients experience, abused children are not generally included as a subset in the polytrauma-burn reports. There were no specific cases in which burn injuries were used to hide other forms of trauma. However, it was the burn injury that prompted relatives or neighbors to bring the child to the hospital or report the family to authorities. More than likely, the visibility of the injury instigated the corrective action.

In summary, there is a 2-fold increase in burn-trauma cases in this urban population compared with the frequency reported in the literature. The profile of a burn-trauma patient in a large county hospital is that of a young African American or Hispanic male injured through an assault, frequently associated with an MVC or an unknown assailant. Road burn due to road friction has also become a frequent modality of debridement or degloving, resulting in loss of epidermis and dermis. Contact with a motor vehicle or flame was a more frequent mechanism of injury in burn-trauma patients compared with the burn-only population, in whom mainly scald and flame injuries occurred. In this urban center, the frequency of assault-related burn-trauma injury increased during the observational period. If this trend continues, it would support the popular notion that road rage and assault are on the rise.

Corresponding author and reprints: Barbara A. Latenser, MD, Department of Trauma, Sumner L. Koch Burn Center, John H. Stroger, Jr Hospital of Cook County, 1900 W Harrison St, Chicago, IL 60612 (e-mail: barbara_latenser@rush.edu).

Accepted for publication March 8, 2003.