Epidemiology of burn cases hospitalized at the Plastic Surgery and Burns Service of Santa Casa de Misericórdia de Santos , Brazil

Introduction: Burns are skin injuries caused by external agents and can result in functional, aesthetic, psychological, and fatal sequelae. The objective is to determine the epidemiological profile of burn cases hospitalized at the Plastic Surgery and Burns Service of Santa Casa de Misericórdia de Santos (Serviço de Cirurgia Plástica e Queimados da Santa Casa de Misericórdia de Santos-SCPQSCMS). Methods: A total of 589 burn cases hospitalized at SCPQSCMS from March 2010 to March 2015 were evaluated. Results: Of these, 180 were children (aged <10 years), 72 were adolescents, 287 were adults, and 50 were elderly. The majority of the study sample were men, and the primary place of occurrence was the home. The most commonly affected regions were the head, face and neck, abdomen, thorax and trunk, and upper limbs. Burns were mainly caused by scalding (36.8%), flammable liquids (18%), fire (14.4%), and electrical injuries (10.5%). The average hospitalization time was 22 days; however, 61% of the sample remained hospitalized for up to 2 weeks and 4% died. Conclusions: The study demonstrated that the profile of patients hospitalized at SCPQSCMS was similar to that found in other units specializing in this type of treatment. Our results emphasize the importance of this type of study to understand and avoid risk factors and behaviors associated with burns. ■ ABSTRACT


INTRODUCTION
Burns are skin injuries caused by external agents, with partial or complete destruction of the skin in some body surface areas due to thermal, electrical, chemical, or radioactive trauma 1 .
Burns are the fourth most common type of traumatic injury worldwide, after traffic accidents, falls, and interpersonal violence, and represent a major global public health challenge as among the most severe injuries 2 .The World Health Organization estimated that there were more than 7.1 million accidental fire-related burns worldwide in 2004, with an overall incidence of 110 cases per 100,000 inhabitants per year 3 .
Approximately 90% of burns occur in low-to middle-income countries in regions that lack the necessary infrastructure to reduce the incidence and severity of these events 2 .The Brazilian Burn Society estimates that 1 million burn injuries occur each year in Brazil; of these, 200,000 are treated by emergency services and 40,000 require hospitalization 4,5 .

OBJECTIVE
The objective of the present study was to determine the epidemiological profile of burn cases hospitalized at the Plastic Surgery and Burns Service of Santa Casa de Misericórdia de Santos (Serviço de Cirurgia Plástica e Queimados da Santa Casa de Misericórdia de Santos-SCPQSCMS), São Paulo, Brazil, from 2010 to 2015, in order to understand the characteristics of this population and to improve services and educational policies for the prevention of burns.

METHODS
This retrospective cross-sectional observational study was conducted using data collected from electronic medical records of SCPQSCMS from 2010 to 2015.The study was approved by the Research Ethics Committee of our institution and registered at the Brazil Registry under Certificate for Ethics Assessment (Certificado de Apresentação para Apreciação Ética -CAAE) No. 62945316.7.0000.5448.Patients with second-and thirddegree burns were included in the study; patients who were admitted to the Burn Service but did not require hospitalization and those with incomplete records were excluded.
The collected data were entered on a spreadsheet and analyzed using statistical software (STATA version 13.1; StataCorp, TX, USA).For descriptive statistics, numerical variables were expressed as mean, median, standard deviation (SD), and 95% confidence interval (95% CI), and categorical variables were expressed as absolute (n) and relative (%) frequencies.Associations were examined using the chi-square or Fisher's exact test, and p-values less than 0.05 were considered significant.
The length of hospital stay was highly variable, with a median of 12 days and mean of 21.6 ± 28.1 days (range, 0-207).Most patients (61%) were hospitalized for up to 14 days, and 120 (21%) were hospitalized for more than 28 days.Adults aged 20 to 59 years were hospitalized for a longer period (Figure 2).
Most patients (91.9%) were discharged and only 4.1% (n = 23) died.Of these, 11 patients had seconddegree burns (five patients were aged 20 to 59 years and six were older than 60 years) and 12 had second-and third-degree burns (one patient was aged 10-14 years, five were aged 20-59 years, and six were older than 60 years).

DISCUSSION
Burns are severe injuries associated with morbidity and mortality; however, their incidence in Brazil is unknown.For this reason, the understanding of the epidemiology and the most frequent causes of burns may aid in the development of health policies related to prevention, treatment, and rehabilitation 10 .
Our results agree with those of other studies, with the highest number of cases occurring in the age group 20 to 49 years, in males, and in the home environment.The main causative agents were flammable liquids, fire, scalding, and heated surfaces and gases.The epidemiological analysis conducted by Coutinho et al. 6 indicates that this age group comprises the largest productive work force, and includes young adults (aged 20 to 30 years); this group also has the highest rate of thermal lesions.
Chemical burns were more common in this age group and occurred in the work environment in 75% of cases.Gimenes et al. 11 reported that although most cases occur in the home, the high percentage of occupational accidents should not be underestimated, and investment in education and incentives for the use of individual and collective protective equipment are essential.
Our results revealed that 16% of burn cases were in the age group 0 to 4 years and 14% were in those aged 5 to 9 years.Other studies 4,10,11 reported that scalding was the primary cause, indicating the importance of prevention in this age group.Millan et al. 10 indicated that these cases might be correlated with the neuropsychomotor development of children.When no longer entirely dependent on adults, a child begins to walk and experience the world more freely, and parents need to be attentive and vigilant in this developmental phase.
Among the elderly, scalding and fire were the primary causes, as reported in an epidemiological study by Bastos et al. 12 .The authors also observed that despite the low incidence in the elderly, this population has a high risk of mortality and represents 33-63% of reported cases.Burns caused by fire were significant in those aged 0-4 years and >20 years.Flammable liquids, scalding, and heated surfaces were more common causes of injury in those aged 0-9 years and 15-59 years.Burns due to chemicals and heated gases were only significant in adults aged 20 to 59 years.The average hospitalization time in our study was 22 days, and the majority (61%) of the study population was hospitalized for up to 14 days.These results agree with those of other Brazilian studies 1,4,6,9 .The body regions most commonly affected were the thorax and upper limbs, and this result was corroborated by a descriptive study conducted by Leão et al. 1 in Minas Gerais.
The mortality rate found in this study (4%) agrees with the results of previous studies 5,6 .A total of 23 patients died in our sample.Of these, 12 were elderly (24%, 12/50), 10 were young adults (3.5%, 10/287), and one was an adolescent (1.4%, 1/72).Dias et al. 5 found that the mortality rate reported by burn units was strongly correlated with the social and economic conditions of the involved countries.Moreover, this rate reflects the severity of the accidents and is dependent on the education level of the population, promotion of prevention campaigns, quality of electrical distribution networks, and resources available for the treatment of burns, among other factors.

CONCLUSION
This study demonstrated that the profile of burn cases admitted to the Plastic Surgery and Burns Service of Santa Casa de Misericórdia de Santos was similar to that found in other burn units.
These findings are important for understanding and avoiding risk factors and behaviors that are associated with burns, and can be used in the prevention of domestic accidents, care for children and the elderly, educational policies, supervision of the sale of flammable liquids, and guidance in the use of personal protective equipment at work.GACP Analysis and/or interpretation of data; statistical analyses; final approval of the manuscript; conception and design of the study; writing the manuscript or critical review of its contents.

JMN
Analysis and/or interpretation of data; statistical analyses; final approval of the manuscript; conception and design of the study; writing the manuscript or critical review of its contents.
ALDQ Analysis and/or interpretation of data; statistical analyses; final approval of the manuscript; writing the manuscript or critical review of its contents.

RPP
Final approval of the manuscript; writing the manuscript or critical review of its contents.
SCSJ Analysis and/or interpretation of data; final approval of the manuscript; writing the manuscript or critical review of its contents.

Figure 2 .
Figure 2. Hospitalization time for burn cases by age group at the Santa Casa de Misericórdia de Santos (n = 589) from 2010 to 2015.Santos, São Paulo, Brazil, 2016.

Table 1 .
Characteristics of burn cases hospitalized at the Plastic Surgery and Burns Service of the Santa Casa de Misericórdia de Santos (n = 589), Santos, São Paulo state, 2016.
NR: Not recorded.