affecting nearly every organ system and leading to significant morbidity and mortality. In order to maintain a morbidity and mortality statistics database for burns, the ABA/TRACS (Trauma Registry of the American College of Surgeons) Burn Patient Registry was created in the US in the 1990s. However, there is still a strong need for homogeneous national and international burn registration systems.

Although mortality has declined over the past few years due to improved medical care and promotion of burn prevention, management of major burns still remains a challenge, even in modern, developed countries. The increasing number of burn survivors are at risk for developing long-term psychological and physical sequelae, with potentially devastating consequences to them, their families and society in general. Furthermore, burns have important human and material costs. Providing adequate hospital care to a burn patient costs approximately US$ 1000 per day and major burns usually require admission to intensive care units, which are very resource-inten- sive expensive.

In most developing countries, the same standard of care is not possible due to limited resources and inaccessibility to sophisticated skills and technologies, leading to a higher morbidity and mortality. Although these countries are in special need of burn prevention, the reality is often the opposite, where there is a lack of government-funded burn prevention programmes. In these countries, some health authorities consider injury prevention to have a much lower priority than disease prevention. Despite mounting evidence that injury is largely pre-

ventable, burn prevention has been forgotten in the past by public health authorities as these injuries are believed to be random accidents. While natural disasters are unavoidable, accidents can be prevented and represent a public health problem that requires government and community involvement. A key to keep in mind is that the best care for burns is prevention, which takes time, energy and money. Eventually, it is likely the most effective solution to the world’s burn problem.

Burn injury risk factors

Burn risk is linked with poverty, lack of running water, crowding, illiteracy, unemployment, lapses in child supervision – mostly in large and single-parent families, recent pregnancies or mothers’ being away from home, prior history of a sibling being burned-, presence of pre-existing physical/emotional challenges in a child and lack of education (although in some societies, higher education of individuals is associated with increased risk of immolation rituals involving burns, for example).

With these risk factors in mind, one can ascertain why burns are more common in the developing world and how low socioeconomic status has been linked to increased risk of unintentional injury and mortality.

Another important risk factor for burns is drug use. Medications, such as sleeping pills, narcotics, synthetic stimulant drugs, such as methamphetamines, alcohol and/or smoking are usually the pro-

drome of flame burns in many teenagers and adults. For instance, in South Korea it is not unusual to see groups of teenagers in a room engaging in butane gas abuse, which causes euphoria and hallucinations. Facial burns result from sniffing the flammable gas, in addition to potentially severe systemic effects, such as pulmonary oedema, gastritis and cardiac dysrhythmias. Sniffing nitrous oxide also causes confusion; in this case, the cold gas results in frostbite to the cheek.

In a large European review, risk factors for death from a burn were found to be older age, higher total body surface area burned and previous comorbidity in the form of chronic diseases. Multiorgan failure and sepsis were the most frequent leading causes of death. Burn shock and inhalation injury were responsible for most of the early deaths (< 48h). Half of the burns were suffered by children < 16 years old and 60% occurred in men (but in elderly people, women were more frequently burned).

When dealing with burn risk factors, it is important to analyze the who, how and where factors in order to design an effective prevention plan.

Table 2. Elderly burn prevention tips

WHO?

Regarding the age of the individual, children under 5 years of age comprise the highest risk group for burn injuries. Causative factors in all incidents involving babies are a mixture of imprudence, impulsiveness, curiosity, lack of experience and a desire to imitate adults. Furthermore, this age group lacks a sense of danger and awareness and they hardly understand cause-and-effect relationships.

At the other end of the age continuum, elderly people over 64 years are also a high risk population. Their risk of dying in a fire is 2.5 times greater than the general population. The main causes of burn injuries in the elderly are flame burns due to smoking and cooking (Table 2). Additional risk factors include medical conditions associated with physical or mental impairment: stroke, poor eyesight, decreased hearing and mobility, diabetes (peripheral neuropathy with decreased or no lower extremity pain perception), dementia (such as Alzheimer’s, with confusion and forgetfulness), depression and suicide.

In India, young women (16–35 years old) are the most prone to suffer burns at home, due to the tradition of cooking at floor level or over an open fire, compounded by the wearing of loose fitting clothing made from non-flame retardant fabric. In the least developed European countries, there is also female burn predominance and a higher proportion of electrical burn injuries comparing with western Europe, with a male predominance.

WHERE?

Most childhood burns occur in the home, in developed as well as in developing countries. The modern home can contain a number of harmful substances and pieces of equipment, such as electricity, gas and chemicals (Table 3). Lapses in child supervision, such as forgetting to turn off the oven or stove element at bath time lead to a higher risk of unintentional burn injuries.

Adult burns are reported to have a more variable location, with almost equal frequencies in the home, outdoors and in the workplace. For all age groups, the kitchen is the most common scene of burns, followed by the bathroom and the outdoors (i. e. backyard, garage).

HOW?

Burns in children are caused usually by scald, flame and contact burns, in order of most to least frequency (although in some countries, such as Australia, contact burns are the second cause after scalds, and, in the developing world, flame burns are the most common). It has been shown that when the child becomes older, flame injury predominates, becoming the most common cause of burns in children aged 6–17 years old.

Not only are young children more prone to suffer contact burns, but also the elderly, the physically impaired people, patients with diabetes, all of whom may have some inability to withdraw from heated objects or who have limited sensation to their extremities (Table 10).

In the developing world, the commonest cause of injury is a flame burn. Most such accidents are related to malfunctioning kerosene pressure stoves and homemade kerosene lamps used for lighting, or from domestic appliances using flammable fuel. On the other hand, many households are made of highly combustible and toxic materials, such as wood and plastics, which burn easily, leading to high mortality rates due to severe smoke inhalation injury.

In the developed world, fire is sometimes related, not only to accidental burns, but also to homi-