Archives of Academic Emergency Medicine. 2021; 9(1): e8 https://doi.org/10.22037/aaem.v9i1.948 OR I G I N A L RE S E A RC H Baseline Characteristics and Outcomes of Patients with Head and Neck Burn Injuries; a Cross-Sectional Study of 2181 Cases Soudabeh Haddadi1∗, Arman Parvizi1, Reza Niknama2, Shadman Nemati3, Ramyar Farzan4, Ehsan Kazemnejad3 1. Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran. 2. Guilan University of Medical Sciences, Rasht, Iran. 3. Otorhinolaryngology Research Center, Department of ENT, Head and Neck Surgery, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran. 4. Department of General Surgery, Velayat Hospital, Guilan University of Medical Sciences, Rasht, Iran. Received: November 2020; Accepted: November 2020; Published online: 11 December 2020 Abstract: Introduction: Despite recent progress in treatment of burn injuries, head and neck burn and its complications is still considered a challenge. This study aimed to evaluate the baseline characteristics and outcomes of patients with head and neck burn. Methods: In this retrospective cross-sectional study, the medical profiles of patients with head and neck burn referring to a burn care center during 2 years were reviewed and analyzed regarding the baseline characteristics and outcomes of participants. Results: 392 (17.97%) cases suffered from head and neck burns. The mean burn percentage of participants was 29.31 ± 24.78, and 126 (32.14%) cases required tracheal intubation. There was a direct correlation between length of hospital stay and the degree of burn (p < 0.001). The length of hospitalization for patients burned by electricity was longer than those burned by other mechanisms (p = 0.003). There was a significant correlation between degree of burn and abnormal laryngoscopy findings (p = 0.036), developing acute respiratory distress syndrome (ARDS) (p < 0.001) and pneumonia (p < 0.001), need for mechanical ventilation (p < 0.001), and mortality rate (p < 0.001). Conclusion: Based on the findings of the present study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases required airway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%) cases died. There was a significant correlation between degree of burn and abnormal laryngoscopy findings, developing ARDS and pneumonia, need for mechanical ventilation, and mortality rate. Keywords: Burns; Patient outcome assessment; Intubation, intratracheal; Head; Neck; Respiration, artificial Cite this article as: Haddadi S, Parvizi A, Niknama R, Nemati S, Farzan R, Kazemnejad E. Baseline Characteristics and Outcomes of Patients with Head and Neck Burn Injuries; a Cross-Sectional Study of 2181 Cases. Arch Acad Emerg Med. 2021; 9(1): e8. 1. Introduction It is estimated that 180,000 people die from burn injuries ev- ery year worldwide. Non-fatal burns are among the leading causes of disability-adjusted life years (DALYs), which often occur in low- and middle-income countries. According to the World Health Organization (WHO), nearly 11 million people ∗Corresponding Author: Soudabeh Haddadi; Anesthesiology Research Cen- ter, Department of Anesthesiology, Alzahra Hospital, Rasht, Iran. Email: so_haddadi@yahoo.com, Phone: +981332338306-7, ORCID:0000-0002-0585- 3235 were severely burned worldwide in 2004, such that they re- quired medical care (1). The proportion of head and neck burns in burn center admissions has been estimated as 47% in a study, indicating the importance of this type of injury (2). Prevention of primary injury should always be a priority, but when the injury occurs, the primary goal should be to pre- vent the progression of injury and ensuring patient survival (3). Burns can cause extensive and devastating injury to the face and neck. Complications of burns can be divided into two categories: cosmetic and functional. Functional compli- cations include airway injuries, carbon monoxide poisoning, corneal and eye burns, chondrites, and ear injuries (3-6). The most important part in the initial evaluation of patients This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Haddadi et al. 2 after burns is to examine the airways and support them (3, 4). It has been estimated that approximately 13,000 to 22,000 people suffer from inhalation burns each year in the United States (4). Although the patient may be able to breathe spon- taneously in the early hours after the burn, it is still possible for the injury to spread and affect the entire respiratory tract (3). Inhalation injury is the third leading predictor of death due to burn after total body surface area (TBSA) burn and aging. The mortality rate of burn victims with inhalation in- juries has been estimated to be about 30%, while only 2% of burn patients without respiratory injury die (4). Immediate primary care can have a significant impact on the rate of primary injury, its progression, and its long-term out- comes (2, 3). Inhalation burns have still remained a major challenge for anesthesiologists as well as intensive care and rehabilitation specialists worldwide, and there is no agree- ment on the appropriate and systematic evidence-based ap- proach for treating the patients in the acute phase (4). In order to plan for prevention and improving the level of care and outcomes of the head and neck burns, the first step is to assess the needs and outcomes of burn patients. There- fore, the present study aims to evaluate baseline characteris- tics and outcomes of patients with head and neck burns. 2. Methods 2.1. Study design and setting This retrospective, cross-sectional study was conducted on patients referring to Velayat Hospital (an academic burn care center in Rasht, North Iran), following face, head, neck, and airway burn injuries from April 2017 to the end of March 2019. Using the patients’ profiles, the baseline characteris- tics and outcomes of patients were collected and analyzed. The study protocol was approved by Vice President for Re- search of Guilan University of Medical Sciences (Ethics code: IR.GUMS.REC.1397.394). Researchers adhered to the princi- ples of Helsinki Ethics recommendations and confidentiality of patients’ data. 2.2. Participants All of the patients referring to Velayat Hospital, following face, head, and neck burn injuries from April 2017 to the end of March 2019 were included. Those who were discharged in less than 24 hours were excluded from the study. 2.3. Data gathering Using a predesigned checklist and census sampling, demo- graphic characteristics, including age, gender, percentage of burn, etiology, burn scenario, comorbidity, first medical treatment, airway condition, need for mechanical ventila- tion, laryngoscopy finding, respiratory complications (acute respiratory distress syndrome (ARDS), pneumonia), length of hospital stay, and mortality rate were collected from the pa- tients’ profiles. To determine the frequency of head and neck burns, all the records of head and neck burns and those un- related to head and neck burns were counted in the speci- fied time period. A medical student was responsible for data gathering. The percentage of burn was measured using rule of 9. The patients became candidates for intubation in case of drop in their saturation with suspected airway injury, pres- ence of dyspnea, tachypnea, cyanosis, or loss of conscious- ness. 2.4. Statistical analysis Data were analyzed using SPSS version 21.0 and presented as frequency (%) or mean ± standard deviation (SD). A p-value less than 0.05 was considered to be statistically significant. 3. Results 3.1. Baseline characteristics of participants Out of the 2181 patients referring to the studied hospital dur- ing 2017-2019, 392 (17.97%) cases suffered from head and neck burns. The mean age of patients was 37.14 ± 18.80 (0.5– 92) years (75.00% Male). Table 1 shows the baseline charac- teristics and outcomes of studied patients. The mean burn percentage of participants was 29.31 ± 24.78 (3 – 100) percent of body surface area (54.34% with 10-30% burns). Flame was the most common burn mechanism (52.3%) and the mean length of hospital stay was 6.02 ± 7.0 (1 -51) days. 36.73% of females were burned by hot liquids, while the cause of burn in 58.16% of males was flame (p < 0.001). There were no statistically significant differences between male and female participants regarding the degree of burn (p = 0.109), airway condition (p = 0.861), laryngoscopic findings (p = 0.908), need for mechanical ventilation (p = 0.248), incidence of ARDS (p = 0.892), incidence of pneumonia (p = 0.775), and mortality (p = 0.861). 3.2. Outcomes 126 (32.14%) cases required tracheal intubation. Laryngo- scopic findings (in patients who required airway manage- ment) showed that 27 (21.43%) cases had erythema and edema. 19 (4.85%) cases developed ARDS, 41 (10.46%) de- veloped pneumonia, and 50 (12.76%) cases died. There was a direct correlation between length of hospital stay and the degree of burn (p < 0.001). The length of hospitalization for patients who were burned by electricity was longer than those burned by other mechanisms (p = 0.003). Table 2 shows the correlation between laryngoscopic findings and baseline characteristics as well as outcomes of cases that underwent laryngoscopy. In addition, the correlation between mortal- ity rate and baseline characteristics and outcomes of cases This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e8 Table 1: Baseline characteristics of patients who referred to the studied Hospital following head and neck burn injuries Variables Number (%) Gender Female 98 (25.0) Male 294 (75.0) Age (years) > 20 58 (14.8) 20-40 170 (43.4) 40-60 116 (29.6) ≥ 60 48 (12.2) Mechanism of burn Flame 205 (52.3) Liquids 85 (21.7) Electricity 13 (3.3) Vapor 36 (9.2) Chemicals 8 (2.0) Unknown 45 (11.5) Outcomes Need for tracheal intubation 126(32.14) ARDS 19 (4.85) Pneumonia 41 (10.46) Mortality 50 (12.76) Mean length of stay 6.02 ± 7.23 Laryngoscopic view of candidate for intubation Normal 99 (78.57) Erythema, edema 27 (21.43) Data are presented as mean ± standard deviation or frequency (%). ARDS: acute respiratory distress syndrome. is shown in table 3. There was a significant correlation be- tween degree of burn and abnormal laryngoscopy findings (p = 0.036), developing ARDS (p < 0.001) and pneumonia (p < 0.001), need for mechanical ventilation (p < 0.001), and mor- tality rate (p < 0.001). 4. Discussion Based on the findings of the present study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases required airway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%) cases died. There was a significant correlation be- tween degree of burn and abnormal laryngoscopy findings, developing ARDS and pneumonia, need for mechanical ven- tilation, and mortality rate. The prevalence of head and neck burn injuries in this study was much lower than that in the study by Hau Tian et al. (2020) who reported the percentage of head and neck burns among 1126 Chinese patients as 65.63% (7). In the present study, 75% of the patients were male and 43.4% were in the age group of 20-40 years old, which was consis- tent with the report by the WHO (1). This result was also sim- ilar to the study by Hamilton et al. (2018) performed in the United States, in which 66% of the patients were male, how- ever most of them were in their 40s (8). Also, in the study conducted by Hau Tian (2020) in China, 73.8% of the pa- tients with head and neck burns were men (7), which was in line with the present study. This can be due to occupa- tional exposure and workplace accidents. However, in an- other study conducted by Costa Santos (2016), women suf- fered from head and neck burns more than men, and the cor- relation between burn complications and gender was found to be statistically significant (9). In their study, Burd et al. (2010) found that although patients may have spontaneous breathing in the first hours after a burn, there is always the possibility of spreading burn injury and edema throughout the respiratory tract (3), which can be caused by edema in the head and neck following the inhala- tion of vapor, smoke, or aspiration of burning liquids (3). In this study, only 32.14% of the patients needed intubation; 78.57% of them had normal glottis and 21.43% had erythema and edema. Also, 11.11% of the patients (N=3) with edema- tous and erythematous view in their laryngoscopy did not need intubation. This rate was significantly lower than the results of the study by Belba et al. (2008), who estimated the intubation rate for the patients with head and neck burns as 39% (10). The presence of soot in the mouth in facial and body burns necessitates a fiberoptic laryngoscopy, as it sta- bilizes the airways in the case of cutaneous lesions, inflam- mation, blisters, and significant wounds in these patients. The classic symptoms of inhalation injury, such as stridor, itching, shortness of breath, and dysplasia confirm the need for tracheal intubation (6). The results of the present study showed that patients with second- and third-degree burns had a higher percentage of abnormal laryngoscopy. Also, patients with comorbidities had a higher rate of abnormal laryngoscopy (more than 3 times). Regarding the outcomes of burns based on laryngoscopy, it could be stated that intu- bation was observed in 88.89%, ventilation in 77.78%, ARDS in 40.74%, pneumonia in 66.67%, and mortality in 70.37% of the patients with abnormal laryngoscopy; these figures were significantly higher than those in the patients with normal laryngoscopy. Costa Santos et al. (2016) found that head and neck burns significantly increased the incidence and severity of pneu- monia in burn patients (9). In the present study, 10.46% of the patients developed pneumonia. Of the 392 patients with head and neck burns, 89.8% did not require mechanical ven- tilation (10.2% needed it) and ARDS was observed in 4.85% of the patients. However, in the study conducted by Miller et al. (2009), ARDS was identified as one of the leading causes of mortality, the incidence of which was estimated to be 20% (11). In the study by Madnani et al. (2016), out of 40 patients in the emergency room, 8 patients required emergency intubation This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Haddadi et al. 4 Table 2: Correlation between laryngoscopic findings and baseline characteristics as well as outcomes of cases who underwent laryngoscopy Variables Laryngoscopic findings P Normal (n= 99) Abnormal* (n = 27) Burn degree Second-degree 27 (27.27) 5 (18.52) Second- to third 63 (63.63) 14 (51.85) 0.036 Third- to fourth 9 (9.10) 8 (29.63) Mechanism of burn Flame 58 (58.59) 18 (66.67) Liquids 5 (5.05) 3 (11.11) Vapor 34 (34.34) 2 (7.41) <0.001 Chemicals 1 (1.01) 0 (0.00) Unknown 1 (1.01) 4 (14.81) Comorbidity No 87 (87.88) 21 (77.78) 0.184 Yes 12 (12.12) 6 (22.22) ARDS No 92 (92.93) 16 (59.26) <0.001 Yes 7 (7.07) 11 (40.74) Pneumonia No 83 (83.84) 9 (33.33) <0.001 Yes 16 (16.16) 18 (66.67) Mortality No 72 (72.73) 8 (29.63) <0.001 Yes 27 (27.27) 19 (70.37) Data are presented as frequency (%); Abnormal: erythema and edema. ARDS: acute respiratory distress syndrome. Table 3: Correlation between mortality rate and baseline characteristics of cases with head and neck burn injuries Variables Outcome P Not survived (n = 50) Survived (n = 342) Degree of burn Second 6 (12.00) 183 (54.79) Second- to third 36 (72.00) 143 (42.81) <0.001* Third- to fourth 12 (24.00) 8 (2.40) Mechanism of burn Flame 35 (70.00) 170 (49.71) Liquids 5 (10.00) 80 (23.39) Electricity 1 (2.00) 12 (3.51) 0.121 Vapor 4 (8.00) 32 (9.36) Chemicals 0 (0.00) 8 (2.34) Unknown 5 (10.00) 40 (11.70) Comorbidity No 34 (68.00) 319 (93.27) 0.027 Yes 16 (32.00) 23 (6.73) Tracheal intubation No 16 (32.00) 326 (95.32) <0.001 Yes 34 (68.00) 16 (4.68) ARDS No 37 (74.00) 336 (98.25) <0.001 Yes 13 (26.00) 6 (1.75) Pneumonia No 29 (58.00) 322 (94.15) <0.001 Yes 21 (42.00) 20 (5.85) Data are presented as number (%). ARDS: acute respiratory distress syndrome. and their vocal cord edema was positive in laryngoscopy (P = 0.01)(12). In the present study, airway edema was also ob- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2021; 9(1): e8 served in vocal cords (13), and mortality rate following burns was 12.76%. Hamilton et al. (2018) in the United States found that although a quarter of patients with head and neck burns suffered from inhalation injuries, mortality occurred in only 2%. The researchers identified airway burns as an impor- tant risk factor for predicting mortality (8). The lower inci- dence of respiratory complications and higher mortality rate in the current study compared to other studies emphasizes the need for proper airway management and its vital role in the prognosis and survival of patients. In the present study, most of the patients had 10-30% burns, 48.95% of which were of the second-degree type. Flame was the most common type of burn mechanism among the patients with 52.3%. The mean length of hospital stay was 6.02±7 days. In the study by Hamilton et al. (2018), the mean length of hospital stay was 4.4 days and, as in the present study, flame was the most common cause of burns, which occurred locally and superfi- cially (8). In another study, Bai et al. (2013) stated that ven- tilator support was significantly associated with increased length of hospitalization (13). However, in the study by San- tos et al. (2016), those who were intubated were discharged earlier (9), which may be due to the high incidence of pri- mary mortality in this group. In the present study, the length of hospital stay correlated with degree of burn, burn mech- anism, airway condition, intubation, and incidence of ADRS and pneumonia. Inhalation injuries in patients with head and neck burns are serious and life-threatening, and the management of airways and respiratory outcomes over the hospitalization course of these patients should be taken into consideration. 5. Limitations One of the most important limitations was the presence of in- complete patient profiles, which was due to the retrospective fashion of the study. 6. Conclusion Based on the findings of the present study, the prevalence of head and neck burn injuries was about 18% and 32.14% of these cases required airway management. 19 (4.85%) cases developed ARDS, 41 (10.46%) developed pneumonia, and 50 (12.76%) cases died. There was a significant correlation be- tween degree of burn and abnormal laryngoscopy findings, developing ARDS and pneumonia, need for mechanical ven- tilation, and mortality rate. 7. Declarations 7.1. Acknowledgment This article has been extracted from Dr. Reza Nicknama’s the- sis for achieving his MD degree from the Faculty of Medicine at Guilan University of Medical Sciences. 7.2. Author contributions All authors passed the criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. 7.3. Funding None declared. 7.4. Conflict of interest None. References 1. Organization WH. Burns Fact sheet 6 March 2018 [26 Au- gust 2020]. Available from: https://www.who.int/news- room/fact-sheets/detail/burns. 2. Hoogewerf CJ, van Baar ME, Hop MJ, Bloemen MC, Mid- delkoop E, Nieuwenhuis MK. Burns to the head and neck: epidemiology and predictors of surgery. Burns. 2013;39(6):1184-92. 3. Burd A, editor Burns: treatment and outcomes. Seminars in plastic surgery; 2010: Thieme Medical Publishers. 4. Sabri A, Dabbous H, Dowli A, Barazi R. The airway in in- halational injury: diagnosis and management. Annals of burns and fire disasters. 2017;30(1):24. 5. Haddadi S, Marzban S, Parvizi A, Dadashi A, Roshan ZA, Kiyarash SSM. Congruency of nasal alar pulse oximetry and arterial blood analysis in patients with burns hospi- talized in ICU. of. 2017;4:2. 6. Herndon DN. Total burn care E-book: Expert consult- online: Elsevier Health Sciences; 2012. 7. Tian H, Wang L, Xie W, Shen C, Guo G, Liu J, et al. Epidemiology and outcome analysis of facial burns: A retrospective multicentre study 2011–2015. Burns. 2020;46(3):718-26. 8. Hamilton TJ, Patterson J, Williams RY, Ingram WL, Hodge JS, Abramowicz S. Management of head and neck burns—a 15-year review. Journal of Oral and Maxillofacial Surgery. 2018;76(2):375-9. 9. Santos DC, Barros F, Gomes N, Guedes T, Maia M. Face and/or neck burns: a risk factor for respiratory infection? Annals of Burns and Fire Disasters. 2016;29(2):97. 10. Belba G, Gedeshi I, Isaraj S, Filaj V, Kola N, Belba M. Head and neck burns: acute and late reconstruction. data of burn injury management in 2007. Annals of Burns and Fire Disasters. 2008;21(4):203. 11. Miller AC, Rivero A, Ziad S, Smith DJ, Elamin EM. In- fluence of nebulized unfractionated heparin and N- acetylcysteine in acute lung injury after smoke inhalation injury. Journal of burn care & research. 2009;30(2):249-56. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem S. Haddadi et al. 6 12. Madnani DD, Steele NP, de Vries E. Factors that predict the need for intubation in patients with smoke inhalation injury. Ear, nose & throat journal. 2006;85(4):278-80. 13. Bai C, Huang H, Yao X, Zhu S, Li B, Hang J, et al. Appli- cation of flexible bronchoscopy in inhalation lung injury. Diagnostic pathology. 2013;8(1):174. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References