Burn Prevention

James H. Holmes

Burns are the sixth or seventh most common cause of injury, depending on the classification scheme of injury definition used. The most recent year for which accurate, composite burn incidence and cost data are available is 2000.¹ In that year, approximately 4,000 people died from burns or in fires (˜1 per 100,000) and approximately 775,000 sustained burns requiring treatment of some sort (˜280 per 100,000). These burn injuries consumed close to $7.5 billion in lifetime costs. However, compared to 1985, the incidence decreased by more than 50% from 616 to 280 per 100,000.

For the approximately 40,000 burn injuries requiring hospitalization, approximately 25,000 are admitted to dedicated burn centers.² On the basis of this data from the National Burn Repository, the overall survival rate now approaches 95%. For patients treated at burn centers, approximately 50% are <10% total burned surface area (TBSA), 40% are 10% to 29% TBSA, and only 10% are >30% TBSA in size. The vast majority are white males, and most injuries occur in the home. Flame and scald injuries account for 80% of all burns.

Although relatively uncommon, burn injuries are nonetheless associated with significant morbidity and costs, and most importantly, virtually all burn injuries are preventable.

HISTORICAL PERSPECTIVE

In the United States, large-scale burn prevention measures really did not begin until the 1940s and 1950s. These initial efforts were in response to a catastrophic Boston nightclub fire and to injuries sustained by children wearing costume clothing. The Cocoanut Grove Nightclub fire in 1942 remains one of the single most important events in the development of burn prevention in the 20th century.³,⁴ A flame from a lit match caused the fire, and the resulting 491 deaths and hundreds of casualties were mainly due to the violation of several fundamental principles of fire safety and burn prevention. This led to extensive changes in fire safety regulations that remain in effect currently, such as laws prohibiting the use of revolving doors as principal exits, doors to all public buildings being required to open outward, and emergency lighting systems and nonflammable decorations being made mandatory for public buildings. Further, this disaster resulted in many advances in burn care and stimulated the formal organization of burn centers, public safety legislation, and burn prevention. Also in the 1940s, publicity stemming from children sustaining burns to the legs while wearing “Roy Rogers chaps” made of highly flammable brushed rayon focused attention on the dangers of flammable clothing.⁵ Thereafter, a rash of burns sustained by young girls wearing “torch sweaters” reinforced this. These incidents resulted in federal legislation (Flammable Fabrics Act of 1953) that subsequently led to extensive research into fabric flammability and measures to reduce it.

BURN PREVENTION EFFORTS AND INITIATIVES

Hot Water Burns

First and foremost, all tap water scald burns are preventable. Full-thickness scald burns occur in adult skin in 2 seconds on exposure to water temperatures of 150°F (66°C), in 4 seconds at 140°F (60°C), in 30 seconds at 130°F (55°C), and in 5 minutes at 120°F (49°C).⁶ These times are variably reduced in children who have a much thinner dermis than adults. To date, tap water scald burn prevention initiatives have involved legislation and manufacturers’ voluntary standards.

The states of Florida and Washington enacted laws in the 1980s mandating preset water heater temperatures at 125°F (52°C) and 120°F (49°C), respectively. An epidemiologic
follow-up study in Washington, done 5 years after the legislation, demonstrated a 50% reduction in the average number of scald burns per year requiring admission to the hospital—5.5 per year in the 1970s to 2.4 per year in the 1980s.⁷ Further, the severity of the burns decreased following the legislation as manifest by reduced TBSA involved, lower mortality, fewer number of operations required, reduced scarring, and decreased hospital length of stay. In addition, the state of Connecticut requires the installation of tempering valves in all new domestic dwellings that prevent the passage of water through showerheads or bathtub inlets if the water temperature exceeds 115°F (46°C).⁸

The manufacturers of water heaters have agreed upon voluntary standards for factory preset temperatures. Gas units are set at 120°F (49°C), whereas electric units are set at 125°F (52°C).⁹ Unfortunately, there is neither any formal monitoring of compliance nor published analysis of the effects of the standards.

Residential Fires

Flame burns sustained in the home are the most common type of thermal injury. The National Fire Protection Association (NFPA) data indicate that house fires result in approximately 3,000 deaths per year and annually account for $5 to $6 billion in direct property losses.¹⁰ Effective strategies to reduce residential fire-related injuries include the installation of smoke detectors and the use of automatic sprinkler systems.

Smoke detectors have been commercially available in the United States since the late 1960s, and their use has been widely accepted. Ongoing data from the Centers for Disease Control indicate that almost 95% of US residences have at least one smoke detector. Studies have demonstrated that both voluntary educational efforts and legislative measures are effective in increasing smoke detector use and subsequent residential fire-related injuries. In Pittsburgh, pediatricians tried to increase smoke detector installation by counseling parents about the importance of smoke detectors and then offering them low-priced ones for purchase in the office. Approximately half of the experimental families purchased smoke detectors, and of those, approximately 75% installed them compared to none in the control families.¹¹ After experiencing an increase in fire-related deaths in 1982, the City of Baltimore initiated a citywide smoke detector giveaway program. In a follow-up study 8 to 10 months after the giveaway, 92% of the homes had installed the detectors with 88% of them functional.¹² In Oklahoma City, a smoke detector giveaway program in an area with a high rate of residential fire-related injuries produced an 80% reduction in the injury rates during the 4 years following the intervention.¹³ Similarly, in St. Louis, the project “Alarms for Life” that was designed by a group of burn survivors resulted in a 50% reduction in residential fire-related deaths in the target population compared to the year before the project. The success of the project precipitated passage of an ordinance mandating smoke detectors in all city residences.¹⁴ Finally, legislative efforts in Montgomery County, MD in 1978 required smoke detectors in all homes. A follow-up study 5 years later demonstrated that Montgomery County had significantly fewer homes with no functioning detectors or no detectors compared to a control county.¹⁵ Of note, the NFPA estimates that homes with smoke detectors have approximately 50% fewer fire-related deaths than homes without detectors. To promote the maintenance of existing smoke detectors, “Change Your Clock, Change Your Battery” is a biannual campaign at daylight savings time organized by Energizer Batteries and the International Association of Fire Chiefs.

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