Fire walking in Singapore: a profile of the burn patient.

Fire walking is a religious ritual practised mainly by Indians, but also by some Chinese, living in Singapore. Seventeen new cases of burns sustained after a fire walking ceremony are reported. All the patients were males. One patient was Catholic, the others being Hindus. All the patients were Indians. The mean age of the patients was 25.47 years (range 19-56 years). All the patients had burns on the feet only. Of the 17 patients, 15 had burns on the non-weight-bearing area of the foot, one had burns on the weight-bearing area of the foot and one had burns on both the weight-bearing and the non-weight-bearing areas of the foot. The mean percentage of total body surface area affected was 0.81% (range 0.25-1.25%). The burn injuries were either erythema or partial thickness burns. The mean duration of disability was 21.4 days (range 14-35 days). Of those burnt, three were novices, six had walked twice and the remaining eight had walked three to 16 times. The profile of a fire walker is generally a young Indian with partial thickness injuries on one or both feet involving the non-weight-bearing area.

Evaluation of the laser scanner as a surface measuring tool and its accuracy compared with direct facial anthropometric measurements.

The development of new laser scanning techniques enabling the capture of 3-D images which can be quantitatively assessed permits their use for surface measurements of the face. We used a laser optical surface scanner to study 30 subjects and took 83 facial anthropometric measurements, using 41 identifiable landmarks on the scanned image. These were compared to the standard anthropometric measurements using the same landmarks. Of these, 12 (14.0%) showed a mean difference less than 1.0 mm and were considered highly reliable measurements and 16 (19.0%) with less than 1.5 mm difference were considered reliable. The highly reliable measurements were mainly in the nasal and circumoral regions and the landmarks involved were mainly those in the mid-saggital plane. This indicates that the laser scanner can be a useful tool for rapid facial measurements in selected anatomical parts of the face. Accurate location of landmarks and operator skill are important factors to achieve reliable results.

Burns mortality and hospitalization time--a prospective statistical study of 352 patients in an Asian National Burn Centre.

A prospective study of 352 patients in an Asian National Burn Centre has been used to develop statistical predictive models for mortality and hospitalization time. The patients are largely of Asian origin. Total burn surface area (% TBSA) and presence of respiratory burns are significant independent predictors of mortality in the multiple logistic regression analysis with an accuracy of 98.3 per cent. Age is not a significant predictor of mortality in our patients. Age, % TBSA, full thickness % TBSA and respiratory burns are significant independent predictors of length of stay in hospital with a R2 value of 0.57 in the multiple linear regression analysis. There were 16 deaths, many of whom had developed multiple complications, common causes of which were sepsis, bronchopneumonia, DIVC and multiorgan failure. The final causes of death were septicaemic shock in 10 patients, extensive burns in four patients, ARDS in one patient and bleeding peptic ulcer in one patient. The development of these two mortality and morbidity predictive models is the first step in the evaluation of our results. These models have to be tested against a future set of patients. After confirmation they will aid in patient management, clinical audit, patient and family counselling. They will also serve as baseline standards for evaluation of new therapies, assist us in the allocation of resources and identifying the at-risk population for improvements in therapy.

Occupational burns in the Burns Centre at the Singapore General Hospital.

This study reviewed all work-related burn injuries within the period 1 April 1992 to 31 March 1993 for the purpose of establishing data on occupational burns in Singapore to identify the specific at-risk population and formulate prevention strategies. All 163 patients who were admitted to the Burns Centre, Singapore General Hospital, as a result of burns suffered in the workplace were reviewed using the World Health Organisation Burns Data Protocol. Burns data recorded included demography, industrial sector involved, aetiology, extent of injury and eventual outcome in terms of mortality and morbidity. Occupational burns accounted for 45% of all admissions to the Burns Centre. Male workers in the 20 to 40-year age group predominated with 90% of admissions. The most common aetiology was flame burns and explosions (52.8%) followed by scalds (24.5%) and electrical (10.4%), chemical (6.1%) and contact (6.1%) burns. The average body surface area (BSA) involved was 8% (range 0.25% to 90%). Twenty-seven patients suffered full-thickness burns and the average area of involvement was 2% (range 0.25% to 90%). The most common anatomical regions involved were the upper limbs (46.3%) followed by lower limbs (31.9%). Eighteen patients (11.0%) sustained major burns requiring fluid resuscitation and 39 patients (23.9%) sustained respiratory burns. Seven patients died, giving a mortality rate of 4.3%. The average BSA for these patients was 46.4% and all had respiratory burns. In all, occupational burns accounted for 2011 patient-days of hospitalization, 630,637 lost days at work and inpatient treatment costs amounting to S $1.32 million.(ABSTRACT TRUNCATED AT 250 WORDS)

Current logistics of acute burn care in Singapore.

OBJECTIVE: To study logistic requirements in acute burn care in Singapore and to correlate statistics on fire, unnatural deaths and burns. DESIGN: Fire data (from Singapore Fire Safety Bureau), mortality data (from Institute of Science & Forensic Medicine) and burn data (from Burns Centre, Singapore General Hospital) were studied. SETTING: Severe burn victims often require prolonged treatment. Useful data was obtained in a 1,500-bed restructured government hospital. PARTICIPANTS: All reported and investigated fire incidents, coroner enquiries of unnatural deaths and admitted burn patients. INTERVENTION: General burn data obtained retrospectively from 398 burn admissions in 1988 and logistic burn data from 41 patients requiring fluid replacement regime. RESULTS: Fire data showed one burn admission in every 12 fires (398/4718), one burn death in every 314 fires (15/4174) or 55 unnatural deaths (15/828). Mortality data showed 15 burn deaths, two prior to admission, 7/13 admitted died of suicidal injuries and mortality rate was 3.3% (national annual average is 1.9%). General burn data showed adults 76% and children 24%, 3:1 male predominance; scalds (46%), fire (32%), explosions (11%) and others (11%). Seventy-eight patients (adults 58, children 20) required fluid resuscitation. Logistic burn data (average burn 35%, 28 partial thickness and 13 full thickness burns) were: ALOS 19.5 days, 2.4 major operations per patient (range 2-7), 56 minor procedures and 2.9 L blood transfusion per patient (those who were operated required 3.8 L and those not operated, 1 L per patient). Blood investigations increased with severity and pattern of injury, Acinetobacter species was commonest microorganisms, antibiotics were used in 66% of patients and commonest burn dressings were tullegra (T/G), followed by T/G with silverzine. CONCLUSION: Data presented useful for correlation of fire, mortality and burn statistics, resource allocation and new burn facility establishment.

Burns mass disasters in Singapore--a three decade review with implications for future planning.

OBJECTIVE: The main objective of this paper is to review three decades (1962-1991) of data relating to burns mass disasters in Singapore. DESIGN: Records of the Burns Centre, Singapore General Hospital were reviewed retrospectively. Only patients admitted were analysed in three separate groups in relation to the cause of the burns mass casualties and place of occurrence. SETTING: Patient selection was based on O'ya's criteria of burns mass disaster and were grouped into separate decades: Group A (1962-71), Group B (1972-81) and Group C (1982-91). INTERVENTION: Data collected will provide useful information on high risk sources, patterns and trends of burns mass disasters in Singapore. MAIN OUTCOME MEASURE: The data will provide the facts and will have implications for future planning and organisation of burn treatment facilities. RESULTS: There were 17 burns mass casualties and 257 patients admitted. The largest single admission was 76 in 1978. Group A had four, Group B had two and Group C had eleven disasters. Explosions (66%) and fires (30%) were the main causes of burns. The predominant place of occurrence in Group A patients was outdoor injuries (78%), Group B was work environment (100%) and Group C was evenly spread out: work environment (55%), indoors (36%) and outdoor (9%). Shipyards and fires were the largest sources of burns mass disasters. Other potential sources identified include hazardous materials, petrochemical industries, aviation industries, mass rapid transit train system, high rise fires, shopping complexes and imported disasters. CONCLUSION: The recommendation is to plan and reorganise burn treatment facilities. This is to cope with existing pattern, frequency and projected patterns of burn mass disasters which have occurred in other highly urbanised and populated countries.

The burned ear (I): An experimental study with the rabbit model to evaluate scalding temperature, surface and histopathologic appearance, and healing responses with depth of injury.

There are few papers on experimental burns of the external ear. An experimental model was made and a study was conducted on 18 white rabbits to evaluate the response of the rabbit ear in relation to temperature, surface and histologic appearances and healing response with depth of injury. The rabbit model showed that: a) the rabbit ear resembled that of the human ear in histological structure. b) there was a definite correlation of the temperature of the scalding agent with the depth of the injury. c) it was possible to classify morphologically the depth of injury based on surface appearance. d) there was an accurate morphologic correlation with that of histopathologic assessment of burns depth. e) the sequential biopsy at different times (immediate, third, fifth day) showed that the depth of the burns was already apparent soon after the injury. f) there was also a correlation of burns depth with the rate of ear healing.

The burned ear (II): A prospective clinical study of 100 patients with 150 ear burns.

A prospective clinical study of 100 patients with 150 ear burns was carried out in the Burns Centre, Singapore General Hospital. The aims of this study were to document the nature of the injury, the results of various methods of treatment, the complications of ear burns and the changes that led to chondritis. Based on the findings of the experimental studies on the burned ear, it is possible to accurately classify the depth of the burn injury based on the surface appearance. The results show that fire was the commonest aetiologic agent for ear burns (65% cases) and hot water scalds second (25% cases). Scalds tended to cause unilateral ear burns whilst fire caused bilateral injuries. The single most important factor in healing of the burned ear was the depth of the injury. Erythema took six days, mid-dermal (MD) burns ten days, uncomplicated deep-dermal (DD) and full thickness (FT) burns 35 days. When chondritis developed deep dermal burns took 43.5 days to heal and full thickness burns took 57.8 days. Conservative treatment of 104 ears resulted in complete healing except for 15 which had pigmentary and/or hypertrophic scar problems. Surgical treatment was used in 23 ears. Three returned to normal appearance, eleven had mild and four had moderate deformities. Five ears were lost (3% cases). Chondritis was present in 12 ears (8% cases), six in DD and six in FT burns. Seven of these ears were successfully salvaged. Favourable results in this study were attributed to the following factors: early detection of chondritis by the EAR SPRINGING SIGN, early surgical intervention, radical cartilage removal, meticulous post-op care to prevent cross infection and avoidance of pressure to the ears.

Anatomy of a burns disaster: the Miri Bank explosion.

A bank explosion in a neighbouring country over 1000 km away resulted in ten badly burned victims being airlifted to the Burns Centre, Singapore General Hospital (BCSGH) for treatment. The severely injured included patients with 90%, 80%, 74%, 66%, 45%, 33% and 31% burns. Nine had respiratory burns (four severe, one moderate, four mild). One patient died, thus, the mortality rate for the six most severely injured was 16.7%. This differs from predicted mortality rates of 78% according to McCoy or 54% according to Thompson, Herndon et al. The factors contributing to this result were the small size of the disaster, the use of an established Burns Mass Disaster plan and an individual management policy that incorporates carefully monitored fluid resuscitation, recognition of respiratory burns with early treatment by intubation thus pre emptying complications, early surgery and a multidisciplinary approach to complications such as infection and renal failure. The average length of stay was 43 days (range 5-122 days). The cost of the hospitalisation of the ten casualties was $312,317.00.

Epidemiology of burns in Singapore children--an 11-year study of 2288 patients.

A retrospective review of 2288 children (12 years and below) admitted to the Burns Centre, Singapore General Hospital over an eleven year period (1978-1988) was made. Annual admissions from 1978-85 ranged from 208-290 cases annually (32-38% of all admissions). Between 1986 to 1988 annual admissions ranged from 73-104 cases annually (22-28% of all admissions). There was a reduction of number as well as proportion of children admitted. The main reasons for this change in trend were due to the successful nationwide campaign on fire and home accident prevention, change in admission policy and introduction of newer dressings to treat smaller burns. Boys accounted for 62% admissions. Toddlers between the age of one to two were most vulnerable (26% admission) and children under three years of age accounted for 50% admissions. Eighty-five percent of burns admitted were 10% or less. Length of stay ranged 8-12 days. The commonest cause of injury was scalds (90%) and flame burns (6%). Flame was responsible for the death of six children and scalds of three children. There were nine deaths in this series giving a mortality of 0.4%. Children mortality contributed to 5.6% of total mortality seen in our burns centre. Age per se did not contribute to a higher mortality. There was a definite correlation of mortality to extent of burns. Only one child died from burns of less than 40%. Case mortality in the 40-60% burns group was around 20% and it increased sharply when extent of burns reached or exceeded 70%. Burns in children exhibit anatomical, physiological, surgical, rehabilitative and psychological differences when compared to adults.

Anatomy of a burns disaster : The Miri Bank explosion

A bank explosion in a neighbouring country over 1000 km away resulted in ten badly burned victims being airlifted to the Burns Centre, Singapore General Hospital (BCSGH) for treatment. The severely injured included patients with 90, 80, 74, 66, 45, 33 and 31 per cent burns. Nine had respiratory burns (four severe, one moderate, four mild). One patient died, thus, the mortality rate for the six most severely injured was 16.7 per cent. This differs from predicted mortality rates of 78 per cent according to McCoy or 54 per cent according to Thompson, Herndon et al. The factors contributing to this result were the small size of the disaster, the use of an established Burns Mass Disaster plan and an individual management policy that incorporates carefully monitored fluid resuscitation, recognition of respiratory burns with early treatment by intubation thuspre empting complications, early surgery and a multidisciplinary approach to complications such as infection and renal failure. The average length of stay was 43 (range 5-122 days). The cost of the hospitalisation of the ten casualties was $ 312,317.00 (AU)

Hypopituitarism following head injury--a case report.

A 16 year-old boy sustained fracture of the floor of the right orbital fossa in a road traffic accident with resultant diplopia and right enophthalmos. Symptoms of hypocortisolism subsequently developed. About two years after the trauma, pubertal changes which had occurred at 13-14 years had completely regressed. Endocrine testings confirmed clinical anterior hypopituitarism. Post-traumatic hypopituitarism may follow injury to the hypothalamus, the pituitary stalk or the pituitary itself. The normal thyroid stimulating hormone (TSH) response to thyrotropin releasing hormone (TRH) in this patient is in favour of a hypothalamic lesion. The patient has responded to replacement hormonal therapy.

The fourth dimension of the face: a preliminary report of growth potential in the face of the Chinese population of Singapore.

Age-related changes were studied in 32 linear measurements from the faces of 180 healthy Chinese subjects of Singapore, aged 6, 12 and 18 years, with equal representation of the sexes. In addition, the differences in 10 inclinations and 6 angles of the facial profile between thirty 6-year-olds and thirty 18-year-olds of each sex were determined. The total absolute and relative growth between 6 and 18 years was established and, in the linear measurements, the relative increments were separately calculated for the 6- to 12-year-old and 12- to 18-year-old periods.

Measuring the cleft deformity.

Comparative studies in cleft lip and palate patients are difficult because of the difficulty in documenting them. Both qualitative assessment and quantitative measurements are needed so that a more meaningful comparison of long-term results could then be made. The different protocols used previously by various authors were reviewed and a protocol was drawn up for the Department of Plastic Surgery, Singapore General Hospital. This was used for a trial period and then revised. The difficulty in measurement lay mainly in determining the accurate anthropometric points on the face from which measurements were made.

Speech and nasendoscopic evaluation of velopharyngeal incompetence (VPI) in cleft palate patients.

Cleft lip and palate patients exhibit several problems prior to and following surgical repair of their deformities. Hypernasality and speech defects remain one of the outstanding problems. 82 cleft palate patients were subjected to a systematised speech evaluation and an examination of the velopharyngeal mechanism. Nineteen patients did not have any surgery of the palate whilst the remaining 63 had at least one surgical procedure to the palate. 54 had a Veau-Wardill-Kilner (V-W-K) procedure and the remaining had either a second palatal repair or a superiorly based pharyngoplasty. Good correlation of speech assessment to nasendoscopic evaluation was found. An improvement in the speech and nasendoscopic coding was found in patients who had surgical intervention to the palate. A nasendoscopic examination, ideally performed by the surgeon and a speech therapist, is a useful adjunct to speech evaluation.

Postburn nailfold retraction: a reconstructive technique.

Postburn nailfold retraction often results in nail deformity and loss of distal interphalangeal joint flexion. A technique of reconstruction of the nailfold using a proximally based transposition flap is described in a patient with postburn nailfold retraction of the left thumb, index and middle fingers.

Rehabilitation of burns of the upper limb.

The authors wish to document the experience of the Burns Unit, Singapore General Hospital in the management of burns of the upper limb. Fifty-six patients with post-burn deformity of the upper limb seen during a five year period (July 1978-July 1983) were reviewed. The cases were analysed and there were no significant differences in age, sex and race distribution. There were 8 axillary contractures, 9 elbow contractures, 10 wrist deformities and 56 hand deformities. Anterior axillary skin fold contracture was the commonest deformity occurring at the shoulder, whilst cubital contractures were mainly found on the lateral aspect of the elbow. The elbow was the commonest site for periarticular heterotopic calcification. Wrist deformities included hypertrophic scars and contractures and they were frequently found on the dorsum of the wrist. A classification of post-burn hand deformity has been described and this was based on the site of the original injury. Burns involving the dorsum of the hand/fingers were subclassified into two groups depending on whether the extensor tendon was involved. The prognosis was good when there was no tendon injury, but when the extensor tendons were involved, poorer hand function resulted and this was reflected by the number of secondary operative procedures required. Flexion contractures were the commonest deformity found on volar burns. When both surfaces were burned the prognosis depended upon the burns depth. Digital burns treated surgically had fewer residual contractures. The role of occupational therapy, scar control, splinting and secondary surgery in relation to the rehabilitation of the burned upper limb is discussed in some detail.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary oral malignant melanoma.

A fifteen year review (1968-1982) of all cases of malignant melanomas seen in Singapore revealed nine cases in the oral region. The cases were analysed and the literature reviewed. The cases usually presented late and the hard palate is the commonest site involved. The highest incidence is around the 4th-6th decade. Oral melanomas have a poorer prognosis when compared to cutaneous melanomas and this is similar to other reported series. No difference in sex incidence was seen in this series and the estimated incidence of oral to all other cases of malignant melanomas was about 6%.

Two tumours of the carotid bifurcation.

Two cases of tumours of the carotid bifurcation are reported here with the objective of outlining a rational approach to their management. A review of the literature confirms that the bad results of surgical treatment are largely due to jeopardization of the carotid circulation at the time of operation. Carotid angiography is therefore essential not only to confirm the anatomical diagnosis but also to provide an indication of the adequacy of the carotid circulation. It is a sine qua non for rational operative decisions which form the basis of safe excisional surgery of these tumours.