|Year : 2019 | Volume
| Issue : 1 | Page : 95-101
Epileptic burn injuries in Kashmir valley: Is “Kangri” a boon or bane?
Peerzada Umar Farooq Baba, Shiv K Sharma, Adil Hafeez Wani
Department of Burns, Plastic and Reconstructive Surgery, SKIMS, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||17-Jan-2020|
Dr. Peerzada Umar Farooq Baba
Department of Burns, Plastic and Reconstructive Surgery, SKIMS, Srinagar - 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: During seizure attacks, patients may suffer severe trauma such as deep burns, limb fractures, and head-and-neck injuries. Most burns in epileptic patients occur during major seizures. Such burns are always full-thickness. Because of extreme cold conditions people in Kashmir valley, especially in rural areas use Kangri to keep themselves warm. This Kangri which is already notorious for causing Kangri cancer has an additional disadvantage in causing deep burns mainly to the hands in epileptic patients.
Objective: (1) To analyze the epidemiological data of burnt hospitalized epileptic patients. (2) To determine the frequency, causes, and consequences of burns in patients with epilepsy stressing on Kangri burns in epileptics. (3) To determine the various preventive measures to reduce the incidence of such injuries.
Materials and Methods: This was a retrospective study conducted in the Department of Burns, Plastic, and Reconstructive Surgery at Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India, from January 2005 to December 2018. All epileptic patients with burns admitted in the hospital were included in the study.
Results: Of 157 patients, 67 (43%) were in the age group of 16–30 years. The mean age was 32.7 years. Majority of the patients 99 (63%) were female. One hundred and two (84%) patients belonged to rural areas. Kangri was the most common etiological agent of epileptic burns in 99 (63%) patients. Eighty-four (53%) had sustained full-thickness burns and total body surface area involved was up to 5% only. The most common site of burns was hands 88 (56%). Amputation of the gangrenous digits/hands was the most common surgery performed in 39 (25%) patients. Complication in burnt epileptic patients was loss of a body part 47 (44%) followed by contracture (32.4%), wound infection (22%), and loss of vision in 1 (0.6%) patients. There was no mortality in our series.
Conclusion: Epileptic patients should avoid high-risk situations like working alone in kitchen. Kangri should be replaced by alternative simple and safe warming devices.
Keywords: Burn, epileptic, Kangri, total body surface area
|How to cite this article:|
Farooq Baba PU, Sharma SK, Wani AH. Epileptic burn injuries in Kashmir valley: Is “Kangri” a boon or bane?. Indian J Burns 2019;27:95-101
|How to cite this URL:|
Farooq Baba PU, Sharma SK, Wani AH. Epileptic burn injuries in Kashmir valley: Is “Kangri” a boon or bane?. Indian J Burns [serial online] 2019 [cited 2020 Aug 8];27:95-101. Available from: http://www.ijburns.com/text.asp?2019/27/1/95/275911
| Introduction|| |
Epilepsy is a clinical phenomenon diagnosed by the occurrence of two or more unprovoked seizures. It is the world's most common neurological disorder, affecting approximately 69 million people worldwide, majority of whom (90%) live in resource-poor countries. The prevalence of epilepsy worldwide is estimated at 10/1000 people (1%).,,
Idiopathic epilepsy occurs with no involvement of the brain structure and has two major aspects:
Generalized epilepsy (also known as “grand mal”) or major seizure, with a characteristic onset and tonic-clonic convulsive movements;
“Absence” attack (also known as “petit mal” seizure), which especially affects children and also has a characteristic aspect. When the brain structure is damaged by various factors (such as trauma and tumors), the seizure attack usually has the form of partial epilepsy (also known as focal or symptomatic) such as temporal lobe epilepsy and the Jacksonian motor seizure.
During seizure attacks, patients may suffer severe trauma such as deep burns, limb fractures, and head-and-neck injuries.,,, Risk factors for injuries associated with epilepsy include high seizure frequency, generalized tonic-clonic type of seizure, and poor antiepileptic drug compliance. Epilepsy is three times more likely to be associated with burns,, with women being five times more likely to be burnt. Most burns are domestic, while performing everyday tasks.,,,
Because of impaired consciousness level during epileptic fit, the skin is exposed to the burning agent for longer, resulting in a deeper burn than would occur in a conscious patient, leading to higher mortality and morbidity.,,,,, Analysis of circumstances of burns suggests that most of burns are avoidable. Very few patients (<5%) could recall receiving warnings about this risk at the time of diagnosis. Patients are either not taking their medications, or receiving inappropriate therapy, or have failed to take appropriate doses of anticonvulsants.
Epidemiological studies are a prerequisite for effective burn prevention programs because each population seems to have its own epidemiological characteristics, and knowledge of epidemiology of burns in epileptics is needed for preventive actions. Because of extreme cold conditions prevailing for about 8 months and poor economic conditions, majority of people in Kashmir valley, especially in rural areas, use “Kangri” (traditional firepot) to keep themselves warm during winter months. The hand being in close proximity to the Kangri almost always suffers burns in epileptic patients once they get a fit and convulse. With this background, the present study was undertaken to study the epidemiology and burn pattern in hospitalized epileptic patients, with special emphasis on the Kangri burn sustained during winter months.
| Materials and Methods|| |
This was a retrospective study conducted in the Department of Burns, Plastic and Reconstructive Surgery at Sher-e-Kashmir Institute of Medical Sciences, Srinagar, India, from January 2005 to December 2018. All epileptic patients with burns admitted in the hospital were included in the study. Collected data included the patient's demographic details, duration, type and frequency of seizures (including treatment status), and previous history of any burns. The mechanism/mode of the burn was noted, as were events surrounding the incident, such as the activity in which the patient was engaged at the time of the burn, burned during seizure or unrelated to seizure and the energy source used. The extent, distribution, estimation (total body surface area [TBSA] involved), depth of the burn, and gangrene of any part were also recorded, as well as the treatment required, the number and type of surgeries, any complications, and length of hospital stay.
| Results|| |
Total number of burn patients admitted during the study (from January 2005 to December 2018) was 1289. Among these, 157 were epileptic patients with burns (8.2%). Majority of the patients were in a younger group of 16–30 years with a mean age of 32.7 years, mostly females (63%). The incidence of epileptic burns was high (84%) in rural population [Table 1]. Kangri (fire pot) burn was the most common (63%) mode of burn injury. This was followed by open fire (19%), hot liquids (12%), and electric burn (5.7%). Hand burns were the most common (56%) followed by trunk (19%), lower limbs (12%), and face (5%). Depth wise, third-degree burn was the most common 72 (46%) followed by second degree 36 (23%), mixed degree 20 (12.7%), first degree 17 (10.8%), and fourth degree 12 (7.7%) [Table 2]. In more than half of the patients 84 (53.5%), TBSA involved was only up to 5% because hands were involved in majority the cases which represent a small percentage of body area. Majority of patients (88%) had a single/ first episode of burn injury; 12% had multiple episodes. About 99 (63%) patients had been epileptic for the past 10–20 years at the time of their presentation. About 95.5% of the patients had generalized tonic-clonic type of seizure [Table 3]. Most of the patients 71 (45%) had a seizure lasting about 6–10 min, with 49% having 3–4 episodes of seizure per month. Treatment status-65.6% of patients were on medication but were found to be taking drugs irregularly, while 22% were on no treatment. Majority of patients 116 (74%) were treated surgically. Rest 41 (26%) who had superficial burns were managed conservatively. Amputation was the most common 39 (24.8%) procedure done followed by debridement in 33 (21%), split-thickness skin grafting of raw area in 31 (19.7%), contracture release and skin grafting in 28 (18%), and flap cover in 7 (4.5%) patients [Table 4]. Apart from the loss of body part (44.7%), usually fingers and hands, the most common complication was the development of contracture (32.4%) followed by wound infection (22%) and loss of vision (1 patient). There was no mortality. The shortest length of hospital stay in our series was 1 day, while as the longest duration was 49 days, with 19 days as the average length of hospitalization.
| Discussion|| |
Burns are common injury in the developing world and are associated with significant morbidity and mortality. Epileptic patients are at higher risk of getting burnt as compared to the general population., Total number of burn patients admitted during the study was 1289. Among these, 157 were epileptic patients with burns which represent 8.2% of our burn unit admissions. Burn as a result of seizure represent 1.6%–10% of admissions to burn unit. Others report that 1%–4% of hospital admissions for burns are seizure-related. Young patients with the age group of 16–30 years was the most common (with a range from 1 to 62 years). The mean age was 32.7 years [Table 1]. This observation is contradictory to the studies conducted by various authors in which they reported older age group with mean age ranging from 39 to 44 years.,,,, The younger age group (as in our study) is, in fact, more active and exposed to hazardous situations both at home and at work, and we found them noncompliant to antiepileptic medication.
Females 99 (63%) outnumber males 58 (37%) with a ratio of 1.7:1 [Table 1]. Most of the studies confirm the female preponderance with many possible reasons.,,,,,,,,, Most females in our part of world are homemakers and perform almost all domestic chores such as cooking, washing, and ironing. They usually take Kangri with them while doing daily work to keep themselves warm because of extreme cold conditions during winter months. Because of this proximity to burn agent and as burn agent can trigger epileptic fit, they are at a higher risk of getting burnt.,,,,, Very few studies, like that of Rimmer et al. and Jiburum et al., reported that male are burnt more commonly than that of females. Majority of our patients belonged to rural areas, in accordance to the studies conducted by various authors;, however, Ansari et al. observed no difference between the two. The probable attribute is the use of unsafe means of cooking like open chulla because of the easy availability of fire wood and nonavailability of modern cooking appliances. There is also a high incidence of Kangri use (paucity of modern heating gadgets) and lack of awareness about safety measures in the rural population.
The mode injury in our series was different from that reported by other authors,,,,,, who reported scalds as the most common, followed by flame and contact burns. In our study, commonest was Kangri burn followed by flame, scalds, and electric burn [Table 2]. Because of extreme cold conditions prevailing for about 8 months and poor economic conditions, majority of people, especially in rural areas, use Kangri to keep themselves warm during winter months. The Kangri consists of earthenware bowl with an outer encasement of wickerwork [Figure 1]c. The inner earthenware bowl is filled with ignited coal to provide heat. It is used under a loose garment known as “Pheran” worn by both male and female population in winter and is usually kept between medial aspects of thighs and lower abdomen. Being easily portable, people usually carry Kangri along with them wherever they go. People put their hands on Kangri to keep themselves warm. The hands, lower abdomen, medial aspects of thighs being in close proximity to the Kangri are almost always involved in burns in epileptic patients once they get a fit. Hence, the most common site of burn was hands [Figure 2] and [Figure 3] followed by trunk [Figure 1]b, lower limbs [Figure 4], and face [Figure 1]a. Similar results were observed in the studies by Josty et al. and Jang et al. Napoli et al. reported burns in critical areas, particularly on the back of hands or one side of the face. Faurie et al. reported that upper extremity is commonly involved, with hands the most common site. However, Botan et al., reported face as the most common site followed by upper limbs, while Unglaub et al. observed trunk and legs as the common sites. Majority of the patients had got third degree burns [Figure 2]a and [Table 2]. This observation is at par with most of the studies in literature wherein full thickness burns predominate; reason being inability to withdraw themselves from burning agent due to altered level of consciousness during an epileptic attack.,,,,,,,,,,, Percentage of TBSA burnt has always been a key to determine the severity of burn injury. However, majority of our patients had <5% of TBSA burnt as the hand represents a very little percentage of body area. Our observation is in concordance with study conducted by Josty et al. and Rimmer et al. who reported TBSA burn of 2.2% and 8.3%, respectively. A case series by Faurie et al. reported most of the burns in the range of 1%–5%. However, some studies have reported mean body surface area involved ranging from 20% to 25% of TBSA.,,
|Figure 1:(a) postoperative contracture with loss of vision left eye (complication of epileptic burn) (b) multiple episodes of burn in an epileptic patient (c) Kangri (Fire pot)|
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|Figure 2: (a) Epileptic Kangri deep burn of hand (b) After debridement with amputation of little finger (c) After Split thickness skin grafting|
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Majority of our patients had generalized type of epilepsy [Table 3] as observed by other authors.,,,, Contrary to this, the study conducted by Hampton et al. showed burns to be significantly more common in patients with complex partial epilepsy with or without grand mal seizures; mean duration of epilepsy was 27 years (with range 4–63 years) and median frequency of seizure was 24/year. In our study, duration of epilepsy ranged from 1 to 56 years with majority of patients having epilepsy for 16–20 years [Table 3]. Mean duration of epilepsy was 16 years. Mean duration of seizure attack was 5–6 min. Mean frequency of seizure 2–3 episodes/month. Epileptic patients who had longer duration of epilepsy (>10 years) had sustained multiple episodes of burns [Figure 1]b and had been admitted in the hospital for multiple times. We found only (12%) had multiple episodes of burns [Figure 1]b. Josty et al. also reported that only 9% patients sustained one reburn injury and two patients sustained two reburn injuries. Jiburum et al. reported that only one out of 18 had sustained multiple episodes of burns, and half of the patients did not have specific period of epilepsy, 16% patients had been epileptic for 20 years. Majority of our patients were burnt during a seizure attack and only 11 got burn injury not related to seizure. The similar results were observed by Hampton et al. who reported that majority of patients sustained burns during seizure attack and only 9 (7%) patients recalled of receiving burn that was unrelated to seizure. Kinton et al. also reported majority of burns related to seizure. The studies conducted by Unglaub et al., Jang et al., Rimmer et al. and Al-Qattan reported that all patients sustained burns during seizures.
Regarding treatment status, about two-thirds of the patients were on medication (but were found to be taking drugs irregularly) and one-fourth were on no treatment; only 12% patients were on regular antiepileptic treatment. Our observation is comparable with Jiburum et al., who reported that only 40% epileptic patients had attempted any form of treatment for their epilepsy; 22% were on native medication and 16.7% were on modern antiepileptic drugs, but none of them was compliant to medication because either they were unable to afford the drugs or they felt safe once the symptoms had disappeared for few months and they, therefore, abandoned the medication. Ansari et al. found that they were either not taking their medications or were receiving inappropriate therapy. The reason for noncompliance of epileptic patients to treatment is attributed to the lack of awareness about the risks associated with epilepsy and nonaffordability of antiepileptic drugs.
Surgery is indicated in deep dermal and full thickness burns to expedite healing and reduce scarring. In most cases, this can be achieved by burn excision and split thickness skin grafting, but occasionally other surgical procedures are indicated because of the site or severity of the injury. Being full thickness, about three-fourths of patients were managed surgically as is found in the series by many authors.,, When a person holding Kangri gets a fit, hand first comes in contact with the fire in Kangri and because of altered consciousness, contact with fire remains for a prolonged period of time giving rise to deep burns and charring or gangrene of fingers/hands. This gangrene later on lands up with amputations of the digits or hands (commonest procedure). This was followed by debridement, split thickness skin grafting [Figure 2], flap cover [Figure 3], contracture release and so on [Table 4]. This observation is contrary to various other studies. Josty et al. reported burn excision and split thickness skin graft as most common surgical procedure (77 patients) followed by amputation of digits (4 patients), release of contracture in 1, cross-finger flap in 1 and ectropion release in one. Napoli et al., Jiburum et al. also reported that most common surgical procedure was escharectomy and grafting followed by amputation. Botan et al. reported that epileptic burnt patients most of time required debridement and split thickness skin graft. Apart from losing a body part, contracture was the most common complication (Jiburum et al. also reported contracture as the commonest complication) followed by wound infection. Loss of vision was seen in one patient of facial burn (due to open chulla) [Figure 1]a.
Faurie et al., Nthumba and Boschini et al. reported longer hospital stay in these patients because of more severe (deep) burns leading to more morbidity. Duration of hospital stay ranged from 1 to 49 days. The average length of hospitalization was 19 days. Josty et al. also reported mean length of hospital stay of 16.8 days and Faurie et al. –an average stay of 32 days. However, in the study by Napoli et al. the mean length of hospital stay was quite longer (47.7 days). Jang et al. reported a mean hospital stay of 37 ± 27 days in their series of epileptic patients.
Lack of good understanding and education regarding epilepsy is the most vital hinder that causes difficulties in management of epileptic burn patients. Epileptic patients and their families should be educated and counseled by medical professionals including primary care physicians. This will help in improving the compliance with treatment. Management of epilepsy and control of seizures should be complemented by education regarding the risk of burns, especially for women who have a much higher risk of burns compared with men. These patients should be kept under regular neurology follow up. We, in our institute, have started a counseling programme in coordination with Neurology Department wherein patients with epilepsy as well as their attending family members are counseled regarding the compliance towards the medication. They are warned against the risks and dangers of various types of trauma and injuries that these may suffer in case of a seizure episode. They are advised against working alone in kitchen (especially women), handling the firepot (kangri), driving a vehicle, talking a bath with the door bolted, swimming and so on. They are advised against jobs having flashing or flickering lights.
There is a need to encourage measures promoting public health awareness regarding epilepsy. Several studies have shown the effectiveness of televised campaigns and audio presentations for health related prevention programs. A television or radio programme in the vernacular language of the community will be most useful. A campaign that demonstrates burn prevention and safety skills such as isolation of all cooking sites with open flames, supervision and ready access to first aid, is likely to be more effective., Nongovernmental organizations should focus on education on the prevention of burns and the prehospital care of burn victims.
| Conclusion|| |
We conclude that burns in epileptic patients are not uncommon in our valley, especially burns due to Kangri. The best way to care for epileptic patients is to prevent them from getting burned in the first place by making impossible all contact with Kangri, boiling liquids, over heated objects, and other sources of thermal energy, both at work and especially at home. Epileptic female patients should not be allowed to enter into the kitchen alone. Epileptic patients in Kashmir valley should avoid use of Kangri for warming purpose and they should use alternative source to get themselves warmed during winter months.
We would like to acknowledge the guidance and support provided by the Ex Head of Our Department, Prof. M. A. Darzi (1951-2018) in conducting/compiling this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bifftu BB, Tadesse Tiruneh B, Mekonnen Kelkay M, Bayu NH, Tewolde AW, Takele WW. Seizure-related injuries among people with epilepsy at the outpatient department of the university of Gondar hospital, Northwest Ethiopia: Cross-sectional institutional-based study. Neurol Res Int 2017;2017:4970691.
Gragnani A, Müller BR, Oliveira AF, Ferreira LM. Burns and epilepsy – Review and case report. Burns 2015;41:e15-8.
Szűcs A, Horváth A, Rásonyi G, Fabó D, Szabó G, Sákovics A, et al.
Ictal analgesia in temporal lobe epilepsy – The mechanism of seizure-related burns. Med Hypotheses 2015;85:173-7.
Malla CN, Misgar MS, Khan M, Singh S. Analytical study of burns in Kashmir. Burns Incl Therm Inj 1983;9:180-3.
Mukhdomi GJ, Desai MH, Herndon DN. Seizure disorders in burned children: A retrospective review. Burns 1996;22:316-9.
Faurie MP, Allorto NL, Aldous C, Clarke DL. A closer look at burn injuries and epilepsy in a developing world burn service. S Afr J Surg 2015;53:48-50.
Park YK, Lee JW, Jang YC. Burns in patients with epileptic seizure. J Korean Soc Plast Reconstr Surg 2005;32:250-4.
Nthumba PM. Burns in sub-Saharan Africa: A review. Burns 2016;42:258-66.
Ibrahim A, Asuku ME. Burns of the face in epilepsy: Risk factors and an opportunity for prevention. Afr J Trauma 2014;3:87-90. [Full text]
Napoli B, Arpa DN, Masellis M. Epilepsy and burns. Ann of MBC 1992;5(3).
Josty IC, Narayanan V, Dickson WA. Burns in patients with epilepsy: Changes in epidemiology and implications for burn treatment and prevention. Epilepsia 2000;41:453-6.
Boschini LP, Tyson AF, Samuel JC, Kendig CE, Mjuweni S, Varela C, et al.
The role of seizure disorders in burn injury and outcome in sub-Saharan Africa. J Burn Care Res 2014;35:e406-12.
Hampton KK, Peatfield RC, Pullar T, Bodansky HJ, Walton C, Feely M. Burns because of epilepsy. Br Med J (Clin Res Ed) 1988;296:1659-60.
Ansari Z, Brown K, Carson N. Association of epilepsy and burns – A case control study. Aust Fam Physician 2008;37:584-9.
Mir MA, Anjum S, Mir RA, Sheikh G, Reshi FA. Etiological and demographic profile of burn injury in Kashmir valley. Internet J Plast Surg 2012;8(1).
Spitz MC, Towbin JA, Shantz D, Adler LE. Risk factors for burns as a consequence of seizures in persons with epilepsy. Epilepsia 1994;35:764-7.
Unglaub F, Woodruff S, Demir E, Pallua N. Patients with epilepsy: A high-risk population prone to severe burns as a consequence of seizures while showering. J Burn Care Rehabil 2005;26:526-8.
Jang YC, Lee JW, Han KW, Han TH. Burns in epilepsy: Seven years of experience from the Hallym burn center in Korea. J Burn Care Res 2006;27:877-81.
Harding GF, Harding PF. Photosensitive epilepsy and image safety. Appl Ergon 2010;41:504-8.
Rimmer RB, Bay RC, Foster KN, Jones MA, Wadsworth M, Lessard C, et al.
Thermal injury in patients with seizure disorders: An opportunity for prevention. J Burn Care Res 2007;28:318-23.
Jiburum BC, Olaitan PB, Otene CI. Burns in epileptics: Experience from Enugu, Nigeria. Ann Burns Fire Disasters 2005;18:148-50.
Richards EH. Aspects of epilepsy and burns. Epilepsia 1968;9:127-35.
Karacaoĝlan N, Uysal A. Deep burns following epileptic seizures. Burns 1995;21:546-9.
Akhtar MS, Ahmad I, Khan AH, Fahud Khurram M, Haq A. Burn injury in epileptic patients: An experience in a tertiary institute. Ann Burns Fire Disasters 2014;27:126-9.
Wani I. Kangri cancer. Surgery 2010;147:586-8.
Botan A. Epilepsy and full-thickness burns. Annals of Burns and Fire Disasters 2010;23:67-71.
Shaikh BF, Memon AR, Tahir SM. Presentation and complication of burn injuries among epileptic patients. J Mod Med Dent Sci 2009;16:91-3.
Kinton L, Duncan JS. Frequency, causes and consequences of burns in patients with epilepsy. J Neurol Neurosurg Psychiatry 1998;65:404-5.
Al-Qattan MM. Burns in epileptics in Saudi Arabia. Burns 2000;26:561-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]