TY - JOUR
AU - MD, Haluk Duman,
AB - Abstract Coal stoves that are used for heating purposes are more popular in economically developing and undeveloped countries because of their lower operational costs. Unfortunately, they may cause serious burn injuries when flammable liquids are misused to kindle or to accelerate a fire within them. Every year, particularly in the winter, many citizens in Turkey have suffered burn injuries caused by this dangerous practice. During the period from January 1989 to January 2009, 82 patients sustained burn injuries as a consequence of coal stove fires and were admitted to burn units. Efforts to inform the public about the danger of using flammable liquids with these kinds of stoves are recommended to minimize the incidence, morbidity, mortality, and cost of this relatively common and preventable type of injury. Although numerous types of burn injuries have been reported in the literature,1,2 flames continue to be the main cause of burns.3,4 Two reports from Turkey documenting thermal injuries because of misuse of paint thinner revealed that kindling a stove was the most common causative factor.5,6 However, on the basis of admissions to our burn unit, we have noted that misuse of not only paint thinner but also other flammable liquids such as accelerants in stoves contributes to burn injuries. Coal stoves (Figure 1) have become a very cost-effective alternative energy source, especially in economically developing and undeveloped countries, because coal is a dense and powerful fuel that allows cost savings in comparison with the rising costs of conventional heating sources. Unfortunately, learning to ignite and burn anthracite coal can be frustrating, and patience is surely a virtue. Therefore, these stoves have become dangerous because of the misuse of flammable liquids to accelerate or start a fire. The universal availability of a number of organic compounds with relatively high volatility, low flash point, low flammability range, and low ignition energies in the home such as gasoline, paint thinner, ethyl alcohol, methylated spirits, and even cologne encourages misuse of these compounds as accelerants in stoves.7,8 The resulting immediate and sudden ignition may release a large amount of fire and may result in serious burns. These injuries may be prevented by simple safety measures. Figure 1. View largeDownload slide A kind of coal stove and ordinary home furnishings, such as a couch, carpet, curtains, and a wooden floor around it. Stove burns mostly occur in closed areas such as the home, and home furnishings tend to be ignited, leading to a house fire. A victim would be exposed to severe burns and inhalation injury. Figure 1. View largeDownload slide A kind of coal stove and ordinary home furnishings, such as a couch, carpet, curtains, and a wooden floor around it. Stove burns mostly occur in closed areas such as the home, and home furnishings tend to be ignited, leading to a house fire. A victim would be exposed to severe burns and inhalation injury. The aim of this study was to identify the incidence, epidemiologic features, morbidity, mortality, and mechanism of burns caused by misuse of flammable liquids in coal stoves. This study describes and evaluates our burn unit's experience in the management of victims of these types of accidents and the characteristic features of this population, and it suggests a preventive program to propagate public awareness about the hazards of this type of burn injury. PATIENTS AND METHODS A retrospective analysis of stove and flammable liquid-related burns was conducted during the period of January 1989 to January 2009 in Gulhane Military Medical Academy Haydarpasa Training Hospital Burn Center, which is a tertiary burn care center in Istanbul, Turkey. This unit renders its services to 13 million citizens, with the majority of them coming from low and middle social classes. Patients who sustained burns from coal stove fires were identified using a computerized departmental database. Data studied included demographic data, the place and mechanism of injury, site and percentage of the TBSA burned, social status and employment, and the patients' treatment along with their outcome, morbidity, and fate. RESULTS During the 20-year period between January 1989 and January 2009, a total of 1728 major burn patients with acute burns were admitted to our burn center. Among them, 82 patients sustained burn injuries as a consequence of coal stove fires. Although, the overall mortality of total burn admissions was 4.05% during this period, the overall mortality rate of this injury was high (20.7%). The average age of this group was 25.9 years. Sixty-six patients were men (80.5%), and 16 (19.5%) were women. Understandably, there was a greatly increased incidence of burns caused by coal stove fires during winter (68 patients, 82.9%) and autumn (8 patients, 9.7%) in comparison with spring (4 patients, 4.9%) and summer (2 patients, 2.4%; Figure 2). Figure 2. View largeDownload slide Seasonal variation of burn injuries. There is a greatly increased incidence of burns during wintertime caused by coal stove fires. Figure 2. View largeDownload slide Seasonal variation of burn injuries. There is a greatly increased incidence of burns during wintertime caused by coal stove fires. In this study, 55 of 82 patients (67.7%) were uneducated, including primary and secondary school levels (Table 1). Occupational status of the patients is shown in Table 2. Also, 71 of 82 patients (86.6%) were of low socioeconomic status. Table 1. Educational status of the patients View Large Table 1. Educational status of the patients View Large Table 2. Occupational status of the patients View Large Table 2. Occupational status of the patients View Large The percentage of TBSA ranged from 15 to 80%, with a mean TBSA burn of 30% (Tables 3 and 4). The anatomical sites most frequently involved were the head and face (90%), neck (85%), hands (60%), anterior trunk (10%), genitalia and buttocks (5%), and lower extremities (5%). Table 3. Burn degree distribution of the patients View Large Table 3. Burn degree distribution of the patients View Large Table 4. The percentage of TBSA View Large Table 4. The percentage of TBSA View Large Hospital stay for treatment of burns ranged from 10 to 95 days, with a mean stay of 27 days. Sixty-eight patients (82.9%) had suffered severe inhalation injuries and were intubated, and 54 of these patients survived. Prospectively, diagnosis of inhalation injury was suspected in patients with facial burns and confirmed with fiber optic bronchoscopy and chest radiographs. Six patients died within the first 72 hours after admission, and 17 patients died thereafter. The morbidity, mortality, and relatively longer period of hospital stay of the admitted patients reflect the seriousness and depth of these burns, and thus, the economic burden these accidents put on the health system in Turkey. DISCUSSION Despite numerous advances in fire safety, precautions, and prevention strategies, people continue to die or be severely injured in fires.8 Although paint thinner has been reported as the most common accelerant used in stoves, other flammable liquids such as gasoline, kerosene, ethyl alcohol, methylated spirits, and even cologne have also been used to kindle stoves. These flammable liquids are good fuels, because they have several physical properties that contribute to their ease of ignition, such as high volatility, low flash point, low flammability range, and low ignition energies. Once ignited, the flame front moves radially outward in all directions away from the ignition source, gathering energy as the flame front expands.7,8 The Mechanism of Injury The burns result from pouring flammable liquids onto an already hot area, and the mechanism is clear: the first portion of the flammable liquid to contact the heat ignites instantaneously, and the ignition “flashes back” along the remainder while it is still in the air. This airborne portion explodes, and burning droplets can be showered a distance of some meters away over other people in addition to the person who poured the flammable liquid on the stove. The majority of the burns result not only from direct contact of flaming liquid with exposed skin but also from clothing and furnishings in the home, which can be secondarily ignited and cause more serious burn injuries. Throwing the flammable liquids container within seconds because of acute panic of the victims and thus spilling flammable liquids elsewhere in the home could be proposed as a mechanism for this secondary ignition (Figure 3A, B). Figure 3. View largeDownload slide Schematic representation of the mechanism of injury. A, Pouring flammable liquids onto an already hot stove. B, The first portion to contact the heat ignites instantaneously, and the ignition “flashes back” along the remainder while it is still in the air. This airborne portion explodes, and burning droplets can be showered a distance of some meters away over furnishings in the home in addition to the person who poured the flammable liquid in the stove. Furthermore, throwing the container with flammable liquid within seconds because of acute panic of the victims, and thus, spilling flammable liquids elsewhere in the home could be proposed as a mechanism for this type of burn. Drawing by Zehra Onut used with permission. Figure 3. View largeDownload slide Schematic representation of the mechanism of injury. A, Pouring flammable liquids onto an already hot stove. B, The first portion to contact the heat ignites instantaneously, and the ignition “flashes back” along the remainder while it is still in the air. This airborne portion explodes, and burning droplets can be showered a distance of some meters away over furnishings in the home in addition to the person who poured the flammable liquid in the stove. Furthermore, throwing the container with flammable liquid within seconds because of acute panic of the victims, and thus, spilling flammable liquids elsewhere in the home could be proposed as a mechanism for this type of burn. Drawing by Zehra Onut used with permission. Although burns caused by flammable liquids used on barbeques are similar to burns resulting from stoves, the mechanism of injury is different. First, flash burns represent the most common mechanism of injury in barbeque-associated burn accidents.9 The most significant causal factor for these barbecue-associated flash burns was the use of accelerants to light the coal, such as petrol, methylated spirits, and lighter fluid. Fortunately, because the period of combustion is very brief, these burns tend to be of partial thickness and to heal spontaneously.10 In addition, many of these burns occur during outdoor activity, and thus, the risk for inhalation injury is minimal. Contrary to barbeque-associated burns, stove-related burns mostly occur in closed areas such as homes and barracks, and thus, the risk for inhalation injury is very high. Furthermore, in addition to flash burns, victims' clothes and home furnishings tend to be ignited, and a house fire can break out. A victim in such a situation would be exposed to an extreme fire that would be likely to result in severe skin burns. The ignition of flammable hydrocarbon liquid vapors in a room produces very turbulent, short-lived fires that distribute a flash of fire (measured at 500–975°C) throughout a room and longer-lived flames at lower levels.11 The hot gases produced include CO2 and water vapor (H2O) as predominant species, with minimal CO and soot early on. The atmosphere in the room becomes markedly deficient in O2 and very rich in CO2 very quickly after ignition. A victim in such a room would be inhaling very hot gases rich in water vapor (superheated steam). Furthermore, steam carries high heat deeper into the respiratory system.11 This is the situation produced in the first seconds of a flammable vapor ignition. Even in the absence of respiratory complications, such high-temperature gases are expected to induce collapse very quickly, possibly even death.6,8,11 Coal burning stoves are becoming more popular as alternative heating appliances in economically developing and undeveloped countries. Many types of coal burning stoves (domestic, industrial, and outdoor models) are available in accordance with different requirements and are made from light steel, welded steel, or cast iron. Coal stoves may be fed from the top or from the bottom. In Turkey, sheet metal coal stoves that are fed from the top are preferential, because they are lowest in cost. Also, because they are light in weight, they warm up rapidly. A sheet metal coal stove regularly reaches surface temperature of more than 400°C. The interior stove temperature is more than 1000°C. In their experiment with a small charcoal briquette, Cahill et al demonstrated that 12 and 16 hours after lighting, the core temperature was 202 ± 17°C and 129 ± 22°C, respectively. One can easily conclude from this experiment that if any flammable liquids are poured into the stove even 16 hours after lighting, they can be easily ignited even when there is no flame in the stove.12 Several epidemiological analyses from Turkey reveal the continuity of this problem. In their analysis of 5264 burn cases, Türegün et al reported a total of 41 burn injuries related to relighting stoves with flammable liquids. Gasoline and liquefied petroleum gas were the main cause of flame burns.13 In their retrospective analysis of 734 acutely burned patients, Acikel et al reported that 45 patients had been burned when kindling a fire in the stove, with 19 of them reported as having major burns. Flammable liquids were reported as the most common causes of flame burns in their studies.14,15 In their analysis of adult burn injuries treated in an Emergency Department over a 5-year period, Avşaroğullari et al16 reported 28 patients burned with flammable liquids. Unfortunately, Acikel et al14,15 and Avşaroğullari et al16 failed to document a detailed analysis of the types of flammable liquids that had caused burn injury in their patients. In their 7 years of burn unit experience, Coruh et al17 reported that gasoline and paint thinner were the second and third most common causes of flame burn injuries, respectively. In addition to the aforementioned epidemiological analyses, two reports from Turkey gave detailed analyses of burn injuries caused by paint thinner ignition during the process of kindling a fire in the stove.5,6 In both studies, the only flammable liquid reported was paint thinner.5,6 However, we have pointed out that other flammable liquids such as gasoline, kerosene, methylated spirits, diesel oil, and even cologne have also been used for kindling a stove in Turkey. In this study, we found that gasoline, thinner, and kerosene were the main cause of flame burns. However, as far as we have been able to ascertain, there is no reported series of thermal injury because of misuse of different flammable liquids. Although this is not a new type of burn injury and it is preventable, we noted that it has not been prevented as expected, and it is a continuing problem in Turkey.5,6,16,17 In barbeque-related burns, the predominance of male injuries is related to social circumstances, with males tending to predominate in outdoor barbeque cooking activity. Similarly, we found that males also predominate in stove lighting activity at home. Although excessive alcohol consumption is commonly associated with injuries related to barbequeing or outdoor recreational activity, we have not noted alcohol consumption in our burn patients.18,19 Burns caused by coal stove fires constitute a significant proportion of referrals to burn units in our country. Affected body sites, in order of most affected to least affected, include the head and face, neck, hands, and trunk. These burns are relatively deeper and carry a high morbidity and mortality because of coexistent inhalation injury. In the barbeque burn series by Khalessi et al, the most common body sites injured were the face and hands; one third of patients required intubation and admission to the intensive care unit. Twenty percent of patients required skin grafting, with those patients whose clothing ignited suffering the most severe injuries and requiring prolonged admission.19 In this study, 68 patients (82.9%) required intubation and admission to the intensive care unit. Williams et al reported gasoline-related lower extremity (51%) and chest (46%) burns in addition to burns of the upper extremities, hand, and face. In their series, buttock and perineal burns were uncommon.19,20 In the series by Khalessi et al, the most severe injuries resulted from clothing catching fire. In their analysis of 74 petrol-related burn injuries, Wilson and Bailie reported that 16 patients were treated only as outpatients, and over half had a hospital stay of less than 5 days. These findings related to barbeque, bonfire, or other outdoor activity burns reflected that a large number of these injuries were relatively minor, not requiring surgery or even admission to the hospital in some cases.9,10,18,19,21 However, according to the findings based on our study, the most severe injuries resulted from not only clothing catching fire but also the patient's own home with initial ignition of the patient's hair or clothing, the mattress, bedclothes, or an overstuffed chair. This explains the difference in burn distribution sites over the body in our series, compared with those reported by other authors.9,10,12,18,–22 Furthermore, it also explains the high incidence of inhalation injury and death in our series. In this study, we identified 68 patients (of 82, or 82.9% of the total number studied) with suspected inhalation injury that required intubation, mechanical ventilation, and fiber optic bronchoscopy in the first 24 hours after admission. Of the 68 patients who had inhalation injury and were treated with conventional mechanical ventilation, 17 died. This leads us to conclude that the most important feature of coal stove burns because of flammable liquid misuse is inhalation injury, which increases mortality and morbidity. All our patients who suffered burns from coal stoves came from low socioeconomic classes, where coal stoves are used as the main instruments for heating, cooking, and warming water for bathing. The poor economic, social, and cultural diversity of patients in this study population highlights the need to consider how culture influences burn injury epidemiology. The lack of public awareness about this problem reflects the high incidence of this burn type in our group of patients. Public awareness should be raised of the dangers of pouring or throwing flammable liquids onto fires.22 The home and workplace users of stoves must be aware of this danger. To draw attention to a possible fire disaster, stickers indicating injury mechanism, as shown in Figure 3 must be placed on the front and top of these stoves. This regulation would be highly beneficial in terms of protecting the public from flammable liquids explosion. In addition, some remarkable banner that emphasizes the importance of possible danger in an ironic way like “You are smart enough not to pour flammable liquids on here” should be put on the front and top of the stoves. Furthermore, the same banner should also be put on the flammable liquid container: “You are smart enough not to pour this flammable liquid onto fire.” In addition, home and workplace visitation should be started, and the stoves should be inspected at least once a year by the regional fire department or regional municipality officer. This should be performed without any extra cost to users. Because these types of stoves are preferred by members of lower socioeconomic groups, these persons often do not know the potential risks of their stoves. Mass media should caution public regarding the potential dangers of flammable liquid usage in stoves. In addition, these types of liquids must be supported with a detailed user manual. Furthermore, effective legal mandates regarding the production of stoves without adequate warning sign must be enacted to act as a deterrent against this practice. As far as we could ascertain, there is no established rule for putting the “warning sign” on the stove according to safety standards in our country (Turkish Standards Institution). Furthermore, in Turkey, there are no current laws against or punishments for companies that manufacture stoves without any warning sign on them that emphasizes the potential danger of flammable liquid usage. The government should immediately take action to enact effective laws against and punishments for this activity. If the stoves are manufactured with warning signs on them, incidence of this type of burn injury may be prevented better than before. Stove users must always keep in mind that fuel splashing on a hot surface can ignite, and use of flammable liquids to start a fire can result in explosions and uncontrolled fires. Instead of flammable liquids, nonflammable, nonhazardous materials such as kindling wood should be used to start a fire. We have some suggestions to prevent this injury. First, fire should be started using a combination of paper and dry kindling. Next, pieces of hard wood should be added until the fire is very hot, flames are strong, and there is approximately a 2-inch bed of burning coal. After that coal can be loaded onto the fire. It must be kept in mind that attempting to add any flammable liquids during any step of the lighting process can result in serious and painful burn injuries.23 Any combustible material should be at least 3 feet clear of the stove. Children must be kept away from stove. The area of floor around a stove (hearth) must be made of ceramic or other nonflammable base. The stove, ductwork, and chimney should be cleaned every year. The ashes should be placed in a suitable metal container and taken outdoors immediately. There should be at least one fire extinguisher in the area. Most burns are preventable. Public understanding and recognition of the severity of the burn injury problem are unusually low in comparison with other injury and illness issues. The focal point of burn prevention is individual responsibility, education, and behavior modification awareness. Burn incidence and severity can be significantly reduced through concentrated community awareness, the educational system, and a year-round program to educate the public. In Turkey, there is an increasing need for establishing a foundation for burn prevention as is present in the United States. Such a burn prevention foundation should work with fire services, emergency service groups, educators, healthcare provider organizations, community service groups, and others dedicated to spreading awareness of fire and burn safety and prevention issues, programs, and services, such as fire safety houses. The firefighters should get involved in helping to educate and target high-risk populations. The fire safety houses should travel to schools and to various community events and locations to provide this very hands-on, life-saving instruction. The fire safety houses should be available for use by fire companies, municipalities, child and youth organizations, and other community groups—to use for health and safety fairs, community days, and other community events. Business and industry should organize fire safety house education, a featured program at employee-family safety days or company picnics.24,25 In conclusion, burns caused by pouring flammable liquids in the coal stove may often result in significant morbidity and mortality. Socioeconomic factors play a significant role in these injuries and must be assessed when planning prevention efforts. These injuries are preventable; therefore, it is important that the public is informed of the risks and precautions that may be taken to stop these injuries from occurring. We think that the most effective method is the mass media. The risks of pouring flammable liquids to ovens or barbeques can be shown on television or through other mass media. By this way, public interest may be awakened. Another method is informing the people at schools or such places. Handouts are another method of awakening public awareness. There must be warnings on the boxes containing these kinds of fluids. Generally, there is only an indicator showing that the boxes are containing flammable liquids, but we think that that is not enough. The hazardous effects of pouring must also be indicated on the boxes. Moreover, the sales of these fluids can be limited by law enforcement. ACKNOWLEDGMENTS We thank Zehra Onut for her drawings and Kamil Akpinar for his contribution to Figure 1. REFERENCES 1. Deveci M, Kulahci Y, Bozkurt M, Sengezer M Unusual type of burn injury caused by industrial bakery ovens. Burns  2002; 28: 201– 4. Google Scholar CrossRef Search ADS PubMed  2. Bozkurt M, Kulahci Y, Zor F Unusual ring burn injury. Burns  2005; 31: 785– 6. Google Scholar CrossRef Search ADS PubMed  3. 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TI - Thermal Burns Associated With the Misuse of Flammable Liquids in Stoves: A Continuing Problem
JO - Journal of Burn Care & Research
DO - 10.1097/BCR.0b013e31820aaf1e
DA - 2011-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/thermal-burns-associated-with-the-misuse-of-flammable-liquids-in-kfRGbclWcW
SP - 302
EP - 308
VL - 32
IS - 2
DP - DeepDyve
ER -