BURNS IN EPILEPTICS: TEN YEARS EXPERIENCE AT A TERTIARY CARE HOSPITAL

Mir Mushtaq 1 , Bashir Ahmad Bhat, 1 Omar Farooq 2 , Shabir Iqbal 1 , Refut Ara 1 , Zulqarnain Masoodi 1 and Bhat Mushtaq Ahmad 1 . 1. Department of plastic surgery SHMS hospital Srinagar Jammu and Kashmir India . 2. Department of Neurology SMHS Hospital. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


827
The age of the patients ranged from15 to 55 years and median age was 25 years. The hospital stay ranged from 10 to 30 days and median duration of hospital was 3 weeks. Three hundred and forty five patients (75.99%) were aware of their epilepsy prior to burn injury but only eighty five patients (24.6%) were on antiepileptic treatment (Table 1). Most of the patients (200) sustained burn injury due to contact with kangri (44.05%) local fire pot used to provide warmth to the body during winter months, and majority of female patients (40.81%) had a burn injury while cooking when they had a seizure attack and fell on fire (chulla). Fourty patients sustained burns due to contact with hot liquids, twenty three patients sustained burns due to contact with heat convector, seventeen patients had burns due to electric blanket, twenty nine patients had a burn due to gas bukhari, twenty patients had burn due to coal bukhari and ten of our patients had burns due to contact with hot water bottle ( Table 2).  (Table 3). 100 % Sixty nine patients developed superficial partial thickness burns, one hundred sixty five patients sustained full thickness burns, one hundred and thirty patients had deep dermal burns, and there were mixed burns in ninety (Table  4). In three hundred and sixty one patients, TBSA involved was less than 20% while as in ninety three patients more than 20% of TBSA was involved (Table 5). In one hundred and Fourty five patients burn wounds were excised and covered with graft (STSG), in eighty seven patients burn wounds were debrided and covered by STSG. Seventy patients required amputation of gangrenous digits in hand, thirty seven patients required amputation of gangrenous toes, in twenty eight patients VAC was applied to the burn wound then STSG was done and in eighteen patients flaps were used to cover the wound. The amputation stumps healed spontaneously with dressings in fourty five patients (11.68%), STSG was done in thirty seven patients (9.61%) and primarily closed in twenty five patients (6.50%) Table 6. The commonest complications observed were partial graft loss in seventy one patients (18.44%), wound infection in fifty two patients (13.50%), and partial flap dehiscence in four patients (1.03%). In fifty one patients there was minor graft loss (10%) and in twenty one patients there was major graft lost (10 to 20%). In patients with minor graft loss (<10%), the residual raw areas healed spontaneously with regular dressings. Patients with major graft loss (10 to 20%) required another sitting of grafting for complete healing of burn wounds. Rest of patients who developed infection and dehiscence of flaps were managed conservatively and successfully by regular dressings and antibiotics. All patients were evaluated by neurologist. Baseline EEG was done in 378 patients, CT/MRI brain was done as advised by neurologist. All patients were put on antiepileptic drugs. Three hundred and twenty patients (70.48%) were diagnosed as generalized tonic clonic seizure, ninety two patients (20.27%) had absence seizures and fourty two patients (9.25%) were having complex partial seizures (Table 7).

Discussion:-
Burns are serious but under recognized complications of epilepsy. The most commonly associated seizure type are, generalized tonic clonic followed by absence and complex partial seizures. In a retrospective study Jang Young Chul et al (8) concluded that; females were commonly affected, there were more seizures in morning hours and epileptic patients should be classified as high risk group. In our study similar results were seen as GTCS was common seizure type (70.48%) followed by Absence seizures (20.27%) and 9.25% patients had complex partial seizures.
Epileptic patients may sustain severe burn injuries during the acute episodes. These patients must be identified, provided with specific treatment, and educated to prevent an unpredictable attack that may lead to burn injuries. It is important for patients and those treating them to realise that because of the impaired conscious level, the skin is exposed to the burning agent for longer time, resulting in usually a deep burn than would occur in a conscious 829 patient. Therefore, referral to a burns unit should be considered earlier when treating such patients. Severe burns as a result of epileptic seizures requiring surgical interventions are published by authors who treat such patients (7,9,10). These studies correspond to our results showing deep burns in 385 out of 454 patients (84.80%) as compared to burn injuries in non-epileptic patients, where the percentage is usually lower.
Epilepsy is three times more likely to be associated with burns; with woman being five times more likely to be burned as revealed by Ansari et al (11). In our study group, more female (70.5%) than male subjects (29.5%) were burnt with a ratio1:2.3. Majority of female patients (35.93%) had a burn injury while cooking they had seizure attack and fell on fire (chulla). This is probably because women tend to do more domestic work than men. Similar observations have been made by others (12,13).These results also reflect that our society is still gender biased, females are not being given the same level of care as compared to other sex. So programs like BETI BACHOV, BETI PADAV (save girl child and educate the girl child) could make a significant difference in reducing the morbidity and mortality of epileptic female patients.
Most of the patients in our study (44.05%) sustained burn injury due to contact with kangri (n: 200). Similar observations have been made by Meirelles et al. (14) who noticed that a large number of patients had visual contact with the flame prior to the accident, suggesting that fire could be a photo stimulator for the onset of seizure attack. The risk factors for the increased incidence of burns in epileptic patients are the duration of the epileptic episode, the frequency of seizure attack (15,16).Napoli et al. concluded that burning agents are important predisposing factor for seizures in epileptic burn patients; the burn agent emits light stimuli that trigger the onset of epileptic seizures (17).
In our series, all of the patients with deep burns required operative interventions. In two hundred sixty patients burn wounds were excised/debrided and covered with graft, seventy patients required amputation of gangrenous digits in hand, thirty seven patients required amputation of gangrenous toes, and in eighteen patients flaps were used to cover the wound. Pedicled groin flap was used in twelve patients, reverse sural artery flap in four patients, and reverse radial forearm flap in two patients. Most of our patients (84.80%) had deep burns and required operative intervention in the form of grafting, flap cover and amputation of gangrenous digits, this is because most of our patients had burns due to kangri, chulla or contact with a heat convector or a bukhari. Kangri is a fire pot filled with burning charcoal and used to provide warmth to body in winter months. During seizure episode patient looses consciousness and hands come in contact with kangri resulting in a deep burn and even gangrene of digits.
Most of patients admitted to our burn unit with epileptic burns where not receiving antiepileptic treatment continuously and thus treatment interruption resulted in recurrence of seizure and subsequent burn injury. Similar observations have been made in Saudi Arabia (18). Majority of patients did not seek any medical treatment for their seizures, rest of them took medication for some period of time and once the seizures got controlled they quit it. Similar non compliance issues have been reported by Manktelow (19). In our study three hundred and forty five patients (75.99%) were aware of their epilepsy prior to burn injury but only eighty five patients (24.6%) were on antiepileptic treatment. The reasons for noncompliance are low socioeconomic status, patients living in rural areas are less health conscious, lack of education and lack of awareness programs. Some of our patients did not take drugs because they could not afford the same. It is recommended that a national epileptic register be maintained for all patients, and all patients be provided with cheap/free antiepileptic medications to increase the compliance to treatment. Some uneducated people believe that this disease is caused by evil forces and hence it is not possible to get cured through modern medicines, therefore instead of going to physician they seek advice and help and from local quakes or any spiritual icon. This was the case with many of our patients and same has been reported by other authors in African countries like Nigeria (20).
Various authors report the incidence of burn injury in epileptic patients accounting for 5% (21) and 10% (22) of total admissions to a burn unit. Compared to these studies our study reveals a tendency towards a lower percentage of burn injury in epileptic patients in our centre (5.006%). What we see in our centre is tip of the ice berg, as most patients with epileptic burns are managed locally. Very less percentage of patients are referred for definitive treatment. Most of these patients are either managed by quacks or spiritual icons.
Burn injury in epileptic patients can be prevented by taking simple measures including the use of fire and radiator guards, flame retardant clothing (23) .In the kitchen, the incidence of burn injuries can be prevented by use of microwave ovens, insulated plastic kettles, and cooker guards (24). Holding regular community awareness programs 830 in far flung areas explaining the nature of disease, its treatment and removing various taboos and stigmas associated with epilepsy will go in a long way to improve compliance and outcome in such patients.

Conclusion:-
Lack of proper education regarding epilepsy is the most important factor that causes difficulties in management of epileptic burn patients. This situation can be made better if social welfare schemes to discourage gender bias, provision of cheap/free antiepileptic medications, maintaining National Register for all epileptic patients and medical awareness programs in rural areas to remove taboos associated with epilepsy by trained professionals. This will help in improving the compliance with treatment. Female epileptics should not enter in kitchen alone. This approach will assist to avert avoidable deformities and reduce morbidity as a result of burns sustained by epileptics. Bibliography:-