Burn

A burn is a type of injury to the skin caused by heat, electricity, chemicals, light, radiation or friction.[1][2][3] Most
burns only affect the skin (epidermal tissue and dermis). Rarely deeper tissues, such as muscle, bone, and blood
vessels can also be injured. Managing burns is important because they are common, painful and can result in
disfiguring and disabling scarring. Burns can be complicated by shock, infection, multiple organ dysfunction
syndrome, electrolyte imbalance and respiratory distress. Large burns can be fatal, but modern treatments,
developed in the last 60 years, have significantly improved the prognosis of such burns, especially in children and
young adults.[4][5]

Classification

A number of different classification systems exist. The traditional system divided burns in first-, second-, or
third-degree.[6] This system is however being replaced by one reflecting the need for surgical intervention. The
burn depths are described as either superficial, superficial partial-thickness, deep partial-thickness, or full-
thickness.[7]

The following are brief descriptions of these classes:

By degree

• First-degree burns are usually limited to redness (erythema), a white plaque and minor pain at the site of
injury. These burns involve only the epidermis. Most sunburns can be included as first-degree burns.
• Second-degree burns manifest as erythema with superficial blistering of the skin, and can involve more
or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial
(papillary) dermis and may also involve the deep (reticular) dermis layer. Deep dermal burns usually take
more than three weeks to heal and should be seen by a surgeon familiar with burn care, as in some cases
severe hypertrophic scarring can result. Burns that require more than three weeks to heal are often excised
and skin grafted for best result.
• Third-degree burns occur when the epidermis is lost with damage to the subcutaneous tissue. Burn
victims will exhibit charring and extreme damage of the epidermis, and sometimes hard eschar will be
present. Third-degree burns result in scarring and victims will also exhibit the loss of hair shafts and
keratin. These burns may require grafting. These burns are not painful, as all the nerves have been
damaged by the burn and are not sending pain signals; however, all third-degree burns are surrounded by
first and second-degree burns.

Other classifications

A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided into superficial and deep
categories) and "Full Thickness" relates more precisely to the epidermis, dermis and subcutaneous layers of skin
and is used to guide treatment and predict outcome.

A description of the traditional and current classifications of burns.

Traditional
Nomenclature Depth Clinical findings Example
nomenclature

Superficial Erythema, significant

first degree Epidermis involvement
thickness pain, lack of blisters

Partial thickness – Blisters, clear fluid, and

second degree Superficial (papillary) dermis
superficial pain

Whiter appearance or
Partial thickness – fixed red staining (no
second degree Deep (reticular) dermis
deep blanching), reduced
sensation
 Epidermis, Dermis, and complete
Charred or leathery,
destruction to subcutaneous fat,
Full thickness third degree thrombosed blood
eschar formation and minimal pain,
vessels, insensate
requires skin grafts

An even simpler, more accurate and more descriptive classification is epidermal, dermal and full thickness.
Dermal injuries are subdivided into superficial, mid and deep.

It is most common for high percentage burns to only be classified as Superficial, Partial thickness and Full
Thickness. The reasoning behind this is that in an emergency setting such as a burn trauma room or ambulance it
is more important to protect the patient from dehydration, hypothermia and infection rather than calculating the
exact depth of a burn.

Causes
Burns are caused by a wide variety of substances and external sources such as exposure to chemicals, friction,
electricity, radiation, and heat.

Chemical burn
Main article: Chemical burn

Most chemicals that cause severe chemical burns are strong acids or bases.[10] Chemical burns can be caused by
caustic chemical compounds such as sodium hydroxide or silver nitrate, and acids such as sulfuric acid.[11]
Hydrofluoric acid can cause damage down to the bone and its burns are sometimes not immediately evident.[12]

Electrical burn

Electrical burns are caused by either an exogenous electric shock or an uncontrolled short circuit. (A burn from a
hot, electrified heating element is not considered an electrical burn.) Common occurrences of electrical burns
include workplace injuries, or being defibrillated or cardioverted without a conductive gel. Lightning is also a
rare cause of electrical burns. Since normal physiology involves a vast number of applications of electrical forces,
ranging from neuromuscular signaling to coordination of wound healing, biological systems are very vulnerable
to application of supraphysiologic electric fields. Some electrocutions produce no external burns at all, as very
little current is required to cause fibrillation of the heart muscle. Therefore, even when the injury does not involve
any visible tissue damage, electrical shock survivors may experience significant internal injury.[13] The internal
injuries sustained may be disproportionate to the size of the burns seen (if any), and the extent of the damage is
not always obvious. Such injuries may lead to cardiac arrhythmias, cardiac arrest, and unexpected falls with
resultant fractures.[14]

Radiation burn
Main article: radiation burn

Radiation burns are caused by protracted exposure to UV light (as from the sun), tanning booths, radiation
therapy (as patients who are undergoing cancer therapy), sunlamps, radioactive fallout, and X-rays. By far the
most common burn associated with radiation is sun exposure, specifically two wavelengths of light UVA, and
UVB, the latter being more dangerous. Tanning booths also emit these wavelengths and may cause similar
damage to the skin such as irritation, redness, swelling, and inflammation. More severe cases of sun burn result in
what is known as sun poisoning. Microwave burns are caused by the thermal effects of microwave radiation.

Scalding
Two-day-old scald caused by boiling radiator fluid.

Scalding is caused by hot liquids (water or oil) or gases (steam), most commonly occurring from exposure to high
temperature tap water in baths or showers or spilled hot drinks.[15] A so called immersion burn is created when an
extremity is held under the surface of hot water, and is a common form of burn seen in child abuse.[16] A blister is
a "bubble" in the skin filled with serous fluid as part of the body's reaction to the heat and nerve damage. The
blister "roof" is dead. Steam is a common gas that causes scalds. The injury is usually regional and usually does
not cause death. More damage can be caused if hot liquids enter an orifice. However, deaths have occurred in
more unusual circumstances, such as when people have accidentally broken a steam pipe. The demographics that
are of the highest risk to suffering from scalding are young children, with their delicate skin, and the elderly over
65 years of age.
Management
Burns over 10% in children and 15% in adults need hospital admission and fluid resuscitation due to the risk of
hypovolaemic shock.[17] Most countries have explicit criteria for the transfer and management of burns patients.
[
Major burns should be managed using the principles of Advanced Trauma Life Support (ATLS). This consists
of a primary survey to identify and treat immediately life threatening conditions and then a secondary survey. The
primary survey in burns patients should follow the ABCDE guidelines (Airway & axial spine control, Breathing
& ventilation, Circulation and arrest of haemorrhage, neurological Disability, Exposure to allow accurate
assessment and Estimation of burn surface area and Fluid resuscitation).[citation needed] If the patient was involved in a
fire accident in an enclosed space, then it must be assumed that he or she has sustained an inhalation injury until
proven otherwise, and treatment should be managed accordingly. At this stage of management, it is also critical
to assess the airway status. Any suspicion of burn injury to the lungs (e.g. through smoke inhalation) is
considered a potential medical emergency and the patient should be reviewed by an anaesthetist. Patients with
these types of injuries may receive Rapid Sequence Induction, either in the field by a trained Paramedic, or in the
hospital upon arrival.

Regardless of the cause, the first step in managing a person with a burn is to stop the burning process at the
source, and cool the burn wound (but not the patient. It is essential to avoid the "lethal triad" of hypothermia,
acidosis and coagulopathy).[18] For instance, with dry powder burns, the powder should be brushed off first. With
other burns the affected area should be rinsed thoroughly with a large amount of clean water. Cold water should
not be applied to a person with extensive burns for a prolonged period (greater than 20 minutes), however, as it
may result in hypothermia. Do not directly apply ice to a burn wound as it may compound the injury. Iced water,
creams, or greasy substances such as butter, should not be applied either.[19]

To help ease pain people may be placed in a special burn recovery bed which evenly distributes body weight and
helps to prevent painful pressure points and bed sores. Survival and outcome of severe burn injuries is
remarkably improved if the patient is treated in a specialized burn center/unit rather than a hospital.

Intravenous fluids

Children with TBSA >10% and adults with TBSA > 15% need formal fluid resuscitation and monitoring (blood
pressure, pulse rate, temperature and urine output).[20] Once the burning process has been stopped, the patient
should be volume resuscitated according to the Parkland formula . This formula is 4 ml lactated ringers/kg x % of
Total body surface area burned, with half this volume given in the first 8 hours. Children also require the addition
of maintenance fluid volume. Such injuries can disturb a person's osmotic balance. This formula dictates the
amount of Lactated Ringer's solution or Hartmann's Solution[21] to deliver in the first twenty four hours after time
of injury. This formula excludes first degree burns, so erythemia alone is discounted. Half of the fluid should be
given in the first eight hours post injury and the rest in the subsequent sixteen hours. Inhalation injuries in
conjunction with thermal burns initially require up to 40–50% more fluid. The formula is a guide only and
infusions must be tailored to the urine output and central venous pressure. Inadequate fluid resuscitation causes
renal failure and death but over-resuscitation also causes morbidity and mortality. All resuscitation formulae
should be delivered as a goal directed therapy to prevent the complications of hypovolaemic shock or over-
hydration.

Wound management

The key to the management of all burn injuries is the management of the burn wound itself. The wound is the
cause of the morbidity and mortality of burn injuries and until the wound is healed the patient remains at risk of
complications. The essential aspects of wound management are an initial assessment, to determine burn area and
depth, and then debridement (removing devitalised tissue and contamination), cleaning and then dressings. Burn
wounds are painful so analgesia (pain relief) should be given. The management of burns over 10% in children
and 15% in adults, and of important areas (hands, face and perineum) is more complex and requires specialist
help. Circumferential burns of digits, limbs or the chest may need urgent surgical release of the burnt skin
(escharotomy) to prevent problems with distal circulation or ventilation. The wound should then be regularly re-
evaluated until it is healed. Wounds requiring surgical closure with skin grafts or flaps should be dealt with as
early as possible. One of the major advances in burn care has been the early excision and skin grafting of full
thickness and deep-dermal burn wounds.[3]

In the management of first and second degree burns little quality evidence exists to determine which type of
dressing should be used.[22] Silver sulfadiazine (Flamazine) is not recommended as it potentially prolongs healing
time[22] while biosynthetic dressings may speed healing.[23]
Antibiotics

Intravenous antibiotics may improve survival in those with large severe burns however due to the poor quality of
the evidence routine use is not currently recommended.[24]

Analgesics

A number of different options are used for pain management. These include simple analgesics ( such as ibuprofen
and acetaminophen ) and narcotics. A local anesthetic may help in managing pain of minor first-degree and
second-degree burns.[25]

Alternative treatments

Hyperbaric oxygenation has not been shown to be a useful adjunct to traditional treatments.[26] Honey has been
used since ancient times to aid wound healing and may be beneficial in first and second degree burns, but may
cause infection.[27]

Prognosis

The outcome of any injury or disease depends on three things: the nature of the injury, the nature of the patient
and the treatment available. In terms of injury factors in burns the prognosis depends primarily on the burn
surface area (% TBSA) and the age of the patient. The presence of smoke inhalation injury, other significant
injuries such as long bone fractures and serious co-morbidities (heart disease, diabetes, psychiatric illness,
suicidal intent etc.) will also adversely influence prognosis. Advances in resuscitation, surgical management,
control of infection, control of the hyper-metabolic response and rehabilitation have resulted in dramatic
improvements in burn mortality and morbidity in the last 60 years. Following a major burn injury, heart rate and
peripheral vascular resistance increase. This is due to the release of catecholamines from injured tissues, and the
relative hypovolemia that occurs from fluid volume shifts. Initially cardiac output decreases. At approximately 24
hours after burn injuries (for patients receiving fluid resuscitation) cardiac output returns to normal, then
increases to meet the hypermetabolic needs of the body.

Infection is a major complication of burns. Infection is linked to impaired resistance from disruption of the skin's
mechanical integrity and generalized immune suppression. The skin barrier is replaced by eschar. This moist,
protein rich avascular environment encourages microbial growth. Migration of immune cells is hampered, and
there is a release of intermediaries that impede the immune response. Eschar also restricts distribution of
systemically administered antibiotics because of its avascularity.

Risk factors of burn wound infection include:

• Burn > 30% TBS

• Full-thickness burn
• Extremes in age (very young, very old)
• Preexisting disease e.g. diabetes
• Virulence and antibiotic resistance of colonizing organism
• Failed skin graft
• Improper initial burn wound care
• Prolonged open burn wound

Burn wounds are prone to tetanus. A tetanus booster shot is required if individual has not been immunized within
the last 5 years.

Circumferential burns of extremities may compromise circulation. Elevation of limb may help to prevent
dependent edema. An Escharotomy may be required.

Acute Tubular Necrosis of the kidneys can be caused by myoglobin and hemoglobin released from damaged
muscles and red blood cells. This is common in electrical burns or crush injuries where adequate fluid
resuscitation has not been achieved.