Burn

A burn is a type of injury to the skin caused by heat, electricity, chemicals, light, radiation or friction.Most

burns only affect the skin (epidermal tissue and dermis). Rarely deeper tissues, such as muscle, bone,
and 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.

 Burn = Coagulative destruction of the skin or mucous membrane

 Caused by heat, chemical or irradiation
 Thermal damage occurs above 48 ºC
 Extent of necrosis is related to temperature and duration of contact
 Burns can result in:
 Increased capillary permeability and fluid loss
 Hypovolaemia and shock
 Increased plasma viscosity and microthrombosis formation
 Haemoglobinuria and renal damage
 Increased metabolic rate and energy metabolism

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

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 sunburn 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, because in some people very bad 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

Superficial thickness

 Needs to be differentiated from erythema

 Epidermis and papillae only are involved
 Results in red serum0filled blisters
 Skin blanches on pressure
 Burn is painful and sensitive
 Healing occurs in 10 days with no scarring

Partial-thickness burns

 Epidermis is lost with varying degrees of dermis

 Burn is usually coloured pink and white
 May or may not blanche on pressure
 Variable degrees of reduced sensation may be present
 Epithelial cells are present in hair follicles and sweat glands
 Results in regeneration and spread
 Healing occurs in 14 days
 Some depigmentation of scar may occur
 May require skin grafting

Full-thickness burns

 Both epidermis and dermis are destroyed

 Burn appears white and does not blanche
 Sensation is absent
 Without grafting healing occurs from edge of wound
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,

second degree Superficial (papillary) dermis
– superficial and pain

Whiter appearance
Partial thickness or fixed red staining
third degree Deep (reticular) dermis
– deep (no blanching),
reduced sensation

Epidermis, Dermis, and complete

Charred or leathery,
destruction to subcutaneous fat,
Full thickness fourth degree* thrombosed blood
eschar formation and minimal
vessels, insensate
pain, requires skin grafts

* It should however be noted that although fourth-degree is not a technical term, it is often used to
describe burns that reach muscle and bone. Third-degree sufficiently describes all burns of this nature.

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.
Assessment

 Initial assessment should be by ATLS principles

 Good early management is required to prevent morbidity or mortality

Airway

 Look for signs of inhalation injury

 Facial burns, soot in nostrils or sputum

Breathing

 Be aware of carbon monoxide poisoning

 Patient may appear 'pink' with a normal pulse oximeter reading

Circulation

 The fluid loss from a burn is significant

 It can result in hypovolaemic shock and acute renal failure

Assessment of extent

Body surface area (BSA) involved can be estimated from

 Lund & Browder chart

 Wallace rule of nine

Area % BSA

Head     9

Each upper limb 9

Each lower limb  18

Front of trunk    18

Back of trunk 18

Perineum 1

 Palm of hand approximates to 1% BSA

(A) Rule of nines (for adults) and (B) Lund-Browder chart (for children) for estimating
extent of burns.

Burn surface area

Burns can also be assessed in terms of total body surface area (TBSA), which is the percentage affected
by partial thickness or full thickness burns (erythema/superficial thickness burns are not counted).
The rule of nines is used as a quick and useful way to estimate the affected TBSA. More accurate
estimation can be made using Lund & Browder charts which take into account the different proportions of
body parts in adults and children. The size of the patient's hand print (palm and fingers) is approximately
1% of their TBSA. The actual mean surface area is 0.8% so using 1% will slightly over estimate the
size. Burns of 10% in children or 15% in adults (or greater) are potentially life threatening injuries
(because of the risk of hypovolemic shock) and should have formal fluid resuscitation and monitoring in a
burns unit.

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

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. 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.

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. 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. 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 hypovolemic shock. 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). 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.

First Aid
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). 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. 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).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 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.

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

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.

Alternative treatments
Hyperbaric oxygenation has not been shown to be a useful adjunct to traditional treatments. 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.

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 catecholaminesfrom 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.