You are on page 1of 16

28/01/13

Classification of burns

Official reprint from UpToDate® www.uptodate.com ©2013 UpToDate®

Classification of burns Authors Phillip L Rice, Jr, MD Dennis P Orgill, MD, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: ago 29, 2012. INTRODUCTION — A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures. Burns occur when some or all of the cells in the skin or other tissues are destroyed by heat, cold, electricity, radiation, or caustic chemicals. Burns are acute wounds caused by an isolated, non-recurring insult and progress rapidly through an orderly series of healing steps [1]. The most common types of burns and their classification will be reviewed here. The clinical assessment, potential acute complications, and management of moderate and severe burns in adults and children, minor burns, and other related injuries are discussed elsewhere. (See "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Treatment of minor thermal burns" and "Smoke inhalation" and "Environmental electrical injuries".) TYPES OF BURNS — The most common type of burn in children is from a scald injury; in adults, the most common burn occurs from a flame. The following is a list of the types of burns that may be incurred by adults and children. Thermal — The depth of the burn injury is related to contact temperature, duration of contact of the external heat source, and the thickness of the skin. Because the thermal conductivity of skin is low, most thermal burns involve the epidermis and part of the dermis [2]. The most common thermal burns are associated with flames, hot liquids, hot solid objects, and steam. The depth of the burn largely determines the healing potential and the need for surgical grafting. (See "Emergency care of moderate and severe thermal burns in adults".) Cold exposure (frostbite) — Damage occurs to the skin and underlying tissues when ice crystals puncture the cells or when they create a hypertonic tissue environment. Blood flow can be interrupted, causing hemoconcentration and intravascular thrombosis with tissue hypoxia. (See "Frostbite".) Chemical burns — Injury is caused by a wide range of caustic reactions, including alteration of pH, disruption of cellular membranes, and direct toxic effects on metabolic processes. In addition to the duration of exposure, the nature of the agent will determine injury severity. Contact with acid produces tissue coagulation, while alkaline burns generate colliquation necrosis. Systemic absorption of some chemicals is life threatening. (See "Topical chemical burns".) Electrical current — Electrical energy is transformed into thermal injury as the current passes through poorly conducting body tissues. Electroporation (injury to cell membranes) disrupts membrane potential and function. The magnitude of the injury depends on the pathway of the current, the resistance to the current flow through the tissues, and the strength and duration of the current flow. (See "Environmental electrical injuries".) Inhalation — Toxic products of combustion injure airway tissues and frequently occur with flash burns from fire and steam. Hot smoke usually burns only the pharynx while steam can also burn the airway below the glottis. Many toxic chemicals produced in fires injure the lower airways with chemical burns. Carbon monoxide, which is produced from combustion, impairs cellular respiration. (See "Smoke inhalation".) Radiation burns — Radio frequency energy or ionizing radiation can cause damage to skin and tissues. The most common type of radiation burn is the sunburn. Depending on the photon energy, radiation can cause very
www.uptodate.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 1/16

Section Editor Marc G Jeschke, MD, PhD

Deputy Editor Rosemary B Duda, MD, MPH, FACS

Burns in the elderly and children may also be associated with abuse. particularly on the volar surfaces of the forearms. medial thighs. and ears. Thin skin. Burns that initially appear to be only epidermal in depth may be determined to be partial-thickness 12 to 24 hours later. Burns extending beneath the subcutaneous tissues and involving fascia. Burn wounds are not usually uniform in depth and many have a mixture of deep and superficial components. deep partial-thickness.) CLASSIFICATION — Cutaneous burns are classified according to the depth of tissue injury: superficial or epidermal (first-degree). scarring is unusual. almost always blister (easily unroofed). The classification system below is largely in agreement with the on-line ABA publication (www.uptodate. They are painful. These burns generally heal in 7 to 21 days. These burns typically heal without functional impairment or hypertrophic scarring. They do not blanch with pressure. Radiation burns are often associated with cancer due to the ability of ionizing radiation to interact with and damage DNA. red. partial-thickness (second degree).) Associated injuries — Events that are associated with a burn may cause other injuries. Deep burns damage hair follicles and glandular tissue. and full-thickness (table 1 and figure 1) [4]. second. such as fractures. or fourth degree was replaced by a system reflecting the need for surgical intervention. muscle and/or bone are considered fourth degree (table 1). neglect. They are characterized as either superficial or deep. and by about day four. Children under the age of five and adults over the age of 55 are also more susceptible to deeper burns because of thinner skin [5. In 2009. although pigment changes may occur. sustains deeper burn injuries than suggested by initial appearance [5]. www. the injured epithelium peels away from the newly healed epidermis. superficial partial-thickness.ameriburn. Such injuries are generally healed in six days without scarring. section on 'Burns' and "Elder mistreatment: Abuse. the American Burn Association (ABA) published an educational resource that reviewed the classification and management of the burn wound.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 2/16 . time of exposure. and blanch with pressure (picture 1). burns that extend into the muscle.org) [1]. Superficial . (See "Biology and clinical features of radiation injury in adults" and "Clinical features of radiation exposure in children". Partial-thickness — Partial thickness burns involve the epidermis and portions of the dermis. test. bone.These burns characteristically form blisters within 24 hours between the epidermis and dermis. The clinical results of ionizing radiation depend on the dose. third. are wet or waxy dry. They are painful to pressure only. This process is commonly seen with sunburns. Burn depth — The traditional classification of burns as first. Current designations of burn depth are superficial. and blanch with pressure (picture 2). red. Over the next two to three days the pain and erythema subside. and type of particle that determines the depth of exposure. or full thickness (third degree).28/01/13 Classification of burns deep internal burns. Appropriate burn wound care may necessitate multiple treatment modalities for different parts of a burn wound depending on the burn depth of each injured part. It is best to assume there are no shallow burns in these areas [6]. which may predispose the burn wound to heavy bacterial colonization and delayed healing. dry. and weeping. and have variable mottled colorization from patchy cheesy white to red (picture 3). A precise classification of the burn wound may be difficult and may require up to three weeks for a final determination [4. and financial exploitation". and/or joints. (See "Physical abuse in children: Epidemiology and clinical manifestations". The term fourth degree is still used to describe the most severe burns. It is advisable for medical facilities to develop. Superficial — Superficial or epidermal burns involve only the epidermal layer of skin. and implement an action plan for emergency preparedness in advance of a potential disaster from radiation exposure [3].6].These burns extend into the deeper dermis and are characteristically different from superficial partial-thickness burns. They do not blister but are painful. A layer of fibrinous exudates and necrotic debris may accumulate on the surface.5]. perineum. Deep .

28/01/13 Classification of burns If infection is prevented and wounds are allowed to heal spontaneously without grafting. joint dysfunction is expected even with aggressive physical therapy. is usually intact. Lund-Browder — The Lund-Browder chart is the most accurate method for estimating TBSA for both adults and children. Early transfer to a burn center should be arranged when injuries meet the criteria for major burns (table 2). Vesicles and blisters do not develop. The palm of the patient's hand. Full thickness burns are usually anesthetic or hypoesthetic. Pale full-thickness burns may simulate normal skin except that the skin does not blanch with pressure. section on 'Initial interventions'. (See "Emergency care of moderate and severe thermal burns in adults". Fourth degree burns — Fourth degree burns are deep and potentially life-threatening injuries that extend through the skin into underlying tissues such as fascia. Children have proportionally larger heads and smaller lower extremities. the palm method may be useful. The eschar eventually separates from the underlying tissue and reveals an unhealed bed of granulation tissue. so the percentage BSA is more accurately estimated using the Lund-Browder chart (table 3 and figure 2). In several observational reports comparing the estimation of burn size at the referring hospital with the estimation at the receiving burn center. When the burn is irregular and/or patchy.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 3/16 . The skin is dry and inelastic and does not blanch with pressure (picture 4). Differentiation from full-thickness burns is often difficult. the Lund-Browder chart is the recommended method because it takes into account the relative percentage of body surface area affected by growth. The two commonly used methods of assessing TBSA in adults are the Lund-Browder chart and "Rule of Nines. the size of larger burns was underestimated. Burns with an appearance compatible with either deep partial-thickness or full-thickness are presumed to be full-thickness until accurate differentiation is possible. Burn eschar." whereas in children. Superficial burns are not included in the TBSA burn assessment. they will heal in three to nine weeks. Features that differentiate partial-thickness from full-thickness burns may take some time to develop. the most expeditious method to estimate TBSA in adults is the "Rule of Nines" [12.11].13]: Each leg represents 18 percent TBSA Each arm represents 9 percent TBSA The anterior and posterior trunk each represent 18 percent TBSA The head represents 9 percent TBSA Palm method — Small or patchy burns can be approximated by using the surface area of the patient's palm. and/or bone. these wounds heal by wound contracture with epithelialization around the wound edges. Without surgery. complete spontaneous healing is not possible. is approximately 0. These burns invariably cause hypertrophic scarring. Hairs can easily be pulled from hair follicles.) The extent of burns is expressed as the total percentage of body surface area (TBSA). If they involve a joint. This resulted in underresuscitation at the referring hospital [7-9]. excluding the fingers.uptodate. Rule of Nines — For adult assessment.5 percent of total body surface area and the entire palmar surface including fingers is 1 percent in children and adults [14-16]. It takes into account the relative percentage of body surface area affected by growth (figure 2) [4. The location of partial-thickness and full-thickness burned areas are recorded on a burn diagram (figure 2). The eschar can compromise the viability of a limb or torso if circumferential. Skin appearance can vary from waxy white to leathery gray to charred and black. www. A deep partial-thickness burn that fails to heal in three weeks is functionally and cosmetically equivalent to a full thickness burn.10. the dead and denatured dermis. Scarring is severe with contractures. muscle. Full-thickness — These burns extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. PERCENT BODY SURFACE AREA ESTIMATES — A thorough and accurate estimation of burn size is essential to guide therapy and to determine when to transfer a patient to a burn center.

The extent of burns is expressed as the total percentage of body surface area (TBSA). Herndon.6 to 1 ratio in large breasted women.) SUMMARY A burn is defined as a traumatic injury to the skin or other organic tissue primarily caused by thermal or other acute exposures. Monafo WW. Collis N. Frank HA. Radiology 2010. 28:42.1. Surgical management of the burn wound and use of skin substitutes. In a review of 60 volunteers to determine the difference in TBSA of the anterior trunk between men and women. Wirth GA. Management of burn wounds. 19:203. 13.) Cutaneous burns are classified according to the depth of tissue injury. NS. www. This additional TBSA is concentrated on the pectoral region. 3rd edition. 79:352. Solari MG. Saunders Elsevier. Ikeda CJ. Nurs Clin North Am 1997. (See 'Percent body surface area estimates' above. J Burn Care Rehabil 1998. Igneri P. Wolbarst AB. There was an equal distribution of anterior and posterior trunk TBSA in men. 12. Sherwood.) Use of UpToDate is subject to the Subscription and License Agreement. (See 'Introduction' above. Wachtel EE. Pham.119. p. N Engl J Med 1996. In: Total Burn Care. Baxter CR. 10. full-thickness.or (Accessed on January 04. Copyright 2009. Wachtel TL. 4. Freiburg C. 8. Hagstrom M. Dermatol Clin 1993. Fenton OM. Barlow MS. Accuracy of burn size estimation and subsequent fluid resuscitation prior to arrival at the Yorkshire Regional Burns Unit. (See 'Percent body surface area estimates' above.uptodate. REFERENCES 1. 3. 2010). Smith G. (See 'Lund-Browder' above. Rogers F. 51:173.) A thorough estimation of burn size is essential to guide therapy. Philadelphia 2007.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 4/16 . relative to the posterior trunk (figure 3). 32:343. Initial management of burns. LC. large breasted women (cup size D and greater) were found to have a significantly greater amount of TBSA on the anterior chest in comparison to men (16 versus 11 percent) [17]. 7. Warden GD. TN. 9. J Burn Care Res 2007. Sartorelli K. Surg Gynecol Obstet 1944. Aarsland. but a 1.) The most accurate method of assessment of TBSA burn in children and adults is the Lund-Browder chart. A. Ann Plast Surg 2003. and fourth degree burns. al. 2. 25:345. 335:1581. DM. Jenkins ME. A three year retrospective study. the TBSA of a woman’s anterior trunk increases by a factor of 0. 11:709. verified burn center. et al. D (Eds). ER. Outpatient burn management. A finite-element model predicts thermal damage in cutaneous contact burns.28/01/13 Classification of burns Anterior chest wall burns in women — The percent of total body surface area (TBSA) burned may be underestimated in women with burns of the anterior trunk and large breasts. Lund CC.) The estimation of percent total body surface area includes partial-thickness. et. O'Connor NE. Herndon. American Burn Association White Paper. Wiley AL Jr. Mertens DM.196. Berry CC. Philadelphia 2007.ameriburn. (See 'Classification' above. A table based on the cup size of a brassiere is intended to complement the Lund and Browder chart for burn estimation in adults. Effects of differences in percent total body surface area estimation on fluid resuscitation of transferred burn patients. 11. (See 'Percent body surface area estimates' above. Superficial burns are not included in the TBSA burn assessment. A review of emergency department fluid resuscitation of burn patients transferred to a regional. Anesthesia for burned patients. Orgill DP. Saunders Elsevier. 254:660. p. DN (Eds). The estimation of areas of burns. 3rd edition. Evaluation of the burn wound: Management decisions. and represents 10 percent of TBSA as compared to 5 percent for men and 7 percent for women with smaller breasts. In: Total Burn Care. The inter-rater reliability of estimating the size of burns www. Browder NC. For every increase in cup size. 6. Evans GR. Woodson. Burns 1999. Heimbach. Nemhauser JB. Girban. Medical response to a major radiologic emergency: a primer for medical and public health practitioners. 5.

com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 5/16 . Dziewulski P. et al. Moore CA. Perry RJ. 16:605. Morgan BD. 17. Nagel TR. Sheridan RL. 14. Schunk JE.uptodate. 113:1591.0 www. Hidvegi N.28/01/13 Classification of burns from various burn area chart drawings. Plummer DL. Estimation of breast burn size. Plast Reconstr Surg 2004. Petras L. 15. Planimetry study of the percent of body surface represented by the hand and palm: sizing irregular burns is more accurately done with the palm. Basha G. Determining the approximate area of a burn: an inconsistency investigated and re-evaluated. 16. J Burn Care Rehabil 1995. 26:156. 13:254. 312:1338. Burns 2000. Topic 819 Version 8. Pediatr Emerg Care 1997. BMJ 1996. Myers S. Using the hand to estimate the surface area of a burn in children. Nduka C.

red. unless surgically treated Fourth degree Extends into fascia and/or muscle Deep pressure Never.uptodate. usually requires surgical treatment Full-thickness Waxy white to leathery gray to charred and black Dry and inelastic No blanching with pressure Deep pressure only Rare. and Peate. www. Warden GD.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 6/16 . WF. Am Fam Physician 1992.28/01/13 Classification of burns GRAPHICS Classification of burns by depth of injury Depth Superficial Appearance Dry. red Blanches with pressure Sensation Painful Healing time 3 to 6 days Superficial partialthickness Blisters Moist. weeping Blanches with pressure Painful to temperature and air 7 to 21 days Deep partialthickness Blisters (easily unroofed) Wet or waxy dry Variable color (patchy to cheesy white to red) Does not blanch with pressure Perceptive of pressure only >21 days. unless surgically treated Adapted from: Mertens DM. Solem LD. 32:343. Postgrad Med 1995. Med Clin North Am 1997. Jenkins ME. and Clayton MC. 45:1321. 97:151.

com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 7/16 .28/01/13 Classification of burns Burn classification www.uptodate.

28/01/13 Classification of burns Superficial burn Red burns that blanch are typical of superficial burns.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 8/16 . MD.uptodate. www. Courtesy of Eric D Morgan and William F Miser.

28/01/13 Classification of burns Superficial partial-thickness burn Blistering burns that blanch with pressure characterize superficial partial-thickness burns.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTitl… 9/16 .uptodate. They are also typically moist and weep. www. Courtesy of Eric D Morgan and William F Miser. MD.

Courtesy of Eric D Morgan and William F Miser.28/01/13 Classification of burns Deep partial-thickness burn Easily unroofed blisters that do not blanch with pressure and have a waxy appearance typify deep partial-thickness burns.uptodate. MD.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 10/16 . www.

com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 11/16 . MD. MD and William F Miser. Courtesy of Eric D Morgan.uptodate.28/01/13 Classification of burns Full-thickness burn Burn areas that are waxy white or leathery gray and insensate characterize full-thickness burns. www.

feet. adults: >10 or <50 years old. or perineum Moderate burn 15-25 percent TBSA in adults with less than 10 percent full-thickness burn 10-20 percent TBSA partial-thickness burn in children under 10 and adults over 40 years of age with less than 10 percent full-thickness burn 10 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes.28/01/13 Classification of burns American Burn Association burn injury severity grading system Minor burn 15 percent TBSA or less in adults 10 percent TBSA or less in children and the elderly 2 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes. or perineum that are likely to result in cosmetic or functional impairment All high-voltage electrical burns All burn injury complicated by major trauma or inhalation injury All poor-risk patients with burn injury TBSA: total body surface area. Care of outpatient burns. Herndon DN (Ed). www. face. face. burn: partial or full-thickness. face.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 12/16 .uptodate. Reproduced from: Hartford CE. ears. All rights reserved. hands. hands. feet. young or old: <10 or >50 years old. Table used with the permission of Elsevier Inc. In: Total Burn Care. or perineum Major burn 25 percent TBSA or greater 20 percent TBSA or greater in children under 10 and adults over 40 years of age 10 percent TBSA or greater full-thickness burn All burns involving eyes. ears. hands. 3rd ed. feet. Elsevier. Philadelphia 2007. ear. Kealey CP.

28/01/13 Classification of burns Modified Lund-Browder chart Numbers refer to the percent body surface area burned.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 13/16 . www.uptodate.

www.75 2.25 2.5 1 13 2 1.28/01/13 Classification of burns Modified Lund-Browder chart for assessing percent total body surface area burn in children and adults Area* Head Neck Trunk Upper arm Forearm Hand Thigh Leg Foot Buttock Genitalia Birth to 1 year 9.5 1 8.5 1 1.75 2. multiply surface area burned by two.25 4 2.5 1.25 4.5 3.5 1 13 2 1.5 1.5 1 13 2 1.5 1 13 2 1.5 1.5 5 to 9 years 5.75 2.25 2.5 1 * Values listed are for one surface area and each individual extremity.75 2.5 1.5 1.75 2.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 14/16 .5 1 13 2 1.5 1 1.25 1. For circumferential burns.25 3 1.75 2.uptodate.5 1 to 4 years 6.5 10 to 14 years Adult 4. Anterior and posterior surface area values are equivalent in estimating TBSA.25 3.5 1 1.25 4.

Reproduced with permission from: Hidvegi N. Estimation of breast burn size. Copyright © 2004 Lippincott Williams & Wilkins. Plast Reconstr Surg 2004. Dziewulski P.28/01/13 Classification of burns Total body surface area of anterior trunk including size of breast The size of the breast is used to determine the percent of the total body surface area burned. 113:1591.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 15/16 . Myers S. This graph should be used in conjunction with the standard tables for estimating total body surface area burned in adults.uptodate. Nduka C. www.

2-5B29A75D3C-473950.114.C21. All rights reserved.54.7 Licensed to: Morehouse School of Medicine | Support Tag: [1103-200.1 . Inc. | Subscription and License Agreement | Release: 21.14] www.28/01/13 Classification of burns © 2013 UpToDate.uptodate.com/contents/classification-of-burns?topicKey=SURG%2F819&elapsedTimeMs=1&source=search_result&searchTerm=burn&selectedTi… 16/16 .