What Burns Are
A burn is an injury to the skin or other organic tissues primarily caused by heat or due to radiation, radioactivity, electricity, friction, or contact with chemicals. The damage results in the destruction of skin cells.

Common Causes

• Scalds: From hot liquids (e.g., water, tea, coffee, soup, bathwater) or steam. Very common in younger individuals.

• Flame Burns: Direct contact with fire (e.g., house fires, playing with matches or lighters).

• Contact Burns: Touching hot objects (e.g., stoves, irons, ovens, hot metal).

• Electrical Burns: Contact with electrical sources (e.g., outlets, faulty wiring, downed power lines). These can cause deep internal damage.

• Chemical Burns: Exposure to strong acids, alkalis, or other corrosive substances.

• Sunburn (Radiation Burn): Overexposure to ultraviolet (UV) rays from the sun.

• Friction Burns: Caused by rubbing against a rough surface (e.g., “rug burn”).

Classification of Burns (By Depth)
The severity of a burn is often determined by its depth and the extent of the body surface area affected.

• Superficial Burn (First-Degree):

  • Affects only the epidermis (outermost layer of skin).

  • Appearance: Red, dry, painful. No blisters.

  • Example: Mild sunburn.

  • Healing: Usually heals in 3-7 days without scarring.

• Partial-Thickness Burn (Second-Degree):

  • Affects the epidermis and part of the dermis (layer beneath the epidermis).

  • Can be subdivided:

    • Superficial Partial-Thickness: Red, painful, moist, and often has blisters. Blanching (turns white) with pressure. Heals in 7-21 days, usually with minimal scarring but possible pigment changes.

    • Deep Partial-Thickness: Mottled (red and white patches), less painful (due to nerve damage), may or may not have blisters (often appear as flat, deflated blisters). Does not blanch as readily. Healing takes longer (3-9 weeks) and scarring is common. May require skin grafting.

• Full-Thickness Burn (Third-Degree):

  • Destroys the epidermis and dermis completely, and may extend into subcutaneous tissue (fat layer).

  • Appearance: Waxy white, leathery, charred, or tan. Dry and inelastic. No sensation in the burned area (painless to light touch) because nerve endings are destroyed, though surrounding areas may be very painful.

  • Healing: Does not heal spontaneously or heals very slowly from the edges with significant scarring. Requires skin grafting for closure.

• Fourth-Degree Burn (Sometimes used classification):

  • Extends deeper than full-thickness, involving underlying muscle, tendon, or bone.

  • Appearance: Charred, devitalized tissue.

  • Management: Often requires extensive debridement, reconstruction, and possibly amputation.

Assessment of Burns
A thorough assessment is crucial for guiding management.

• 1. Airway, Breathing, Circulation (ABCs): This is the priority.

  • Airway: Check for signs of inhalation injury (e.g., burns to the face/neck, singed nasal hairs, soot in mouth/sputum, hoarse voice, wheezing, difficulty breathing). Inhalation injury can cause airway swelling and obstruction.

  • Breathing: Assess respiratory rate, effort, and oxygen saturation.

  • Circulation: Check heart rate, blood pressure, capillary refill, and peripheral pulses. Establish IV access for moderate to major burns.

• 2. Estimate Total Body Surface Area (TBSA) Burned:

  • This is the percentage of the body surface affected by partial-thickness and full-thickness burns (superficial burns are generally not included in TBSA calculations for fluid resuscitation).

  • Methods for estimation:

    • Lund-Browder Chart: More accurate, especially for individuals whose body proportions differ from adults (i.e., larger head and smaller limbs relative to total body surface). It assigns percentages to different body parts based on age.

    • Rule of Nines (Modified for Younger Individuals): Divides the body into areas of 9% or multiples of 9%. Adjustments are needed for younger individuals (e.g., the head is proportionally larger, legs smaller).

    • Palmar Surface Method: The surface area of the individual’s palm (including fingers) is approximately 1% of their TBSA. Useful for small or scattered burns.

• 3. Assess Burn Depth: As described above (superficial, partial-thickness, full-thickness).

• 4. Identify Circumferential Burns: Burns that go all the way around a limb or the chest/abdomen can act like a tourniquet, restricting blood flow (in limbs) or breathing (in the chest). These may require escharotomy (surgical incision through the burn eschar).

• 5. Check for Associated Injuries: Other trauma may have occurred, especially in cases like explosions or falls.

• 6. Obtain History: How the burn occurred, time of injury, any first aid given.

Severity of Burns
Burns are categorized as minor, moderate, or major based on TBSA, depth, location, presence of inhalation injury, associated injuries, age, and pre-existing medical conditions. Major burns often require specialized burn center care.

• Factors increasing severity in younger individuals: Thinner skin leads to deeper burns with less exposure; higher surface area to volume ratio leading to greater fluid and heat loss.

Management of Burns

• 1. First Aid (Immediate Care):

  • Stop the Burning Process: Remove the individual from the source of heat. Extinguish flames (stop, drop, and roll). Remove hot or smoldering clothing and jewelry (unless stuck to the skin).

  • Cool the Burn: Apply cool (not ice-cold) running water to the burned area for 10-20 minutes. Do not use ice, as it can cause further tissue damage. For chemical burns, flush with copious amounts of water for an extended period.

  • Cover the Burn: Cover with a clean, dry cloth or dressing (e.g., cling film loosely applied for scalds, sterile non-adherent dressing if available). This helps prevent infection and reduce pain by limiting air exposure.

  • Keep Warm: Prevent hypothermia, especially with larger burns, by covering unburned areas.

• 2. Hospital Management (depends on severity):

  • Airway Management: If inhalation injury is suspected, intubation may be necessary to secure the airway.

  • Fluid Resuscitation: Crucial for moderate to major burns to prevent burn shock. Large amounts of intravenous (IV) fluids are given, especially in the first 24 hours. The Parkland formula (or modified versions) is often used to calculate fluid needs based on TBSA and body weight. Urine output is a key indicator of adequate resuscitation.

  • Pain Management: Burns are very painful. Analgesics (e.g., paracetamol, ibuprofen for mild pain; opioids like morphine for severe pain) are essential. Non-pharmacological methods (e.g., distraction) can also help.

  • Wound Care:

    • Cleaning: Gentle cleaning of the burn wound.

    • Debridement: Removal of dead tissue and debris to promote healing and prevent infection.

    • Dressings: Application of topical antimicrobial agents (e.g., silver sulfadiazine, mafenide acetate) and specialized burn dressings to protect the wound, absorb exudate, and promote healing.

  • Infection Prevention and Control: Meticulous hygiene. Tetanus prophylaxis is updated if needed. Systemic antibiotics are generally not used prophylactically but are given if infection develops.

  • Nutritional Support: Burns significantly increase metabolic rate and nutritional needs. High-protein, high-calorie diets are essential for healing. Enteral feeding (via nasogastric tube) may be required if oral intake is insufficient.

  • Surgical Management:

    • Escharotomy: Incision through the full-thickness eschar of a circumferential burn to relieve pressure and restore circulation or improve ventilation.

    • Skin Grafting: For deep partial-thickness and full-thickness burns. Healthy skin (autograft) is taken from an unburned area of the individual’s body (donor site) and transplanted to the burned area.

  • Therapy and Rehabilitation:

    • Physical therapy and occupational therapy are vital to maintain range of motion, prevent contractures (tightening of skin, muscles, tendons leading to deformity), and promote functional recovery.

    • Pressure garments and silicone sheeting may be used to manage scarring.

Potential Complications

• Infection: Burn wounds are highly susceptible to infection (local wound infection, cellulitis, sepsis).

• Dehydration and Burn Shock: Due to massive fluid loss from the burn surface.

• Hypothermia: Difficulty maintaining body temperature, especially in individuals with large TBSA burns, due to heat loss from the burn surface.

• Respiratory Complications: Airway obstruction, pneumonia, acute respiratory distress syndrome (ARDS), especially with inhalation injury.

• Scarring: Can be hypertrophic (raised) or keloid.

• Contractures: Tightening of the skin over joints, limiting movement.

• Psychological Impact: Pain, fear, anxiety, body image issues, post-traumatic stress disorder (PTSD).

• Growth Issues: Severe burns and prolonged hospitalization can affect growth and development. Contractures can also affect bone growth.

Prevention of Burns
Prevention is key. Strategies include:

• Setting water heater thermostats to a safe temperature.

• Keeping hot liquids and foods out of reach.

• Using back burners on stoves and turning pot handles inward.

• Keeping matches, lighters, and flammable materials secured.

• Using smoke detectors and having a fire escape plan.

• Covering electrical outlets and keeping cords out of reach.

• Supervising individuals closely in kitchens, bathrooms, and around heat sources.