Author- Dr. Mohammad Shamim, MD
Definition: Burns are injuries to the skin and other tissues caused by heat, chemicals, electricity, radiation, or friction. They are classified based on the depth and extent of tissue damage.
Types of Burns
Thermal Burns
These are the most common type of burns and occur when skin comes into contact with a heat source. Thermal burns can be caused by:
- Flames: Direct exposure to fire.
- Scalds: Hot liquids like boiling water, oil, or steam.
- Contact Burns: Touching hot objects like metal or glass.
- Flash Burns: Caused by a sudden burst of heat, like an explosion.
Clinical Features:
- Redness
- Blistering (in deeper burns)
- Pain (varies with depth)
Chemical Burns
Caused by exposure to strong acids, alkalis, or other corrosive substances. Common sources include household cleaning agents, industrial chemicals, and some cosmetics.
Clinical Features:
- Pain
- Redness or discoloration
- Tissue necrosis (death)
- Swelling
- Systemic toxicity (if chemicals are absorbed)
Management: Immediate irrigation with copious amounts of water is critical. Neutralizing agents are generally not recommended because they can cause further tissue damage.
Electrical Burns
These occur when an electrical current passes through the body. Electrical burns can cause severe damage internally, even if the external injury appears minor. They are classified as:
- Low-voltage: Less than 1,000 volts.
- High-voltage: More than 1,000 volts.
Clinical Features:
- Entry and exit wounds (may appear as small burns)
- Muscle damage
- Cardiac arrhythmias (irregular heartbeat)
- Nerve damage
Management: Immediate medical attention is required to assess internal injuries. Cardiac monitoring is essential because of the risk of arrhythmias.
Radiation Burns
These burns result from exposure to ionizing radiation (like X-rays or radiation therapy) or non-ionizing radiation (like ultraviolet rays from the sun).
Clinical Features:
- Redness (erythema)
- Peeling skin
- Pain and blistering
- Delayed effects like pigmentation changes or ulceration
Management: Treatment focuses on symptomatic relief, including cooling, moisturizing, and pain management. Preventive measures like sun protection are key.
Friction Burns
Caused by the skin rubbing against a rough surface, generating both heat and abrasion. These burns are common in activities like road accidents (road rash) or sports.
Clinical Features:
- Pain and redness
- Broken skin
- Bleeding
- Infection risk due to debris in the wound
Management: Wound cleaning and dressing, with attention to preventing infection.
Classification of Burns
Burns are classified based on depth:
First-Degree Burns (Superficial Burns)
- Involvement: Only the epidermis.
- Example: Sunburn.
- Treatment: Cool compresses, aloe vera, oral pain relievers.
Second-Degree Burns (Partial-Thickness Burns)
- Involvement: Epidermis and part of the dermis.
- Superficial Partial-Thickness: Affects the upper dermis, with blisters and intense pain.
- Deep Partial-Thickness: Extends deeper into the dermis; might require more complex wound care.
- Treatment: Blister management, dressings, pain control, and possibly grafting for deep burns.
Third-Degree Burns (Full-Thickness Burns)
- Involvement: Entire dermis and possibly underlying tissues.
- Appearance: White, waxy, or charred; dry and leathery.
- Sensation: Little to no pain due to nerve damage.
- Treatment: Requires surgical intervention, such as skin grafting.
Fourth-Degree Burns
- Involvement: Extends through skin, subcutaneous tissue, and into muscle and bone.
- Appearance: Blackened or charred.
- Treatment: Extensive surgery, potential amputation, and long-term rehabilitation.
Extent of Burns
Rule of Nines:
This method estimates the percentage of body surface area (BSA) affected by dividing the body into regions, each representing a multiple of 9%:
- Head and neck: 9%
- Each arm: 9%
- Each leg: 18%
- Anterior torso: 18%
- Posterior torso: 18%
- Perineum: 1%
Lund-Browder Chart
This chart is more accurate, particularly in children, as it adjusts for the different body proportions seen with age. It provides a more precise calculation of BSA involved in burns.
Management
Initial Assessment and Stabilization
Airway, Breathing, Circulation (ABC)
Ensure the patient has a clear airway, is breathing effectively, and has adequate circulation. This is especially critical in burns involving the face, neck, or chest, where swelling can obstruct the airway.
Fluid Resuscitation
Burns, especially those covering more than 20% BSA, can cause significant fluid loss and shock.
- Parkland Formula:
- Dose Calculation: 4 mL of Lactated Ringer’s solution per kilogram of body weight per percentage of Total Body Surface Area (TBSA) burned.
- Example: For a 70 kg adult with 30% TBSA burn: 4×70×30=8,400 mL
- Administer 4,200 mL in the first 8 hours.
- Administer the remaining 4,200 mL over the next 16 hours.
- Example: For a 70 kg adult with 30% TBSA burn: 4×70×30=8,400 mL
Medical Management
Pain Management
Burn injuries are extremely painful. Analgesics, including opioids, are often required for adequate pain control.
Mild Pain (First-Degree Burns):
- Acetaminophen (Tylenol): 500-1000 mg orally every 6 hours as needed. Maximum 4,000 mg/day.
- Ibuprofen (Advil, Motrin): 400-800 mg orally every 6-8 hours as needed. Maximum 3,200 mg/day.
Moderate to Severe Pain (Second- and Third-Degree Burns):
- Morphine Sulfate:
- IV dose: 0.1 mg/kg every 2-4 hours as needed.
- Titrate to pain relief.
- Hydromorphone (Dilaudid):
- IV dose: 0.2-1 mg every 2-3 hours as needed.
- Titrate to pain relief.
- Fentanyl:
- IV dose: 25-100 mcg every 1-2 hours as needed.
Wound Care
- First-Degree Burns: Treatment focuses on cooling the burn, hydrating the skin, and relieving pain. Aloe vera or moisturizing lotions help soothe the skin.
- Second-Degree Burns: Blisters should be left intact if possible to prevent infection. After cleaning the wound, apply an antibiotic ointment and cover it with a non-stick dressing. Dressing changes should be done regularly, and the wound should be monitored for signs of infection.
- Third-Degree Burns: Cover the wound with a sterile, non-stick bandage and seek immediate medical attention. These burns often require surgical intervention.
Debridement:
Involves removing dead tissue from the burn wound to promote healing and reduce infection risk. This can be done surgically or through the use of special dressings.
Antibiotic Ointments and Dressings
Topical Antibiotics for Second- and Third-Degree Burns
- Silver Sulfadiazine (Silvadene):
- Apply a thin layer (approximately 1/16 inch thick) to the burn wound once or twice daily.
- Not recommended for use on the face, near the eyes, or in patients with sulfa allergies.
- Mupirocin (Bactroban):
- Apply a small amount to the affected area 2-3 times daily.
- Effective for burns with secondary bacterial infection.
- Bacitracin:
- Apply a thin layer 1-3 times daily.
- Often used for smaller or superficial burns.
Antibiotics (Systemic for Infections)
- Cefazolin (Ancef):
- IV dose: 1-2 grams every 8 hours.
- Vancomycin:
- IV dose: 15-20 mg/kg every 8-12 hours.
- Adjust based on renal function and serum levels.
Tetanus Prophylaxis
- Tetanus Toxoid:
- Administer 0.5 mL intramuscularly if the patient has not been vaccinated in the last 5 years.
- Tetanus Immune Globulin (TIG):
- Administer 250-500 units intramuscularly if the patient’s vaccination status is unknown or they have not completed the tetanus vaccine series.
Gastrointestinal Protection
For Severe Burns (Risk of Curling’s Ulcer):
- Proton Pump Inhibitors (PPIs):
- Pantoprazole (Protonix): 40 mg IV once daily.
- Esomeprazole (Nexium): 20-40 mg IV or orally once daily.
- H2 Receptor Antagonists:
- Ranitidine (Zantac): 50 mg IV every 6-8 hours.
Surgical Interventions
Skin Grafting
Healthy skin is taken from an unburned area of the body and transplanted to cover a burn wound. Grafts can be:
- Autografts: Skin taken from the patient.
- Allografts: Donor skin.
- Xenografts: Animal skin (often from pigs).
- Synthetic Grafts: Artificial skin substitutes.
Escharotomy (Performed by Healthcare Professionals):
Performed to relieve pressure in circumferential burns (where the burn encircles a limb or chest), preventing tissue ischemia and necrosis.
 Local Anesthesia:
- Lidocaine: 1% or 2% without epinephrine, 3-5 mg/kg.
- Maximum dose without epinephrine: 300 mg.
- Administer as needed before making incisions to relieve constriction.
Rehabilitation
Physical Therapy
Essential to maintain joint mobility and prevent contractures, which are common complications of deep burns. Stretching exercises, splinting, and active movement are key components.
Occupational Therapy
Helps patients regain the ability to perform daily activities and adapt to any physical limitations resulting from the burn injury.
Psychological Support
Burn injuries can have profound psychological effects. Patients may suffer from post-traumatic stress disorder (PTSD), depression, or anxiety. Counseling, support groups, and psychiatric care are important aspects of holistic burn management.
For Anxiety or Pain-related Distress:
- Benzodiazepines (e.g., Lorazepam):
- 0.5-2 mg orally or IV every 6-8 hours as needed.
Long-term Care
Scar Management
Techniques include the use of pressure garments, silicone sheets, and massage therapy to reduce hypertrophic scars and keloids. Laser therapy or surgical revision may be necessary for severe scarring.
Reconstructive Surgery
In cases where burns cause significant deformities, reconstructive surgery can help restore function and improve appearance. This might include procedures like Z-plasty to release contractures, or flap surgery to cover large wounds.
Nutritional Support
Healing from burns significantly increases the body’s metabolic demands. A high-protein, high-calorie diet is crucial to support tissue repair, immune function, and overall recovery.
Caloric Needs:
- Increased by 1.5 to 2 times the normal caloric intake.
- High-Protein Diet: 1.5-2 g of protein per kg of body weight daily.
- Vitamins and Minerals:
- Vitamin C: 500 mg twice daily to aid in collagen synthesis.
- Zinc: 220 mg once daily to support immune function and wound healing.
Prevention and Education
Preventing burns involves both public education and personal safety measures:
- Fire Safety Education: Teaching children and adults about the dangers of fire, the importance of smoke detectors, and fire escape plans.
- Chemical Safety: Proper storage and handling of household and industrial chemicals, and the use of protective gear when necessary.
- Electrical Safety: Regular inspection of electrical wiring, appliances, and outlets to prevent electrical fires and injuries.
- Sun Protection: Advocating for the use of sunscreen, protective clothing, and avoiding sun exposure during peak hours to prevent radiation burns.
- First Aid Training: Educating the public on basic first aid for burns can significantly improve outcomes by ensuring proper initial care.
Conclusion
Managing burns requires a comprehensive approach, from initial stabilization to long-term care and rehabilitation. Proper assessment, timely intervention, and continuous care are essential to minimize complications and promote healing. Multidisciplinary care teams, including surgeons, therapists, and psychologists, play a crucial role in addressing the physical and emotional challenges that burn patients face. Prevention through education and awareness is equally important to reduce the incidence of burns and improve safety standards.
References
- Harrison’s Principle of Internal Medicine
- Current Medical Diagnosis and Treatment
- Bailey & Love’s Short Practice of Surgery
- American Burn Association (ABA) Guidelines
- Topical Antimicrobial Agents in Burn Wound Care