Burn

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This article is about the injury. For other uses, see Burn (disambiguation).

Burn
blisters[2]
Second degree: Blisters and pain[2]
Third degree: Area stiff and not painful[2]

Fourth degree: Bone and tendon loss
tetanus toxoid[2]
Frequency67 million (2015)[7]
Deaths176,000 (2015)[8]

A burn is an

chemicals, friction, or ultraviolet radiation (such as sunburn).[5] Most burns are due to heat from hot liquids (called scalding), solids, or fire.[9] Burns occur mainly in the home or the workplace. In the home, risks are associated with domestic kitchens, including stoves, flames, and hot liquids.[6] In the workplace, risks are associated with fire and chemical and electric burns.[6] Alcoholism and smoking are other risk factors.[6] Burns can also occur as a result of self-harm or violence between people (assault).[6]

Burns that affect only the superficial skin layers are known as superficial or first-degree burns.

scarring may occur.[2] In a full-thickness or third-degree burn, the injury extends to all layers of the skin.[2] Often there is no pain and the burnt area is stiff.[2] Healing typically does not occur on its own.[2] A fourth-degree burn additionally involves injury to deeper tissues, such as muscle, tendons, or bone.[2] The burn is often black and frequently leads to loss of the burned part.[2][11]

Burns are generally preventable.

Tetanus toxoid should be given if not up to date.[2]

In 2015, fire and heat resulted in 67 million injuries.

developing world, particularly in Southeast Asia.[6] While large burns can be fatal, treatments developed since 1960 have improved outcomes, especially in children and young adults.[13] In the United States, approximately 96% of those admitted to a burn center survive their injuries.[14] The long-term outcome is related to the size of burn and the age of the person affected.[2]

History

Guillaume Dupuytren (1777–1835), who developed the degree classification of burns

Cave paintings from more than 3,500 years ago document burns and their management.[13] The earliest Egyptian records on treating burns describes dressings prepared with milk from mothers of baby boys,[15] and the 1500 BCE Edwin Smith Papyrus describes treatments using honey and the salve of resin.[13] Many other treatments have been used over the ages, including the use of tea leaves by the Chinese documented to 600 BCE, pig fat and vinegar by Hippocrates documented to 400 BCE, and wine and myrrh by Celsus documented to the 1st century CE.[13] French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s.[16] Guillaume Dupuytren expanded these degrees into six different severities in 1832.[13][17]

The first hospital to treat burns opened in 1843 in London, England, and the development of modern burn care began in the late 1800s and early 1900s.[13][16] During World War I, Henry D. Dakin and Alexis Carrel developed standards for the cleaning and disinfecting of burns and wounds using sodium hypochlorite solutions, which significantly reduced mortality.[13] In the 1940s, the importance of early excision and skin grafting was acknowledged, and around the same time, fluid resuscitation and formulas to guide it were developed.[13] In the 1970s, researchers demonstrated the significance of the hypermetabolic state that follows large burns.[13]

The "Evans formula", described in 1952, was the first burn resuscitation formula based on body weight and surface area (BSA) damaged. The first 24 hours of treatment entails 1ml/kg/% BSA of crystalloids plus 1 ml/kg/% BSA colloids plus 2000ml glucose in water, and in the next 24 hours, crystalloids at 0.5 ml/kg/% BSA, colloids at 0.5 ml/kg/% BSA, and the same amount of glucose in water.[18][19]

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two or three days, followed by peeling of the skin over the next few days.

Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all children.[22] Numbness or tingling may persist for a prolonged period of time after an electrical injury.[23] Burns may also produce emotional and psychological distress.[24]

Type[2] Layers involved Appearance Texture Sensation Healing Time Prognosis and Complications Example
Superficial (first-degree) Epidermis[10] Red without blisters[2] Dry Painful[2] 5–10 days[2][25] Heals well.[2] A sunburn is a typical first-degree burn.
Superficial partial thickness (second-degree) Extends into superficial (papillary) dermis[2] Redness with clear blister.[2] Blanches with pressure.[2] Moist[2] Very painful[2] 2–3 weeks[2][20] Local infection (cellulitis) but no scarring typically[20]

Second-degree burn of the thumb

Deep partial thickness (second-degree) Extends into deep (reticular) dermis[2] Yellow or white. Less blanching. May be blistering.[2] Fairly dry[20] Pressure and discomfort[20] 3–8 weeks[2] Scarring, contractures (may require excision and skin grafting)[20] Second-degree burn caused by contact with boiling water
Full thickness (third-degree) Extends through entire dermis[2] Stiff and white/brown.[2] No blanching.[20] Leathery[2] Painless[2] Prolonged (months) and unfinished/incomplete[2] Scarring, contractures, amputation (early excision recommended)[20] Eight day old third-degree burn caused by motorcycle muffler.
Fourth-degree Extends through entire skin, and into underlying fat, muscle and bone[2] Black; charred with eschar Dry Painless Does not heal; Requires excision[2] Amputation, significant functional impairment and, in some cases, death.[2] 4th-degree electrical burn

Cause

Burns are caused by a variety of external sources classified as thermal (heat-related), chemical, electrical, and radiation.[26] In the United States, the most common causes of burns are: fire or flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%).[27] Most (69%) burn injuries occur at home or at work (9%),[14] and most are accidental, with 2% due to assault by another, and 1–2% resulting from a suicide attempt.[24] These sources can cause inhalation injury to the airway and/or lungs, occurring in about 6%.[4]

Burn injuries occur more commonly among the poor.

developmental disabilities in children and chronic diseases in adults.[28]

Thermal

Main article: Thermal burn
See or edit source data.
Rate of deaths (per 100,000) due to fire between 1990 and 2017.[29]

In the United States, fire and hot liquids are the most common causes of burns.[4] Of house fires that result in death, smoking causes 25% and heating devices cause 22%.[5] Almost half of injuries are due to efforts to fight a fire.[5] Scalding is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature tap water in baths or showers, hot cooking oil, or steam.[30] Scald injuries are most common in children under the age of five[2] and, in the United States and Australia, this population makes up about two-thirds of all burns.[4] Contact with hot objects is the cause of about 20–30% of burns in children.[4] Generally, scalds are first- or second-degree burns, but third-degree burns may also result, especially with prolonged contact.[31] Fireworks are a common cause of burns during holiday seasons in many countries.[32] This is a particular risk for adolescent males.[33] In the United States, for non-fatal burn injuries to children, white males under the age of 6 comprise most cases.[34]  Thermal burns from grabbing/touching and spilling/splashing were the most common type of burn and mechanism, while the bodily areas most impacted were hands and fingers followed by head/neck.[34]

Chemical

Main article: Chemical burn

Chemical burns can be caused by over 25,000 substances,

halogenated hydrocarbons as found in paint remover, among others.[2] Hydrofluoric acid can cause particularly deep burns that may not become symptomatic until some time after exposure.[36] Formic acid may cause the breakdown of significant numbers of red blood cells.[21]

Electrical

Main article: Electrical burn

Electrical burns or injuries are classified as high voltage (greater than or equal to 1000 

volts), or as flash burns secondary to an electric arc.[2] The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).[4][37] Lightning may also result in electrical burns.[38] Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.[23] Mortality from a lightning strike is about 10%.[23]

While electrical injuries primarily result in burns, they may also cause

cardiac arrhythmias or cardiac arrest.[23]

Radiation

Main article: Radiation burn

microwaves.[43] While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.[43]

Non-accidental

In those hospitalized from scalds or fire burns, 3–10% are from assault.[44] Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes.[44] An immersion injury or immersion scald may indicate child abuse.[31] It is created when an extremity, or sometimes the buttocks are held under the surface of hot water.[31] It typically produces a sharp upper border and is often symmetrical,[31] known as "sock burns", "glove burns", or "zebra stripes" - where folds have prevented certain areas from burning.[45] Deliberate cigarette burns most often found on the face, or the back of the hands and feet.[45] Other high-risk signs of potential abuse include: circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse.[46]

acid burns represent 13% of intentional burns, and are frequently related to domestic violence.[46] Self-immolation (setting oneself on fire) is also used as a form of protest in various parts of the world.[24]

Pathophysiology

Three degrees of burns

At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down.[49] This results in cell and tissue damage.[2] Many of the direct health effects of a burn are caused by failure of the skin to perform its normal functions, which include: protection from bacteria, skin sensation, body temperature regulation, and prevention of evaporation of the body's water. Disruption of these functions can lead to infection, loss of skin sensation, hypothermia, and hypovolemic shock via dehydration (i.e. water in the body evaporated away).[2] Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.[2]

In large burns (over 30% of the total body surface area), there is a significant

stomach ulcers.[51]

Increased levels of

immune function.[50]

Diagnosis

Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.[2] It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary.[21] In those who have a headache or are dizzy and have a fire-related burn, carbon monoxide poisoning should be considered.[52] Cyanide poisoning should also be considered.[21]

Size

Burn severity is determined through, among other things, the size of the skin affected. The image shows the makeup of different body parts, to help assess burn size.

The size of a burn is measured as a percentage of total body surface area (TBSA) affected by partial thickness or full thickness burns.[2] First-degree burns that are only red in color and are not blistering are not included in this estimation.[2] Most burns (70%) involve less than 10% of the TBSA.[4]

There are a number of methods to determine the TBSA, including the Wallace rule of nines, Lund and Browder chart, and estimations based on a person's palm size.[10] The rule of nines is easy to remember but only accurate in people over 16 years of age.[10] More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children.[10] The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA.[10]

Severity

American Burn Association severity classification[52]
Minor Moderate Major
Adult <10% TBSA Adult 10–20% TBSA Adult >20% TBSA
Young or old < 5% TBSA Young or old 5–10% TBSA Young or old >10% TBSA
<2% full thickness burn 2–5% full thickness burn >5% full thickness burn
High voltage injury High voltage burn
Possible inhalation injury Known inhalation injury
Circumferential burn Significant burn to face, joints, hands, or feet
Other health problems Associated injuries

To determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate, and minor. This is assessed based on a number of factors, including total body surface area affected, the involvement of specific anatomical zones, the age of the person, and associated injuries.[52] Minor burns can typically be managed at home, moderate burns are often managed in a hospital, and major burns are managed by a burn center.[52] Severe burn injury represents one of the most devastating forms of trauma.[53] Despite improvements in burn care, patients can be left to suffer for as many as three years post-injury.[54]

Prevention

Historically, about half of all burns were deemed preventable.[5] Burn prevention programs have significantly decreased rates of serious burns.[49] Preventive measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing.[5] Experts recommend setting water heaters below 48.8 °C (119.8 °F).[4] Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves.[49] While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit[55] with recommendations including the limitation of the sale of fireworks to children.[4]

Management

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.

Hyperbaric oxygenation may be useful in addition to traditional treatments.[58]

Intravenous fluids

In those with poor

urinary output of >30 mL/h in adults or >1mL/kg in children and mean arterial pressure greater than 60 mmHg.[21]

While

Blood transfusions are rarely required.[2] They are typically only recommended when the hemoglobin level falls below 60-80 g/L (6-8 g/dL)[65] due to the associated risk of complications.[21] Intravenous catheters may be placed through burned skin if needed or intraosseous infusions may be used.[21]

Wound care

Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia.[2][10] It should be performed with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause further injury.[10][49] Chemical burns may require extensive irrigation.[2] Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second-degree burns should be re-evaluated after two days.[49]

In the management of first and second-degree burns, little quality evidence exists to determine which dressing type to use.[66] It is reasonable to manage first-degree burns without dressings.[49] While topical antibiotics are often recommended, there is little evidence to support their use.[67][68] Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time.[66][69] There is insufficient evidence to support the use of dressings containing silver[70] or negative-pressure wound therapy.[71] Silver sulfadiazine does not appear to differ from silver containing foam dressings with respect to healing.[72]

Medications

Burns can be very painful and a number of different options may be used for

transcutaneous nerve stimulation may be used to aid with itching.[22] Antihistamines, however, are only effective for this purpose in 20% of people.[73] There is tentative evidence supporting the use of gabapentin[22] and its use may be reasonable in those who do not improve with antihistamines.[74] Intravenous lidocaine requires more study before it can be recommended for pain.[75]

Intravenous

steroids is of unclear evidence.[78]

Allogeneic cultured keratinocytes and dermal fibroblasts in murine collagen (Stratagraft) was approved for medical use in the United States in June 2021.[79]

Surgery

Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible.[80] Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy.[81] This is done to treat or prevent problems with distal circulation, or ventilation.[81] It is uncertain if it is useful for neck or digit burns.[81] Fasciotomies may be required for electrical burns.[81]

Skin grafts can involve temporary skin substitutes, derived from animal (human donor or pig) skin or synthesized. They are used to cover the wound as a dressing, preventing infection and fluid loss, but will eventually need to be removed. Alternatively, human skin can be treated to be left on permanently without rejection.[82]

There is no evidence that the use of copper sulphate to visualise phosphorus particles for removal can help with wound healing due to phosphorus burns. Meanwhile, absorption of copper sulphate into the blood circulation can be harmful.[83]

Alternative medicine

Honey has been used since ancient times to aid wound healing and may be beneficial in first- and second-degree burns.[84] There is moderate evidence that honey helps heal partial thickness burns.[85][86] The evidence for aloe vera is of poor quality.[87] While it might be beneficial in reducing pain,[25] and a review from 2007 found tentative evidence of improved healing times,[88] a subsequent review from 2012 did not find improved healing over silver sulfadiazine.[87] There were only three randomized controlled trials for the use of plants for burns, two for aloe vera and one for oatmeal.[89]

There is little evidence that vitamin E helps with keloids or scarring.[90] Butter is not recommended.[91] In low income countries, burns are treated up to one-third of the time with traditional medicine, which may include applications of eggs, mud, leaves or cow dung.[28] Surgical management is limited in some cases due to insufficient financial resources and availability.[28] There are a number of other methods that may be used in addition to medications to reduce procedural pain and anxiety including: virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.[74]

Patient support

Burn patients require support and care – both physiological and psychological. Respiratory failure, sepsis, and multi-organ system failure are common in hospitalized burn patients. To prevent hypothermia and maintain normal body temperature, burn patients with over 20% of burn injuries should be kept in an environment with the temperature at or above 30 degree Celsius.

better source needed
]

Metabolism in burn patients proceeds at a higher than normal speed due to the whole-body process and rapid fatty acid substrate cycles, which can be countered with an adequate supply of energy, nutrients, and antioxidants. Enteral feeding a day after resuscitation is required to reduce risk of infection, recovery time, non-infectious complications, hospital stay, long-term damage, and mortality. Controlling blood glucose levels can have an impact on liver function and survival.

Risk of thromboembolism is high and acute respiratory distress syndrome (ARDS) that does not resolve with maximal ventilator use is also a common complication. Scars are long-term after-effects of a burn injury. Psychological support is required to cope with the aftermath of a fire accident, while to prevent scars and long-term damage to the skin and other body structures consulting with burn specialists, preventing infections, consuming nutritious foods, early and aggressive rehabilitation, and using compressive clothing are recommended.

Prognosis

Prognosis in the USA[93]
TBSA Mortality
0–9% 0.6%
10–19% 2.9%
20–29% 8.6%
30–39% 16%
40–49% 25%
50–59% 37%
60–69% 43%
70–79% 57%
80–89% 73%
90–100% 85%
Inhalation 23%

The prognosis is worse in those with larger burns, those who are older, and females.

disability adjusted life years.[12]

Complications

A number of complications may occur, with

urinary tract infections and respiratory failure.[4] Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.[94] Pneumonia occurs particularly commonly in those with inhalation injuries.[21]

Anemia secondary to full thickness burns of greater than 10% TBSA is common.

Keloids may form subsequent to a burn, particularly in those who are young and dark skinned.[90] Following a burn, children may have significant psychological trauma and experience post-traumatic stress disorder.[95] Scarring may also result in a disturbance in body image.[95] To treat hypertrophic scars (raised, tense, stiff and itchy scars) and limit their effect on physical function and everyday activities, silicone sheeting and compression garments are recommended.[96][97][98] In the developing world, significant burns may result in social isolation, extreme poverty and child abandonment.[24]

Epidemiology

Disability-adjusted life years for fires per 100,000 inhabitants in 2004.[99]

In 2015 fire and heat resulted in 67 million injuries.

Southeast Asia with a rate of 11.6 per 100,000.[4] The number of fatal burns has changed from 280,000 in 1990 to 176,000 in 2015.[101][8]

In the developed world, adult males have twice the mortality as females from burns. This is most probably due to their higher risk occupations and greater risk-taking activities. In many countries in the developing world, however, females have twice the risk of males. This is often related to accidents in the kitchen or domestic violence.[24] In children, deaths from burns occur at more than ten times the rate in the developing than the developed world.[24] Overall, in children it is one of the top fifteen leading causes of death.[5] From the 1980s to 2004, many countries have seen both a decrease in the rates of fatal burns and in burns generally.[24]

Developed countries

An estimated 500,000 burn injuries receive medical treatment yearly in the United States.[49] They resulted in about 3,300 deaths in 2008.[5] Most burns (70%) and deaths from burns occur in males.[2][14] The highest incidence of fire burns occurs in those 18–35 years old, while the highest incidence of scalds occurs in children less than five years old and adults over 65.[2] Electrical burns result in about 1,000 deaths per year.[102] Lightning results in the death of about 60 people a year.[23] In Europe, intentional burns occur most commonly in middle aged men.[44]

Developing countries

In India, about 700,000 to 800,000 people per year sustain significant burns, though very few are looked after in specialist burn units.[103] The highest rates occur in women 16–35 years of age.[103] Part of this high rate is related to unsafe kitchens and loose-fitting clothing typical to India.[103] It is estimated that one-third of all burns in India are due to clothing catching fire from open flames.[104] Intentional burns are also a common cause and occur at high rates in young women, secondary to domestic violence and self-harm.[24][44]

See also

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    )
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General and cited references

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