Burns Disease

BASICS

DESCRIPTION

Burns are tissue injuries caused by application of heat, chemicals, electricity, or irradiation to the tissue. Extent of injury (depth of burn) is result of intensity of heat (or other exposure) and the duration of exposure.

Partial thickness: First degree involves superficial layers of epidermis. Second degree involves varying degrees of epidermis (with blister formation) and part of the dermis.
Full thickness: Third degree involves destruction of all skin elements with coagulation of subdermal plexus
System(s) affected: Skin/Exocrine, Endocrine/Metabolic
Genetics: N/A
Incidence/Prevalence in USA:
- 2 to 5 million burns/year in USA require assistance, 1,000,000/year require hospitalization, 12,000/year die
- Burns are leading cause of accidental death in children
Predominant age: All ages
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

First degree
- Erythema of involved tissue
- Skin blanches with pressure
- Skin may be tender
Second degree
- Skin is red and blistered
- Skin is very tender
Third degree
- Burned skin is tough and leathery
- Skin is not tender

CAUSES

Open flame and hot liquid are most common (heat usually 15-45°C or greater)
Caustic chemicals or acids (may show little signs or symptoms for the first few days)
Electricity (may have significant injury with very little damage to overlying skin)
Excess sun exposure

RISK FACTORS

Hot water heaters set too high
Work place exposure to chemicals, electricity or irradiation
Young children and elderly adults with thin skin are more susceptible to injury
Carelessness with burning cigarettes
Inadequate or faulty electrical wiring

DIAGNOSIS

LABORATORY

Hematocrit
Type and cross
Electrolytes
Blood urea nitrogen
Urinalysis

Drugs that may alter lab results: N/A
Disorders that may alter lab results: Pre-existing cardiac disease

PATHOLOGICAL FINDINGS

First degree: devitalization of superficial layers of epidermis, congestion of intradermal vessels
Second degree: coagulation necrosis of varying depths of epidermis, clefting of epidermis (blister), coagulation of subdermal plexus, skin appendages intact
Third degree: necrosis of all skin elements, coagulation of subdermal plexus

SPECIAL TESTS

Children - glucose (hypoglycemia may occur in children because of limited glycogen storage)
Smoke inhalation - arterial blood gas, carboxyhemoglobin
Electric burns - electrocardiogram, urine myoglobin, creatine kinase (CK) isoenzymes

IMAGING

Chest x-ray
Xenon scan may be useful in suspected smoke inhalation

DIAGNOSTIC PROCEDURES

Bronchoscopy may be necessary in smoke inhalation to evaluate lower respiratory tract

TREATMENT

APPROPRIATE HEALTH CARE

Hospitalization for all serious burns
- Second degree burns over 10% body surface area (BSA), any 3rd degree burn
- Burns of hands, feet, face or perineum
- Electrical/lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
Transfer to burn center for:
- 2nd and 3rd degree burns over 10% BSA in patients under 10 years and over 50 years of age
- 2nd and 3rd degree burns over 20% BSA in any age range
- Burns of hands, feet, face or perineum
- Electrical/lightning burns
- Inhalation injury
- Chemical burns
- Circumferential burn
- Chemical burns with threat of functional impairment

GENERAL MEASURES

Based on depth of burns and accurate estimate of total body surface area (BSA) involved (Rule of nines)

Rule of nines
- Each upper extremity - adult and child 9%
- Each lower extremity - adult 18%; child 14%
- Anterior trunk - adult and child 18%
- Posterior trunk - adult and child 18%
- Head and neck - adult 10%; child 18%
Quick estimate (for smaller burns)
- The surface area of the patient's hand is approximately 1% of their BSA.
Tetanus prophylaxis
Remove all rings, watches, etc., from injured extremities to avoid tourniquet effect
Remove clothing and cover all burned areas with dry sheet
Flush area of chemical burn (for approximately 2 hours)
100% oxygen administration in all major burns, consider early intubation
Do not apply ice to burn site
Nasogastric tube (high risk of paralytic ileus)
Foley catheter
Pain relief
- IV Demerol, morphine or methadone for severe pain
- Oral analgesics eg, Tylenol with codeine, Percocet, Lortab for moderate pain
ECG monitoring in first 24 hours following electrical burn
Whirlpool hydrotherapy followed by silver sulfadiazine (Silvadene) occlusive dressings in severe burns
Once or twice a day cleansing with dressing changes
Epilock or Elastogel may be used as dressing in selected patients (especially useful for outpatient treatment of minor burns)
Burn fluid resuscitation
Calculate fluid resuscitation from time of burn, not from time treatment begins.
- 2-4 mL Ringer's lactate x body weight (kg) x % BSA burn (1/2 given in first eight hours, 1/4 in second eight hours and 1/4 in third eight hours). In children, this is given in addition to maintenance fluids and is adjusted according to urine output and vital signs.
- Colloid solutions are not recommended during the first 12-24 hours of resuscitation
Other
- Use of biological membranes or skin substitutes may be indicated for burn coverage

SURGICAL MEASURES

Escharotomy may be necessary in constricting circumferential burns of extremities or chest
Tangential excision with split thickness skin grafts

ACTIVITY

Early mobilization is the goal

DIET

High protein, high calorie diet when bowel function resumes; nasogastric tube feedings may be required in early post-burn period. TPN if NPO expected for > 5 days.

PATIENT EDUCATION

Use of sunscreen
Access to electrical cords/outlets
Isolate household chemicals
Use low temperature setting for hot water heater
Household smoke detectors with special emphasis on maintenance
Family/household evacuation plan
Proper storage and use of flammable substances

FOLLOW UP

PREVENTION/AVOIDANCE

Skin grafts or newly epithelialized skin is highly sensitive to sun exposure and thermal extremes

POSSIBLE COMPLICATIONS

Gastroduodenal ulceration (Curling's ulcer)
Marjolin's ulcer - squamous cell carcinoma developing in old burn site
Burn wound sepsis-usually gram negative organisms
Pneumonia
Decreased mobility with possibility of future flexion contractures

EXPECTED COURSE AND PROGNOSIS

First degree burn: complete resolution
Second degree burn: epithelialization in 10-14 days (deep second degree burns will probably require skin graft)
Third degree burn: no potential for re-epithelialization, skin graft required
Length of hospital stay and need for ICU care depends on extent of burn, smoke inhalation and age
A 50% survival can be expected with a 62% burn in ages 0-14 years, 63% burn in ages 15-40 years, 38% burn in age 40-65 years, 25% burn in patients over 65 years
90% of survivors can be expected to return to an occupation as remunerative as their pre-burn employment

MISCELLANEOUS

ASSOCIATED CONDITIONS

Smoke inhalation syndrome
- Occurs within 72 hours of burn
- Suspected in burns occurring in an enclosed space
- Intubation, ventilation with positive end-expiratory pressure (PEEP) assistance

AGE-RELATED FACTORS

Pediatric:

Consider child abuse when dealing with hot water burns in children
- Observe distribution of burns
- Pay attention to straight lines, especially if bilateral

Geriatric: Prognosis poorer for severe burns
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

BSA = body surface area

Clinical Investigations

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