Burns

Overview

Definition

Burns are acute traumatic injuries to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions or underlying tissue caused by exposure to thermal energy, chemicals, electrical discharge, or radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma.

Epidemiology

• Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of fire-related injuries worldwide is 1.1 per 100,000:
  • 85,000 emergency department visits/year in the United States
  • Most are minor, only 2% cover > 40% total body surface area (TBSA).
• Cause 34,000 deaths/year:
  • Fatality directly correlated with % surface area burned
  • ½ of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with 60%–70% surface area burns die.
• Different etiology based on age:
  • Scalding with hot liquid more common in children
  • Flame burns more common in adults

Etiology

• Heat Heat Inflammation
• Electric
• Chemical
• Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma

Classification

Burns are described using 2 identifiers—degree and severity:

1. Degree: depth of burn on body
2. Severity: % of TBSA burned

Thermal burn degree

Burn severity

To determine the severity of the burn, calculate the percentage of TBSA injured:

• A patient’s hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy is approximately 1% of TBSA.
• Use the rule of 9s in adolescents and adults.
• Modified rule of 9s applies to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship under 15.

Thermal Burns

Pathophysiology

Burns occur due to direct contact with:

• Flames
• Heated objects
• Steam
• Hot water

Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions has low heat Heat Inflammation conductivity, so most thermal burns only involve the epidermis Epidermis The external, nonvascular layer of the skin. It is made up, from within outward, of five layers of epithelium: (1) basal layer (stratum basale epidermidis); (2) spinous layer (stratum spinosum epidermidis); (3) granular layer (stratum granulosum epidermidis); (4) clear layer (stratum lucidum epidermidis); and (5) horny layer (stratum corneum epidermidis). Skin: Structure and Functions.

Injured areas can be subdivided into 3 zones, like a bullseye:

1. Zone of coagulation and necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage:
   • Innermost zone
   • Irreversible cell death Cell death Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects. Cell Injury and Death and damage
2. Zone of ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage:
   • Decreased circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment
   • Tissue may progress to necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage.
3. Zone of hyperemia:
   • Vasodilation Vasodilation The physiological widening of blood vessels by relaxing the underlying vascular smooth muscle. Pulmonary Hypertension Drugs
   • Usually heals without long-term complications

Management

• Airway Airway ABCDE Assessment, breathing, and circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment (ABC) assessment
• Administer high-flow oxygen via non-rebreather mask and keep saturation > 92%.
• Consider early endotracheal intubation Endotracheal Intubation Neonatal Respiratory Distress Syndrome with evidence of airway Airway ABCDE Assessment or lung compromise due to fire:
  • Signs of inhalational injury:
    • Soot around mouth 
    • Stridor Stridor Laryngomalacia and Tracheomalacia (high-pitched inspiratory sound because air is being forced through a very narrow opening)
    • Burns on face (loss of eyebrows, oropharyngeal inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, blistering, or carbon deposits, carbonaceous sputum)
    • Carboxyhemoglobin Carboxyhemoglobin Carbon Monoxide Poisoning level > 10%
    • Singed nasal hair
  • Hypoxemia Hypoxemia Neonatal Respiratory Distress Syndrome despite 100% O₂ 
  • Respiratory distress/failure 
  • Depressed Glasgow coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma scale Scale Dermatologic Examination ( GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma)
• Fluid resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome:
  • Prevention of hypovolemia Hypovolemia Sepsis in Children and tissue hypoperfusion is the major goal.
  • Always establish 2 large-bore intravenous (IV) lines.
  • Calculated using Parkland formula: volume = 4 mL of fluid x body weight (kg) x % TBSA:
    • Example: 70-kg male experiences deep partial-thickness burns to the entire left leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy. IV volume = 4 mL x 70 kg x 18 TBSA = 5,040 mL.

Superficial burn management

Superficial burn management consists of non-steroidal anti-inflammatory drugs ( NSAIDs NSAIDS Primary vs Secondary Headaches) and cold packs for pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.

Partial-thickness burn management:

• Clean and dress
• Topical antibiotics
• Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways medication ( NSAIDs NSAIDS Primary vs Secondary Headaches, acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen)

Full-thickness burn management:

• Antibiotics
• Aggressive IV fluids IV fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids
• Outcomes best in certified burn centers

Potential complications

• Carbon monoxide poisoning Carbon monoxide poisoning Carbon monoxide (CO) is an odorless, colorless, tasteless, nonirritating gas formed by hydrocarbon combustion (e.g., fires, car exhaust, gas heaters). Carbon monoxide has a higher affinity to hemoglobin than oxygen, forming carboxyhemoglobin (COHb). Increased levels of COHb lead to tissue hypoxia and brain damage. Carbon Monoxide Poisoning:
  • Can be seen in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who have been in fires
  • Causes cellular asphyxia Asphyxia A pathological condition caused by lack of oxygen, manifested in impending or actual cessation of life. Drowning by displacing O₂ from hemoglobin 
  • Signs and symptoms:
    • Elevated carboxyhemoglobin Carboxyhemoglobin Carbon Monoxide Poisoning 
    • Oxygen saturation Oxygen Saturation Basic Procedures unreliable to rule out CO toxicity CO toxicity High-Risk Headaches, use co-oximeter.
  • Management:
    • 1st-line treatment: 100% O₂ (via mask or endotracheal tube)
    • Consider hyperbaric oxygen Hyperbaric oxygen The therapeutic intermittent administration of oxygen in a chamber at greater than sea-level atmospheric pressures (three atmospheres). It is considered effective treatment for air and gas embolisms, smoke inhalation, acute carbon monoxide poisoning, caisson disease, clostridial gangrene, etc. The list of treatment modalities includes stroke. Decompression Sickness if carboxyhemoglobin Carboxyhemoglobin Carbon Monoxide Poisoning > 25%, central nervous system Central nervous system The main information-processing organs of the nervous system, consisting of the brain, spinal cord, and meninges. Nervous System: Anatomy, Structure, and Classification (CNS) changes ( coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma, altered mental status Altered Mental Status Sepsis in Children, seizure), cardiac ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage, dysrhythmia.
• Cyanide poisoning Cyanide Poisoning Hydrogen cyanide is an extremely poisonous, colorless, flammable liquid used in multiple industries and includes rubber, plastic, and household paints. Exposure to cyanide can occur via inhalation, dermal contact, or intestinal ingestion. Cyanide Poisoning:
  • Lethal complication in some closed-space fires
  • Formed when plastics burn
  • Exposure via inhalation
  • Signs and symptoms: Suspect in any burn patient with lactic acidosis Acidosis A pathologic condition of acid accumulation or depletion of base in the body. The two main types are respiratory acidosis and metabolic acidosis, due to metabolic acid build up. Respiratory Acidosis.
  • Management: Treat with sodium Sodium A member of the alkali group of metals. It has the atomic symbol na, atomic number 11, and atomic weight 23. Hyponatremia thiosulfate, nitrites, and hydroxocobalamin.
• Sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock:
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with large-surface-area burns at high risk for severe infection
  • Signs and symptoms:
    • Temperature < 36.5°C (97.7°F) or > 39°C (102.2°F) 
    • Tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, tachypnea Tachypnea Increased respiratory rate. Pulmonary Examination 
    • Refractory hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension (systolic blood pressure < 90 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma Hg)  
    • Oliguria Oliguria Decreased urine output that is below the normal range. Oliguria can be defined as urine output of less than or equal to 0. 5 or 1 ml/kg/hr depending on the age. Renal Potassium Regulation
    • Unexplained hyperglycemia Hyperglycemia Abnormally high blood glucose level. Diabetes Mellitus
    • Thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
    • Mental status changes
  • Management:
    • Diagnosis requires wound culture and biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma (to determine tissue invasion depth).  
    • Causative micro-organisms usually gram-negative bacteria gram-negative bacteria Bacteria which lose crystal violet stain but are stained pink when treated by gram’s method. Bacteriology
    • Treatment involves empiric, broad-spectrum Broad-Spectrum Fluoroquinolones IV antibiotics.
• Acute respiratory distress syndrome Acute Respiratory Distress Syndrome Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome (ARDS) (ARDS):
  • Diffuse interstitial lung damage
  • Caused by:
    • Direct damage from heat Heat Inflammation inhalation
    • Large volumes of fluid given to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with significant burns 
  • Signs and symptoms:
    • Worsening hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage
    • Worsening chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests with infiltrates
  • Management:
    • Monitor breathing status.
    • Intubate if necessary.

Other Types of Burns

Electrical burns

• Pathophysiology:
  • Body tissues are poor conductors.
  • Electrical energy converts to thermal energy.
• Symptoms:
  • Thermic:
    • Local burns
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions injuries can occur at entry and exit of current.
  • Electrical:
    • Cardiac arrhythmia ( ventricular fibrillation Ventricular fibrillation Ventricular fibrillation (VF or V-fib) is a type of ventricular tachyarrhythmia (> 300/min) often preceded by ventricular tachycardia. In this arrhythmia, the ventricle beats rapidly and sporadically. The ventricular contraction is uncoordinated, leading to a decrease in cardiac output and immediate hemodynamic collapse. Ventricular Fibrillation (V-fib)) and cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest
    • Muscle injuries leading to muscle contractions
    • CNS injuries with disturbances of consciousness 
  • Severity depends on:
    • Voltage: low < 1,000 V versus high > 1,000 V
    • Lightning
    • Duration of exposure
    • Moisture and conductivity of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
• Management:
  • ABC assessment
  • IV access, cardiac monitoring, and measurement of oxygen saturation Oxygen Saturation Basic Procedures
  • Minor burns managed by topical antibiotics and dressings.
  • More severe burns may require surgery or skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions grafting.
  • Severe burns on arms, legs, or hands may require aggressive surgical management to remove damaged muscle or even amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation.

Chemical burns (acid and alkali)

• Pathophysiology:
  • Damage to tissue caused by:
    • Alteration of pH pH The quantitative measurement of the acidity or basicity of a solution. Acid-Base Balance
    • Direct toxic effects on metabolic processes
  • Amount of damage determined by:
    • Nature of chemical (e.g., acidic versus basic)
    • Concentration
    • Duration of exposure
    • More extreme pH pH The quantitative measurement of the acidity or basicity of a solution. Acid-Base Balance = more severe injury
• Management:
  • Remove chemical:
    • Rinse skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions under running water for 10–20 minutes (exceptions include dry lime, phenols, and elemental metals).
    • In case of chemical contact with eyes, rinse eyes continuously for ＞20 minutes.
  • Consider treating for effects of systemic absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption of chemicals.
  • Chemical burns almost always require hospitalization Hospitalization The confinement of a patient in a hospital. Delirium:
    • Difficult to remove 100% of chemical
    • Continue to damage tissue slowly

Radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma burns

• Definition: damage caused by ionizing radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma (most common example is sunburn)
• Pathophysiology: Depth and severity of injury is dependent on type of radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, distance from source, and duration of exposure:
  • 𝝰 particles cannot penetrate far, injuring upper layers of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions.
  • 𝛃 particles penetrate more (> 1 inch or 2.54 cm), usually injuring deeper layers of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions.
  • 𝛄 radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma penetrates further (> 1 foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy or 30 cm) causing deeper tissue injury and acute radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma syndrome.
  • Neutron radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma can cause severe tissue damage.
• Extent of cutaneous damage based on dose of radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma:
  • ≥ 3 gray (Gy): hair loss
  • ≥ 6 Gy: erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
  • > 10 Gy: dry desquamation Desquamation Staphylococcal Scalded Skin Syndrome (SSSS)
  • > 15 Gy: moist desquamation Desquamation Staphylococcal Scalded Skin Syndrome (SSSS)
  • > 20 Gy: cell death Cell death Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects. Cell Injury and Death
• Management:
  • Decontamination and safeguarding care personnel from radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma 
  • Management of radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma burns mirrors that of thermal burns.