Burn Care 101: Types, Causes, Management ,Treatment and Recovery | Medical

Introduction

Burn injuries occur when heat energy is transferred to the body's tissues. In most cases, burns affect only the skin, including the epidermis and dermis. Tissue damage happens due to coagulation, protein destruction, or ionization of cellular contents. The skin and the mucous membranes of the upper airways are common sites of tissue damage.

In some cases, deeper tissues such as muscles, bones, and blood vessels may also be affected. Damage to the skin can lead to increased fluid loss, infections, hypothermia, scarring, weakened immunity, and changes in function, appearance, and body image.

Definition of Burn

A burn is defined as damage or injury to body tissues caused by heat, flames, or other sources such as thermal, chemical, electrical, or radiation exposure.

Types of Burns

1. Primary Injury – Direct damage to the skin and underlying tissues due to the burn source.
2. Secondary Injury – Complications that arise after the initial burn, such as infections, fluid loss, or organ dysfunction.

A. Primary Injury

Primary injury refers to the immediate damage caused by the burn. In most cases of trauma, little can be done to prevent this initial damage. However, prompt removal of the heat source and rapid cooling of the affected area can help minimize the severity of tissue destruction.

B. Secondary Injury

Secondary injury refers to the harmful effects that develop as a result of the primary burn injury. Severe burns can lead to significant fluid loss, secondary infections, and the release of harmful toxins from both internal (endogenous) and external (exogenous) sources. Additionally, the body’s powerful inflammatory response can cause widespread complications, including:

• Fluid shift and loss, leading to dehydration and shock.
• Coagulopathy, affecting blood clotting and increasing the risk of bleeding.
• Edema (swelling), which can restrict blood flow to surrounding tissues.
• Burn eschar (hardened dead tissue), causing tight constriction and impairing circulation, potentially leading to further tissue damage.

Causes of Burns

1. Thermal Burn
   Thermal burns occur due to exposure to flames, hot liquids, or heated objects. Common causes include residential fires, explosive automobile accidents, and scald injuries from boiling water or steam.
2. Chemical Burn
   Chemical burns result from direct contact with strong acids, alkalis, or organic compounds. These substances can cause severe tissue damage, with strong acids and bases being the most harmful.
3. Electrical Burn
   Electrical burns are caused by an external electric shock. They can occur from contact with exposed or faulty electrical wiring, household appliances, or high-voltage power lines. These burns may cause both external and internal injuries.
4. Radiation Burn
   Radiation burns occur due to prolonged exposure to ultraviolet (UV) light, tanning booths, radiation therapy, sunlamps, or X-rays. Severe sunburns can lead to a condition known as sun poisoning, which may cause fever, chills, and dehydration.
5. Inhalation Burn
   Inhalation burns affect the respiratory system, particularly the upper airways, and can lead to acute respiratory distress syndrome (ARDS). These burns result from exposure to toxic smoke, chemical fumes, asphyxiants, or direct heat inhalation, causing serious breathing difficulties and lung damage.
6. Cold Burn (Frostbite)
   Cold burns, also known as frostbite, occur when the skin and underlying tissues freeze due to prolonged exposure to extreme cold. This type of burn damages the skin in a way similar to heat burns, causing tissue destruction, numbness, and potential long-term complications such as necrosis or gangrene.
7. Example: Frostbite caused by exposure to freezing temperatures, direct contact with ice, or supercooled liquids.

Classification of Burns

A. According to Burn Depth

Burns are classified based on how deeply they penetrate the skin and underlying tissues:

1. First-Degree Burns (Superficial Burns)
   • Affect only the outer layer of the skin (epidermis).
   • Symptoms: Redness, mild swelling, and pain.
   • Example: Sunburn.
2. Second-Degree Burns (Partial-Thickness Burns)
   • Affect both the epidermis and part of the dermis.
   • Symptoms: Blisters, intense pain, swelling, and moist appearance.
   • Example: Scald burns from hot liquids.
3. Third-Degree Burns (Full-Thickness Burns)
   • Extend through the entire dermis, often affecting underlying tissues.
   • Symptoms: Skin appears charred, white, leathery, or waxy; may be painless due to nerve damage.
   • Example: Severe flame burns.
4. Fourth-Degree Burns
   • Extend beyond the skin, damaging muscles, tendons, and bones.
   • Symptoms: Blackened, charred tissue with possible loss of sensation and function.
   • Example: High-voltage electrical burns.

B. According to Burn Severity

Burn severity is classified based on the extent of tissue damage, the percentage of body surface area affected, and complications:

1. Minor Burns
   • First-degree burns or small second-degree burns covering less than 10% of body surface area (BSA).
   • Usually heal without medical intervention.
2. Moderate Burns
   • Second-degree burns covering 10–20% of BSA.
   • May require medical treatment to prevent infection and promote healing.
3. Severe Burns
   • Third-degree burns covering more than 10% of BSA or burns involving critical areas such as the face, hands, feet, genitals, or major joints.
   • Often require hospitalization, surgery, or skin grafting.
4. Critical Burns
   • Extensive third- or fourth-degree burns, burns affecting more than 30% of BSA, or burns complicated by inhalation injury, electrical burns, or severe trauma.
   • Require intensive medical care and can be life-threatening.

Clinical Features of Burns

First-Degree Burn (Superficial Burn)

• Affects only the epidermis.
• Appears red without blistering.
• Painful with minor swelling.
• No changes in capillary refill time.
• Heals quickly within 5–10 days without scarring.

Second-Degree Burn (Partial-Thickness Burn)

• Affects the epidermis and the superficial layer of the dermis.
• Blisters form, and the base of the blister appears pink.
• Painful with no change in capillary refill time.
• Typically heals within 14 days, often without significant scarring.

Third-Degree Burn (Full-Thickness Burn)

• Destroys both the epidermis and dermis, affecting nerve endings, sweat glands, and hair follicles.
• No sensation due to nerve damage.
• No capillary refill response.
• Does not heal spontaneously and requires skin grafting.
• Contractures (tightening of skin) may develop as healing progresses.

Fourth-Degree Burn

• Causes complete destruction of the epidermis, dermis, subcutaneous tissue, muscles, and bones.
• Often results in severe tissue necrosis, requiring extensive surgical intervention or amputation.

 Classification of Burns According to Severity

1. Minor Burns

• Includes all first-degree burns.
• Second-degree burns affecting less than 10% of the total body surface area (TBSA).
• Usually heal with minimal medical intervention.

2. Moderate Burns

• Burns involving critical areas such as the hands, feet, face, or genitals.
• Second-degree burns covering more than 10% of TBSA.
• Requires medical treatment to prevent complications.

3. Severe Burns

• Burns affecting more than 25% of TBSA.
• All third-degree burns are classified as moderate to severe depending on the extent of tissue damage.
• Full-thickness (third-degree) burns covering 10% or more of TBSA are considered severe.
• Require specialized burn care, hospitalization, and possible skin grafting.

Assessment of Burns

Burns are assessed based on the Total Body Surface Area (TBSA) affected, specifically considering partial-thickness and full-thickness burns. Several methods are used to estimate TBSA involvement, including the Rule of Nines, Lund and Browder Chart, Palm Method, and Jackson’s Burn Model.

1. Rule of Nines (Quick Estimation of TBSA)

The Rule of Nines is a simple and efficient method used to estimate the percentage of TBSA affected by burns. It is primarily applied to adults and provides a quick assessment for emergency treatment.

For Adults:

• Head (front and back): 9%
• Chest (front and back): 18%
• Arms (right + left): 18% (9% each)
• Perineum: 1%
• Legs (right + left): 36% (18% each)

For Children:

• Head: 18%
• Back: 18%
• Arms (right + left): 18% (9% each)
• Perineum: 1%
• Legs (right + left): 27% (13.5% each)

This method is not as accurate for children due to their different body proportions, making other methods more suitable.

2. Lund and Browder Method (More Accurate TBSA Estimation)

• The Lund and Browder Chart is a widely used, more precise method for estimating TBSA affected by burns, especially in children.
• Unlike the Rule of Nines, this method adjusts for age-related differences in body proportions.
• It is often used in hospitals and burn centers to ensure accurate treatment and fluid resuscitation.

3. Palm Method (For Scattered Burns)

• Used when burns are irregularly distributed across the body.
• The patient’s palm (excluding fingers) represents approximately 1% of TBSA.
• This method is particularly useful for small or patchy burns where other assessment techniques may not be applicable.

4. Jackson’s Burn Model (Understanding Burn Zones)

Burn wounds are dynamic and may worsen if blood supply is compromised. Jackson’s Model describes three distinct zones within every burn wound:

1. Zone of Coagulation:
   • The innermost zone where tissue is irreversibly damaged due to direct heat exposure.
2. Zone of Stasis:
   • The surrounding area with reduced blood flow.
   • Tissue here is potentially salvageable with proper care.
3. Zone of Hyperemia:
   • The outermost zone with increased blood flow due to inflammation.
   • Tissue in this area is not permanently damaged and can recover.

Pathophysiology of Burns

Burn injuries cause both local and systemic effects, impacting various physiological processes in the body.

Local Effects of Burns

1. Tissue Damage

• Direct cellular destruction occurs due to heat exposure, leading to cell rupture or necrosis.
• In the peripheral zone, some cells may remain viable but are injured.
• Collagen denaturation and damage to peripheral microcirculation occur.
• Capillaries may either: 
  • Thrombose (in cases of severe damage), or
  • Increase permeability, causing edema and serous fluid leakage.
• The key difference between partial-thickness and full-thickness burns is depth of injury, but partial-thickness burns may worsen and progress to full-thickness burns if capillary damage persists.

2. Inflammation

• A marked inflammatory response occurs immediately after the burn.
• In mild cases, inflammation appears as erythema, which resolves in a few hours.
• More severe burns may cause prolonged inflammation, leading to further tissue damage and delayed healing.

3. Infection

• Burn wounds serve as an ideal environment for microbial colonization.
• Within 24–48 hours, burn sites are inevitably colonized by microorganisms.
• This can lead to: 
  • Localized wound infection, or
  • Regional/systemic infections if not managed properly.

Systemic Effects of Burns

1. Fluid Loss & Hypovolemia

• Damaged capillaries lead to fluid loss, either: 
  • Externally (visible loss), or
  • Internally (into the surrounding tissues, causing edema).
• Widespread edema may occur regionally or even involve the entire body.
• Cytokines play a role in increasing capillary permeability, exacerbating fluid shifts.
• Hypovolemia prevention is a critical priority in early burn resuscitation to avoid shock and organ failure.
• Effective fluid replacement minimizes the risk of other systemic complications.

2. Multiple Organ Failure (MOF)

• Severe burns can lead to progressive failure of major organs, including: 
  • Kidneys (renal failure)
  • Liver (hepatic dysfunction)
  • Heart (cardiac failure)
• This occurs due to prolonged hypovolemia, systemic inflammation, and toxin release.

3. Inhalation Injury

• Occurs most commonly in individuals trapped in enclosed spaces during a fire.
• Often associated with burns to the head, neck, and upper respiratory tract.
• Can cause: 
  • Airway edema and obstruction.
  • Early symptoms such as stridor, hoarseness, cough, and respiratory distress.
  • Delayed respiratory complications, including pulmonary edema and carbon monoxide poisoning.

Management of Burns

1. Management of Minor Burns

Initial Care

1. Clean the burn with soap and water or a diluted water-based antiseptic to remove loose skin.
2. Blisters smaller than 1 cm in diameter should be left intact to minimize the risk of infection.
3. Larger blisters or those in high-risk areas (likely to burst) should be aspirated under aseptic technique.

Dressing and Wound Care

1. Non-adhesive dressings with gauze padding are generally effective. However, biological dressings are preferred, especially for children.
2. Reassess the burn at 48 hours to evaluate its depth and condition.
3. For superficial partial-thickness burns, dressings should be changed every 3–5 days, provided there is no infection.
4. If infection occurs, wound inspection and dressing changes should be done daily. 
   • Antibiotic treatment:
     a. Flucloxacillin (7-day course) as the first-line treatment.
     b. Erythromycin if Flucloxacillin is unsuitable.
     c. Clarithromycin for patients intolerant to erythromycin.

Pain and Tetanus Prophylaxis

1. Provide adequate pain relief with appropriate analgesics.
2. Assess the need for tetanus prophylaxis and administer it if required.

2. Management of Major Burns

A. First Aid Management

1. Stop the burning source immediately.
2. If the patient is on fire, instruct them to STOP, DROP, and ROLL.
3. Remove clothing that is not stuck to the burn.
4. Remove jewelry and watches to prevent constriction from swelling.
5. Cool the burn under running cold tap water for 20 minutes (effective for up to 3 hours after injury).
6. Cover the burn with a clean dressing or cling film.
7. Seek medical assistance immediately.

B. Emergency Management

▲ Airway Management

• Consider intubation in patients with airway involvement or difficulty breathing.
• Place the patient in Fowler’s position (upright) to aid breathing.
• Administer humidified 100% oxygen at 15 L/min.

▲ Fluid Management

• Use the Parkland Formula for fluid resuscitation: 4 \times \text{weight (kg)} \times \text{TBSA (% of burn surface area)}
• Administer Ringer’s Lactate (RL) solution.
• Maintain an accurate fluid balance chart.
• Monitor the patient's body weight regularly.

▲ Wound Care

• Cover the burn wound with appropriate dressings or skin grafts as needed.

▲ Nutritional Support

• Adequate nutrition is crucial for: 
  • Wound healing
  • Graft survival
  • Preventing progression of partial-thickness burns to full-thickness burns
• Caloric requirements per day: (\text{Weight in kg} \times 25) + (40 \times \text{TBSA %})

Conclusion

Burn injuries can have significant local and systemic effects, leading to tissue damage, inflammation, infection, fluid loss, multiple organ failure, and respiratory complications. The severity of a burn is determined by the Total Body Surface Area (TBSA) affected, which can be estimated using methods like the Rule of Nines, Lund and Browder chart, and Palm method. Proper assessment is crucial to determining the appropriate treatment approach.

Effective burn management includes immediate first aid, such as stopping the burning source, cooling the affected area, and seeking medical assistance. Emergency interventions, including airway stabilization, fluid resuscitation, and wound care, are vital to prevent complications and ensure optimal recovery. Minor burns require careful cleaning, dressing, and infection prevention, while major burns demand aggressive fluid replacement, respiratory support, and, in some cases, surgical interventions like skin grafting.

Nutritional support plays a crucial role in wound healing, preventing burn progression, and promoting tissue regeneration. Early and appropriate intervention is key to reducing morbidity and mortality, minimizing complications, and ensuring faster healing and functional recovery. By following standardized burn management protocols, healthcare professionals can significantly improve patient outcomes and quality of life after a burn injury.