Dr. Yogeesh.R CMO KRH,Mysore BURNS Dr. Yogeesh.R CMO KRH,Mysore

A burn is a type of injury to skin or other tissues caused by heat  cold  electricity  chemicals  friction radiation.

Signs and symptoms The characteristics of a burn depend upon its depth.  Types 1. Superficial (1st-degree) 2. Superficial partial thickness (2nd-degree) 3. Deep partial thickness (2nd-degree) 4. Full thickness (3rd-degree) 5. 4th-degree

1. Superficial (1st degree) Involves epidermis Appears red without blisters Painful 5–10 days Heals well  Repeated sunburns increase the risk of skin cancer later in life

2. Superficial partial thickness (2nd degree) Extends into superficial (papillary) dermis Redness with clear blister  Blanches with pressure Moist Very painful Heals in less than 2–3 weeks Local infection/cellulitis but no scarring typically

3. Deep partial thickness (2nd-degree) Extends into deep (reticular) dermis Less blanching May be blistering Fairly dry Pressure and discomfort Heals in 3–8 weeks Scarring, contractures (may require excision and skin grafting)

4. Full thickness (3rd-degree) Extends through entire dermis Stiff and white/brown No blanching Leathery Painless Prolonged (months) and incomplete Scarring, contractures, amputation (early excision recommended)

5. 4th-degree Extends through entire skin, and into underlying fat, muscle and bone Black charred with eschar Dry Painless Requires excision Amputation, significant functional impairment, and, in some cases, death

CAUSES Fire and hot liquids are the most common causes of burns 1. Thermal burns Fire and hot liquids are the most common causes of burns  Of house fires that result in death, smoking causes 25% and heating devices cause 22%  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  Scald injuries are most common in children under the age of five .

Contact with hot objects is the cause of about 20-30% of burns in children. Generally, scalds are first- or second-degree burns, but third-degree burns may also result, especially with prolonged contact

2. Chemical Chemicals cause from 2 to 11% of all burns and contribute to as many as 30% of burn-related deaths. Most chemical burn deaths are secondary to ingestion Common agents include: sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover, among others. Hydrofluoric acid can cause particularly deep burns that may not become symptomatic until some time after exposure. Formic acid may cause the breakdown of significant numbers of red blood cells.

3. Electrical Electrical burns or injuries are classified as high voltage (greater than or equal to 1000 volts), low voltage (less than 1000 volts), or as flash burns secondary to an electric arc. The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%). Lightning may also result in electrical burns. Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside

Electrical injuries apart from burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions.  In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone.  Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest.

4. Radiation burns Radiation burns may be caused by protracted exposure to ultraviolet light (such as from the sun, tanning booths or arc welding) or from ionizing radiation (such as from radiation therapy, X- rays or radioactive fallout). Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.

5. Non-accidental In those hospitalized from scalds or fire burns, 3–10% are from assault. Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes. An immersion injury or immersion scald may indicate child abuse

Pathophysiology At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down. This results in cell and tissue damage. Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin. They include disruption of the skin's sensation, ability to prevent water loss through evaporation, and ability to control body temperature. Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.

4. In large burns (over 30% of the total body surface area), there is a significant inflammatory response.  This results in increased leakage of fluid from the capillaries and subsequent tissue edema. This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated. Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers.

Increased levels of cortisol and catecholamines can cause a hypermetabolic state that can last for years. This is associated with increased cardiac output, palpitations and poor immune function.

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.

1.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.  First-degree burns that are only red in color and are not blistering are not included in this estimation. Most burns (70%) involve less than 10% of the TBSA. 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. The rule of nines is easy to remember but only accurate in people over 16 years of age. 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.

2. Severity American Burn Association devised a classification system for burns 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. Minor burns can typically be managed at home, moderate burns are often managed in hospital, and major burns are managed by a burn center

First aid and treatment 1. Thermal burns The most important first action is to stop the burning process. The source of the burn should promptly be removed (or the patient removed from the source). Burning clothing should be removed as should all jewelry that could act as a tourniquet as swelling occurs, but burned clothing stuck to the skin must not be removed. Cooling the burn with cold running water has been shown to be beneficial if accomplished within 30 minutes of the injury. The pain or inflammation can then be effectively treated using acetaminophen (paracetamol), or ibuprofen. Ice, butter, cream and ointment cannot be used since they can worsen the burn. CPR can be performed and be sent to a hospital if the burn is severe enough. Severe burn patients are often treated through trauma resuscitation, airway management, fluid resuscitation, blood transfusion, wound management, and skin grafting, as well as the use of antibiotics.

2. Electrical burns An electrically burned patient should not be touched or treated until the source of electricity has been removed.  Electrical injuries often extend beyond burns and include cardiac arrhythmia, such as ventricular fibrillation. First aid treatments include assessment of consciousness of the victim, evaluation of pulse and circulation

Typically, an electrical burn patient has a lower affected body surface area than other burn patients, yet complication risks are much higher due to internal injury. Often, the damaged internal tissue demands hospitalization. Burn treatment for severe wounds may require skin grafting, debridement, excision of dead tissue, and repair of damaged organs

This requires administration of systemic antimicrobial therapy. 3. Radiation burns Radiation burns should be covered by a clean, dry dressing as soon as possible to prevent infection. Wet dressings are not recommended.  The presence of combined injury (exposure to radiation plus trauma or radiation burn) increases the likelihood of generalized sepsis. This requires administration of systemic antimicrobial therapy.

Cool the burn to help soothe the pain Cool the burn to help soothe the pain. Hold the burned area under cool (not cold) running water for 10 to 15 minutes or until the pain eases. Or apply a clean towel dampened with cool tap water. Remove rings or other tight items from the burned area. Try to do this quickly and gently, before the area swells. Don't break small blisters (no bigger than your little fingernail). If blisters break, gently clean the area with mild soap and water, apply an antibiotic ointment, and cover it with a nonstick gauze bandage.

Seek medical help

Apply moisturizer or aloe vera lotion or gel, which may provide relief in some cases. If needed, take an over-the-counter pain reliever, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others). Consider a tetanus shot. Make sure that your tetanus booster is up to date. Doctors recommend people get a tetanus shot at least every 10 years.

Prognosis and Complications The prognosis is worse in those with larger burns, those who are older, and those who are females. A number of complications may occur, with infections being the most common. In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure. 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. Pneumonia occurs particularly commonly in those with inhalation injuries.

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