Introduction to Burns

Original Editor - Carin Hunter
Top Contributors - Carin Hunter, Jess Bell, Stacy Schiurring, Kim Jackson and Nikhil Benhur Abburi

What is a Burn?

A burn is an injury to the skin or other organic tissue primarily caused by exposure to heat or other causative agents (radiation, electricity, chemicals). According to the World Health Organization (WHO), it is a global public health problem, causing an estimated 180,000 deaths annually. It is among the leading causes of disability in low and middle-income countries and almost two-thirds of burns occur in the WHO African and South-East Asia regions. Burns do not only affect the skin. They can also have tissue, organ and system network effects (e.g. from smoke inhalation) and have psychological effects. Burns affect all genders although females have slightly higher rates of death from burns compared to males. They also affect all age groups and are the fifth most common cause of non-fatal childhood injuries.

Types of Burns

1. Thermal Burns

Thermal burn injuries are caused by exposure to an external heat source or hot liquids. An external heat source can be a hot, solid object or even a cold object. Scalds are caused by wet substances, hot water, steam from hot water or cold water. The types of thermal burns are:

1.1 Flame Burns

Flame burns are caused by exposure to an open fire. These burns are often associated with an inhalation injury and trauma. They tend to be mostly deep dermal or full-thickness burns. Flame burns are common in adults, but they are also associated with abuse in children, domestic violence and certain rituals.

1.2 Contact Burns

Contact burns are caused by contact with an extremely hot object or surface, commonly stoves, heaters and irons. Contact burns tend to be deep dermal or full-thickness burns. They are often seen in people with epilepsy, those who misuse addictive substances or in elderly people after a loss of consciousness.

1.3 Frostbite or Ice Burns

Frostbite occurs when the skin is exposed to cold, typically any temperature below -0.55C (31F), for an extended period of time. This causes the water in the cells of the skin and underlying tissue to freeze and crystalise. This crystallisation causes direct cellular injury. Indirect injury occurs when the tissue becomes ischaemic. Frostbite can affect any part of the body, but the extremities, such as the hands, feet, ears, nose and lips, are most likely to be affected. If frostbite penetrates the deeper skin layers, impacting tissue and bone, it can cause permanent damage.

An ice / snow burn is caused by ice or something very cold touching the skin for an extended period of time. Prolonged exposure to freezing temperatures, snow, or high-velocity winds can increase the chance of this type of burn. Ice burns are commonly caused by ice or cold packs being pressed directly against the skin when treating an injury or sore muscles.

1.4 Scalds

Scalds are caused by hot liquids, such as boiling water and cooking oil. Common mechanisms of injury include spilling a hot drink or cooking oil or being exposed to hot bath water. Scalds tend to cause superficial to superficial partial burns. Scald burns cause about 70% of burns in children. They often occur in older adults as well.

2. Electrical Burns

An electrical burn is an injury caused by heat, which is produced when an electrical current passes through a body. This can cause deep tissue injuries. Injury severity depends on many factors, including the pathway of the current, the resistance of the current in the tissues, and the strength and duration of the flow. AC (Alternating Current) and DC (Direct Current) are both potentially lethal, but there are differences in presentation. Due to the nature of the flow of current in DC burns, individuals often cannot pull themselves away from the current. This increases the duration of the exposure to the current. With AC current, indivuduals can let go during the "off" period. However, the voltage is often much higher. Electrical burns are often associated with cardiac arrest, ventricular fibrillation, and tetanic muscle contractions.

For more information, please see AC and DC Electric Shock Effects Compared

3. Chemical Burns

Chemical burns or caustic burns are injuries that are caused by the skin coming into direct contact with a chemical agent. These can be strong acids, alkaline, or organic compounds. Chemical compounds can have different effects on human tissue depending on the following:

• The strength or concentration of the chemical
• The site of contact (eye, skin, mucous membrane)
• Ingestion or inhalation
• Skin integrity
• Volume of substance
• Duration of exposure
• Chemical process
  • Acids can causes "coagulation necrosis" of the tissue
  • Alkaline burns can cause "liquefaction necrosis"

4. Radiation Burns

A radiation burn is damage due to prolonged exposure to radiation. The most common type of radiation burn is sunburn caused by prolonged exposure to ultraviolet rays (UV). High exposure to radiotherapy can also cause erythema, known as radiation burns. These are often associated with cancer because ionising radiation can interact with and damage DNA.

5. Inhalation Burns/Injury

Inhalation injury refers to pulmonary injury resulting from inhalation of smoke or chemical products of combustion. Inhalation injury results in direct cellular damage, alterations in regional blood circulation and perfusion, obstruction of the airways, and the release of pro-inflammatory cytokine and toxin release. Inhalation injuries also cause reduced functionality of mucociliary clearance and weakening of alveolar macrophages. This injury can be split into three categories:

5.1 Heat Injury to the Upper Airway

The greatest complication of a heat injury to the upper airway is obstruction due to extensive swelling of the tongue, epiglottis, and aryepiglottic folds. The burns do not commonly extend into the lower airway as the larynx reflexively closes, and the heat dissipates as air is not a good heat conductor. Swelling can take a few hours to develop. Thus, it is recommended to regularly assess the airway as the client's presentation may change after the initial evaluation as fluid resuscitation commences.

5.2 Chemical Injury to the Lower Airways

Combustion of materials leads to the production of materials toxic to the respiratory tract. This may cause local chemical irritation in the respiratory tract.

Common conditions:

• Smoke produces toxins that may damage both the airway epithelial cells and capillary endothelial cells which can cause acute respiratory distress syndrome
• Burning rubber and plastic produces sulfur dioxide, nitrogen dioxide, ammonia and chlorine, which affect the respiratory airways and alveoli
• Burning laminated furniture as this furniture may contain glues that release cyanide gas during combustion
• Burning cotton or wool produces aldehydes that are toxic to the human body

Agent	Characteristics	Effects	Source of Exposure
Ammonia	Highly water soluble; colourless; sharp, pungent odour	Highly irritating to eyes and upper airways; upper airway obstruction, such as laryngeal oedema, bronchospasm and noncardiogenic pulmonary edema may occur	Agriculture (mostly fertilisers); plastics, pesticides, explosives and detergents manufacture; refrigerants, home cleaning products
Hydrogen chloride	Highly water soluble; colourless to slightly yellow; pungent odour	Laryngeal oedema, tracheobronchitis	Dyes, fertilisers, textiles, rubber manufacture; metal ore refining; meat wrappers
Hydrogen sulfide	Slightly water soluble; colourless; rotten egg odour (sewer or swamp gas)	Airway irritant and chemical asphyxiant	Decaying organic matter, in sewer and barns; petroleum refining, viscose rayon, rubber and mining industries; hot-asphalt paving
Hydrogen fluoride	Highly water soluble; colourless; pungent odour; corrosive	Chemical pneumonitis; can cause clinically important hypocalcemia	Phosphate fertiliser, metal refining and etching, glass and ceramic etching, microelectronic, masonry, pharmaceuticals, chemical manufacture; rust removal agents
Sulfur dioxide	Highly water soluble; colourless; pungent odour	Bronchoconstriction, airway oedema, asthma, bacterial pneumonitis, bronchiolitis obliterans	Airway pollution, burning of oil and coal,smelting, power plants, wineries, paper manufacture, chemical manufacture, food preparation
Chlorine	Intermediate water solubility; greenish yellow noncombustible gas	Tracheobronchitis, acute respiratory distress syndrome	Household cleaners (household accidents involving the inappropriate mixing of hypochlorite cleaning solutions with acidic agents), paper production, sewage treatment, swimming pool maintenance, chemical manufacture, disinfection, chemical warfare
Oxides of nitrogen	Low water solubility; nearly colourless; a sharp sweet smelling (nitric oxide), strong harsh odour (nitrogen dioxide)	Bronchoconstriction, airway oedema, asthma, bronchiolitis obliterans	Agriculture (Silo filler’s disease); manufacture of dyes, lacquers and fertiliser; firefighters; welding, air pollution, hockey rinks
Phosgene	Low water solubility; colourless; musty odour at room temperature	Mild upper airway irritation, noncardiogenic pulmonary oedema	Firefighters, welding, paint strippers, chemical warfare; Phosgene is used an intermediate in the manufacture of dyes, insecticides, plastics and pharmaceuticals; household substances such as solvents, paint removers and dry cleaning fluid can produce phosgene when exposed to heat or fire

Table showing some chemical irritants causing acute inhalation injury: their effects and sources of exposure. Table from Acute Inhalation Injury

5.3 Systemic Toxicity due to Carbon Monoxide or Cyanide Exposure

Carbon monoxide (CO) is produced during a fire when any carbon-based product is not completely burned. When inhaled, CO binds with haemoglobin in the blood stream and reduces oxygen delivery. Diagnosis requires an accurate history, recording any changes in mental status and high carboxyhaemoglobin levels. Occasionally, patients may require mechanical ventilation and treatment of shock.

Common symptoms can include:

• Headaches
• Nausea and vomiting
• Dizziness
• Exhaustion
• Changes in mental state
• Chest pain
• Difficulty breathing
• Myocardial ischaemia
• Poisoning can lead to a brain injury with associated neurological problems. Symptoms include:
  • Cognitive sequelae
  • Anxiety and depression
  • Persistent headaches, dizziness
  • Sleep problems
  • Motor weakness
  • Vestibular and balance problems
  • Gaze abnormalities
  • Peripheral neuropathies
  • Hearing loss
  • Tinnitus
  • Parkinsonian-like symptoms

Cyanide is often a byproduct of burning household materials. Cyanide intoxication often occurs in conjunction with a CO inhalation injury. Cyanide intoxication lowers the lethal threshold of both cyanide and CO. Diagnosis requires an accurate history, recording changes in mental status, carboxyhaemoglobin concentrations higher than 10% and high lactate levels.

For more information, please see Inhalation Injury

6. Friction Burn

A friction burn is an abrasion that occurs when the skin rubs against another surface. A friction burn is not a true burn. However, because friction can generate heat, in extreme cases, a patient will present with burns to the outer layer of the skin. Common causes are rope burn, rug burn, chafing or skinning.

Burn Classification

Burns can be classified according to their severity or depth. The characteristics of a burn can vary in the amount of pain and colour of burn, depending on its depth. Always be the on the look out for signs of inhalation burns, which are common in burns around the mouth or nose. Burns may have many complications and can cause shortness of breath, hoarseness of the voice, and stridor (noisy breathing due to airflow obstruction) or wheezing. Common symptoms are itchiness (a sign of healing), and numbness or tingling following an electrical injury. Burns can have a significant impact on an individual's mental health and this should always be taken into consideration.

Classification by Depth

Type	Layers Involved	Signs and Symptoms	Healing Time	Prognosis and Complications
First-Degree / Superficial	Epidermis	Red Dry Pain No blisters	5–10 days	Heals well. Repeated sunburns increase the risk of skin cancer later in life.
Second-Degree / Superficial Partial Thickness	Epidermis and can extend into the superficial dermis	Redness with a clear blister. Blanches with pressure, but shows rapid capillary refill when released. Generally moist Very painful	2–3 weeks	Local infection (cellulitis) but no scarring typically
Second-Degree / Deep Partial Thickness	Extends into deep (reticular) dermis Often causes damage to the hair follicle and glandular tissue	Appears yellow or white. Less blanching than superficial. Very painful to pressure and uncomfortable Blisters are common Often moist and waxy Occasionally dry and may appear ivory or pearly white	3–8 weeks	Scarring, contractures (may require excision and skin grafting)
Third-Degree / Full Thickness	Extends through entire dermis and can often affect the underlying subcutaneous tissue	Appearance can vary from waxy white, leathery grey or charred black. Skin is dry, lacking in elasticity No blanching Not painful (nerve ending damage is common) Stiff and white/brown. No blanching	Prolonged (months) and unfinished/incomplete	Eschar, or the dead, denatured skin, is removed Results in scarring, contractures and amputation (early excision recommended) Cannot heal without surgery
Fourth-Degree	Extends through entire skin, and into underlying fat, muscle and bone	Black; charred with eschar Dry No elasticity Painless	Does not heal; Requires excision	Amputation, significant functional impairment and in some cases, death

Classification by Size

The Parkland Burn Formula is the most widely used formula to estimate the fluid resuscitation required by a burns patient on hospital admission, usually within the first 24 hours. When applying this formula, the first step is to calculate the percentage of body surface area (BSA) damaged, which is most commonly done using the "Wallace Rule of Nines". When conducting a paediatric assessment, the Lund-Browder Method is commonly used, as children have a greater percentage surface area of their head and neck compared to an adult. The formula recommends 4 milliliters per kilogram of body weight in adults (3 milliliters per kilogram in children) per percentage burn of total body surface area (%TBSA) of crystalloid solution over the first 24 hours of care.

4 mL/kg/%TBSA (3 mL/kg/%TBSA in children) = total amount of crystalloid fluid during first 24 hours

The latest research has indicated that while this method is still in use, the fluid levels should be constantly monitored, while assessing the urine output, to prevent over-resuscitation or under-resuscitation.

The Rule of Nine and Lund-Browder Method Percentages

When using these methods, it is important to note that there are discrepancies in the figures assigned to each area. Initially, all areas in the Rule of Nine were assigned 9%. This has evolved over the years and there has been an attempt to break down the areas to get to a more accurate estimate. Always note, the team working with the patient must agree on which form everyone will use. This should be kept standard throughout treatment. It is also important to note that it is an estimate figure used for the Fluid Resuscitation calculation. This will need to be closely monitored and adjusted by the dietitian.

Please find assessment examples below:

• Burn Wound Assessment Sheet - Adult
• Burn Wound Assessment Sheet - Paediatric

Palmar Surface Method

The "Rule of Palm" or Palmar Surface Method can be used to estimate body surface area of a burn. This rule indicates that the palm of the patient, with the exclusion of the fingers and wrist, is approximately 1% of the patients body surface area. When a quick estimate is required, the percentage body surface area will be the number of the patient's own palm it would take to cover their injury. It is important to use the patient's palm and not the provider's palm.

Jacksons’ Burn Wound Model

Jacksons’ Burn Wound Model is a model used to understand the pathophysiology of a burn would. This model divides the wound into three zones.

• Zone of Coagulation: This is the area central to the injury and is the area that experiences the greatest tissue damage.

• Zone of Stasis or Zone of Ischaemia: This area is adjacent to the zone of coagulation and as the name suggests, it is a zone in which the there is slowing of circulating blood due to the damage. This zone can usually be saved with the correct wound care.

• Zone of Hyperemia: This zone is circumferential and is characterised by the eased blood supply and inflammatory vasodilation. This tissue has a good recovery rate, as long as there are no complications, such as severe sepsis or prolonged hypo-perfusion.

For more information please see the article on A Systematic Review on Classification Identification and Healing Process of Burn Wound Healing

Summary of the Pathophysiology of Burns

The video below describes the pathophysiology of Burns