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MINISTRY OF REPUBLIC HEALTH
KHARKIV NATIONAL MEDICAL UNIVERSITY
SURGERY
Content: Burns, burn disease, and treatment of burns.
Written by
Amal Nass
Course:3
Group:3
KHARKIV 2008
Burns.
Burns are injuries to tissue that result from heat, electricity, radiation, or chemicals.
Burns are usually caused by heat (thermal burns), such as fire, steam, tar, or hot liquids. Burns
caused by chemicals are similar to thermal burns, whereas burns caused by radiation (see
Radiation Injury), sunlight (see Sunlight and Skin Damage: Introduction), and electricity (see
Electrical and Lightning Injuries: Electrical Injuries) tend to differ significantly.
Thermal and chemical burns usually occur because heat or chemicals contact part of the body's
surface, most often the skin. Thus, the skin usually sustains most of the damage. However,
severe surface burns may penetrate to deeper body structures, such as fat, muscle, or bone.
When tissues are burned, fluid leaks into them from the blood vessels, causing swelling and pain.
In addition, damaged skin and other body surfaces are easily infected because they can no longer
act as a barrier against invading organisms.
electrical burns
Electrical burns may cause serious injury that is not readily apparent. Often the entry and exit
points for the electrical shock may not be easily found.
Electricity flows more easily through tissues in the body that are designed to deal with
electricity. Nerves and muscles are "wired" for this task and often are damaged. If significant
muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing
electrolyte disturbances and kidney failure.
chemical burns
Chemical burns are caused by caustic substances that contact the skin. Caustic substances are
sometimes found in household products, including those containing lye (in drain cleaners and
paint removers), phenols (in deodorizers, sanitizers, and disinfectants), sodium hypochlorite (in
disinfectants and bleaches), and sulfuric acid (in toilet bowl cleaners). Many chemicals used in
industry and during armed conflicts can cause burns. Wet cement left on the skin can cause
severe burns as well.
The first step in stopping chemical burns is to remove contaminated clothing and brush away any
dry particles. Next, the area is rinsed with large amounts of water. Because chemicals can
continue to inflict damage long after first contacting the skin, rinsing should continue for at least
30 minutes. In rare cases involving certain industrial chemicals (for example, metal sodium),
water should not be used because it can actually worsen the burn. In addition, some chemicals
have specific treatments that can further reduce skin damage. Further treatment of chemical
burns is the same as that for thermal burns.
Classification
Burns are classified according to strict, widely accepted definitions. These definitions may not
correspond to a person's understanding of those terms. For example, a doctor may classify a burn
as serious even though the person regards it as minor. The definitions classify the burn's depth
and the extent of tissue damage.
A first degree burn is superficial and causes local inflammation of the skin. Sunburns often are
categorized as first degree burns. The inflammation is characterized by pain, redness, and a mild
amount of swelling. The skin may be very tender to touch.
Second degree burns are deeper and in addition to the pain, redness and inflammation, there is
also blistering of the skin.
Third degree burns are deeper still, involving all layers of the skin, in effect killing that area of
skin. Because the nerves and blood vessels are damaged, third degree burns appear white and
leathery and tend to be relatively painless.
Burns are not static and may mature. Over a few hours a first degree burn may involve deeper
structures and become second degree. Think of a sunburn that blisters the next day. Similarly,
second degree burns may evolve into third degree burns.
Regardless of the type of burn, inflammation and fluid accumulation in and around the wound
occur. Moreover, it should be noted that the skin is the body's first defense against infection by
microorganisms. A burn is also a break in the skin, and the risk of infection exists both at the site
of the injury and potentially throughout the body.
Only the epidermis has the ability to regenerate itself. Burns that extend deeper may cause
permanent injury and scarring and not allow the skin in that area to return to normal
What is the significance of the amount of body area burned?
In addition to the depth of the burn, the total area of the burn is significant. Burns are measured
as a percentage of total body area affected. The "rule of nines" is often used, though this
measurement is adjusted for infants and children. This calculation is based upon the fact that the
surface area of the following parts of an adult body each correspond to approximately 9% of total
(and the total body area of 100% is achieved):

Head = 9%

Chest (front) = 9%

Abdomen (front) = 9%

Upper/mid/low back and buttocks = 18%

Each arm = 9%

Each palm = 1%

Groin = 1%

Each leg = 18% total (front = 9%, back = 9%)
As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen
were burned, this would involve 55% of the body.
Only second and third degree burn areas are added together to measure total body burn area.
While first degree burns are painful, the skin integrity is intact and it is able to do its job with
fluid and temperature maintenance.
If more than15%-20% of the body is involved in a burn, significant fluid may be lost. Shock may
occur if inadequate fluid is not provided intravenously. The Parkland formula (named for the
trauma hospital in Dallas) estimates the amount of fluid required in the first few hours of care
following a burn:

4cc/ kg of weight/% burn = initial fluid requirement in the first 24 hours, with half given
in the first 8 hours.

As an example: A 175lb (or 80kg) patient with 25% burn will need 4cc x 80kg x 25%, or
8000cc of fluid in the first 24 hours, or more than 7 pounds of fluid.
As the percentage of burn surface area increases, the risk of death increases as well. Patients with
burns involving less than 20% of their body should do well, but those with burns involving
greater than 50% have a significant mortality risk, depending upon a variety of factors, including
underlying medical conditions and age.
Symptoms and Diagnosis
First-degree burns are red, moist, swollen, and painful. The burned area whitens (blanches) when
lightly touched but does not develop blisters. Second-degree burns are red, swollen, and painful,
and they develop blisters that may ooze a clear fluid. The burned area may blanch when touched.
Third-degree burns usually are not painful because the nerves have been destroyed. The skin
becomes leathery and may be white, black, or bright red. The burned area does not blanch when
touched, and hairs can easily be pulled from their roots without pain. No blisters develop. The
appearance and symptoms of deep burns can worsen during the first hours or even days after the
burn.
Smoke Inhalation
Many people who have been burned in fires have also inhaled smoke. Sometimes people inhale
smoke without sustaining skin burns. Smoke inhalation often causes no serious, lasting effects.
However, if the smoke is unusually hot or dense or if inhalation is prolonged, serious problems
can develop. The hot smoke can burn the windpipe (trachea), resulting in swelling. As the
swelling narrows the trachea, airflow into the lungs is obstructed. Inhalation of chemicals
released in the smoke, such as hydrogen chloride, phosgene, sulfur dioxide, and ammonia, can
swell and damage the lungs and trachea. Eventually, the small airways leading to the lungs
narrow, further obstructing airflow. Smoke can also contain chemicals that poison the body's
cells, such as carbon monoxide(see Poisoning: Carbon Monoxide Poisoning) and cyanide.
Damage to the trachea or the lungs can cause shortness of breath, which can take up to 24 hours
to develop. Obstruction of airflow due to swelling of the airways can produce wheezing and
worsen shortness of breath. The person may have soot in the mouth or nose, singed nasal hairs,
or burns around the mouth. Lung damage may cause chest pain, coughing, and wheezing. If the
oxygen supply is depleted due to smoke, the person may pass out. High levels of carbon
monoxide in the blood may cause confusion or disorientation or may even be fatal.
To assess the extent of a tracheal burn, a doctor may pass a flexible viewing tube (bronchoscope)
into the trachea. A doctor may assess lung damage with a chest x-ray or with a test that
determines the level of oxygen in the blood.
A person who has inhaled smoke is given oxygen through a face mask. If a tracheal burn is
suspected, a breathing tube is inserted through the person's nose or mouth in case the trachea
later swells and obstructs airflow. If the person begins to wheeze, drugs that open small airways,
such as albuterol
, may be
given, usually as a mist that is combined with oxygen and inhaled through a face mask. If lung
damage causes shortness of breath that persists despite use of a face mask and albuterol
, a ventilator
may be necessary. Relieving the stress of breathing conserves the person's energy and usually
allows faster recovery and healing.
Complications
Most minor burns are superficial and do not cause complications. However, deep second-degree
and third-degree burns swell and take more time to heal. In addition, deeper burns can cause scar
tissue to form. This scar tissue shrinks (contracts) as it heals. If the scarring occurs at a joint, the
resulting contracture may restrict movement.
Severe burns can cause serious complications due to extensive fluid loss and tissue damage.
Complications from severe burns may take hours to develop. The longer the complication is
present, the more severe are the problems it tends to cause. Young children and older adults tend
to be more seriously affected by complications than other age groups.
Dehydration eventually develops in people with widespread burns, because fluid seeps from the
blood to the burned tissues. Shock develops if dehydration is severe (see Shock). Destruction of
muscle tissue (rhabdomyolysis) occurs in deep third-degree burns. The muscle tissue releases
myoglobin, one of the muscle's proteins, into the blood. If present in high concentrations,
myoglobin harms the kidneys. Rhabdomyolysis can be diagnosed from tests of the blood and
urine.
Thick, crusty surfaces (eschars) are produced by deep third-degree burns. Eschars can become
too tight, cutting off blood supply to healthy tissues or impairing breathing.
Treatment
Before burns are treated, the burning agent must be stopped from inflicting further damage. For
example, fires are extinguished. Clothing—especially any that is smoldering (such as melted
synthetic shirts), covered with hot tar, or soaked with chemicals—is immediately removed.
First-degree burn
Soak the burn in cool water. Then treat it with a skin care product like aloe vera cream or an
antibiotic ointment. To protect the burned area, you can put a dry gauze bandage over the burn.
Take an over-the-counter pain reliever, such as acetaminophen (one brand name: Tylenol),
ibuprofen (some brand names: Advil, Motrin) or naproxen (brand name: Aleve), to help with the
pain.
Second-degree burn
Soak the burn in cool water for 15 minutes. If the burned area is small, put cool, clean, wet cloths
on the burn for a few minutes every day. Then put on an antibiotic cream, or other creams or
ointments prescribed by your doctor. Cover the burn with a dry nonstick dressing (for example,
Telfa) held in place with gauze or tape. Check with your doctor's office to make sure you are upto-date on tetanus shots.
Change the dressing every day. First, wash your hands with soap and water. Then gently wash
the burn and put antibiotic ointment on it. If the burn area is small, a dressing may not be needed
during the day. Check the burn every day for signs of infection, such as increased pain, redness,
swelling or pus. If you see any of these signs, see your doctor right away. To prevent infection,
avoid breaking any blisters that form.
Burned skin itches as it heals. Keep your fingernails cut short and don't scratch the burned skin.
The burned area will be sensitive to sunlight for up to one year.
Third-degree burn
For third-degree burns, go to the hospital right away. Don't take off any clothing that is stuck to
the burn. Don't soak the burn in water or apply any ointment. You can cover the burn with a
sterile bandage or clean cloth until you receive medical assistance.
A person with an electrical burn (for example, from a power line) should go to the hospital right
away. Electrical burns often cause serious injury inside the body. This injury may not show on
the skin.
A chemical burn should be washed with large amounts of water. Take off any clothing that has
the chemical on it. Don't put anything on the burned area. This might start a chemical reaction
that could make the burn worse.
Hospitalization is sometimes necessary for optimal care of burn injuries. For example, elevating
a severely burned arm or leg above the level of the heart to prevent swelling is more easily
accommodated in a hospital. In addition, burns that prevent a person from performing essential
daily functions, such as walking or eating, make hospitalization necessary. Severe burns, deep
second- and third-degree burns, burns occurring in the very young or the very old, and burns
involving the hands, feet, face, or genitals are usually best treated at burn centers. Burn centers
are hospitals that are specially equipped and staffed to care for burn victims.
Superficial Minor Burns: Superficial minor burns are immersed immediately in cool water if
possible. The burn is carefully cleaned to prevent infection. If dirt is deeply embedded, a doctor
can give analgesics or numb the area by injecting a local anesthetic and then scrub the burn with
a brush.
Often, the only treatment required is application of an antibiotic cream, such as silver
sulfadiazine
. The cream prevents infection and forms a seal to prevent further bacteria
from entering the wound. A sterile bandage is then applied to protect the burned area from dirt
and further injury. A tetanus vaccination is given if needed (see Immunization: Tetanus).
Care at home includes keeping the burn clean to prevent infection. In addition, many people are
given analgesics, often opioid analgesics, for at least a few days. The burn can be covered with a
nonstick bandage or with sterile gauze. The gauze can be removed without sticking by first being
soaked in water.
Small, Shallow Burns
Most people who sustain small burns attempt to treat them at home rather than visit the doctor.
Indeed, simple first-aid measures may be all that is necessary to treat small, shallow burns that
are clean. In general, a clean burn is one that affects only clean skin and that does not contain
any dirt particles or food. Running cold water over the burn can relieve pain. Covering the burn
with an over-the-counter antibiotic ointment and a nonstick, sterile bandage can prevent
infection.
Generally, a doctor's examination and treatment are recommended if a tetanus vaccination is
needed. Likewise, a doctor should examine a burn if it has any of the following characteristics:
Is larger than about the size of the person's palm
Contains blisters
Darkens or breaks the skin
Involves the face, hand, foot, genitals, or skinfolds
Is not completely clean
Causes pain that is not relieved by acetaminophen
Causes pain that does not improve within one day after the burn was sustained.
Deep Minor Burns: As with more superficial burns, deep minor burns are treated with antibiotic
cream. However, any dead skin and broken blisters must be removed before the antibiotic cream
is applied. In addition, keeping a deeply burned arm or leg elevated above the heart for the first
few days reduces swelling and pain. The burn may require frequent re-examination at a hospital
or doctor's office, possibly as often as daily for the first few days.
A skin graft may be needed. Most skin grafts replace the burned skin. Other skin grafts help by
temporarily covering and protecting the skin as it heals on its own. In a skin grafting procedure, a
piece of healthy skin is taken from an unburned area of the person's body (autograft), from
another living or dead person (allograft), or from another species (xenograft)—usually pigs
because their skin is most similar to human skin. The skin graft is surgically sewn over the
burned area after removing any dead tissue and ensuring that the wound is clean. Autografts are
permanent. Allografts and xenografts, however, are rejected after 10 to 14 days by the person's
immune system. Artificial skin has been developed recently and can also be used to replace the
burned skin. Burned skin can be replaced anytime within several days of the burn.
Physical and occupational therapy usually are needed to prevent immobility caused by scarring
around the joints. Stretching exercises are started within the first few days after the burn. Splints
are applied to ensure that joints that are likely to be immobile rest in positions that are least likely
to lead to contractures. The splints are left in place except when the joints are moved. If a skin
graft has been used, however, therapy is not started for the first 5 to 10 days after the grafts are
attached so that the healing graft is not disturbed. Bulky dressings that put pressure on the burn
can prevent large scars from developing.
Severe Burns: Severe, life-threatening burns require immediate care. Dehydration is treated with
large amounts of fluids given intravenously. A person who has gone into shock as a result of
dehydration is also given oxygen through a face mask.
Destruction of muscle tissue is also treated with large amounts of fluids given intravenously. The
fluids dilute the myoglobin in the blood, preventing extensive damage to the kidneys. Sometimes
a chemical, sodium bicarbonate, is given intravenously to help dissolve myoglobin and thus also
prevent further damage to the kidneys.
Eschars that cut off blood supply to an extremity or that impair breathing are cut open in a
surgical procedure called escharotomy. Escharotomy usually causes some bleeding, but because
the burn causing the eschar has destroyed the nerve endings in the skin, there is little pain.
Keeping the burned area clean is important, because the damaged skin is easily infected.
Cleaning may be accomplished by gently running water over the burns periodically. Wounds are
cleaned and bandages changed 1 to 3 times per day.
A proper diet that includes adequate amounts of calories, protein, and nutrients is important for
healing. People who cannot consume enough calories may drink nutritional supplements or
receive them by way of a tube inserted through the nose into the stomach (a nasogastric tube), or
nutrition may be given intravenously. Additional vitamins and minerals are usually given.
Because severe burns take a long time to heal, sometimes years, and can cause disfigurement, the
person can become depressed. Depression often can be relieved with drugs or psychotherapy or
both.
Prognosis
First- and second-degree burns heal in days to weeks without scarring. Deep second-degree and
small (less than 1 inch) third-degree burns take weeks to heal and usually cause scarring. Larger
third-degree burns require skin grafting. Burns that involve more than 90% of the body surface,
or more than 60% in an older person, usually are fatal.
First aid for burns
For major burns (second and third degree burns)
1. Remove the victim from the burning area, remembering not to put the rescuer in danger.
2. Remove any burning material from the patient.
3. Call 911 or activate the emergency response system in your area if needed.
4. Once the victim is in a safe place, keep them warm and still. Try to wrap the injured areas
in a clean sheet if available. DO NOT use cold water on the victim; this may drop the
body temperature and cause hypothermia.
Burns of the face, hands, and feet should always be considered a significant injury (although this
may exclude sunburn.
For minor burns (first degree burns or second degree burns involving a small area of the
body)

Gently clean the wound with lukewarm water.

Though butter has been used as a home remedy, it should NOT be used on any burn.

Rings, bracelets, and other potentially constricting articles should be removed (edema, or
swelling from inflammation may occur and the item may cut into the skin).

The burn may be dressed with a topical antibiotic ointment like Bacitracin or Neosporin.

If there is concern that the burn is deeper and may be second or third degree in nature,
medical care should be accessed.

Tetanus immunization should be updated if needed.
For electrical burns
Victims of electrical burns should always seek medical care.
For chemical burns
1. Identify the chemical that was involved.
2. Contact the Poison Control Center in your area or your local hospital's Emergency
Department. Many chemical burns may be treated with local wound care. Some
chemicals can cause life- and limb-threatening injuries and need emergent intervention.
3. Victims with chemical burns to their eyes should always seek emergency care.
By giving immediate first aid before professional medical help arrives, you can help lessen the
severity of the burn. Prompt medical attention to serious burns can help prevent scarring,
disability, and deformity. Burns on the face, hands, feet, and genitals can be particularly serious.
Children under age 4 and adults over age 60 have a higher chance of complications and death
from severe burns.
In case of a fire, you and the others there are at risk for carbon monoxide poisoning. Anyone
with symptoms of headache, numbness, weakness, or chest pain should be tested.
REFERENCES
Minor burn - first aid - series
Reviewed last on: 2/19/2008
John E. Duldner, Jr., MD, MS, Assistant Professor of Emergency Medicine, Director of Research,
Department of Emergency Medicine, Akron General Medical Center and Northeastern Ohio Universities
College of Medicine. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve,
MD, MHA, Medical Director, A.D.A.M., Inc.
References
Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice.
5th ed. St. Louis, Mo.: London: Mosby; 2002.