According to the American Burn Association, each year in the United States 1.1 million burn injuries require medical attention.
- Approximately, 50,000 of these require hospitalization and approximately 4,500 of these patients die.
- It’s estimated that 2/3 of burns happen in the home.
- Unintentional fire or burn injuries were the 5th leading cause of injury deaths in the US in 2015 for children age 1-4; and the 3rd for ages 5-9.
- In 2011-2015, children under 5 years old were 2.4 times as likely as the general population to suffer burn injuries that require emergency treatment.
- The World Health Organization (WHO) reports that for 2000, the direct costs for care of children with burns in the US exceeded $211 million.
- Solar – Sunburn
- Flame – Damage from superheated oxidized air. Most likely to come to the hospital and be admitted.
- Scald – Hot liquids are the most common cause of burns. Specific heat of liquid important to consider; for example, a grease burn is deeper than a burn from water even with the same temperature and duration
- Contact – Burn from hot or cold solid materials; for example dry ice or an iron.
- Chemical – Need no heat source
- Acid – Coagulation necrosis
- Alkali – Deeper burns due to liquefaction necrosis
- Solvents – Cleaning solutions
- Oxidizers – Silver nitrate
- Reducing agents
- Alkylants – Dimethyl sulfate, mustard gas
- Electricity – Deep tissue damage often exceeds skin injury. Goes through low resistance tissues, eg. nerve, blood, vessels, muscle. The most severe tissue destruction is at entry and exit points.
- Medical – Stevens Johnson Syndrome, Epidermolysis Bullosa
Depending on the type of burn and the extent of the burn, there are established guidelines to determine the need for transfer to a burn center. In evaluating a patient with a burn, the total body surface area (TBSA) is calculated and the depth of the burn is assessed prior to deciding on transfer or plan of care.
Depth of Burns
Determining the depth of a burn dictates a treatment plan. The skin is made up of two main layers: epidermis (top layer) and the dermis.
Superficial burn wounds are similar to a sunburn and only involve the top layer of skin. First-degree burns typically heal in 3-5 days. They are characterized by erythema (redness), mild edema (swelling), and tenderness. The majority of first-degree burns do not require a trip to the hospital however if the burn covers a large area of the body, or the patient is an infant or elderly, then medical attention may be needed. Most first-degree burns can be treated with cool compresses, NSAIDs for pain, and further sun protection.
Superficial Second-Degree – Injury to superficial dermis characterized by blisters,
blanchable erythema, glossy appearance from leaking fluid, intact hair follicles. Large superficial second-degree burns should be seen by a medical professional to determine a proper treatment plan. Typically, these wounds heal over weeks with good wound care.
Deep Second-Degree – Injury deep into the dermis characterized by decreased sensation, loss of hair follicles, non-blanching. Deep second-degree burns may heal slowly over weeks to months, but they typically heal with hypertrophic or keloid scars (thick scars) and/ or contractures (limitation to range of motion if at a joint). Therefore,
at times deep partial thickness burn wounds benefit from excision of the wound and skin grafting. Deep burns need to be assessed by a medical professional.
Injury through the skin into the subcutaneous fat characterized by dry, leathery eschar that tends to be painless. The color of the tissue can be black, brown, white or cherry red. Third-degree burns need immediate medical attention.
Injury past the subcutaneous fat into muscle, tendon or bone. The tissue is often dry and leathery. Fourth-degree burns need immediate medical attention.
Each patient, having a different set of circumstances, should have a customized plan of care. Pain control is an important consideration during this time period. Should one require intravenous pain medication, they should be monitored in a hospital setting but if oral pain medication is sufficient, the patient may be managed on an outpatient basis. If the patient requires intravenous pain medication only during their dressing changes, an outpatient sedation procedure may be set up to eliminate the need for 24 hour hospital admission.
Depending on the location of the wound and the depth of the burn, different topical agents can be used for wound care. This can range from antibiotic ointment to silvadene cream to a mepilex silver sponge. However, surgery may be required to excise dead tissue if the burn is extensive and deep; this is called debridement. Debridement may be performed in serial fashion in order to remove as little tissue as necessary until a healthy wound bed is achieved. Serial debridement may be necessary because tissue can take time to declare whether it will survive or not after injury; this can be over a couple of weeks. After debridement is performed, then the open areas need to be covered. This can be performed as an autograft (patient’s own skin), allograft (human cadaveric skin, skin substitute such as Integra), xenograft (animal skin), or a moist wound dressing.
If autologous skin grafting is required, the wound itself is excised and an area of skin is taken from another area of the body and placed in the prepared wound bed to assist in wound healing. Frequently the skin is taken from the anterolateral thigh and the scar from this site may be hidden under shorts. Upon suturing or stapling down the skin graft, pressure must be applied to the graft over a 5-7 day time period to allow for revascularization (reestablishment of blood flow) of the graft to occur. This is done using either a bolster or negative-pressure wound therapy (wound vac).
It is very important that a proper treatment plan is made by medical professionals who have burn care experience. The specialists at the Craniofacial Team of Texas trained at Level 1 Burn Centers and have extensive experience taking care of burn patients. If you need a burn care specialist, call 512-377-1142 or toll free 877-612-7069 to schedule an appointment or complete an online appointment request.