BURNS HISTORY AND FACTORS

Burns have been a part of human history for centuries, and they can occur due to various causes such as flames, scalding liquids, contact with hot surfaces, exposure to chemicals, or even electricity. Here is a brief overview of the relevant history and associated factors related to burns:

1. Flame Burns: Burns caused by exposure to flames have been prevalent throughout history, especially in situations where open fires were commonly used for cooking, heating, and lighting. Flame burns can occur in various settings, including domestic environments, industrial accidents, and warfare. In the past, open fires in homes posed a significant risk, particularly in crowded urban areas where wooden structures and thatched roofs were common.
2. Scald Burns: Scald burns result from contact with hot liquids or steam. Historically, scalding injuries were common in domestic settings where hot water was stored in open containers or heated over open fires. For example, in the past, people used kettles or pots to heat water, which could accidentally spill and cause scalding injuries. Additionally, the risk of scalding was high in industries involving hot liquid processes such as brewing, dyeing, or metalworking.
3. Closed Space Burns: Burns occurring in closed spaces can be caused by fires or explosions, resulting in thermal injuries due to heat exposure. Throughout history, incidents such as building fires, mining accidents, or shipboard fires have led to significant numbers of burn injuries. In enclosed environments, the lack of ventilation and the rapid spread of flames can exacerbate the severity of burns.
4. Exposure Time: The duration of exposure to the burn source plays a crucial role in determining the severity of burns. Prolonged exposure to flames, scalding liquids, or hot surfaces increases the likelihood of deeper and more severe burns. In situations where individuals were unable to escape from burning structures or were trapped in closed spaces, the exposure time would be longer, resulting in more extensive injuries.
5. Associated Injuries: Burn injuries can lead to various associated injuries depending on the circumstances. Inhalation injuries can occur when individuals breathe in hot gases, smoke, or toxic fumes during a fire, leading to respiratory problems. Burns can also cause secondary injuries such as fractures or trauma from falls or explosions. Additionally, psychological trauma, including post-traumatic stress disorder (PTSD), is commonly associated with burn injuries.

It’s important to note that advancements in fire safety, awareness, and healthcare have contributed to a significant reduction in burn-related injuries over time. However, burns remain a significant public health concern globally, and ongoing efforts are made to prevent and treat these injuries effectively.

 

Burn Depth & Size

In a patient with a major burn, the burn depth and size are essential factors that determine the severity and potential complications associated with the burn injury. Let’s discuss each of these aspects:

1. Burn Depth: Burn depth refers to how deeply the burn injury has penetrated the layers of the skin and underlying tissues. The depth of a burn is categorized into different degrees, including first-degree, second-degree, third-degree, and sometimes fourth-degree burns:

• First-degree burns: These burns only affect the outermost layer of the skin, known as the epidermis. They typically cause redness, pain, and mild swelling. First-degree burns usually heal within a week without scarring.
• Second-degree burns: These burns affect both the epidermis and the underlying layer of skin, called the dermis. Second-degree burns can be further divided into two types:
  • Superficial partial-thickness burns: These burns involve the upper layers of the dermis and are characterized by redness, blistering, pain, and sensitivity. They usually heal within two to three weeks with minimal scarring.
  • Deep partial-thickness burns: These burns extend deeper into the dermis, causing a pale white appearance or mottled color. They are associated with intense pain, blistering, and potential scarring. Healing time may take several weeks to months, and there is a higher risk of complications.
• Third-degree burns: These burns destroy the entire thickness of the skin, including the epidermis, dermis, and sometimes extending into the underlying subcutaneous tissue. Third-degree burns often appear white, charred, leathery, or blackened. They are typically painless since the nerve endings are damaged. Healing from third-degree burns is not possible without medical intervention, and skin grafting is usually necessary.
• Fourth-degree burns: These burns are the most severe and extend through the skin, subcutaneous tissue, muscle, and potentially down to the bone. They may appear charred or have a deep blackened appearance. Fourth-degree burns require immediate medical attention and extensive surgical intervention to remove necrotic tissue and reconstruct the affected area.

2. Burn Size: Burn size refers to the total percentage of the body surface area (BSA) affected by the burn. Estimating the burn size is crucial for determining the appropriate treatment plan and predicting patient outcomes. Healthcare professionals often use the “Rule of Nines” or the Lund-Browder chart for a more accurate assessment of burn size. These methods divide the body into different regions, with each area accounting for a specific percentage of the total BSA.

The size of a major burn is usually expressed as a percentage, representing the proportion of the body surface affected. For example, a major burn might be classified as a burn involving more than 20% of the total body surface area. The larger the burn size, the higher the risk of complications, such as hypovolemia (fluid loss), infection, impaired thermoregulation, and systemic inflammatory response syndrome (SIRS).

It’s important to note that the depth and size of a burn can greatly impact the patient’s prognosis and treatment course. Therefore, prompt and appropriate medical care is crucial for optimizing outcomes in patients with major burns.

 

Burn Degrees & Percentages

Burns are classified into different degrees based on the severity of the injury and the layers of skin affected. Here are the general percentages and degrees of burns:

1. First-Degree Burns:
   • Superficial burns that affect only the outermost layer of the skin (epidermis).
   • Symptoms include redness, pain, and minor swelling.
   • General percentage: Typically covers a small area.
   • Degree of burn: Mild.
2. Second-Degree Burns:
   • Partial-thickness burns that affect both the outer layer (epidermis) and the underlying layer (dermis) of the skin.
   • Symptoms include redness, blistering, severe pain, swelling, and possible weeping of fluid.
   • General percentage: Can cover a varying percentage of the body, depending on the specific case.
   • Degree of burn: Moderate.
3. Third-Degree Burns:
   • Full-thickness burns that damage all layers of the skin, extending into the deeper tissues below.
   • Symptoms may include charred or white skin, blackened areas, numbness (as nerve endings are destroyed), and a leathery texture.
   • General percentage: The percentage can vary widely, and severe cases can involve large areas of the body.
   • Degree of burn: Severe.

It’s important to note that the general percentage and degree of burns are approximate guidelines and can vary depending on the individual case. The extent and severity of burns are typically assessed by medical professionals using specialized burn assessment techniques.

 

Burn Admission Indications

Burn Pain Management

 

Fluid Replacement

Burns result in the loss of fluids and electrolytes, leading to hypovolemia and potentially life-threatening complications. The primary goals of fluid replacement in burns are to restore and maintain adequate tissue perfusion, prevent hypovolemic shock, and support the body’s healing process. Here is an outline of the fluid replacement approach in burns:

1. Initial assessment:
   • Evaluate the burn extent and depth to determine the need for fluid resuscitation.
   • Calculate the total body surface area (TBSA) affected by the burn using established formulas like the Rule of Nines or Lund-Browder chart.
   • Assess the patient’s overall condition, vital signs, and comorbidities that may influence fluid management decisions.
2. Parkland formula:
   • The Parkland formula is commonly used to estimate the initial fluid resuscitation volume required in the first 24 hours.
   • The formula suggests administering 4 mL of lactated Ringer’s solution or normal saline per kilogram of body weight per percentage of TBSA burned.
   • The calculated fluid volume is typically divided equally over the first 8 hours and administered through an intravenous (IV) line.
3. Titration and monitoring:
   • After the initial fluid bolus, closely monitor the patient’s vital signs, urine output, and other clinical indicators.
   • Adjust the fluid infusion rate based on the patient’s response and urine output.
   • In adults, a urine output of 0.5-1 mL/kg/hour is generally targeted.
   • In children, a urine output of 1-2 mL/kg/hour is often desired.
4. Electrolyte replacement:
   • Burns can cause significant electrolyte imbalances, including hyponatremia, hyperkalemia, and metabolic acidosis.
   • Regularly monitor serum electrolyte levels and replace them accordingly.
   • Potassium levels may rise initially due to tissue damage, and careful monitoring and supplementation are necessary.
5. Colloid solutions and blood products:
   • In severe burns, colloids (e.g., albumin) or blood products may be necessary to maintain oncotic pressure and prevent edema formation.
   • The decision to administer colloids or blood products depends on factors such as burn severity, ongoing fluid losses, and laboratory parameters.
6. Ongoing assessment and adjustment:
   • Continuously reassess the patient’s fluid status, clinical condition, and response to treatment.
   • Modify the fluid replacement regimen as needed, considering factors such as wound healing, infection, and organ function.
7. Special considerations:
   • Inhalation injuries: Patients with inhalation injuries may require early intubation and mechanical ventilation to secure the airway and optimize oxygenation.
   • Electrical burns: These burns can cause significant muscle damage and rhabdomyolysis, leading to myoglobinuria and acute kidney injury. Fluid management should address these complications.

It is essential to note that burn management is a complex process, and the specific fluid replacement approach may vary based on individual patient characteristics, burn severity, and institutional protocols. The outlined steps provide a general framework, but a comprehensive understanding of burn resuscitation guidelines and close monitoring of the patient are crucial for optimal outcomes.