Burns

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Introduction
Burn injuries are among the most severe forms of trauma, with the potential to affect multiple organ systems. Despite medical advancements, severe burns are still associated with significant morbidity, mortality, and high healthcare costs due to the need for prolonged hospitalization, rehabilitation, and scar management. Early emergency care can have a profound impact on outcomes, functionality, and survivability.

1. Epidemiology of Burns

Burns are the fourth most common trauma worldwide, following road traffic collisions, falls, and violence【1】. Severe burns are most prevalent in low- and middle-income countries. In the UK, 90% of burn cases are non-complex, but of the 10% that are severe, almost half involve children, especially those under 5 years of age【2】. This makes pediatric burns a crucial consideration for EMS teams and healthcare providers.

2. Anatomy of the Skin

The skin is the body's largest organ and consists of three main layers:

  • Epidermis: Outermost layer (30–40 cells thick) made of keratinized cells, which provide a waterproof barrier. It is avascular and contains no nerve endings【3】.

  • Dermis: Beneath the epidermis, it houses sensory nerves, sweat glands, hair follicles, and capillary vessels. The dermis is connected to the epidermis by a "basement membrane" that becomes less interwoven with age, making older adults more prone to skin injury【4】.

  • Hypodermis: Contains subcutaneous fat, larger blood vessels, and nerves【3】.

3. Types of Burns

Burns are categorized by the source of injury, which can affect their depth and severity:

  • Thermal Burns: Caused by flame, hot liquids (scalds), steam, or hot objects (e.g., hair straighteners). Scalds are the most common burn in children, while dry thermal burns dominate in adults【2】.

  • Chemical Burns: Caused by acids, alkalis, and corrosive substances. Alkali burns are often more severe than acidic burns due to deeper penetration【5】.

  • Electrical Burns: Result from current passing through the body, causing entry and exit wounds and extensive internal damage. While low-voltage burns have a lesser effect, high-voltage burns pose significant risk, and cardiac monitoring is advised due to the risk of arrhythmia【6】.

  • Radiation Burns: Most commonly caused by sunburn, though patients undergoing radiation therapy or exposed to radiation in hazardous environments may also suffer burns【7】.

4. Pathophysiology of Burns

Jackson's Burn Wound Model explains burn damage through three zones:

  • Zone of Coagulation: The area closest to the heat source where cell death occurs irreversibly.

  • Zone of Stasis: Surrounds the coagulation zone, with reduced perfusion that may recover with proper treatment.

  • Zone of Hyperemia: The outermost area with increased perfusion, which is typically reversible【8】.

Systemically, large burns (over 20-30% Total Body Surface Area, or TBSA) trigger a Systemic Inflammatory Response Syndrome (SIRS), leading to capillary leak, fluid loss, and hypovolemic shock【9】.

5. Assessment of Burns

Initial assessment should follow the A-E approach, with concurrent treatment as necessary (e.g., cooling while conducting the examination).

Burn Severity and Extent

  • Total Body Surface Area (TBSA): Can use the "Rule of Nines" for adults, but for children, consider the Lund and Browder chart or Mersey Burns App for more accuracy【10】 In our personal practice we always use the mersey burns app.

  • Depth of Burns: Superficial burns are red and painful, while deeper burns (deep partial or full-thickness) are insensate, may not blanch, and require surgical intervention【3】.

  • Airway Burns: Signs such as singed nasal hair, hoarseness, or soot in sputum may suggest airway burns, but only total body surface area and shortness of breath have been confirmed as independent risk factors for intubation【11】.
    Airway deterioration is generally slow, and related to fluid resuscitation (fluid creep) so no need to panic. recognition and transport is key.

  • Circumferential Burns: Deep circumferential burns around limbs or the chest can restrict blood flow or breathing, potentially necessitating an escharotomy【12】.

6. Management of Burns

Stop the Burn Process

  • Cooling: 20 minutes of cool running water (if within 3 hours of injury) reduces pain and burn depth【13】.

  • Remove: Remove any clothing, jewelry, or objects that may retain heat or chemicals.

Pain Relief

  • Use analgesia early. Severe pain is expected, so effective pain management is crucial【14】.

Fluid Resuscitation

  • For burns >10% TBSA in children or >15% in adults, use the Parkland formula to calculate fluid needs:Fluid Requirement=4 mL×Body Weight (kg)×TBSA(%)Fluid Requirement=4mL×Body Weight (kg)×TBSA(%) Half of the fluid is given in the first 8 hours and the rest over the next 16【15】. Over-resuscitation can cause pulmonary edema, especially in children and the elderly【16】.

Prevent Hypothermia

  • Keep the patient warm using warming blankets and warmed IV fluids【17】.

Advanced Interventions

  • Escharotomy: May be required for circumferential chest burns affecting breathing【12】.

  • Airway Management: For suspected inhalation injury, consider early intubation to avoid airway swelling【11】.

7. Special Considerations

  • Chemical Burns: Brush off dry chemicals and irrigate with large volumes of water. Check pH with litmus paper to guide management【18】.

  • Electrical Burns: Perform ECGs on all patients to detect arrhythmias caused by electrical current passage through the heart【6]. Risk of a delayed arrhythmia is low.

  • Pediatric Patients: Pediatric burns have unique considerations due to the smaller size of their body surface area and higher risk of fluid overload【2】.

Summary of Key Points

  • Burns affect multiple organ systems, and early intervention can reduce long-term morbidity.

  • Initial assessment should use the A-E method, addressing airway and cooling simultaneously.

  • Analgesia is really important. Ensure this is addressed.

  • Use Mersey Burns App for TBSA assessment to reduce overestimation.

  • Calculate and provide fluid resuscitation using the Parkland formula, but avoid over-resuscitation, especially in children and elderly patients.

  • Escharotomy may be needed for circumferential burns.

  • Burns affecting special areas (e.g., face, hands, genitals) warrant specialist care.

References:

  1. Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011;37(7):1087–1100.

  2. NICE Clinical Knowledge Summaries. Burns and scalds. Available from: https://cks.nice.org.uk/topics/burns-scalds/background-information/prevalence/

  3. NCBI. Burn depth classification. Available from: https://www.ncbi.nlm.nih.gov/books/NBK597343/

  4. McCulloh C, Murphy KG, et al. Accuracy of prehospital assessment of total body surface area burned. Burns. 2018;44(5):1192–8.

  5. ScienceDirect. Chemical burns: Pathophysiology and treatment. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0305417918300160

  6. Walter RJ, Navsaria PH, et al. Risk of arrhythmias following electrical burns. Int J Burns Trauma. 2013;3(1):8–12.

  7. The BMJ. Radiation burns pathophysiology and treatment. Available from: https://www.bmj.com/content/374/bmj.n1857

  8. Jackson DM. The diagnosis of the depth of burning. Br J Surg. 1953;40(164):588–96.

  9. BMJ Learning. Major trauma: Burns. Available from: https://www.rcemlearning.co.uk/modules/major-trauma-burns/

Emergency Care, Paediatrics, TraumaJoshua Barkerburns, fire, trauma, burn, scald, flame, injury, fluid, childrenComment