Steven E. Wolf, MD, Golden Charity Guild Charles R. Baxter, MD Distinguished Chair in Burn Surgery; Professor and Vice-Chair for Research, Department of Surgery, University of Texas - Southwestern Medical Center
Burns are injuries to tissue that result from heat, electricity, radiation, or chemicals.
Burns cause varying degrees of pain, blisters, swelling, and skin loss.
Deep, extensive burns can cause serious complications, such as shock and severe infections.
Small, shallow burns may need only to be kept clean and to have an antibiotic cream applied.
People with deep or extensive burns may require intravenous fluids, surgery, and rehabilitation, often at a burn center.
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, sunlight, and electricity differ significantly. Events associated with a burn, such as jumping from a burning building, being struck by debris, or being in a motor vehicle crash, may cause other injuries.
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. In addition, damaged skin and other body surfaces are easily infected because they can no longer act as a barrier against invading microorganisms.
More than 2 million people in the United States require treatment for burns each year, and between 3,000 and 4,000 die of severe burns. Older people and young children are particularly vulnerable. When children and elderly people are burned, doctors also consider the possibility that the person was abused.
When Chemicals Burn the Skin
Chemical burns are caused by caustic substances that contact the skin. Caustic substances are sometimes present 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 steps in stopping chemical burns are
Remove contaminated clothing.
Brush away any dry powders or particles.
Rinse the area 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.
If more information is needed concerning treatment of a burn caused by a specific chemical, the local Poison Control Center can be contacted at 1-800-222-1222.
Doctors classify burns according to strict, widely accepted definitions. The definitions classify the burn’s depth and the extent of tissue damage.
The depth of injury from a burn is described as first, second, or third degree:
First-degree burns are the most shallow (the most superficial). They affect only the top layer of skin (epidermis).
Second-degree burns (also called partial-thickness burns) extend into the middle layer of skin (dermis). Second-degree burns are sometimes further described as superficial (involving the more superficial part of the dermis) or deep (involving both the superficial and the deep parts of the dermis).
Third-degree burns (also called full-thickness burns) involve all three layers of skin (epidermis, dermis, and fat layer). Usually, the sweat glands, hair follicles, and nerve endings are destroyed as well.
Estimating the Extent of a Burn
To determine the severity of a burn, doctors estimate what percentage of the body’s surface has second-degree or third-degree burns. For adults, doctors use the rule of nines. This method divides almost all of the body into sections of 9% or of 2 times 9% (18%). For children, doctors use charts that adjust these percentages according to the child’s age (Lund-Browder charts). Adjustment is needed because different areas of the body grow at different rates.
Burns are classified as minor, moderate, or severe. These classifications may not correspond to a person’s understanding of those terms. For example, doctors may classify a burn as minor even though it can cause the person significant pain and interfere with normal activities. The severity determines how they are predicted to heal and whether complications are likely. Doctors determine the severity of the burn by its depth and by the percentage of the body surface that has second-degree or third-degree burns. Special charts are used to show what percentage of the body surface various body parts comprise. For example, in an adult, the arm constitutes about 9% of the body. Separate charts are used for children because their body proportions are different.
Minor burns: All first-degree burns as well as second-degree burns that involve less than 10% of the body surface usually are classified as minor.
Moderate and severe burns: Burns involving the hands, feet, face, or genitals, second-degree burns involving more than 10% of the body surface area, and all third-degree burns involving more than 1% of the body are classified as moderate or, more often, as severe.
Symptoms of Burns
Symptoms of a burn wound vary with the burn’s depth:
First-degree burns are red, swollen, and painful. The burned area whitens (blanches) when lightly touched but does not develop blisters.
Second-degree burns are pink or red, swollen, and extremely painful. Within 24 hours (often shortly after the burn), blisters develop 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.
The appearance and symptoms of deep burns can worsen during the first hours or even days after the burn.
Did You Know...
The deepest burns may cause the least pain because the nerves that sense pain are destroyed.
Diagnosis of Burns
Evaluation of depth and extent of wound
Sometimes blood and urine tests
Doctors frequently examine hospitalized people for complications and assess burn wound depth and extent. In people with large burns, blood pressure, heart rate, and urine volume are measured often to help assess the extent of dehydration or shock and the need for intravenous fluids. Doctors do blood tests to monitor the body’s electrolytes and blood count. Electrocardiography (ECG) and chest x-ray are also required. Tests of blood and urine are done to detect proteins caused by the destruction of muscle tissue (rhabdomyolysis) that sometimes occurs with deep third-degree burns.
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 contains certain poisonous chemicals or is unusually dense or if inhalation is prolonged, serious problems can develop.
Hot smoke sometimes burns the throat, resulting in swelling. As the swelling narrows the throat, the flow of air into the lungs is blocked (obstructed). Breathing hot steam can burn the lungs as well as the throat, causing severe breathing problems.
Inhalation of chemicals released in the smoke, such as hydrogen chloride, phosgene, sulfur dioxide, toxic aldehyde chemicals, and ammonia, can cause swelling and damage to the windpipe (trachea) and even the lungs. 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 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 cause difficulty breathing air in, wheezing, and shortness of breath. People 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, people 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 injury due to smoke inhalation, doctors may pass a flexible viewing tube (bronchoscope) into the trachea. Doctors may assess lung damage with a chest x-ray or with a test that determines the level of oxygen in the blood. Blood tests may be done to help diagnose carbon monoxide or cyanide poisoning.
People who have inhaled smoke are given oxygen through a face mask. If a tracheal burn is suspected, a breathing tube is inserted through the nose or mouth in case the trachea later swells and obstructs airflow. If people begin 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.
Complications of Burns
Minor burns are usually 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 in a limb or digit, the resulting contracture may restrict movement of nearby joints.
Severe burns and some moderate burns can cause serious complications due to extensive fluid loss and tissue damage. These complications may take hours or days to develop. The deeper and more extensive the burn, 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. The following are some complications of some moderate and severe burns:
Dehydration eventually develops in people with widespread burns, because fluid seeps from the blood to the burned tissues and, if burns are deep and extensive enough, to the whole body.
Chemical imbalances can result from extensive burns.
Destruction of muscle tissue (rhabdomyolysis) sometimes occurs with 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.
Infection can complicate burn wounds. Sometimes the infection can spread throughout the bloodstream and cause severe illness or death.
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.
The body temperature can become dangerously low (hypothermia) when cool fluids are given to try to correct dehydration, especially if the person is exposed in a cool emergency room environment as doctors evaluate and treat severe burns.
Treatment of Burns
For minor burns, cooling the wound with room temperature water for several minutes, followed by wound care and dressing
For severe burns, hospitalization and treatment of complications as well as burns
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 a hot substance (for example, tar), or soaked with chemicals—is immediately removed.
Hospitalization is sometimes necessary for optimal care of burns. 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 people from carrying out essential daily functions, such as walking or eating, or that cause severe pain, often make hospitalization necessary. Severe burns, deep second-degree 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 immediately cooled with room temperature water for several minutes, if possible. The burn is carefully cleaned to prevent infection. If dirt is deeply embedded, doctors 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.
Care at home includes keeping the burn clean to prevent infection. In addition, many people are given analgesics, often opioids, 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 room temperature water over the burn can help relieve pain. Covering the burn with an over-the-counter antibiotic ointment and a nonstick, sterile bandage can help 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 the size of the person’s open hand
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 decrease within one day after the burn was sustained
Deep minor burns
As with more superficial burns, deep minor burns are treated with antibiotic cream. Sometimes doctors do not use antibiotic cream but instead apply special sterile dressings that can be left in place for several days to a week. Some of these dressings contain silver, which helps kill bacteria. Other dressings are slightly porous—just enough to allow fluid to drain from the burn but not enough to let bacteria through. Any dead skin and broken blisters should be removed by a health care practitioner before the antibiotic cream or dressing 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 admission to a hospital or 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 to replace burned skin that will not heal. 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), a dead person (allograft), or an animal (xenograft). Autografts can be solid pieces of skin or meshed grafts. For a meshed graft, doctors use a tool to make multiple, regularly spaced, small incisions in the piece of skin. The incisions allow the donor skin to be stretched to cover a much larger area (often several times the area of the original piece of skin). Meshed grafts are used in areas where appearance is less of a concern and when burns involve more than 20% of the body surface and donor skin is scarce. Meshed grafts heal with an uneven gridlike appearance, sometimes with excessive scarring. After any dead tissue is removed and the wound is clean, a surgeon sews or staples the skin graft over the burned area. Artificial skin can also be used. Autografts are permanent. Allografts and xenografts, however, are rejected after 10 to 21 days by the person’s immune system, and artificial skin is removed. Although allografts and xenografts provide temporary protection to healing skin, an autograft eventually must be placed if the wound is full-thickness and is too large to heal by itself. 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 and to help people function if joint motion is limited. 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 3 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, life-threatening burns require immediate care. People who have gone into shock as a result of dehydration are given oxygen through a face mask.
Large amounts of intravenous fluids are given, beginning immediately, for people who have dehydration, shock, or burns that cover a large area of the body. Fluids are also given to people who develop destruction of muscle tissue. 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.
A surgical procedure to cut open eschars that cut off blood supply to a limb or that impair breathing may be needed. This procedure is 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.
Skin care is extremely important. Keeping the burned area clean is essential, 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 at various intervals (usually once per day or less frequently), depending on the type of dressing. Skin grafts are needed to cover burns that will not heal.
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 less often nutrition may be given intravenously. Additional vitamins and minerals are usually given.
Physical and occupational therapy are needed.
Depression is treated. Because severe burns take a long time to heal and can cause disfigurement, people can become depressed. Depression often can be relieved with drugs, psychotherapy, or both.
First-degree and some second-degree burns heal in days to weeks without scarring. Deep second-degree and small third-degree burns take weeks to heal and usually cause scarring. Most require skin grafting. Burns that involve more than 90% of the body surface, or more than 60% in an older person, are often fatal.
Burns are usually caused by heat (thermal burns), such as fire, steam, tar, or hot liquids. Burns can be caused by other agents. Which of the following agents causes burns that most closely resemble thermal burns?