Publish date: Posted on
Last updated: November 27, 2024
Keywords #
first degree burn
second degree burn
third degree burn
Diagnosis #
Burns are relatively common and are due to a broad variety of exposures—including thermal injury. Burn severity is determined by both the source of the burn as well as the amount of time exposed to the source. The longer the exposure, the deeper the penetration and the more severe the damage. Most burns are minor and can be treated in an outpatient setting. Treatment is varied and dependent on the cause of the burn, but can be summarized as wound care, infection prevention, pain management, treatment of complications, and in severe cases, skin grafting and rehabilitation.[1]
Key Concepts #
- Burns are a common traumatic injury and frequently occur at home.
- Mechanism of injury, injury location, and total body surface area are all important determinants of treatment.
- Most burns can be treated in an outpatient setting with simple dressings.
- A small portion of burns require hospitalization and, in very severe cases, require transfer to a certified burn unit.
- Mainstays of treatment consist of moisture control, fluid resuscitation, infection prevention, pain management, and if necessary, skin grafting.[3]
Epidemiology #
Burns are a common household injury, and an estimated 450,000 patients receive medical treatment for burns every year in the United States. Of those 450,000 patients, approximately 40,000 require hospitalization while the rest are managed in the outpatient setting. Seventy-five percent of hospitalized burn patients are treated in dedicated burn centers where the survival rate is 96.6%. The majority of burns occur in men (69%). Approximately 73% of burns happen at home and 71% are accidental. There are various etiologies for burn injuries: fire/flame (43%), scald (34%), hot object contact (9%), electric (4%), and chemical (3%).[4]
Clinical Features #
- Superficial (1st degree burns): the skin is warm, erythematous, painful, blanching, and dry without blisters or eschar. Epithelium remains intact in the acute phase but will slough off in 7-14 days. Self-limited and no potential for scar.[1]
- Superficial partial-thickness (superficial 2nd degree burns): blanching, blistering and moist, hyperemic and erythematous, more painful, typically heal in approximately 1-3 weeks with appropriate wound care, low risk of scarring.
- Deep partial-thickness (deep 2nd degree burns): non-blanching, pain secondary to applied pressure only, pink or pale, require more than 3 weeks to heal, high risk of hypertrophic scar and pigment change.[1]
- Full-thickness (3rd degree burns): dry, leathery, waxy, non-blanching, insensate. Frequently in shades of brown, white, gray, or black with overlying eschar. They will not heal without surgical excision with skin grafting or tissue transposition. Sequela, such as contractures and hypertrophic scars, are common.
- Deeper injury (4th degree burns): some sources use the term “4th degree burn” to refer to injuries that penetrate to and/or expose deep structures (e.g., bone, muscle, tendon).[1]
Differential Diagnoses #
- Thermal burn
- Chemical burn
- Electrical burn
- Radiation burn
- Friction burn
Diagnostic Workup #
There are three essential steps in evaluation that once assessed will help guide treatment strategy. These steps are determining the mechanism/source of the burn (see differential above), the anatomical location/depth of the tissue damage, and the total body surface area (TBSA) affected. If burns were caused by flame or explosion, signs of inhalation injury should also be assessed and include facial burns, singed facial hair, coughing, hoarseness, voice changes, and stridor. A helpful guide for assessing depth of burn penetration is “dead tissue shrinks, damaged tissue swells”. TBSA can be determined by either using the Rule of Nines or the Lund and Bowder chart. [3]
Treatment #
For superficial burns, cooling, cleansing, emollients, and over the counter pain relievers may be utilized. Avoidance of sun exposure and tight clothing should be pursued as well as tetanus prophylaxis as indicated.[3] For deeper burns, drainage of blisters and debridement of non-viable skin is important as well as the application of topical antimicrobial agents and dressings to keep wounds clean and moist. Pain control may require additional use of opiate medications.[2] Fluid resuscitation must be considered in any patient with deep burns covering more than 20% TBSA. Skin grafting should be pursued to facilitate recovery, minimize risk of infection, and prevent scarring.[3] Severe burns often require titration of intravenous opiates – ventilator support may be required to protect the airway and achieve adequate pain control in some patients.[2] Prevention and vigilant surveillance for infection are necessary to ensure recovery.
Slide Viewer #
https://utahderm.med.utah.edu/image-viewer/References #
- Levi, Benjamin, and Stewart Wang. “Burns.” Fitzpatrick’s Dermatology, 9e Sewon Kang, et al. McGraw-Hill, 2019, https://accessmedicine-mhmedical-com.proxy.rvu.edu/content.aspx?bookid=2570§ionid=210422321.
- Drigalla, Dorian, and Brandon Barth. “Burns & Smoke Inhalation.” CURRENT Diagnosis & Treatment: Emergency Medicine, 8e C. Keith Stone, and Roger L. Humphries. McGraw-Hill, 2017, https://accessmedicine-mhmedical-com.proxy.rvu.edu/content.aspx?bookid=2172§ionid=165069359.
- “Burns.” Essential Elements of Wound Diagnosis Rose Hamm, and Joseph N. Carey. McGraw-Hill, 2021, https://accessmedicine-mhmedical-com.proxy.rvu.edu/content.aspx?bookid=3026§ionid=254229016.
- Schneider, Jeffrey C., and Sasha E. Knowlton. “Rehabilitation of the Burn Patient.” Principles of Rehabilitation Medicine Raj Mitra. McGraw-Hill, 2019, https://accessmedicine-mhmedical-com.proxy.rvu.edu/content.aspx?bookid=2550§ionid=206767578.
