Burn Injuries
Even though the number of burn injuries is going down in the US, about 1.25 million people get burned each year. About 60,000-80,000 people require hospitalization for their burns and 5500 die from their injuries. Most burns requiring hospitalization involve body areas greater than 10 percent or those that involve the face, hands, feet, or perineum. Most burns are flame burns or scald burns.
Mortality Rate
The mortality rate at which 50 percent of the patients die is about 98 percent total burn surface area. This has improved dramatically over the years. This is true of people under the age of 14. The statistics are worse for elderly adults, where a 35 percent degree burn kills half of all patients.
Criteria for Burn Unit Admission
Not all people need to be admitted to a burn center. Those that do meet these criteria:
- Second and third-degree burns greater than 10 percent of body surface area.
- Full-thickness burns
- Any burn of the face, hands, feet, eyes, ears or perineum
- Electrical injury
- Inhalational injury
- Chemical burns
- Burns in patients with other significant health problems
Classifying Burns
Burns are classified into six different causes: flash burns, flame burns, liquid spill, liquid immersion, grease, or steam burns. They are also classified according to burn depth. There are superficial burns (first-degree burns), partial-thickness burns (second degree) full-thickness or deep partial-thickness burns (third degree), or burns involving deep tissues or organs (fourth-degree).
Skin Layers
The skin is the barrier to burns, and when it is breached, there is deeper involvement beneath the skin. There is a deep layer, known as the “zone of stasis” involved in deeper wounds in which the blood flow is greatly diminished. Giving medications that improve blood flow to the skin can decrease the depth of the burn.
Inflammatory Response in Burns
There is an inflammatory response released whenever there is a burn. This response affects the area directly around the burn as well as distant organs. It can cause both constriction and dilation of the blood vessels, increased leakiness of the capillaries, and swelling around the wound. The heart has a decrease in circulating blood volume and decreased cardiac output. There can be direct damage to the heart. Kidney flow decreases, which can cause kidney failure. There is a high degree of total body metabolism around the time of the burn.
Care of the Burn Patient
First, the burning process must be stopped. This involves removing the patient from the source of the wound, removing clothing, and jewelry. The patient is wrapped in a clean sheet or blanket. The patient should receive 100 percent oxygen and should have a secure airway if there is any evidence of an inhalation injury.
Treatment for Carbon Monoxide Injury
An oxygen level and carbon monoxide level should be obtained because carbon dioxide can make the oxygen levels falsely higher. Treatment of carbon monoxide injury involves giving 100 percent oxygen by mask or by using an endotracheal tube. Hyperbaric chambers are used to treat injuries that involve high levels of carbon monoxide as they get rid of the carbon dioxide in the blood. If the chest is burned all the way around, the injury may restrict ventilation and, as in compartment syndrome, cuts are made in the skin to open up the skin around the chest wall to allow for swelling to get out.
Administering IV Fluids
IVs must be used to provide fluid resuscitation of the client. This involves giving Lactated Ringer’s solution in adults and a solution of Lactate Ringer’s solution and sugar in kids under two. The amount of fluid given can be calculated based on the amount of tissue burned.
Fluid that has a greater concentration of salt in it has its advantages. It can reduce the amount of swelling around the wound and decreases net fluid intake. Some doctors have found that giving this type of fluid can damage the kidneys so it must be used carefully or not at all. The amount of fluid is considered adequate when the adult has a urine output of 0.5 cc/kg per hour and when a child has a urine output of 1.0 cc/kg per hour.
Treating Other Injuries
Other injuries can happen along with the burn so that the patient should be fully evaluated for associated injuries that may be life-threatening. While other injuries are being treated, the burns need to be covered. Coldwater or ice should not be given in burn patients as this can cause hypothermia.
First Degree Burns
Superficial or first-degree burns involve only the outer layer of the skin. They are red and painful but do not blister. Treatment is aimed at making the person comfortable and applying salves that may or may not contain aloe. The burn heals in 3-6 days and will not scar.
Second Degree Burns
Second degree or partial thickness wounds can be superficial or deep. All partial thickness burns have some degree of damage to the dermis part of the skin. They are very painful and often include red areas that blanch with touching and often result in blisters. The blisters often don’t show up for several hours. The burns heal in 21-28 days, depending on the depth of the burn. They often heal with excessive scarring. The longer the wound takes to heal, the worse the scarring will be.
Third Degree Burns
Full-thickness or third-degree burns are burned down to the subcutaneous tissue. These burns are often firm and leathery and generally do not hurt. The surface of such a burn is called an eschar. It is usually not sensitive to pinpricking but can be sensitive to putting pressure on the burn. These burns often require grafting in order to heal well.
Fourth Degree Burns
Fourth-degree burns involve other tissues, such as muscle, bone, and tendon. These often are charred burns that occur from prolonged exposure to fire or to a hot surface. These are the most difficult types of burns to heal.
Treatment of Burns
If there is a full-thickness or partial thickness burn that surrounds the chest wall or an extremity, there can be so much swelling that the circulation is blocked off to the part of the body past the burned areas. This is called “compartment syndrome”. In some cases, cuts need to be placed in certain areas of the burn to allow the swollen area to balloon out from the skin cut, relieving the pressure on the blood vessels and nerves. The burned area can involve the upper extremity, the lower extremity, the hands, and the feet as well as on the abdomen as noted above.
Inhalation Injuries
Inhalation injuries contribute to the death rate of burns. It can block the normal gas exchange of the lungs, making getting oxygen difficult. Damage is caused by inhaling toxins. The upper airways are heated and this pushes toxins in the deeper part of the lungs, causing a chemical injury in the lungs. Clots of inflammatory tissue can solidify in the bronchial tree, trapping air inside the lungs. These fibrin clots need to be manually removed using a bronchoscopy device.
Smoke Inhalation
People with smoke inhalation usually have been exposed to smoke in an enclosed space and present with wheezing and difficulty breathing. They often have facial burns and coal dust in their sputum. Bronchoscopy is a good way to look down inside the lungs to see if there are burned areas there. Mechanical ventilation with a ventilator is usually required and several bronchoscopy procedures need to be done to evaluate the ulcerations of the airways and swelling of the airways.
The management of inhalation injuries involves keeping the airways open, clearing secretions, and improving air exchange while the lung heals. Chest therapy and physiotherapy are used along with suction to get the mucus out of the lungs. Heparin can be given through a nebulizer in order to reduce the formation of hard casts of material in the bronchial tree and improves ventilation.
Chemical Burns
Chemical burns need prompt treatment to eliminate the presence of a deep burn. If the chemical composition of the burning substance is known, this will give the doctor an idea of how long to irrigate the wound. Wounds are treated with copious amounts of water to get rid of the offending agent on the skin. Burn fluids with a low pH (acids) tend to coagulate the proteins in the skin and don’t go deep. High pH fluids (such as alkali) dissolve tissue and can go much deeper than the skin.
Some chemical burns require emergency surgery to get rid of dead tissue and to test the pH of the remaining tissue. After the chemical injury has been removed, the burns are treated in much the same way as thermal burns. Hydrofluoric acid burns are especially dangerous because the substance binds calcium in the bloodstream, lowering calcium levels. Calcium needs to be replaced in these types of burns.
Electrical Burns
Electrical burns cause mostly internal burns. The electrical current passes down the area of least resistance, such as the vessels, nerves, and muscles. There may be very little to see on the outside but severe burns to the above areas nevertheless. Muscle damage is particularly dangerous and can result in proteins being released from the muscles which can damage the kidneys if not a lot of fluid is given to treat the condition. Compartment syndrome can occur, necessitating the same cuts to the skin as described above to treat the swollen muscles.
Burn Care
The use of dressings that are antimicrobial has greatly reduced the incidence of burn-related infections. They used to allow bacteria to separate the outer eschar from the healthy skin but this has been replaced by cutting out the burned area and grafting the burn. Topical antibiotic ointments are given in those situations that don’t need grafting. The wound should then be covered with sterile dressings that are comfortable to wear and that prevent infection from occurring.
Full-thickness burns will not heal in a timely fashion without grafting. This is also true for some partial-thickness burns. Ideally, if grafting is necessary, the patient’s own skin is the best graft to use. Burn grafts can be mesh-like or not.
Some doctors remove the burn in stages, while others remove the entire thing in just one sitting. Ideally, the removal of dead tissue should occur within the first 24 hours, before bacteria have set in. The loss of the skin graft can occur if the graft becomes infected or if fluid builds up underneath the skin graft. If there is residual dead material in the burn, the graft often will not stick.
Infections
Infection is minimized by removing the burned area quickly and by using anti-bacterial agents to cover the wound. Antibiotic salves can be applied once or twice a day or the person can be immersed in an antibacterial solution. Antibiotic salves include silver sulfadiazine or Silvadene, bacitracin, neomycin, polymyxin B, or mupirocin. No single agent is completely effective and each has its advantages and disadvantages. Nystatin powder can also be used to prevent fungus infections in the wound.
Antibiotics given by IV have usefulness just prior to surgery and can decrease the amount of blood infection until the wound has healed.
Major Burns Can Affect the Rest of the Body
Major burns can affect the rest of the body besides the skin. There is a generalized inflammatory response that can affect the blood, lungs, liver, kidneys, and heart. Each of these areas must be taken care of in the course of burn management.
Fluid resuscitation is very important as there is a lot of fluid lost through the burn and through the donor sites. Daily weights are important to make sure enough fluid is being given to the patient. Urine output can also be a measure of adequate fluid intake.
Organ Failure
Kidney failure can happen from inadequate resuscitation of the patients or can happen 2-4 weeks later if the patient is taking medications that damage the kidneys or have an infection. Patients may get life-threatening congestive heart failure, high potassium levels, and pulmonary edema, which may lead to the need for dialysis.
Liver failure can happen because of toxins associated with a chemical injury or from flame burns in which gasoline or other chemicals were used. Later on, liver function can diminish if there is a blood-borne infection. These can cause a fatty liver that cannot do its job. The liver can stop making blood clotting factors, which can lead to bleeding complications.
Nutrition Important After Burn Trauma
Patients with major burns have the highest metabolic rate when compared to other critically-injured patients. Lean body mass is quickly lost in the weeks after a burn injury. This requires early feeding of nutrition to the client, either through oral intake if able, or through parenteral support.
I’m Ed Smith, a Sacramento Burn Injury attorney. If you need a Sacramento lawyer because of a serious burn from a fire, call me today for free, friendly advice. In Sacramento 916-921-6400. Elsewhere 800-404-5400.
Member of Million Dollar Advocates Forum.