Burn

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

A burn is an injury caused by heat, cold, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, and epidermal tissue can all be damaged with subsequent pain due to profound injury to nerve endings. Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress. Beyond physical complications, burns can also result in severe psychological and emotional distress due to scarring and deformity.

The first case of burns injury was discovered from more than 3,500 years ago. French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s. For many decades after original description, there was little progress in defining the pathogenesis of burns occurred and different treatment. In the 1900’s, it was found that the development of modern burn care began by Arabian physician his name Rhazes, at about the ninth century. In 1940’s major advances procedure was acknowledged(skin graft). to improve the body structure and early wound healing of patients. The term was subsequently formally adopted in medical nomenclature to describe individuals of all ages with a characteristic common symptom pattern, disease causes, and treatment.

Burns may be classified according to severity into first, second and third degree burn injury. It may also be classified based on superficial and deep categories into “Superficial Thickness” , “Partial Thickness” of burns.

A burn is an injury caused by heat, cold, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, and epidermal tissue can all be damaged with subsequent pain due to profound injury to nerve endings. Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress. Beyond physical complications, burns can also result in severe psychological and emotional distress due to scarring and deformity

Burn injury may be caused by chemicals, friction, electricity, radiation, extreme temperatures(hot and cold) and Inhalation injury in burns.

Burn injuries is the most frequently observed form of scald (thermal) injuries, and it typically develops in Children, younger children and younger patients. An estimated 1,344,100 fires Americans of all ages have burn injuries. An estimated patients aged 20 and 30 years are the most prevalent age group . Burn injuries has been known to affect females more than males. people of low and middle income and people in low-income countries are more likely to develop burn injuries than older whites. Pulmonary complications following burns and inhalation injury are responsible for up to 77 percent of the deaths.

Natural History, Complications and Prognosis

Burns injuries is a common condition that involves complications such as the disability . If left untreated, progresses from early stage of burn to advanced skin scar and contraction. Common complications of burns injuries include infection, bedsores, post-burn seizures, hypertrophic scars and keloids, Respiratory complications, systemic complications. There is a cure for burns injuries and the treatment focuses on the stage of the burn( size and depth) so fluid resuscitation, wound excision, grafting and coverage, infection control and nutritional support can be part of the management of the burn injuries.

Although each patient experiences burn injury in a unique way, there are many common symptoms. The symptoms of burn we can divided it in to two types, skin and airways symptoms.

Patients with burn injury usually appear as burned(injury) skin . When a doctor or physician has been admitted burned patient, the diagnosis is usually known by physical examination of the patient. Physical examination of burn injury consists of a thorough of thickness and total body surface area of the patient body. Patient may be have burn on his head, neck, arm, leg, Anterior trunk,Posterior trunk, and genitalia.

There are no specific diagnostic laboratory findings associated with burn injury. However, laboratory findings are done to the estimate the severity of the burn and the symptoms. These include CBC analysis like increase WBC for infection and inflammation , RBC decrease due to trauma of the burn, high hematocrit, because of lost a lot of fluid from leaky blood vessels. BUN reflects kidney damage, decrease total Protein, albumin, and globulin values (proteins have been lost through damaged blood vessels).

ECG has minimal diagnostic value in diagnosing burns but plays a role in diagnosing concurrent conduction abnormalities and monitoring side effects of sever and electrical weapons . Electrocardiogram of a patient with acute burn injury may show prolonged QT and sinus tachycardia .Fatal cardiac arrest by electrical weapons .

CT scan of the burn may be helpful in the diagnosis of burn injury. Findings include skin thickening, subcutaneous soft tissue, and The deep fascia and underlying muscle layer. Computed tomography (CT) the chest evaluate the lungs for inhalation injury and smoke inhalation

Education, engineering, and enforcement are often recommended as both a possible prevention and a sensible way of managing the burn injury. Combination of prevention and care strategies have made progress reducing the incidence of burn injuries and burn severity and lowering rates of burn death and length of hospital stay.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor-In-Chief: Eman Alademi, M.D.[2]

The first case of burns injury was discovered from more than 3,500 years ago. French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s. For many decades after original description, there was little progress in defining the pathogenesis of burns occurred and different treatment. In the 1900’s, it was found that the development of modern burn care began by Arabian physician his name Rhazes, at about the ninth century. In 1940’s major advances procedure was acknowledged(skin graft). to improve the body structure and early wound healing of patients. The term was subsequently formally adopted in medical nomenclature to describe individuals of all ages with a characteristic common symptom pattern, disease causes, and treatment.

Burns injury was discovered from more than 3,500 years ago, since the people use the fire either to prepare the food or to warm themselves.

• many types of treating records during the centuries, Egyptians treated burns by incantations and a mixture of gum, goat’s hair, and milk from a woman who had given birth to a son^[1].

• In the 1500 BCE (years before Christ) Smith papyrus reports of some type of linen strips soaked in an oily preparation ( honey and the salve of resin)^[2].

• Between the sixth and fifth centuries B.C., Chinese and Japanese used tinctures and extracts made from tea leaves rich in tannic acid( recent use) documented to 600 BCE, Neanderthal, man treated burns with extracts of plants, 430 B.C., Hippocrates suggested pig fat, vinegar and tanning with solutions of oak bark. In ancient Rome there were apparently three methods in use:^[3]

• • (1) Celsus described treatment with a honey and bran, and then cork and ashes(wine and myrrh) documented to 100 CE.

• • (2) Pliny the Elder wondered if it would not be better to allow burns to remain exposed to the open air rather than covering them with grease.

• • (3) Galen prescribed vinegar or wine. French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s. Guillaume Dupuytren expanded these degrees into six different severities in 1832.

• Paulus of Aegina, a Byzantine of the seventh century A.D. whose writings reflected Greco-Roman thought, used various emollient preparations.

• The famous Arabian physician, Rhazes, at about the ninth century, used ice cold water. The first hospital to treat burns opened in 1843 in London, England, and the development of modern burn care began in the late 1800s and early 1900s.

• During World War I, Henry D. Dakin and Alexis Carrel developed standards for the cleaning and disinfecting of burns and wounds using sodium hypochlorite solutions, which significantly reduced mortality.

• In the 1940s, the importance of early excision and skin grafting was acknowledged, and around the same time, fluid resuscitation and formulas to guide it were developed. In the 1970s, researchers demonstrated the significance of the hypermetabolic state that follows large burns ^[4][5][6][7].

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Burns may be classified according to severity into first, second and third degree burn injury. It may also be classified based on superficial and deep categories into “Superficial Thickness” , “Partial Thickness” of burns.

The most common system of classifying burns categorizes them as first, second, or third-degree. Sometimes this is extended to include a fourth or even up to a sixth degree, but most burns are first- to third-degree, with the higher-degree burns typically being used to classify burns post-mortem. The following are brief descriptions of these classes:^[1]The basis of burn classification is depth. When examining a burn, there are four components needed to assess depth: appearance, blanching to pressure, pain, and sensation.^[2] Burns can be categorized by thickness according to the American Burn Criteria using those four elements. Burn injuries tend to be a dynamic process. Some burns, especially partial-thickness, may progress over 2 to 4 days, peaking at day 3.^[3]

• First-degree burns(Partial Thickness Superficial) are usually limited to redness (erythema), a white plaque and minor pain at the site of injury. These burns only involve the epidermis of the skin.^[4][3]
• Second-degree burns(Superficial partial-thickness) manifest as erythema (red) which blanches with pressure, with superficial blistering and wet of the skin, and can involve more or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer.So the pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.^[4][3]
• Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
• Third-degree burns(full thickness) occur when most of the epidermis is lost with damage to underlying ligaments, tendons and muscle. Burn victims will exhibit charring of the skin, and sometimes hard eschars will be present. An eschar is a scab that has separated from the unaffected part of the body. These types of burns are often considered painless, because nerve endings have been destroyed in the burned area. Hair follicles and sweat glands may also be lost due to complete destruction of the dermis. Third degree burns result in scarring and may be fatal if the affected area is significantly large. If extensive enough, it can increase the risk of infection, including bacterial, and can result in death. Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.
• Fourth-degree burns damage bone tissue and may result in a condition called compartment syndrome, which threatens both the life of the limb and the patient. charred skin with possible exposed bone.
• Fifth-degree burns are burns in which most of the hypodermis is lost, charring and exposing the muscle underneath. Sometimes, fifth-degree burns can be fatal .charred, white skin, and exposed bone.
• Sixth-degree burns, the most severe form, are burn types in which almost all the muscle tissue in the area is destroyed, leaving almost nothing but charred bone. Often, sixth-degree burns are fatal. loss of skin with exposed bone.

A newer classification of “Superficial Thickness” , “Partial Thickness” (which is divided into superficial and deep categories) and “Full Thickness” relates more precisely to the epidermis, dermis and subcutaneous layers of skin and is used to guide treatment and predict outcome.^[5]

Burns can also be assessed in terms of total body surface area (TBSA), which is the percentage affected by partial thickness or full thickness burns (superficial thickness burns are not counted). The rule of nines is used as a quick and useful way to estimate the affected TBSA.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

A burn is an injury caused by heat, cold, electricity, chemicals, light, radiation, or friction. Burns can be highly variable in terms of the tissue affected, the severity, and resultant complications. Muscle, bone, blood vessel, and epidermal tissue can all be damaged with subsequent pain due to profound injury to nerve endings. Depending on the location affected and the degree of severity, a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance and respiratory distress. Beyond physical complications, burns can also result in severe psychological and emotional distress due to scarring and deformity.

Burns is the result of damage to the skin involving the two main layers – the thin, outer epidermis and the thicker, deeper dermis by a temperatures greater than 44 °C (111 °F), leads to cell and tissue damage because of breaking down of the cells proteins then start losing their three-dimensional shape. Burn caused by^[1][2]:

• Thermal injuries the most common type of burn.

• Electrical injuries (can be deceiving with small entry and exit wounds, however, there may be extensive internal organ injury or associated traumatic injuries).

• Chemical injuries (divided into acid or alkali burns. Alkali burns tend to be more severe causing more penetration deeper into the skin by liquefying the skin (liquefaction necrosis) and acid burns penetrate less because they cause a coagulation injury (coagulation necrosis).

• Non-accidental injury like:^[3][4]

Most burns are small and superficial causing only local injuries, However, burns can be larger and deeper, and patients can also have a systemic response to severe burns ​^[5][6]

The three zones of a burn were described by Jackson in 1947.

Zone of coagulation—This occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins.

Zone of stasis—The surrounding zone of stasis is characterized by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insults—such as prolonged hypotension, infection, or edema—can convert this zone into an area of complete tissue loss.

Zone of hyperemia—In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.

These three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening.

The increase of the catecholamines and cortisol,or The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% of total body surface area and the site of injury lead to:

1. Cardiovascular system changes—Capillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial compartment. Peripheral and splanchnic vasoconstriction occurs. Myocardial contractility is decreased, possibly due to release of tumor necrosis factor α (TNFα). These change^[7][8]s, coupled with fluid loss from the burn wound,^[9] result in systemic hypotension and end organ hypoperfusion because of Increased levels of catecholamines. and a fast heart rate^[10]
2. Renal system changes—kidney failure because of the Poor blood flow to organs.^[11]
3. Respiratory system changes—Inflammatory mediators cause bronchoconstriction, and in severe burns adult respiratory distress syndrome can occur.
4. Gastrointestinal system changes— stomach ulcers because of the Poor blood flow to organs.^{[12][13][14][15][16][17]}
5. Skin^{[18][19][20][21]}
6. Immune system changes—Non-specific down regulation of the immune response occurs, affecting both cell mediated and humeral pathway^[22][23][24].^[25][26]
7. Metabolic changes—The basal metabolic rate increases up (hypermetabolic) to three times its original rate because of Increased levels of catecholamines and cortisol . This, coupled with splanchnic hypoperfusion, necessitates early and aggressive enteral feeding to decrease catabolism and maintain gut integrity. Immunological^[27][28][29] ​
8. Increased leakage of fluid from the capillaries, and subsequent tissue edema. This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated.^[30]
   ​

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:Eman Alademi, M.D.[2]

Burn injury may be caused by chemicals, friction, electricity, radiation, extreme temperatures(hot and cold) and Inhalation injury in burns.

Burns may be caused by a wide variety of substances and external sources such as exposure to chemicals^[1]. friction, electricity, radiation, and extreme temperatures, both hot and cold.

Most chemicals (but not all) that can cause moderate to severe chemical burns are strong acids or bases. Chemical burns are usually caused by caustic chemical compounds, such as sodium hydroxide, silver nitrate, and more serious compounds (such as sulfuric acid and Nitric acid). Hydrofluoric acid ^[2]can cause damage down to the bone and its burns are sometimes not immediately evident.^[3][4]

Electrical burns are generally caused by an exogenous electric shock, such as being struck by lightning^[5][6][7][8]or defibrillated or cardioverted without a conductive gel. The internal injuries sustained may be disproportionate to the size of the burns seen, and the extent of the damage is not always obvious. Such injuries may lead to cardiac arrhythmias, cardiac arrest, and unexpected falls with resultant fractures.

Radiation burns may be caused by protracted and overexposure to UV light (as from the sun), tanning booths, radiation therapy (as patients who are undergoing cancer therapy), sunlamps, and X-rays. By far the most common burn associated with radiation is sun exposure, specifically two wavelengths of light UVA, and UVB, the latter being the more dangerous of the two. Tanning booths also emit these wavelengths and may cause similar damage to the skin such as irritation, redness^[9], swelling, and inflammation. More severe cases of sun burn result in what is known as sun poisoning.

Scalding ^[10]is a specific type of burning that is caused by hot fluids or gases. They most commonly occur in the home from exposure to high temperature tap water.^[11][12]

Steam is a common gas that causes scalds. The injury is usually regional and usually does not cause death. More damage can be caused if hot liquids enter an orifice. However, deaths have occurred in more unusual circumstances, such as when people have accidentally broken a steam pipe.

The demographics that are of the highest risk to suffering from scalding are young children, with their delicate skin, and the elderly over 65 years of age.

A cold burn (see frostbite) is a kind of burn which arises when the skin is in contact with a low-temperature body.

They can be caused by prolonged contact with moderately cold bodies (snow and cold air for instance) or brief contact with very cold bodies such as dry ice, liquid helium, liquid nitrogen, or liquid discharged from an upside-down gas duster. In such a case, the heat transfers from the skin and organs to the external cold body.

The effects are very similar to that of a burn caused by extreme heat. The remedy is also the same. For a minor cold burn, it is advisable to keep the injured organ under a flow of water of comfortable temperature. This will allow heat to transfer slowly from the water to the organs.

pulmonary complications were common in burn patients, inhalational injury has now replaced these two causes as the main cause of mortality in burn patients. Inhalational injury by itself has been shown to be associated with pulmonary dysfunction for at least 6 months after the injury. Pulmonary complications in burn patients can arise from direct injury to the respiratory tract via the inhalation of heated air and chemicals released by combustion, and also iatrogenic factors such as fluid-overloading during resuscitation and lung damage by mechanical ventilation.

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Editor-In-Chief: Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1][[2]] Associate Editor(s)-in-Chief:Eman Alademi, M.D.[3]

Burn injuries is the most frequently observed form of scald (thermal) injuries, and it typically develops in Children, younger children and younger patients. An estimated 1,344,100 fires Americans of all ages have burn injuries. An estimated patients aged 20 and 30 years are the most prevalent age group . Burn injuries has been known to affect females more than males. people of low and middle income and people in low-income countries are more likely to develop burn injuries than older whites. Pulmonary complications following burns and inhalation injury are responsible for up to 77 percent of the deaths.

• The incidence of burn injury is approximately 86% of sustained burns/ scald (thermal) injuries, 4%sustained electrical burn injuries, and 3%remaining Are chemical. ^[1][2]

• In the 10 years from 2008 to 2017, the incidence in the United States of burns is approximately 1,344,100 fires, resulting in deaths per 100,000 individuals with a case-fatality rate of 3190 civilian, 16,225 civilian injuries.

• Patients of all age groups may develop burns injury, but flame and scale burns it’s commonly affects individuals Children and younger(children younger than five years old are more often injured with scald burns) than/older(More adults are injured with flame burns ). patients aged between 20 and 30 years are the most prevalent age group, representing 15 percent of cases ^[3]. Older adults are most likely to sustain a burn in the bathroom, followed by the kitchen^[4] . Pediatric burns occur more commonly in the home (84 percent) when children are unsupervised (80 percent)^[5][6] .

• There is no racial predilection to burn injury.

• Female ^[7]are more commonly affected by critical burn injury than male (>25% body surface area) was statistically significant in adults^[8][9][10]

• Burn injuries more commonly affect people of low and middle income and people in low-income countries^{[2][11][12][13][14][15]}.

• Pulmonary complications following burns and inhalation injury are responsible for up to 77 percent of the deaths, among which the majority are due to carbon monoxide poisoning^[16][17]. Inhalation injury is a common then burn injury that tends to affect patient. The incidence of this injury increases with age and size of the burn injury^[18][19] .In addition, inhalation injury has been shown to be an independent predictor of mortality in burn^[20].

• Armed conflict increases the incidence of burns, as shown by a survey of burns in Baghdad that demonstrated a rise in incidence from 30 per 100,000 in 2003 to 117 per 100,000 after invasion^[21]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Eman Alademi, M.D.[2]

Burns injuries is a common condition that involves complications such as the disability . If left untreated, progresses from early stage of burn to advanced skin scar and contraction. Common complications of burns injuries include infection, bedsores, post-burn seizures, hypertrophic scars and keloids, Respiratory complications, systemic complications. There is a cure for burns injuries and the treatment focuses on the stage of the burn( size and depth) so fluid resuscitation, wound excision, grafting and coverage, infection control and nutritional support can be part of the management of the burn injuries.

Patients with burn injury If left untreated^[1], may progress to develop^[2]:

• infection and sepsis“: burn infection, Wound-associated inflammation is limited by immediate debridement of devitalized tissue and tangential excision of burn tissue and wound closure, primarily by skin grafts, within 48 hours of a full-thickness burn^[3][4]. ( “Hypermetabolic response to moderate-to-severe burn injury and management”, section on ‘Early excision and grafting’ and “Burn wound)

• post-burn seizures,

• scar tissue called hypertrophic scars and keloids,

• Respiratory complications: include inhalation injuries^[5][6]aspiration of fluids by unconscious patients, bacterial pneumonia, pulmonary edema, obstruction of pulmonary arteries, and postinjury respiratory failure. The three basic categories of direct-inhalation injuries are inhalation of dry heat and soot, carbon monoxide poisoning, and smoke inhalation.

• systemic complications^[7] like: Multisystem organ dysfunction — Multiple organ dysfunction syndrome (MODS) is a progressive disorder that commonly occurs in acutely ill patients, regardless of etiology of the injury or illness. MODS exists in a continuum with the systemic inflammatory response syndrome (SIRS) which affects most patients with a severe burn, with or without an infection^[8] . The risk of MODS increases with burn wounds >20 percent total body surface area (TBSA), increasing age, male gender, sepsis, hypoperfusion, and under-resuscitation^[9][10]. Approximately 50 percent of patients who succumbed to the burn injury had been diagnosed with MODS^[11]. Most patients with MODS have an inability to attenuate the inflammatory response to injury. (See “Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis“, section on ‘Multiple organ dysfunction syndrome‘ and “Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis”, section on ‘Definitions’.)

In general, the burn wound or lungs are the most likely sites for an infection in the severely burned patient that subsequently develops MODS^[12][13]. The release of endotoxins and/or exotoxins from an infective process initiates a cascade of inflammatory mediators that leads to organ damage and ultimately organ failure. Targeting the different cascade systems involved in the pathogenesis of burn-induced MODS is often not a feasible option^[14].

Prevention of sepsis from burn wound infection is the most promising approach and illustrated by:

1. physiologically: such as the recognition of the importance of burn surface area, infection control and nutritional support and skin grafting and coverage,, ^[15]However, this was not reflected in improving survival and many patients still died of shock and infection

2.psychologically.^[16]

Prognosis is generally depend on the etiological characteristics of the different age groups that should be considered for prevention. BI can be a reliable index of prognosis in severely burned patients. The results of the study showed that a large BI, elderly age, delayed admission after injury and combined inhalation injury are the main risk factors for extensively burned patients. ^[17][18][19].

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