Burns

What are burns?

Burns are a type of traumatic injury caused by thermal, electrical, chemical, or electromagnetic energy. Smoking and open flame are the leading causes of burn injury for older adults, while scalding is the leading cause of burn injury for children. Both infants and the elderly are at the greatest risk for burn injury.

What are the different types of burns?

A burn injury usually results from an energy transfer to the body. There are many types of burns caused by thermal, radiation, chemical, or electrical contact.

  • Thermal burns - burns due to external heat sources which raise the temperature of the skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames, when coming in contact with the skin, can cause thermal burns.
  • Radiation burns - burns due to prolonged exposure to ultraviolet rays of the sun, or to other sources of radiation such as x-ray.
  • Chemical burns - burns due to strong acids, alkalies, detergents, or solvents coming into contact with the skin and/or eyes.
  • Electrical burns - burns from electrical current, either alternating current (AC) or direct current (DC).

The skin and its functions

The skin is the largest organ of the body and has many important functions. It is composed of the following layers, with each layer performing specific functions.

Epidermis The epidermis is the thin outer layer of the skin which consists of the following three parts:
  • Stratum corneum (horny layer)
    This layer consists of fully mature keratinocytes which contain fibrous proteins (keratins). The outermost layer is continuously shed. The stratum corneum prevents the entry of most foreign substances as well as the loss of fluid from the body.
  • Keratinocytes (squamous cells)
    This layer, just beneath the stratum corneum, contains living keratinocytes (squamous cells), which mature and form the stratum corneum.
  • Basal layer
    The basal layer is the deepest layer of the epidermis, containing basal cells. Basal cells continually divide, forming new keratinocytes, replacing the old ones that are shed from the skin's surface.

The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment).

Dermis

The dermis is the middle layer of the skin. The dermis contains the following:

  • Blood vessels
  • Lymph vessels
  • Hair follicles
  • Sweat glands
  • Collagen bundles
  • Fibroblasts
  • Nerves

The dermis is held together by a protein called collagen, made by fibroblasts. This layer also contains pain and touch receptors.

Subcutis

(also known as the subcutaneous layer)

The subcutis is the deepest layer of skin. The subcutis, consisting of a network of collagen and fat cells, helps conserve the body's heat and protects the body from injury by acting as a "shock absorber."

The skin is the body's largest organ, covering the body. In addition to serving as a protective shield against heat, light, injury, and infection, the skin also:

  • Regulates body temperature.
  • Stores water and fat.
  • Is a sensory organ.
  • Prevents water loss.
  • Prevents entry of bacteria.

What are the classifications of burns?

Burns are classified as first-, second-, or third-degree, depending on how deep and severe they penetrate the skin's surface.

  • First-degree (superficial) burns
    First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color.
  • Second-degree (partial thickness) burns
    Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.
  • Third-degree (full thickness) burns
    Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed.

Burns that are more severe and extensive require specialized treatment. Because the age of a burn victim and the percentage of the body's surface area that has been burned are the two most important factors affecting the prognosis of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center:

  • Younger than 10 years or older than 50 years with partial- or full-thickness burns over 10 percent or more of the total body surface area (TBSA)
  • Age 10 years or older or age 50 years or younger with partial- or full-thickness burns over 20 percent or more of the TBSA
  • Any age with full-thickness burns covering 5 percent or more of the TBSA
  • Burns of the face, hands, feet, or perineum (groin, or genital area), or burns that extend all the way around a portion of the body
  • Burns accompanied by an inhalation injury affecting the airway and/or the lungs
  • Burn patients with existing chronic conditions such as diabetes, high blood pressure, heart disease, kidney disease, or multiple sclerosis
  • Suspected child or geriatric abuse
  • Chemical burn
  • Electrical injury
  • Scald burns
  • Grease burns
  • Tar burns
  • Radiation burn

The effects of burns

A severe burn can be a seriously devastating injury - not only physically but emotionally. It can affect not only the burn victim, but the entire family. Persons with severe burns may be left with a loss of certain physical abilities, disfigurement, loss of a limb, loss of mobility, scarring, and infection. In addition, severe burns are capable of penetrating deep skin layers, causing muscle or tissue damage that may affect every system of the body.

Burns can also cause emotional problems such as depression, nightmares, or flashbacks from the traumatizing event. The loss of a friend or family member and possessions in the fire may add grief to the emotional strain of a burn.

The burn rehabilitation team

Because so many functions and systems of the body can be affected by severe burns, the need for rehabilitation becomes even more crucial.

Many hospitals have a specialized burn unit or center and some facilities are designated solely for the rehabilitation of burn patients. Burn patients need the highly specialized services of medical specialists who work together on a multidisciplinary team, including any/all of the following:

  • Physiatrists
  • Plastic surgeons
  • Internists
  • Orthopaedic surgeons
  • Infection disease specialists
  • Rehabilitation nurses who specialize in burn care
  • Psychologists/psychiatrists
  • Physical therapists
  • Occupational therapists
  • Respiratory therapists
  • Dietitians
  • Social workers
  • Case managers
  • Recreation therapists
  • Vocational counselors

The burn rehabilitation program

Burn rehabilitation begins during the acute treatment phase and may last days to months to years, depending on the extent of the burn. Rehabilitation is designed to meet each patient's specific needs; therefore, each program is different. The goals of a burn rehabilitation program include helping the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially.

In order to help reach these goals, burn rehabilitation programs may include the following:

  • Complex wound care
  • Pain management
  • Physical therapy for positioning, splinting, and exercise
  • Occupational therapy for assistance with activities of daily living (ADLs)
  • Cosmetic reconstruction
  • Skin grafting
  • Counseling to deal with common emotional responses during convalescence, such as depression, grieving, anxiety, guilt, and insomnia
  • Patient and family education and counseling
  • Nutritional counseling

Advances in the understanding and treatment of burns, state-of-the-art burn units and facilities, comprehensive burn rehabilitation services, and integrated medical care have all contributed to the increase in survival rate and recovery of burn patients.



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