Burn injuries are among the leading causes of accidental death. Every year, an estimated 500,000 people in the United States suffer burn injuries requiring medical attention, and up to 40,000 require hospitalization. Hospital stays may be lengthy and may involve multiple surgical procedures.
Burns can result from thermal, chemical, and electrical injuries. Each type is treated differently, as described below.
Serious burns are complex injuries affecting skin, muscles, tendons, bones, nerves, and blood vessels. Skin damage impairs the body's normal fluid and electrolyte balance, thermal regulation, and ability to fight infection. Long-term effects include diminished muscle and joint function and impaired manual dexterity. Involvement of the respiratory system can lead to airway obstruction and respiratory failure and arrest. Burns can also cause permanent disfigurement with concomitant sexual and psychological concerns regarding intimacy and self-esteem.
The following factors are associated with increased risk of burns:
Use of wood stoves.
Exposed heating sources or electrical cords.
Unsafe storage of flammable or caustic materials.
Careless smoking. Cigarettes are the leading cause of house fires.
Water heaters set above 120°F.
Microwave-heated foods and containers.
Age. Children under 4, especially those who are poorly supervised, are at particular risk. Adults over age 60 are at higher risk of hospitalization due to burns.
Gender. Globally there is variation in gender differences and rates of burn injury. In the US, however, no gender differences were found.
Substandard or older housing.
Substance abuse. Use of alcohol and illegal drugs increases risk.
Absent or nonfunctioning smoke detectors. The presence of a functioning detector decreases risk of death by fire.
A detailed history will assess the mechanism, duration, and timing of the burn. Physical examination will ascertain burn location and severity and check for dehydration, disfigurement, and infection. Biopsy is rarely needed to verify infection. Even minor burns can exacerbate diabetes, hypertension, and cardiac disease; patients with these conditions should usually be referred to a burn center. Fires in enclosed spaces should raise the suspicion for smoke-inhalation injury. Clinicians should also be attentive to i njuries that suggest physical abuse.
Burns are classified based on the mechanism and depth. The depth is classified as superficial or epidermal (first degree), partial-thickness (second degree), or full thickness (third degree). Fourth degree burns are those that penetrate the subcutaneous layer and fascia and may involve muscle or bone.
Burns that affect only the epidermis are superficial and are characterized by erythema or discoloration, mild swelling, and pain. These burns do not cause blisters. Sun overexposure is a common cause. Injuries heal in 3 to 6 days.
Superficial Partial Thickness: These burns affect the epidermis and superficial layers of the dermis, causing a red color and blistering. Fluid is lost through damaged skin, and the burns are painful and tender since nerve endings are still intact. These burns will blanch with pressure. Injuries heal in 1-3 weeks. Scarring is uncommon, but skin color changes can persist for several months after the burn is healed.
Deep Partial Thickness: Burns affecting the deep layers of dermis, damaging glandular tissue and follicles, are termed deep partial-thickness burns. Blisters are present, but the skin usually has a mottled appearance. Healing takes > 3 weeks, and scarring is common.
Burns that penetrate all layers of the dermis and sometimes extend into the subcutaneous tissue are classified as full-thickness burns. Injuries may have a charred appearance and/or contain white or gray patches. Healing occurs only at the wound edges, and by secondary intention. Scarring is significant, unless skin grafting is performed.
Fourth Degree Burns
Fat, muscle, tendon, and bone may be affected.
Burn patients require specialized care and support. The American Burn Association (ABA) estimates the level of care required for burns according to the location, depth, and percentage of total body surface area (TBSA) affected. The Lund-Browder chart is the most precise tool for estimating TBSA and should always be used for burns in children, because it takes into account the changes in body proportions at different ages. The Rule of Nines is a faster method for estimating TBSA in adults. It assigns percentages of the skin surface in multiples of nine (e.g., a leg is assumed to be 9% of the skin surface, as is the abdomen, and both arms together.)
The types of burn cases that should be referred to a burn unit include:
- Partial-thickness burns covering more than 10% TBSA.
- Burns involving the face, hands, feet, genitalia, perineum, or major joints.
- Third and fourth degree burns.
- Electrical burns.
- Chemical burns.
- Inhalation injuries.
- Patients with preexisting medical disorders that could complicate management or recovery.
- Patients with concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.
- Burns in children
- Patients who will require special social, emotional, or long-term rehabilitative intervention.
Immediate care can be lifesaving. Before burns are treated, the burning agent must be prevented from inflicting further damage. Materials such as melted synthetic shirts, hot tar, or chemicals should be immediately removed, or, in special cases (e.g., hydrofluoric acid), chemically inactivated.
Burns should be thoroughly cleaned under local or general anesthesia. Sterile dressings may be applied, although minor burns may need only topical treatm ent (see below). Tetanus vaccination and analgesics may be administered as needed. B urns that do not heal as predicted or that match the ABA referral criteria above require a specialist consultation or referral.
Superficial burns should be cooled in cool or room temperature water if possible, or a cool moist cloth can be applied until pain subsides. Very cold water and ice should not be used, as these may damage skin. Mild soap and water can then be used to clean the wound. Burst blisters or sloughed skin should be debrided prior to dressing application; however, most superficial burns do not require a dressing.
Partial thickness burns should be treated with a combination of topical antimicrobial agent (chlorhexidine, silver sulfadiazine, or combination antibiotics) and a gauze dressing, including fine mesh gauze, bismuth-impregnated petroleum based gauze (Xeroform), biosynthetic gauze, silicon-coated gauze, hydrogel, or silver treated gauze.
As stated above, all other burn injuries should be assessed and treated by a specialized team at a recognized burn center.
Nutritional support is a key component of burn care. Elevations in metabolic rate far above that predicted by the Harris-Benedict equation occur in adults with a burn covering 25% of total body surface area (TBSA), a hypermetabolic state that exceeds the metabolic increases found in any other disease state. Resting metabolic rate (RMR) is approximately 180% of basal rate during acute admission in these patients, and their calorie needs may exceeed 5,000 kcal/day. Patients with a surface burn of 40% can lose 25% of preadmission weight in 3 weeks without nutrition support; losses exceeding 10% are associated with significantly poorer outcome, including impaired immunity and delayed healing.
Energy and Macronutrient Support
Significant weight loss is preventable with nutritional support. Recommended daily energy intake is as follows: for adults, 25 kcal/kg plus 40 kcal per each percent of burn area; for children, 1,800 kcal plus 2,200 calories per m 2 of burn area. Individualized nutrition assessment is recommended for patients with burns on > 20% of TBSA.
Enteral nutrition support with a high-protein, high-carbohydrate diet is recommended, and timing may be critical. Feedings started within ~ 4-36 hours following injury appear to have advantages over delayed (> 48 hours) feedings. If patients are hemodynamically stable (a prerequisite for prevention of bowel ischemia), these benefits include reductions in sepsis associated with gut permeability and clinical infection, as well as significantly shortened hospital stays. Enteral support can reduce the burn-related increase in secretion of catabolic hormones and help maintain gut mucosal integrity. The duodenal route is better tolerated than gastric feeding, due to an 18% failure rate in the latter from regurgitation.
High-carbohydrate, low-fat diets for burn patients result in less proteolysis and more improvement in lean body mass and may reduce infectious morbidity and shorten hospitalization time when compared with a high-fat regimen.
Protein and fluid needs must also be considered carefully. Protein oxidation rates are 50% higher in burn patients, and protein needs are ~ 1.5-2.0 grams/kg. Children should not be supplemented with more than 2.0 grams of protein/kg; higher levels may lead to increased urea production with no benefits.
Additional vitamin-mineral supplements may be indicated. Levels of the fat-soluble vitamins A and E and carotenoids fall below normal in burn injury patients. In one study, vitamin E treatment reduced elevation in lipid peroxide levels in burn patients, although improved outcome was not noted as a result. Vitamin D synthesis is impaired in the skin of burn patients, both acutely and long-term. Blood levels appear to continue to fall, are below the normal range several years after recovery, and may negatively affect lumbar spine bone mineral density. Consequently, supplementation with the recommended dietary allowance of 400 IU of vitamin D per day has been suggested for patients with significant burns.
Glutamine, an amino acid formed in the skeletal muscle, is depleted following a burn injury. Glutamine supplementation at 25 grams/kg/day has shown to reduce incidence of infections, hospital stays, and mortality.
Patients with major burns also suffer acute trace-element deficiencies, at least partly because of large exudative losses through the burned areas. A lack of certain trace elements (e.g., selenium and zinc) can exacerbate poor immunity, and burns are the second-leading cause of immunodeficiency (after HIV infection). Although a role for free radicals and lipid peroxides in burn trauma has been established,  little research has been done on the effects of antioxidant supplements in human burn injury. However, the addition of selecium, zinc, and copper to a standard trace element formula and enteral nutrition was associated with a significant decrease in the number of bronchopneumonia infections and with a shorter hospital stay.
Evaluating Nutritional Response to Feeding
The response of burn patients to their nutritional intake should be evaluated weekly or biweekly. Nitrogen balance studies are not useful, as a large amount of protein is extruded from the wound beds daily. In addition, standard measures of nutritional repletion, such as visceral proteins (e.g., albumin and ferritin), are influenced not only by nutritional status, but also by inflammatory processes. When low concentrations are observed, the simultaneous concentrations of acute phase reactants, such as C-reactive protein, must be compared with their own reference standard to separate nutritional effects from inflammatory effects. Nevertheless, weekly or biweekly pre-albumin levels can guide nutritional status.
Low-fat, high-protein, high-carbohydrate enteral tube feedings with appropriate caloric content. Weekly or biweekly assessments of nutritional status.
Physical therapy, occupational therapy, and mental health consultations, as appropriate.
What to Tell the Family
Burn injuries can be very traumatic. It is important for the family to know that the patient may need a great deal of support. This is especially true for second, third, and fourth degree burns. Burn patients may be hospitalized for days or months, and may require multiple surgeries. In severe burns, the patient will be physically incapacitated and emotionally traumatized. The family will play an essential role supporting the patient.
- Burn Incidence and Treatment in the United States: 2016. American Burn Association web site. Available at: http://www.ameriburn.org/who-we-are/media/burn-incidence-fact-sheet . Accessed September 8, 2017.
- Edgar DW et al: The influence of advancing age on quality of life and rate of recovery after treatment for burn. Burns 39:1067, 2013 [PMID:23810399]
- Resources for Optimal Care of the Injured Patient 2014. American College of Surgeons web site. Available at: https://www.facs.org . Published 2014. Accessed September 8, 2017.
- Wasiak J et al: Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev Mar 28 [PMID:23543513]
- De-Souza DA, Greene LJ: Pharmacological nutrition after burn injury. J Nutr 128:797, 1998 [PMID:9566984]
- Herndon DN, Tompkins RG: Support of the metabolic response to burn injury. Lancet 363:1895, 2004 [PMID:15183630]
- Andel H et al: Nutrition and anabolic agents in burned patients. Burns 29:592, 2003 [PMID:12927986]
- Williams FN et al: What, how, and how much should patients with burns be fed? Surg Clin North Am 91:609, 2011 [PMID:21621699]
- McClave SA, Marsano LS, Lukan JK: Enteral access for nutritional support: rationale for utilization. J Clin Gastroenterol 35:209, 2002 [PMID:12192194]
- Cancio LC et al: Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma 56:404, 2004 [PMID:14960986]
- Pintaudi AM et al: Oxidative stress after moderate to extensive burning in humans. Free Radic Res 33:139, 2000 [PMID:10885621]
- Latha B, Babu M: The involvement of free radicals in burn injury: a review. Burns 27:309, 2001 [PMID:11348738]
- Klein GL et al: Synthesis of vitamin D in skin after burns. Lancet 363:291, 2004 [PMID:14751703]
- Berger MM et al: Trace element supplementation modulates pulmonary infection rates after major burns: a double-blind, placebo-controlled trial. Am J Clin Nutr 68:365, 1998 [PMID:9701195]
- Horton JW: Free radicals and lipid peroxidation mediated injury in burn trauma: the role of antioxidant therapy. Toxicology 189:75, 2003 [PMID:12821284]
- Manelli JC et al: A reference standard for plasma proteins is required for nutritional assessment of adult burn patients. Burns 24:337, 1998 [PMID:9688199]