Burn

Burns are a significant global health concern, resulting in substantial morbidity, mortality, and long-term disability. These injuries occur when the skin and underlying tissues are damaged by various sources of energy. The severity of a burn depends on several factors. Understanding the different types of burns, their causes, and the appropriate management is crucial for effective first aid, treatment, and rehabilitation. 

A burn is a type of injury to the skin, and sometimes deeper tissues, caused by exposure to heat, radiation, electricity, friction, or contact with chemicals. The damage can range from superficial redness to severe tissue destruction involving all layers of the skin and even underlying muscle and bone. 

The skin, the body's largest organ, plays a vital role in protection against infection, regulation of body temperature, and maintenance of fluid balance. When the skin's integrity is compromised by a burn, these functions are impaired, leading to a variety of local and systemic effects. 

Burns represent a significant public health problem globally, with a disproportionate impact on low- and middle-income countries.

Worldwide Prevalence: The World Health Organization (WHO) estimates that burns cause approximately 180,000 deaths annually worldwide. Non-fatal burns are even more prevalent, with millions of people suffering burn injuries each year. Children are at a higher risk of burn injuries.

Prevalence in India: India accounts for a significant proportion of the global burn burden. Burns are a leading cause of accidental death and disability, especially among women and children. 

Burns are primarily classified based on the depth of the injury:

First-Degree Burns (Superficial Burns): 

These burns affect only the outermost layer of the skin (epidermis). They are typically characterised by redness, pain, and slight swelling. The skin remains intact without blisters. A common example is sunburn. These burns usually heal within a few days to a week without scarring.
 

Second-Degree Burns (Partial-Thickness Burns): 

These burns involve the epidermis and a portion of the dermis (the layer of skin beneath the epidermis). They are characterised by redness, pain, swelling, and the formation of blisters. Second-degree burns can be further subdivided into:

• Superficial Partial-Thickness Burns: These involve the upper layer of the dermis. The blisters are usually present, and the skin underneath is moist and pink. These burns are painful and typically heal within two to three weeks with minimal scarring.
• Deep Partial-Thickness Burns: These extend deeper into the dermis. The skin may appear waxy white or mottled red and white. Blisters may be present or absent (if they have ruptured). These burns are painful but may have reduced sensation compared to superficial partial-thickness burns due to nerve damage. Healing can take several weeks to months and often results in scarring. Skin grafting may be required in some cases.

Third-Degree Burns (Full-Thickness Burns): 

These severe burns destroy the entire thickness of the skin, including the epidermis and dermis, and may extend into the subcutaneous tissue (fat layer). The skin may appear white, leathery, charred, or waxy. There is often no pain in the burned area initially because nerve endings have been destroyed. However, the surrounding areas with less severe burns will be painful. Third-degree burns always require skin grafting to heal and result in significant scarring.
 

Burns can also be classified based on their cause:

• Thermal Burns: Caused by heat sources such as flames, hot liquids (scalds), steam, hot objects (contact burns), and explosions.
• Chemical Burns: Result from contact with corrosive substances like strong acids, alkalis, or organic compounds. The severity depends on the type and concentration of the chemical, the duration of contact, and the extent of penetration.
• Electrical Burns: Caused by the passage of electrical current through the body. The severity can be deceptive as the visible skin injury may be small, but significant internal damage can occur, affecting the heart, nerves, and muscles.
• Radiation Burns: Result from exposure to ionising radiation, such as from sunburn (UV radiation), radiation therapy, or radioactive materials. The severity depends on the dose and duration of exposure.
• Friction Burns: Occur when skin is rubbed forcefully against a surface, generating heat. Examples include road rash.

Burns can result from a wide range of accidents and exposures:

• Fire and Flames: House fires, cooking accidents, playing with matches or lighters, and exposure to open flames are common causes of thermal burns.
• Scalds: Contact with hot liquids (water, oil, coffee, tea) or steam, often occurring during cooking, bathing, or spills. Scalds are a frequent cause of burns in young children.
• Contact with Hot Objects: Touching hot stoves, irons, exhaust pipes, or other heated surfaces can cause contact burns.
• Chemicals: Exposure to strong acids (e.g., hydrochloric acid, sulphuric acid), alkalis (e.g., sodium hydroxide, potassium hydroxide), and other corrosive chemicals found in household cleaners, industrial products, or during chemical accidents.
• Electricity: Contact with faulty electrical wiring, power lines, lightning strikes, or electrical appliances can cause electrical burns. The path of the current through the body determines the extent of internal damage.
• Radiation: Prolonged sun exposure (sunburn), radiation therapy for cancer treatment, and exposure to radioactive materials can lead to radiation burns.
• Friction: Sliding across rough surfaces like roads or carpets can cause friction burns, also known as abrasions or road rash.
• Explosions: Can cause a combination of thermal burns (from the heat of the explosion), blast injuries, and penetrating trauma.

The symptoms of a burn vary significantly depending on the depth and extent of the injury:

• First-Degree Burns:
  
  • Redness of the skin.
  • Pain at the burn site.
  • Slight swelling.
  • The skin is dry and may be sensitive to touch.
  • No blisters.
• Second-Degree Burns (Superficial Partial-Thickness):
  
  • Intense pain.
  • Red, moist, and weeping skin.
  • Blisters are present.
  • Swelling.
• Second-Degree Burns (Deep Partial-Thickness):
  
  • Pain, although potentially less than superficial partial-thickness burns.
  • Skin may appear blotchy, red, pale, or waxy.
  • Blisters may be present or easily ruptured.
  • Swelling.
  • The burn may feel wet or dry.
• Third-Degree Burns:
  
  • The burned area may be painless initially due to nerve damage.
  • Skin appears white, leathery, charred black, or waxy.
  • The skin is dry and non-elastic.
  • No blisters are present (though they may be present in surrounding areas with less severe burns).
  • Swelling.

Other General Symptoms Associated with More Severe Burns:

• Shock (pale and clammy skin, weakness, rapid heartbeat, shallow breathing).
• Dehydration (decreased urination, dry mouth).
• Infection (redness, swelling, pus, increased pain, fever).
• Breathing difficulties (if the burns involve the face or airways, or due to smoke inhalation).
• Scarring and contractures (tightening of the skin that can restrict movement) in the long term.

The diagnosis of a burn involves assessing the depth, extent, and cause of the injury. Healthcare professionals will typically:

• Take a Medical History: Inquire about how the burn occurred, the burning agent, the duration of exposure, and any underlying medical conditions.
• Perform a Physical Examination: Carefully examine the burned area to determine the depth and extent of the burn. The "Rule of Nines" is often used in adults to estimate the total body surface area (TBSA) affected by the burn. In children, Lund-Browder charts are more accurate due to the different proportions of their body parts.
• Assess Airway, Breathing, and Circulation (ABCs): In severe burns, ensuring a stable airway, adequate breathing, and proper circulation is the immediate priority. Signs of smoke inhalation or airway compromise will be assessed.
• Evaluate Pain Levels: Pain management is an important aspect of burn care.
• Check for Associated Injuries: Especially in cases of electrical burns or trauma, other injuries may be present.
• Consider the Location of the Burn: Burns to certain areas, such as the face, hands, feet, genitalia, and major joints, are considered more critical due to the potential for functional impairment and cosmetic disfigurement.

In most cases, blood tests and imaging studies are not routinely required for the initial diagnosis of uncomplicated burns. However, they may be necessary in severe burns to assess for complications such as electrolyte imbalances, infection, or internal organ damage (especially in electrical burns).

The treatment of burns depends on the severity of the injury:

First-Degree Burns: 

Usually treated at home with cool running water for 10-20 minutes to cool the burn, followed by the application of a soothing lotion or aloe vera. Over-the-counter pain relievers like paracetamol or ibuprofen and antiseptic creams (Brands: Silverex, Megaheal) can help.
 

Second-Degree Burns (Superficial Partial-Thickness): 

Treated by cooling the burn, cleaning it gently, and applying a thin layer of antibiotic ointment followed by a non-stick dressing. Blisters should generally be left intact unless they rupture on their own, in which case they should be cleaned and covered. Pain management is important.
 

Second-Degree Burns (Deep Partial-Thickness) and Third-Degree Burns: 

These burns typically require treatment in a specialised burn centre. Treatment may involve:

• Fluid Resuscitation: Intravenous fluids are crucial to prevent dehydration and shock, especially in large burns.
• Wound Care: Regular cleaning and dressing changes are essential to prevent infection and promote healing. Specialised dressings may be used.
• Pain Management: Strong pain medication is usually required.
• Skin Grafting: For deep partial-thickness and full-thickness burns, skin grafts (taking healthy skin from an unburned area of the body or from a donor) are often necessary to close the wound and reduce scarring.
• Escharotomy: In circumferential burns (burns that go all the way around a limb or torso), swelling can impair circulation or breathing. An escharotomy is a surgical procedure to release the tight burned skin.
• Nutritional Support: Burn injuries increase metabolic demands, so adequate nutrition is vital for healing.
• Physical and Occupational Therapy: To prevent contractures, maintain range of motion, and regain function.
• Psychological Support: Burns can have significant emotional and psychological impacts. Counselling and support groups can be beneficial.

While conventional medical treatment is essential for significant burns, some complementary therapies may be used alongside medical care to support healing and manage symptoms. These should always be discussed with a healthcare professional:

• Aloe Vera: Topical application of pure aloe vera gel may help soothe minor burns and promote healing due to its anti-inflammatory and moisturising properties.
• Honey: Medical-grade honey has shown some promise in promoting wound healing and possessing antimicrobial properties. However, it should only be used under medical supervision for burns
• Aromatherapy: Certain essential oils, such as lavender or chamomile, may help promote relaxation and reduce anxiety when used in aromatherapy. They should not be applied directly to the burn.

Several factors can increase the risk of burn injuries:

• Age: Young children and older adults are at higher risk due to their limited mobility, slower reaction times, and thinner skin.
• Socioeconomic Status: Individuals in low-income communities may be at higher risk due to unsafe housing conditions, use of open fires for cooking and heating, and limited access to safety education.
• Occupation: Certain occupations, such as cooking, welding, electrical work, and working with chemicals, carry a higher risk of burns.
• Alcohol and Drug Use: Impaired judgment and coordination due to substance use can increase the likelihood of accidents leading to burns.
• Smoking: Increases the risk of house fires.
• Lack of Smoke Detectors: Homes without working smoke detectors have a significantly higher risk of fire-related injuries and deaths.
• Scalding Hazards: Unattended cooking, hot bathwater, and accessible hot beverages pose a risk, especially to young children.
• Electrical Hazards: Faulty wiring, overloaded circuits, and misuse of electrical appliances can lead to electrical burns.
• Lack of Awareness and Education: Insufficient knowledge about burn prevention and safety measures contributes to the risk.

Burns, especially if severe, can lead to a range of complications:

• Infection: The loss of the skin barrier makes burn victims highly susceptible to bacterial, fungal, and viral infections, which can be life-threatening.
• Fluid Loss and Dehydration: Damaged skin cannot effectively retain fluids, leading to significant fluid loss, dehydration, and shock.
• Hypothermia: Loss of skin also impairs the body's ability to regulate temperature, increasing the risk of hypothermia (low body temperature).
• Scarring and Contractures: Deep burns often result in significant scarring. Contractures occur when scar tissue tightens, restricting movement, especially around joints.
• Breathing Problems: Smoke inhalation can damage the lungs, leading to acute respiratory distress syndrome (ARDS) and other respiratory complications. Burns to the face and neck can also cause airway swelling.
• Compartment Syndrome: Swelling in burned limbs can increase pressure within muscle compartments, compromising blood flow and potentially leading to tissue damage and nerve injury.
• Psychological Trauma: Burn injuries can be emotionally devastating, leading to anxiety, depression, post-traumatic stress disorder (PTSD), and body image issues.
• Heterotopic Ossification: In rare cases, bone formation can occur in the soft tissues around joints affected by burns, further restricting movement.
• Sepsis: A severe and life-threatening complication of infection where the body has an overwhelming response to the infection.

Living with the aftermath of a significant burn injury can present numerous physical and emotional challenges. Here are some tips for managing life after burns:

• Follow Medical Advice: Adhere strictly to the treatment plan provided by your healthcare team, including wound care, medication, and therapy.
• Pain Management: Work closely with your doctors to manage pain effectively. Explore various pain relief strategies, including medication, relaxation techniques, and physical therapy.
• Wound Care: Continue meticulous wound care as instructed to prevent infection and promote healing. This may involve regular cleaning, applying prescribed ointments, and dressing changes.
• Scar Management: Be diligent with scar management techniques, such as massage with moisturising creams, silicone sheets or gels, and pressure garments (if recommended) to help minimise scarring and prevent contractures.
• Physical and Occupational Therapy: Participate actively in physical and occupational therapy to regain strength, flexibility, range of motion, and functional skills.
• Moisturise Regularly: Keep the healed burn areas well-moisturised to prevent dryness, itching, and skin breakdown.
• Protect from Sun Exposure: Burned skin is more sensitive to the sun. Protect healed areas from direct sunlight by using sunscreen with a high SPF and wearing protective clothing.
• Maintain a Healthy Lifestyle: Eat a balanced diet rich in protein and vitamins to support healing. Stay hydrated and get regular exercise as tolerated.

Misconception: Applying butter to a burn helps it heal faster.

Correction: Butter is greasy and can trap heat and bacteria, increasing the risk of infection. It offers no therapeutic benefit for burns. Cool running water is the appropriate first aid.

Misconception: All blisters should be popped immediately.

Correction: Intact blisters protect the underlying skin from infection. They should generally be left alone. If a blister is large or in a high-friction area and ruptures on its own, it should be gently cleaned and covered with a sterile dressing.

Misconception: Ice water is the best way to cool a burn.

Correction: Ice water can cause further damage to the skin due to extreme cold and can increase the risk of hypothermia, especially in large burns. Cool (not ice-cold) running water is recommended.

Seek immediate medical attention for any of the following:

• Third-degree burns (full-thickness burns).
• Second-degree burns that cover a large area of the body (more than 10-15% TBSA in adults, any significant area in children).
• Burns involving the face, hands, feet, genitalia, or major joints.
• Electrical burns, even if the skin injury appears minor.
• Chemical burns.
• Burns accompanied by smoke inhalation or breathing difficulties.
• Burns in infants and young children.
• Burns in elderly individuals or those with underlying medical conditions.
• Any burn that shows signs of infection (increased redness, swelling, pus, fever).
• Burns that are not healing properly.
• Significant pain that is not controlled by over-the-counter medication.

If you or someone you know has sustained a burn, here are some important questions to ask the doctor:

• What is the depth and extent of the burn?
• What type of burn is it (thermal, chemical, electrical, etc.)?
• What is the recommended treatment plan?
• How should I care for the burn at home?
• What signs of infection should I watch for?
• What pain medication should I take?
• Will there be scarring? If so, what can be done to minimise it?
• Will physical therapy or occupational therapy be needed?
• What are the potential long-term complications?
• Are there any restrictions on activities?

Supporting someone recovering from a burn injury requires empathy, patience, and understanding:

• Offer Emotional Support: Listen to their feelings, validate their experiences, and provide reassurance. Burns can be emotionally traumatic, leading to anxiety, depression, and body image issues.
• Provide Assistance: Help with daily tasks such as wound care, dressing changes, transportation to appointments, and household chores.
• Be Patient: Recovery from burns can be a long and challenging process, both physically and emotionally. Be patient and understanding during setbacks.
• Encourage Independence: While offering support, also encourage the individual to regain independence at their own pace.
• Respect Their Privacy: Be mindful of their comfort level regarding their scars and treatment. Avoid asking insensitive questions or making unsolicited comments.
• Accompany Them to Appointments: Offer to go with them to medical appointments for support and to help take notes.

Burns are a significant health issue with the potential for severe physical and emotional consequences. By implementing safety measures in homes, workplaces, and communities, we can significantly decrease the burden of burns worldwide. For those who have sustained burn injuries, comprehensive medical care, coupled with ongoing support and rehabilitation, is vital for recovery and better quality of life.