burn
(bŭrn 
)
Tissue injury resulting from excessive exposure to thermal, chemical, electrical, or radioactive agents.
Incidence: Burns are among the most common kinds of traumatic injury. The incidence of burns in the U.S. is approx. 1.4 per 1,000,000 per year, according to the World Health Organization. Approx. 50,000 Americans are hospitalized annually after severe burn injuries.
Causes: Burns may result from ultraviolet radiation, bursts of steam, explosions, heated liquids and metals, chemical fires, electrocution, or direct contact with flame or flammable clothing.
Symptoms and Signs: The effects may be local, resulting in cell injury or death, or both local and systemic, involving primary shock (which occurs immediately after the injury and is rarely fatal) or secondary shock (which develops insidiously following severe burns and is often fatal). Burns are usually classified as:
First degree: a superficial burn in which damage is limited to the outer layer of the epidermis and is marked by redness, tenderness, and mild pain. Blisters do not form, and the burn heals without scar formation. A common example is sunburn.
Second degree: a burn that damages partial thickness of the epidermal and some dermal tissues but does not damage the lower-lying hair follicles, sweat, or sebaceous gland s. The burn is painful and red; blisters form, and wounds may heal with a scar.
SEE: illus..
Third degree: a burn that extends through the full thickness of the skin and subcutaneous tissues beneath the dermis. The burn leaves skin with a pale, brown, gray, or blackened appearance. The burn is painless because it destroys nerves in the skin. Scar formation and contractures are likely complications.
Fourth degree: a burn that extends through the full thickness of the skin and into underlying bone, fat, muscles, and tendons. Third- and fourth-degree burns are best managed at specialized burn centers.
SEE: illus..
Complications: Sloughing of skin, gangrene, scarring, erysipelas, nephritis, pneumonia, immune system impairment, or intestinal disturbances are possible complications. Shock and infection must always be anticipated with higher-degree or larger burns. The risk of complication is greatest when more than 25% of the body surface is burned.
Treatment: The first responsibility in the care of the burn patient is to assess the patency of the airway and to ensure that breathing is unimpaired. If smoke inhalation or airway injury is suspected, intubation should be performed before edema makes this impossible. Airway injury is most likely to occur after facial burns or smoke inhalation in closed spaces. A cough productive of soot or charred material increases the likelihood of inhalational injury.
The second task in burn care is to ensure cardiac output and tissue perfusion. Volume resuscitation with crystalloid is given per stand ard protocols; at the same time, urinary output, blood pressure and pulse, body weights, and renal function are closely monitored to ensure adequate hydration.
The immediate care of the burn itself involves the removal of any overlying clothing and jewelry and the irrigation of the affected tissues with cool water, taking care to avoid excessively cooling the body. To help prevent hypothermia and infection, cover the burn wounds with sterile dressings if available, or a clean sheet, separating burn wound surfaces. Gentle tissue débridement should be followed by application of nonadherent dressings, skin substitutes, topical antiseptics, or autografts, as dictated by circumstances. Tetanus prophylaxis is routinely given, usually with both tetanus toxoid and tetanus immune globulin.
In specific circumstances, additional interventions such as hyperbaric oxygen therapy for carbon monoxide intoxication, escharotomy for circumferential burns, antibiotic therapy for infections, pressor support for hypotension, or nutritional support may be needed.
Patients with large or complex burn injuries should be transferred to regional burn centers or to the care of surgeons with special knowledge of burn management.
Patient Care: A person in burning clothing should never be allowed to run. The individual should lie down and roll. A rug, blanket, or anything within reach can be used to smother the flames. Care must be taken so that the individual does not inhale the smoke. The clothing should be cut off carefully so that the skin is not pulled away. Synthetic fabrics that have melted into the burn wound are best removed later in the emergency department or burn center. Jewelry should be removed even if not near the burn wounds due to concerns for fluid shifts and swelling. Blisters should not be opened, as this increases the chance for infection. Patients with large burn areas or third- and fourth-degree burns must receive appropriate tetanus prophylaxis.
During rehabilitation, individually fitted elastic garments are applied to prevent hypertrophic scar formation, and joints are exercised to promote a full range of motion. The patient is encouraged to increase activity tolerance, obtain adequate rest, strive for physical and emotional independence, and resume vocational and social functioning. Referrals for occupational therapy, psychological counseling, support groups, or social services are often necessary. Reconstructive and cosmetic surgery may be required. Support groups and services are available to assist the patient with life adjustments.
Patients' previous psychological states may predispose them to injury and may have an adverse effect on recovery. Patients with burn injuries demonstrate a wide range of emotional responses including anger, frustration, irritability, and psychological states (delirium, anxiety, depression, and grief). Posttraumatic stress disorder (PTSD) may occur after a burn injury. Often, the PTSD patient will need help from primary or specialized care providers to recover psychologically. Explain patient needs and care concerns to the family to help alleviate their cares, concerns, and varied psychological responses. Involve them in patient care as permissible. Family members should be encouraged to sit with the patient, and to touch, speak to, read to, and otherwise communicate. Providing patients with a sense of purpose will help relieve feelings of helplessness and will provide both patient and family with more comfortable memories.
The provision of optimal nutrition to burn patients is an important component of recovery. Because of protein losses, the total protein consumed by a burn patient should be at least 2.5 g/kg of body weight daily. Total caloric needs may exceed 30 kcal/kd/daily. The risk of infections may be reduced by the provision of dietary supplements, esp. arginine and glutamine.
acid b.A burn caused by exposure to corrosive acids such as sulfuric, hydrochloric, and nitric.
Most burn areas should be flushed with large volumes of water. Some acid burns could be made worse with water. For further details of definitive treatment, see under sulfuric acid poisoning.
actinic b.Burns caused by ultraviolet or sun rays. Treatment is the same as for dry heat burns.
battery b.A contact burn of the aerodigestive tract resulting from aspiration or swallowing of a battery into the esophagus or trachea. It can be managed with substances that coat the damaged epithelium, such as sucralfate or orally administered honey.
b. of aerodigestive tract Necrosis of the oral mucosa, trachea, or esophagus due to the ingestion of caustic substances. After an assessment of the patient's airway, breathing, and circulation, the medical team determines the severity of the exposure by physical examination or laryngoscopy. Some patients may require hospitalization for local care and the administration of intravenous steroids, histamine antagonists, and antibiotics. Late complications may include strictures of the affected internal organs.
alkali b.A burn caused by caustic alkalis such as lye, caustic potash (potassium hydroxide), and caustic soda (sodium hydroxide), marked by a painful skin lesion, and often associated with gelatinization of tissue.
The burn is irrigated with large volumes of water and dressed.
Be careful to brush dry powder off the skin before applying water, as some chemicals, such as lye, react with water.aspirin b.A shallow red ulcer in the oral cavity, produced when acetylsalicylic acid (aspirin) tablets are held in the mouth, e.g., in an attempt to relieve dental pain.
brush b.A combined burn and abrasion resulting from friction.
Loose dirt is carefully brushed away and the area is cleansed with soap and water. An antiseptic solution or ointment is applied, and the burn is covered with a dressing. Tetanus toxoid or antitoxin is given if required. A brush burn is also informally called a “road rash” as in the case of a motorcyclist who slid across the pavement.
chemical b.Tissue destruction caused by corrosive or irritating chemicals such as strong acids or bases, phenols, pesticides, disinfectants, fertilizers, or chemical warfare agents.
Irrigate with large quantities of water.
electric b.Tissue destruction caused by the passage of electrical current through the body, usually as a result of industrial accidents or lightning exposures. Entry and exit wounds are usually present; significant internal organ damage may be found along the path of the current through the body.
b. of eye A burn of the eyeball due to contact with chemical, thermal, electrical, or radioactive agents.
The eye should be washed immediately with the nearest available supply of water, even if it is not sterile. Irrigation may need to be continued for hours if the burn is caused by lye. Care must be taken to prevent runoff from draining into the uninjured eye.
fireworks b.Injury from explosives; usually a burn, often with embedded foreign bodies and a high incidence of infection and tetanus, which should be treated with meticulous care of the injury and the use of antitetanus toxoid and immune globulin.
flash b.A burn resulting from an explosive blast such as occurs from ignition of highly inflammable fluids, or in war from a high-explosive shell or a nuclear blast.
gunpowder b.A burn resulting from exploding gunpowder, usually at very close range. It is often followed by tetanus, which should be prevented by administration of antitetanus toxoid and immune globulin and meticulous care of the injury area.
inhalation b.Inhalation injury.
radiation b.A burn resulting from overexposure to radiant energy as from x-rays, radium or other radioactive elements, sunlight, or nuclear blast.
respiratory b.A burn to the components of the respiratory system usually caused by inhaling superheated gases.
SEE: inhalation injury.
thermal b.A burn resulting from contact with fire, hot objects, or fluids.
SEE: illus..
SEE: radiation burn.