Burns can be caused by friction, cold, head, radiation, chemical or electrical sources and involve tissue destruction due to energy transfer however, different burn injuries cause different physiological and pathological responses. Thermal burns result when the skin makes contact with fire/flames, hot objects, and scalding. Frostbite may also cause a thermal burn by indirect cellular injury from crystallization of water in tissue, ischemia, and reperfusion, leading to skin necrosis and deep tissue injury. Contact with heat/flames is the most common cause of thermal burns and can be localized or systemic. These types of burns can be classified in one of five categories including superficial or first degree, which involves the epidermis only, superficial partial thickness burn or second degree A, which is painful with weeping and requires wound care but not surgery, deep partial thickness or second degree B, which is less painful due to partial destruction of pain receptors and drier and requires surgery and will leave scarring, full thickness or third degree, which extends through full dermis and is not painful due to nerve damage and requires surgery, and forth degree, which involves muscle and bones and is often blackened, leading to loss of burned part of the body (Jeschke et al, 2020).
Chemical burns are less prevalent than thermal burns and occur equally at home and at work, usually in industrialized settings. This type of burn causes tissue damage by a chemical reaction and percutaneous absorption of the chemical. Carbon monoxide, ammonia, hydrochloric and sulfuric acids are the most common types of agents involved in these burns. Additionally, these chemicals can be broken down into acidic and alkaline categories. Acids cause coagulation necrosis with protein precipitation and resultant tough, leathery eschar, which limits deep penetration. Alkaline agents cause liquefaction necrosis where tissue is turned into a liquid, viscous mass, resulting in a poor barrier to penetration and an ongoing burn. Some chemical agents can cause thermal burns by exothermic reactions (Friedstat, Brown, & Levi, 2017).
Electrical burns can be considered a type of thermal burn with temperatures reaching > 100 oC. In this type of burn, electrical forces drive water into the lipid membrane, resulting in cell rupture. Bones have the highest conductivity in the body and can heat to high temperatures and burn surrounding structures including muscles, leading to edema, compartment syndromes and bone necrosis. Additionally, the muscles receive direct injury from the current flow, which may result in cardiac ischemia, arrhythmias, cardiac arrest and myoglobinuria with subsequent acute kidney injury (Friedstat, Brown, & Levi, 2017).
The method used to determine percentage of body mass that has been burned is called the “Rule of 9’s.” This method assigns a percentage to body parts that can be calculated to give a total percentage. The Rule of 9’s states that each arm and the head are assigned 9%, each leg, the front, and back of the torso are assigned 18% respectively, and the perineum is assigned 1%. Once the total percentage of burned body mass is calculated, it is then used in the Parkland Formula to calculate fluid needs (Ete et al, 2019).
Complications associated with treating burn patients include compromised immune system and subsequent infections due to impaired neutrophil killing capacity and increased growth of gut bacteria with increased intestinal permeability, ventilator associated pneumonia and ARDS secondary to inhalation injuries, compartment syndrome, hypothermia, cardiogenic shock, MODS, and failure of engraftment (Jeschke et al 2020).
When I was a new nurse and working in the ED, a woman was brought in via EMS after she “blew up her meth lab.” Using the Rule of 9’s and clinical assessment, it was determined that she had full thickness burns over 78% of her body. This hospital did not have a burn center, thus, the team scurried to attempt to stabilize the patient for air transport to a facility with burn management capacity. She was intubated in the field and was edematous and showing signs of early burn shock shortly after arrival. EMS began fluid resuscitation in the field however, she remained hypotensive and tachycardic, despite continued massive fluid administration. It was determined that the ceiling was too low for her to be airlifted to the next destination due to inclimate weather so she was transported by ambulance and died 20 minutes in route.
Ete, G., Chatarvedi, G., Barreto, E., & Kingsley, P.M. (2019). Effectiveness of Parkland Formula in the estimation of resuscitation fluid
volume in adult thermal burns. Chinese Journal of Traumatology, 22(2), 113-116. https://doi:10.1016/j.ctee.2019.01.006
Friedstat, J., Brown, D.A., & Levi, B. (2017). Chemical, electrical, and radiation injury. Clinical Plastic Surgery, 44(3), 657-669.
Jeschke, M.G., van Baar, M.E., Choudry, M.A., Chung, K.K.,, Gibran, N.J., & Logjetty, S. (2020). Burn injury. Nature Public Health
Collection, 6(1): 11. https://doi:10.1038/s41572-020-0145-5
Jun 2, 2022, 12:08 AM
In the United States, burn injuries account for half a million hospital visits, 40 000 inpatient admissions, and 4000 deaths (Nielson et al., 2017). The annual healthcare resource utilization and spending for burn injuries are more than the U.S. $ 1 billion, excluding post-hospital care and rehabilitation (Nielson et al., 2017). In most cases, burn injuries are less severe, and treatment can be done at home or outpatients (Greenhalgh, 2019). However, significant burn injuries can lead to bodily deformations and cause morbidity if left untreated (Greenhalgh, 2019). Furthermore, the pathophysiological response of burn injuries in the acute phase can lead to lifelong effects on the human body (Greenhalgh, 2019).
There are several types of burns, namely thermal, chemical and electrical. Thermal burns are those injuries caused by exposing the body surface to extreme temperatures, which causes tissue damage (Jeschke et al., 2020). Most burn injuries do not require hospitalization and can be treated as an outpatient (Jeschke et al., 2020). Chemical burns are a type of injury caused by exposure to body tissue with acids or alkalis (Jeschke et al., 2020; Nielson et al., 2017). Chemical burn injuries can significantly affect the patient’s vision without prompt treatment (Jeschke et al., 2020; Nielson et al., 2017). Electrical burns are injuries caused by a current and are associated with higher death incidence and morbidity (Jeschke et al., 2020; Nielson et al., 2017); in most cases, electrical burn injuries are often accidental and preventable (Jeschke et al., 2020; Nielson et al., 2017).
The degree of burn injuries is determined by several factors, such as type of burns, depth, and size affected (Jeschke et al., 2020; Nielson et al., 2017). Therefore, the extent of burns must be quantified or approximated to create a reasonable treatment plan (Giretzlehner et al., 2021). Today, several validated processes quantify burns, such as the Rule of Nines, Parkland Formula, etc. (Giretzlehner et al., 2021).
A typical burn scenario becomes complicated if the injuries involve genitalia, hands, feet, or the face of the patient. These injuries can complicate the many aspects of the treatment plan because of their high potential to disfigure and high impact on the quality of life of the patient.
Giretzlehner, M., Ganitzer, I., & Haller, H. (2021). Technical and Medical Aspects of Burn Size Assessment and Documentation. Medicina (Kaunas, Lithuania), 57(3), 242. https://doi.org/10.3390/medicina57030242
Greenhalgh, D.G. (2019). Management of burns. N Engl J Med, 380, 2349-2359.
Jeschke, M. G., van Baar, M. E., Choudhry, M. A., Chung, K. K., Gibran, N. S., & Logsetty, S. (2020). Burn injury. Nature reviews. Disease primers, 6(1), 11. https://doi.org/10.1038/s41572-020-0145-5
Nielson, C.B et al. (2017). Burns: Pathophysiology of Systemic Complications and Current Management. Journal of Burn Care & Research, 38(1), e469–e481. https://doi.org/10.1097/BCR.0000000000000355
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