Burns

Introduction:

Burns can happen when the skin is exposed to heat (from fire or hot liquids), electricity,
corrosive chemicals, or radiation (UV rays from the sun or tanning beds, or radiation
treatments). Burns are classified as follows, according to the severity of tissue damage:

 First-degree burns -- affect only the outer layer of the skin (epidermis), causing pain
and redness
 Second-degree burns -- extend to the second layer of the skin (the dermis), causing
pain, redness, and blisters that may ooze
 Third-degree burns -- involve both layers of the skin and may also damage the
underlying bones, muscles, and tendons. The burn site appears pale, charred, or
leathery. There is generally no pain in the area because the nerve endings are
destroyed.

Between 1 - 2 million Americans seek medical attention for burns each year. Most burns occur
at home, at work, or are part of an injury from a motor vehicle accident. Between 50,000 -
70,000 people are hospitalized for burns every year in the United States, 30 - 40% of whom
are children younger than 15 years of age. Most burns in children come from scalding liquids.
All burns -- even minor ones -- may cause complications if not properly treated. Skin is the
body's natural barrier to infection, and burns destroy that protection. People who are burned
are very prone to developing infections, so treatment usually involves preventing or treating
infections.

Signs and Symptoms:

Signs and symptoms of burns are different depending on how severe the burn is (as described
above). Your doctor will evaluate the extent of the burn (the amount of skin or body surface
area that the burn covers) to assess the risk for such complications as infection, dehydration,
and disfigurement.

Infection

People who get burned are very prone to infection. It can be hard to tell if a minor burn is
infected because the skin surrounding a burn is usually red and may become warm to the
touch -- both of which are also signs of infection. Any change in the appearance of a burn, or
in the way that the person feels, should be brought to the attention of a doctor. Potential
signs of infection include:

 Change in color of the burnt area or surrounding skin

 Purplish discoloration, particularly if swelling is also present
 Change in thickness of the burn (the burn suddenly extends deep into the skin)
 Greenish discharge or pus
 Fever

Dehydration
In severe or widespread burns, fluid is lost through the skin, and the person can become
dehydrated. Dehydration can lead to life-threatening shock. A doctor will treat dehydration
with intravenous (IV) fluids. Potential signs of dehydration include:

 Thirst
 Lightheadedness or dizziness, particularly when moving from sitting or lying position to
standing
 Weakness
 Dry skin
 Urinating less often than usual

Burn Patterns

Burns have typical and atypical patterns. Typical patterns result from accidental burns while
atypical patterns may be a sign of physical abuse. Typical burns (from spilling hot liquid, for
example) tend to occur in exposed areas such as the arms, face, and neck. Atypical burns
may occur in unexposed areas such as the buttocks. Burns involving entire hands and feet are
also not typical, nor are third-degree burns involving a very small, focused area (resembling,
for example, a cigarette).

Causes:

Burns are caused by exposure to thermal (heat), electrical, radiation, or chemical sources.
Thermal burns occur when hot metals, scalding liquids, steam, or flames come in contact with
the skin. Exposure to electrical current causes electrical burns, and contact with caustic
chemicals causes chemical burns. Prolonged exposure to the sun's ultraviolet rays or to other
sources of radiation (such as from tanning booths) can also cause burns.

The most serious burns are usually caused by scalding hot or flammable liquids, and fires.
Exposure to chemicals and electrical currents also cause severe injury and damage to the
skin.

Risk Factors:

Risk factors for burns include:

 Wood stoves, exposed heating sources, or electrical cords

 Unsafe storage of flammable or caustic materials
 Careless smoking
 Child abuse
 Hot water heater set above 130 °F
 Heated foods and containers
 Too much exposure to the sun

Preventive Care:

These actions can reduce your risk for burns:

 Installing smoke detectors

 Teaching children about fire and burn prevention in schools
 Stopping smoking and heavy alcohol use
 Wearing flame-retardant clothes (particularly children)
 Planning emergency exit routes in the home, school, and workplace
  Practicing fire drills

These steps may help reduce the severity of a burn once it occurs:

 Giving first aid immediately

 Getting prompt medical attention
 If hospitalization is necessary, being treated by a dedicated burn unit with staff
specially trained in burn care

Diagnosis:

When diagnosing a burn, a doctor evaluates the depth and extent of the damage, the degree
of pain, the amount of swelling, and signs of infection. Doctors classify the burn based on the
depth and extent of the injury. Burns that cover a significant portion of the body, burns
associated with smoke inhalation, burns from electrical injuries, and burns associated with
suspected physical abuse require immediate emergency medical attention. In the emergency
room, all wounds are wrapped with sterile cloths. Patients may receive oxygen (either through
a mask or tube) and fluids. Patients are also evaluated for associated injuries (such as from
physical abuse). Doctors may also conduct tests to determine whether the wound is infected.

Treatment:

While minor burns may be treated at home, all other burns require immediate emergency
medical attention because of the risk of infection, dehydration, and other potentially serious
complications.

These are first aid steps for burns:

First-degree burns:

 Run cool water on burned area for 5 - 10 minutes or cover the area with a cool
compress.
 Don't apply oil, butter, or ice to the burn.
 Take ibuprofen or acetaminophen to relieve pain and swelling.
 Any burn to the eye requires immediate emergency help.

Second-degree burns:

 Do not break blisters.

 Do not remove clothing that is stuck to the skin.
 Run cool water on burned area for 5 - 10 minutes, or cover the area with a cool
compress then carefully remove clothing that is not stuck to the skin.
 Elevate burned area above the heart.
 Take ibuprofen or acetaminophen to relieve pain and swelling.
 If not near a medical facility, apply bacitracin ointment or honey on broken blisters to
prevent infection (this is the only situation in which bacitracin or honey should be
applied to burned skin).
 If the burn is near the mouth, nose, or eye, seek emergency medical help immediately.

Third-degree burns:

 If the person is on fire, have them stop, drop, and roll.

 Call 911.
  Check airway, breathing, and circulation.
 Do not remove clothing that is stuck to the skin.
 Run cool water continuously on burned area. Do not immerse large burn areas in water.
 Elevate burned area above the heart.
 Cover the burned area with a sterile bandage or a clean sheet. Do not apply any
ointments.

People who are burned seriously will be admitted to a hospital. There, doctors will concentrate
on keeping the burned area clean and removing any dead tissue through a process called
debridement. Medications will be used to reduce pain and prevent infection. A tetanus shot
will be given if the person has not had one in 5 or more years.

Burns often cause pain and anxiety, even during recovery. A person may also experience
emotional distress if a burn changes his or her appearance. Complementary therapies that
may help alleviate such pain and anxiety include:

 Massage therapy
 Hypnosis
 Therapeutic touch
 Acupuncture

Good nutrition is important as people recover, because vitamins and minerals have been
shown to promote wound healing and prevent the spread of infection.

Medications

 Antimicrobial ointments (such as silver sulfadiazine, mafenide, silver nitrate, and

povidone-iodine) are used to reduce risk of infection. Bacitracin may be used for first-
degree burns.
 Antibiotics (such as oxacillin, mezlocillin, and gentamicin) are used to treat infection.
Antibiotics will also probably be used if the risk of developing infection is high (for
example, when the body surface area of the burn is large).
 Prescription pain medications (such as acetaminophen with codeine, morphine, or
meperidine) are used for severe burns.

Surgery and Other Procedures

In the case of severe burns, debridement and skin grafting may be performed. Debridement
is the removal of dead tissue. In skin grafting, a piece of skin is surgically sewn over the burn,
after any dead tissue is removed. The skin can be from another part of the person's body,
from a donor, or from an animal (usually a pig). Skin grafts from the person's own body are
permanent. Artificial skin may also be used. Cosmetic surgery may be done to improve both
the function and appearance of the burned area.

Nutrition and Dietary Supplements

Minor burns can be treated with natural products. Severe burns, however, always require
immediate medical attention. It is especially important for people who have been seriously
burned to get enough nutrients in their daily diet. Burn patients in hospitals are often given
high-calorie, high-protein diets to speed recovery.
Do not try to treat a second- or third-degree burn by yourself. Always seek medical advice.
Ask your doctor which supplements are best for you. Always tell your health care provider
about the herbs and supplements you are using or considering using, as some supplements
may interfere with conventional treatments.

Following these tips may improve your healing and general health.

 Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes),
and vegetables (such as squash and bell peppers).
 Avoid refined foods, such as white breads, pastas, and sugar.
 Eat fewer red meats and more lean meats, cold-water fish, tofu (soy) or beans for
protein.
 Use healthy cooking oils, such as olive oil or vegetable oil.
 Reduce or eliminate trans-fatty acids, found in commercially baked goods such as
cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and
margarine.
 Avoid caffeine and other stimulants, alcohol, and tobacco.
 Drink 6 - 8 glasses of filtered water daily.

The following supplements may also help. Be sure to ask your doctor before taking them if
your burns are moderate or severe:

 A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-complex

vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
 Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil, one to two
times daily, to help decrease inflammation, and for healing and immunity. Cold-water
fish, such as salmon or halibut, are good sources, but you may need a supplement to
get a higher dose.
 Vitamin C (1,000 mg two to six times per day) helps skin heal by enhancing new tissue
growth and strength. Lower dose if diarrhea develops.
 Vitamin E (400 - 800 IU a day) promotes healing. May be used topically once the burn
has healed and new skin has formed. Higher doses may help in healing burns. Talk to
your doctor before taking vitamin E if you are scheduled to have surgery.
 Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant and immune activity.
 L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal health
and immunity.
 Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony
forming units) a day. Taking antibiotics can upset the balance of bacteria in your
intestines. Probiotics or "friendly" bacteria can help restore the balance, improving
gastrointestinal and immune health. You should refrigerate your probiotic supplements
for best results.

Herbs

Minor burns may be treated with herbs, but you should never take or apply any herb when
you have moderate o severe burns. Call for emergency help first.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any
therapy, you should work with your health care provider to get your problem diagnosed
before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you
should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf
or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures
alone or in combination as noted.

 Turmeric (Curcuma longa) standardized extract, 300 mg three times a day, for pain and
inflammation.

These herbs may be applied topically (externally) to minor burns:

 Aloe (Aloe vera), as a cream or gel. Apply externally to the burned area, 3 - 4 times
daily as needed, for soothing and healing.
 Calendula (Calendula officinalis), or pot marigold, as an ointment or a tea applied
topically. To make tea from tincture, use 1/2 to 1 tsp. diluted in 1/4 cup water. You can
also steep 1 tsp. of flowers in one cup of boiling water for 15 minutes, then strain and
cool. Test skin first for any allergic reaction.
 Gotu kola (Centella asiatica) as a cream containing 1% of the herb, may help repair
skin tissue.
 Propolis, a resin created by bees to build their hives, has been used historically to treat
skin wounds. One study found that people given propolis to apply to minor burns healed
as well as those treated with silver sulfadiazine, a prescription ointment. More research
is needed, however. If you use propolis for a minor burn, test skin first for any reaction.

Acupuncture

Electrical Stimulation

Transcutaneous electrical nerve stimulation (TENS) uses controlled, low-voltage electrical

stimulation of the skin to relieve pain. Recent studies have suggested that TENS applied to
acupuncture points (called electroacupuncture) on the ear (auricular acupuncture) may relieve
pain for people with burns.

Massage and Physical Therapy

Massage Therapy

People with burns suffer pain, itching, and anxiety both from the burn itself and during the
healing of wounds. Some studies suggest that massage may help ease these symptoms in
both the emergency-care and recovery phases. People receiving a massage reported
significantly less itching, pain, anxiety, and depressed mood compared to those who received
standard care only. Ask your doctor before using massage after a burn.

Physical Therapy

Occupational and physical therapy begin very early for people who are hospitalized for burns.
Occupational and physical therapists use a number of techniques to improve movement and
function of the areas affected by a burn, and to reduce scar formation. Physical therapy may
include the practices listed below:

 Body and limb positioning

 Splinting
 Help with activities of daily living until normal function and ability are recovered
 Passive (physical therapist moves the person's limbs) and active exercises
 Help with walking
Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies
in the treatment of burns, professional homeopaths may consider the following measures to
treat first and second-degree burns and to aid recovery from any burn. Before prescribing a
remedy, homeopaths take into account a person' s constitutional type -- your physical,
emotional, and intellectual makeup. An experienced homeopath assesses all of these factors
when determining the most appropriate treatment for each individual.

 Place the burned area in cold water until the pain goes away (this generally takes at
least a few minutes).
 Arnica Montana -- taken orally immediately after the burn.
 Calendula -- apply to the skin for first-degree burns and sunburns. This remedy is
sometimes considered the treatment of choice for children. Calendula may also be used
in the healing stages of second- and third-degree burns to stimulate regrowth of skin
and to decrease scar formation.
 Hypericum perforatum -- used on the skin if there are sharp, shooting pains with the
burn.
 Urtica urens -- taken orally for stinging pains, itching, and swelling of first-degree
burns. A cream or gel may also be applied to the skin for first-degree burns and
sunburns. This remedy may be used for children.
 Causticum -- taken orally for burning pains with great rawness (as from an open
wound) or when there are long-term physical or emotional symptoms after a burn.
 Phosphorus -- taken by mouth for electrical burns, especially if the individual is easily
startled and excitable.

Mind-Body Medicine

Hypnosis

Several studies suggest that hypnosis may reduce pain and anxiety and enhance relaxation in
people with burns.

Therapeutic Touch

Therapeutic touch (TT) is based on the theory that the body, mind, and emotions form a
complex energy field. Therapists seek to correct the body's imbalances by moving their hands
just over the body, what they call "the laying on of hands." This practice has been used for a
number of conditions including pain and anxiety, but studies have shown conflicting results.
One study of patients hospitalized for severe burns suggests that TT may reduce pain and
anxiety associated with burns.

Other Considerations:

Prognosis and Complications

 Infection is the most common complication of burns and is the major cause of death in
burn victims. More than 10,000 Americans die every year from infections caused by
burns.
 Compromised immune system
 Functional or cosmetic damage (reconstructive surgery may be necessary)
 Increased risk of developing cancer at the burn site
  Carbon monoxide poisoning (in the case of a fire)
 Heart attack which may be severe enough to cause the heart to stop (called
cardiopulmonary arrest)

First-degree burns generally heal on their own in 10 - 20 days if no infection develops. In rare
cases, first-degree burns spread more deeply to become second degree (this spread is caused
by infection). Third-degree burns may require a skin graft.

 Reviewed last on: 12/23/2008

 Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative
medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

Annals of Burns and Fire Disasters - vol. XIII - n. 3 - September 2000

THE IMPORTANCE OF EARLY PHYSICAL THERAPY TO PREVENT CONTRACTURE IN THE

BURNED HAND

Petronic I., Nikolic G., Markovic M., Marsavelski A., Golubovic Z., Janjic G., Cirovic D.
University Children's Hospital, Belgrade, Yugoslavia

SUMMARY. Keloid scars are most commonly observed after full-thickness and second-degree burns. Keloid scars are commonly
localized on the limbs, face, and neck because of the exposed nature of these parts. A prospective investigation was
conducted at the University Children's Hospital in Belgrade over a three-year period, during which 35 children with hand
burns were treated. Early physical therapy consisted of electrokinetic therapy, corrective orthosis, and the application of
elastic bandages. In the late phase, working hydrokinesia and occupation therapy were performed. After physical therapy the
outcome was followed up. A significant number (67.7%) of immature scars healed, unlike mature scars, which had to be
managed surgically. Treatment aimed at the aesthetic and functional improvement of the hands. It should be noted that
favourable aesthetic results and a full range of movement were achieved only in cases where physical therapy was applied
simultaneously with wound epithelializafion and initiated as early as possible in collaboration with the surgeon.

Introduction

Burns have an important place in the pathology of children in relation to their frequency and gravity. The
severity of burns in children is also related to the fragility of the child's organism so that an area of
burned surface that does not represent severe injury in an adult may be very dangerous for a child.
The incidence of keloid formation after burns ranges from 6 to 9%. Numerous methods have been used
with greater or lesser success (e.g. atraumatic excision, irradiation, local infiltration of corticosteroids
with or without excision, cryosurgery) for the prevention and treatment of keloids. The aetiopathogenesis
continues to be obscure.
The basic purpose of the application of certain agents of physical therapy is to prevent the development
of hypertrophic or keloid scar after treatment of the burn. Besides their poor aesthetic appearance, keloid
scars may endanger joint functioning. Physiotherapy primarily makes it possible to maintain a full range
of movements and functioning of the affected joints.

Material and method

During the three-year period 1996-1999, at the University Children's Hospital in Belgrade, we treated 35
children with scars secondary to burns of the hand. After completion of the surgical treatment of the
bum, i.e. when epithelialization begins, we carefully examine the burn surface and investigate the
functional state of the surrounding joints. At the first sign of compromised function or attraction of the
surrounding healthy tissue, we initiate physiatric therapy in an attempt to discontinue the formation of
keloids and to promote the regression of any already existing.
Electrotherapy is applied by potassium-iodide electrophoresis, with iodide solution 1 % as an active
substance locally instilled by the biological effect of a galvanic current. Electrophoresis is conducted in a
series of 15 consecutive applications with pauses of two weeks and repeated in several series if needed.
Besides electrophoresis, regular kinesitherapy is also necessary.
Kinesitherapy is initiated by active exercises and continued with actively supported and passive exercises
in all cases of scarred joint surroundings. Therapeutic exercises are used for the prevention of
contractures, muscle atrophy, tendon coalescence, shortening of the joint capsule, and oedema, while the
circulation and lymph drainage are improved.
Occupational therapy with rings and toys is also very important in cases of hand scarring. Thermotherapy
is less frequently used since heat influences long-term hyperaemia, and longer perfusion may have an
adverse effect, i.e. promotion of keloid growth. We applied thermotherapy very carefully in cases of
hand burns and finger bums, when fixed contractures had already developed. Thermotherapy, i.e.
paraffin compresses, was used as an initial procedure.
We always used elastic bandaging for the scars since the extent of keloids can be reduced by permanent
controlled pressure` In cases of involvement of joints in the extremities, we applied corrective splints that
maintained or increased the range of movement in the given joint.

Results

The majority of burns in the 0-3 year-old group were sustained by the child pulling on an object or
during play and play-learning behaviour. Contact with hot solids was in second place. Burns caused by
flame were of significant importance in the older age group. This explains why the most frequent
localization of scalding was the upper limbs, trunk, and face. Keloid scars were commonly localized in
the limbs, face, and neck, because of the greater exposure of these parts (Table 1). We treated 35 children
with scars induced by burns in the hand. Keloid scars were most commonly noted after full-thickness burns
(84.21 %) and deep second-degree burns (63.93%).

Localization
Table I - The commonest localizations of burns
and keloid scars in the children observedNumber
of cases
Face and neck 30
Arms 35
Abdominal region 20
Back and gluteal region 17
Legs 24
Total 126

After physical therapy had been conducted a significant number of immature scars were found to have healed,
contrary to mature scars, which had to be managed surgically (Figs. 1,2).

Fig. 1 - Infant with keloid scars before Fig. 2 - Same child after physical
therapy. therapy.

In immature keloids leading to extensive functional disorders, surgical therapy is initiated earlier in order
to prevent degenerative processes around the joints. Mature (older) keloids cannot in practice be
conservatively treated. In such cases surgery must be performed and followed by prolonged physical
therapy (Table II).

Keloid maturity
Table II -
 Immature 27 19 8
Mature 8 2 6
Total 35 21 14

Discussion

The aim of this work is to point out that in spite of successful treatment, the later phase of burned
children's lives may be affected owing to concomitant consequences. It should however be noted that
favourable aesthetic results and a full range of movement were achieved only in burns where physical
therapy applied simultaneously with wound epithelialization.
The prevention of invalidating injury starts with medical rehabilitation during medical treatment and
continues with the training of family members for continuation of the treatment at home.

RESUME. Les cicatrices chéloïdales se manifestent le plus communément à la suite des brûlures à toute épaisseur et des
brûlures de deuxième degré. Elles sont localisées principalement sur les membres, le visage et le cou, à cause de la majeure
exposition de ces parties du corps. Les Auteurs ont effectué une étude prospective pendant une période de trois ans, pendant
lequel 35 enfants atteints de brûlures de la main ont été traités dans l'Hôpital Universitaire des Enfants à Belgrade. Les
premiers soins physiques consistaient de la thérapie électrokinétique les orthoses correctives et l'application de pansements
élastiques. Dans les phases successives les Auteurs ont utilisé l'hydrokinèse du travail et la thérapie occupationnelle. Après
la thérapie physique les patients ont été suivis et un nombre significatif (67,7%) des cicatrices immatures sont guéries,
contrairement aux cicatrices matures, qu'il fallait traiter chirurgicalement. Le but du traitement était l'amélioration esthétique
et fonctionnelle des mains. Il faut noter que les résultats esthétiques positifs et la capacité totale de la mobilité ont été
possibles seulement dans les cas où la thérapie physique et l'épithélialisation ont été efféctuées en même temps et avec le
moindre délai possible en collaboration avec le chirurgien.

BIBLIOGRAPHY

1. Melhom J.M., Homer RX: Bums of the upper extremity in children: Long-term evaluation of function following
treatment. J. Pediat. Orthop., 7: 563-7, 1987.
2. Mercer N.S.C.: Silicone gel in the treatment of keloid scars. Br. J. 9. Plast. Surg., 42: 83-7, 1989.
3. Strasser M.: Creative use of metal rings in hand therapy. J. Burn Care Rehabil., 4 : 350-1, 1989.
4. Israel D.J., Heydon K.M., Edluch R.F., Pozos R.S., Wittmers L.E.: Core temperature response to immersed bicycle
ergometer exercise at water temperatures of 21, 25 and 29 °C. J. Burn Care Rehabil., 4: 336-44, 1989.
5. Kaufman T., Nawman R.A., Weinberg A., Wexler M.R.: The Kerlix tongue-depressor splint for skin-grafted areas
in burned children. Innovat. Burn Care, 5: 462-3, 1989.
6. Schnebly A.W., Ward S.R., Warden D.C., Saffle R.J.: A nonsplinting approach to the care of the thermally injured
patient. J. Burn Care Rehabil., 3: 263-6, 1989.
7. Wilder P.R., Doctor A., Palsy J.R., Saunders J.T., Edlich F.R.: Evaluation of cohesive and elastic support bandages
for joint immobilization. J. Burn Care Rehabil., 3: 258-62, 1989.
8. Wright M.R., Taddonio T.E., Prasad J.K., Thomson P.D.: The microbiology and cleaning of thermoplastic splints in
burn care. J. Burn Care Rehabil., 1: 79-82, 1989.
9. Ward R.S., Schnebly W.A., Krantz M., Warden C.D., Saffle J.R.: Use of positive plaster impressions to facilitate
measurement of anti-burn scar support gloves for the severely burned hand. J. Burn Care Rehabil., 4: 351-3, 1989.
10. Ward R.S., Schnebly A., Kravitz M., Warden C.D., Saffle J.R.: Have you tried the sandwich splint? J. Burn Care Rehabil., 1:
835, 1989.  

This paper was received on 3 January 2000

Address correspondence to: Dr Ivana Petronic MD, PhD, University
Children's Hospital, Tirsova 10, 11000 Belgrade, Yugoslavia.

 
 Burns
Author: Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery,
Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School
Contributor Information and Disclosures
Updated: Feb 7, 2008
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 References

Introduction

Outcomes for burn patients have improved dramatically over the past 20 years, yet burns still cause substantial morbidity and
mortality. Proper evaluation and management, coupled with appropriate early referral to a specialist, greatly help in minimizing
suffering and optimizing results.

Burn injury is a common cause of morbidity and mortality. In the United States, approximately 1.25 million people with burns
present to the emergency department each year. Among these, 63,000 have minor burn injuries that are treated primarily in the
emergency department and an additional 6000 sustain major burn injuries that require hospital admission.

For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education article Thermal
(Heat or Fire) Burns.

Initial Evaluation and Resuscitation

Before management of the burn wound can begin, the patient should be properly and completely evaluated. Often, this is a brief
effort, particularly in patients with small, uncomplicated wounds. In those with larger burns, evaluation of the wound is often of
secondary importance. As described by the American College of Surgeons Committee on Trauma, evaluation of the burn patient is
organized into a primary survey and secondary survey.

Primary survey

Burn patients should be systematically evaluated using the methodology of the American College of Surgeons Advanced Trauma
Life Support course. This evaluation is described by the primary survey, with its emphasis on support of the airway, gas exchange,
and circulatory stability. First evaluate the airway; this is an area of particular importance in burn patients. Early recognition of
impending airway compromise, followed by prompt intubation, can be lifesaving. Obtain appropriate vascular access and place
monitoring devices, then complete a systematic trauma survey, including indicated radiographs and laboratory studies.

Secondary survey

Burn patients should then undergo a burn-specific secondary survey, which should include a determination of the mechanism of
injury, an evaluation for the presence or absence of inhalation injury and carbon monoxide intoxication, an examination for corneal
burns, the consideration of the possibility of abuse, and a detailed assessment of the burn wound.

Of particular importance is eliciting a detailed history upon first evaluation and transmitting this information with the patient to the
next level of care. Inhalation injury is diagnosed based on a history of a closed-space exposure and soot in the nares and mouth.
Carbon monoxide intoxication is probable in persons injured in structural fires, particularly if they are obtunded;
carboxyhemoglobin levels can be misleading in those ventilated with oxygen. Persons with facial burns should undergo a careful
examination of the cornea prior to the development of lid swelling that can compromise examination. After evaluation of the burn
wound, begin fluid resuscitation and make decisions concerning outpatient or inpatient management or transfer to a burn center
(see American Burn Association burn center transfer criteria in Evaluation of the Burn Wound).

Burn physiology

Tissue burn involves direct coagulation and microvascular reactions in the surrounding dermis that may result in extension of the
injury. Large injuries are associated with a systemic response caused by a loss of the skin barrier, the release of vasoactive
mediators from the wound, and subsequent infection. This results clinically in interstitial edema in distant organs and soft tissues,
with an initial decrease in cardiac output and the metabolic rate.

After successful resuscitation, a hypermetabolic response occurs, with near doubling of cardiac output and resting energy
expenditure. Accelerated gluconeogenesis, insulin resistance, and increased protein catabolism accompany this response.
Modification of this physiology through the administration of beta-adrenergic blockade, beta-adrenergic supplementation,
nonsteroidal anti-inflammatory agents, recombinant growth hormone, androgenic steroids, and insulinlike growth factor 1 have
been proposed to modify this physiology. Currently, data do not support the routine use of these therapies.

Fluid resuscitation

Burn patients demonstrate a graded capillary leak, which increases with injury size, delay in initiation of resuscitation, and the
presence of inhalation injury for the first 18-24 hours after injury. Because the changes are different in every patient, fluid
resuscitation can only be loosely guided by formulas. The inherent inaccuracy of formulas requires continuous reevaluation and
adjustment of infusions based on resuscitation targets.

Most formulas recommend that all crystalloid be isotonic during the first 24 hours, generally Ringer lactate solution. Hypertonic
saline has been recommended for resuscitation, but this practice has largely been abandoned because it is technically challenging
and is not associated with improved clinical outcomes. In smaller children, whose gluconeogenetic capacity is immature,
hypoglycemia is a threat and Ringer lactate solution with 5% dextrose should be added at a maintenance rate.

The modified Brooke or Parkland formulas are reasonable consensus formulas and are used to help determine the initial volume
of infusion. Half of the total calculated 24-hour volume is administered in the first 8 hours post injury. Should the resuscitation be
delayed, this volume is administered so that infusion is completed by the end of the eighth hour post injury. After 18-24 hours,
capillary integrity generally returns and fluid administration should be decreased, following resuscitation endpoints. At this point,
colloid administration is useful, generally 5% albumin in Ringer lactate solution.

As a general rule, burns over less than 15% of the body surface area are not associated with an extensive capillary leak, and
children with burns of this size can be treated with fluid administered at 150% of a calculated maintenance rate and close
observation of their hydration status. Those who are able and willing to take fluid by mouth may be given fluid by mouth, with
additional fluid administered intravenously at a maintenance rate.

Pigmented urine is commonly seen in the setting of high-voltage or very deep thermal injury. This pigment should be cleared
promptly to avoid renal failure. This can usually be achieved through the administration of additional crystalloid. The administration
of bicarbonate may facilitate clearance of myoglobin by preventing its entry into the tubular cells. In rare circumstances, loop
diuretics or mannitol can be useful, but this obscures urine output as a valid indicator of circulating volume.

Electrolyte levels should be carefully monitored and corrected. Cerebral edema and seizures can occur with severe hyponatremia,
and rapid correction of hyponatremia may result in central pontine demyelinating lesions. Serum sodium, potassium, ionized
calcium, phosphorous, and magnesium levels should be monitored and kept within physiologic range. Ideally, begin enteral
feedings during resuscitation, except in patients with massive injuries or those who are underresuscitated and less likely to tolerate
tube feedings because of ileus secondary to splanchnic underperfusion.

Evaluation of the Burn Wound

After the patient has been fully evaluated and stable hemodynamics and gas exchange are ensured, evaluate the burn wound in
detail. Evaluate burn wounds initially for extent, depth, and circumferential components. Decisions regarding the type of
monitoring, wound care, hospitalization, and transfer are made based on this information. The American Burn Association burn
center transfer criteria are as follows:

 Second- or third-degree burns greater than 10% total body surface area (TBSA) in patients younger than 10 years or
older than 50 years
 Second- or third-degree burns greater than 20% TBSA in persons of other age groups
 Second- or third-degree burns that involve the face, hands, feet, genitalia, perineum, or major joints
 Third-degree burns greater than 5% TBSA in persons of any age group
 Electrical burns, including lightening injury
 Chemical burns
 Inhalational injury
 Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect
mortality
 Any patients with burns or concomitant trauma (eg, fracture) in which the burn injury poses the greatest risk of morbidity
or mortality: In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma
center until stable before being transferred to a burn center. Physician judgment is necessary in such situations and
should be in concert with the regional medical control plan and triage protocols.
 A lack of qualified personnel or equipment for the care of children (transfer to facility with these qualities)
 Burn injury in patients who require special social/emotional and/or long-term rehabilitative support, including cases
involving suspected child abuse or substance abuse
Extent of burn

An accurate estimate of burn size is important for treatment and transfer decisions. Burn size or extent can be estimated in a
number of ways. Perhaps most accurate is the age-specific chart based on the Lund-Browder diagram that compensates for the
changes in body proportions with growth (see the image below). A burn is drawn on a cartoon figure, and an associated age-
specific table is used to calculate the body surface area involved.

Initial evaluation and management of the burn patient. Burn size is best estimated using a chart that
corrects for changes in body proportion with aging.
An alternative in adults is the "rule of nines." This is less accurate in children because their body proportions are different from
those of adults. For areas of irregular or nonconfluent burns, the palmar surface of the patient's hand can be used. For a wide age
range, the area of the palm without the fingers represents 0.5% of the body surface.

Burn depth

Burn depths are routinely underestimated during the initial examination. Devitalized tissue may appear viable for some time after
injury, and often, some degree of progressive microvascular thrombosis is observed on the wound periphery. Consequently, the
wound appearance changes over the days following injury. Serial examination of burn wounds can be very useful.

Burn depth is classified as first, second, third, or fourth degree, as follows:

 First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial
second-degree burns, with sloughing occurring the next day.
 Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic
scars (see the image below) vary enormously.


Initial evaluation and management of the burn patient. Second-degree burns are often red, wet,
and very painful. Their depth, ability to heal, and tendency to result in hypertrophic scar formation
vary enormously.
 Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by
contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both
second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly
with pain control. Debride blisters if infection occurs. See the images below.

 Initial evaluation and management of the burn patient. Third-degree burns are usually leathery in
consistency, dry, and insensate. These wounds do not heal.

Initial evaluation and management of the burn patient. Management of burn blisters is
controversial. Burn blisters occasionally obscure the presence of full-thickness wounds.
 Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner
has difficulty accurately determining burn depth during early examination. As a general rule, burn depth is underestimated
upon initial examination.

Note circumferential, or near-circumferential, burn wounds because they may cause progressive extremity ischemia or interfere
with ventilation as burn wound swelling increases. In such situations, timely escharotomy is essential. Perform extremity
escharotomies as soon as peripheral perfusion is threatened. Do not wait until the extremity is overtly ischemic. Perform torso
escharotomies as soon as ventilation appears compromised.

Burn Wound Infection

An ability to make the diagnosis of burn wound infection is important. A clinically focused set of burn wound infection definitions
has recently been published and is summarized as follows:

 Burn impetigo
o Diagnostic points - Loss of epithelium from previously epithelialized surface; not related to local trauma
o Treatment strategies - Regular cleaning of debris and exudate; topical antistaphylococcal antibiotics; grafting of
chronically unstable areas of epithelium
 Burn-related surgical wound infection
o Diagnostic points - Infection in surgically created would that has not yet epithelialized; includes loss of any
overlying graft or membrane
o Treatment strategies - Regular cleaning of debris and exudate; systemic and topical antistaphylococcal
antibiotics; grafting of chronically unstable areas of epithelium
 Burn wound cellulitis
o Diagnostic points - Infection occurs in uninjured skin surrounding a wound; signs of local infection progress
beyond what is expected from burn-related inflammation
o Treatment strategies - Systemic antibiotics directed against Streptococcus pyogenes; proper treatment of primary
wound
 Invasive burn wound infection
o Diagnostic points - Infection occurs in unexcised burn and invades viable underlying tissue; diagnosis may be
supported by results from histologic examination or quantitative culture
o Treatment strategies - Systemic antibiotics directed against presumed pathogen; wound excision, with biologic
closure when possible
Two of these, burn wound cellulitis and invasive burn wound infection, are seen with some regularity by clinicians outside a burn
center environment.

Burn wound cellulitis (see the image below) usually manifests with progressive erythema, swelling, and pain in the uninjured skin
around a wound. Usually, this is seen in the first few days after the burn occurred and is typically caused by S pyogenes. Infection
can progress rapidly, but it is generally sensitive to penicillin. Excision of associated deep eschar can be essential to the
successful treatment of cellulitis. Elevation to reduce edema is an important adjunct.

Initial evaluation and management of the burn patient. Burn wound cellulitis manifests with increasing
erythema, swelling, and pain in uninjured skin around the periphery of a wound.
Invasive burn wound infection (see the image below) is a rapid proliferation of bacteria in burn eschar that invades underlying
viable tissues. A change in color, new drainage, and, occasionally, a foul or sickly sweet odor are clinical findings. Pseudomonal
and other gram-negative species are common causes. This infection can be life-threatening and usually requires combined
treatment with surgery and antibiotics.

Initial evaluation and management of the burn patient. Invasive burn wound infection implies that bacteria
or fungi are proliferating in eschar and invading underlying viable tissues. These wounds display a change
in color, new drainage, and often a foul odor. These infections are life-threatening.
Fever and systemic toxicity commonly accompany both infections. Inspect burn wounds frequently to identify infection early. This
is an important consideration in outpatient burn care. Someone must inspect the wounds managed in the outpatient environment
to promptly detect infections. Errors in initial depth assessment are routine. Infections occur and must be treated in a timely
manner. A wound monitoring plan is an essential part of burn care.

Burn Wound Management

Most burns are small; patients with small burns are appropriately treated in an outpatient setting if the burns do not involve critical
areas such as the face, hands, genitals, or feet. The outpatient setting is the primary focus of this section. Outpatient burn
management can be taxing and, when poorly performed, can cause unnecessary suffering and compromise long-term results. In
some situations, the best plan is to coordinate outpatient management with the burn unit's team of doctors, nurses, and therapists
because their expertise may facilitate attaining optimal outpatient results. However, most small burns can be properly managed by
community-based providers with burn center consultation as needed.

Selection for outpatient care

Several factors are relevant to the decision regarding the location of burn care. Airways must not be compromised. The wound
must be small enough so that fluid resuscitation is unnecessary, which generally precludes outpatient care for burns over 10-15%
of TBSA. The patient must be able to ingest adequate fluid orally. Typically, serious burns to the face, ears, hands, genitals, or feet
should initially be managed in an inpatient setting.

The patient and family must be able to support an outpatient care plan. An adult caregiver should be available who can be with a
child treated in an outpatient setting. A family member or visiting nurse must be available who can perform the necessary wound
cleansing, inspection, and dressing applications because most patients cannot do this themselves. The family must have adequate
transportation to return for clinic visits and unexpected emergency visits. If abuse is suspected, outpatient management is
contraindicated. Finally, if the initial examination findings indicate that surgery is needed for a full-thickness wound area, the
patient should be promptly admitted for surgery. Despite all of these qualifications, most patients with smaller burns can be
successfully treated in an outpatient setting.

Outpatient wound care strategies

Components of outpatient burn care include the following:

 Patient and family education

 Wound cleansing
 Choice of topical or membrane dressing
 Pain control
 Early return instructions
 Follow-up clinic visits
 Long-term follow-up care

Wound cleansing and dressing techniques must be taught to the person who changes the dressings. Ideally, document this
instruction.

The choice of the many medications or membranes to place on burn wounds remains unclear, but certain basic principles apply to
all situations. Gently clean the wound of debris and exudate on a regular basis. This usually requires daily removal of accumulated
exudate and topical medications. Small superficial burns managed in this setting present a low risk of infection, thus, a clean rather
than sterile technique is reasonable. Patients may clean the burn with lukewarm tap water and mild soap.

Soaking dressings in lukewarm tap water may decrease the pain associated with their removal. Gently cleanse the wound with a
gauze or clean washcloth, inspect for signs of infection, pat dry with a clean towel, and re-dress the patient. To manage infections
promptly, teaching the patient and family to return promptly if they notice erythema, swelling, increased tenderness, odor, or
drainage is important. The frequency of wound cleansing and dressing change is debated, but most small burns are managed
adequately with daily cleansing and dressing.

Wound dressing, whether one is using topical medication or a wound membrane, should provide 4 benefits, including (1)
prevention of wound desiccation, (2) control of pain, (3) reduction of wound colonization and infection, and (4) prevention of added
trauma to the wound. Most topical dressings for outpatient use have a viscous carrier that prevents wound desiccation and a
broader antibacterial spectrum that reduces wound colonization. The addition of a gauze wrap minimizes soiling of both clothing
and unburned skin and protects the wound from the external environment. A large number of excellent agents are available.

Superficial facial burns are commonly treated with a clear, viscous antibacterial ointment. Wounds around the eyes can be treated
with heavy topical ophthalmic antibiotic ointments. Treat deep burns of the external ear with mafenide acetate because it
penetrates the eschar and prevents purulent infection of the cartilage. Appropriate wound care strategies address these principles.

Pain control in the outpatient setting can be difficult, and if pain and anxiety cannot be adequately managed at home, then
hospitalization is appropriate. For most patients, an oral narcotic medication administered 30-60 minutes prior to a planned
dressing change provides adequate pain control. Because most dressings are occlusive, pain control between dressing changes
tends to be managed adequately without narcotics in most patients. Elaborate specific conditions may mandate an early return to
the hospital. Particularly important are (1) pain and anxiety associated with wound care to the degree that wound care is
compromised, (2) signs of infection, or (3) a wound that appears deeper than appreciated during the initial examination. Review
wound care instructions with caregivers.

Inpatient management

The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn
injury. Management strategies for these patients are beyond the scope of this article yet generally require a coordinated approach
that involves a specialized team. Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation,
(2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

Excision and grafting

Early excision and closure of full-thickness wounds changes the natural history of burn injury, avoiding the otherwise common
occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation because this
correlates with the physiologic threat represented by the injury. These operations can be bloody and physiologically stressful, but
the blood and stress can be minimized with proper planning and execution.
A prediction regarding the probability a wound will require operative management is of enormous practical value. Examination by
an experienced burn surgeon remains the most reliable method, despite the many devices developed to measure burn depth or
burn blood flow. The changes in wound appearance over the first few days after injury make serial examinations particularly useful
tools in surgical planning.

Patients with small burns rarely develop overwhelming wound sepsis, and burn care providers often have the luxury of time to
allow the wound to fully evolve, allowing accurate operative planning. An initial nonoperative approach to such wounds helps
minimize the need for operation. Patients with larger injuries generally do better if their wound is addressed during the first few
days after the burn occurred. If wounds cover more than 40% TBSA, this may require staged procedures. If the wounds involve
more than 50% of the body surface, achieving immediate autograft closure is often impossible. When autograft material is
exhausted, temporary biologic closure is achieved with human allograft or other temporary wound closure material. Wounds are
later resurfaced with autograft when donor sites have healed.

Most wounds can be managed with layered excisions that optimize appearance and function. Sheet grafts are used whenever
reasonable. Blood loss associated with these operations has been estimated in the past at 3.5-5% of the blood volume for every
1% of the body surface excised. However, less blood loss can be achieved through the use of extremity tourniquets, dilute
epinephrine injection, and a brisk operative pace. Intraoperative hypothermia should be anticipated and prevented though
operating room heating.

Skin substitutes

Temporary skin substitutes provide protection from mechanical trauma, a vapor barrier, and a physical barrier to bacteria. These
membranes contribute to a moist wound environment with a low bacterial density that is consistent with optimal wound healing.
Split thickness human allograft remains the optimal temporary skin cover.

A number of membranes have been developed to effect permanent wound coverage, including epidermal, dermal, and composite
substitutes. A sheet of autologous epithelial cells can be grown from a full-thickness skin biopsy specimen. These can be useful in
patients with massive injury, but they are very fragile, expensive, and provide unreliable definitive cover. Dermal analogs include
Integra R (Integra Life Sciences, Plainsboro, NJ) and AlloDerm R (LifeCell Corporation, The Woodlands, Tex); both require an
associated epithelial autograft. Integra R is a bilayer material with an inner layer of 2-mm thick collagen isolated from bovine tissue
and chondroitin-6-sulfate and an outer layer of 0.009-in polysiloxane polymer with vapor transmission characteristics similar to
skin. Allogenic dermis designed to be combined with a thin epithelial autograft, AlloDerm R is another promising dermal analog.
Hopefully, an autologous composite skin substitute will ultimately be developed.

Medications and Membranes

The choice of medication or membrane for a wound is a never-ending source of discussion and argument. Fortunately, most
medications and membranes perform well if physicians carefully monitor wounds, keep them clean, prevent desiccation, and
properly manage secondary infection.

A wide range of topical medications is available, including simple petrolatum, various antibiotic-containing ointments and aqueous
solutions, and debriding enzymes. Some of the available topical medications and their characteristics are described in the lists
below. All of them can be effective when used properly by experienced providers in a program of burn care that includes wound
evaluation, regular cleansing, and monitoring.

Medications

 Silver sulfadiazine - Broad antibacterial spectrum; painless application

 Aqueous 0.5% silver nitrate - Broad-spectrum coverage, including fungi; leeches electrolytes
 Mafenide acetate - Broad antibacterial spectrum; penetrates eschar best
 Petrolatum - Bland and nontoxic
 Various debriding enzymes - Useful in selected partial-thickness wounds
 Various antibiotic ointments - Useful in many superficial partial-thickness wounds

Membranes

 Porcine xenograft - Adheres to wound coagulum and provides excellent pain control
 Split-thickness allograft - Vascularizes and provides durable temporary closure of wounds
 Various hydrocolloid dressings - Provide vapor and bacteria barrier while absorbing wound exudate
 Various impregnated gauzes - Provide vapor and bacteria barrier while allowing drainage
 Various semipermeable membranes - Provide vapor and bacteria barrier
 o Acticoat (Westhaim Biomedical, Saskatchewan, Canada) - Nonadherent wound dressing that delivers a low
concentration of silver for antisepsis
o Biobrane (Dow-Hickman, Sugarland, Tex) - Synthetic bilaminate that facilitates fibrovascular tissue growth into
inner layer and provides temporary vapor and bacteria barrier
o Transcyte (Smith and Nephew, Largo, Fla) - Synthetic bilaminate that facilitates fibrovascular tissue growth into
inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapor and bacteria
barrier
o AlloDerm R - Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
o Integra R - Provides scaffold for neodermis; requires delayed thin autograft

Wound membranes are different from medications and dressings in that they provide transient physiologic wound closure. This
implies a degree of protection from mechanical trauma, vapor transmission characteristics similar to skin, and a physical barrier to
bacteria. These membranes facilitate a moist wound environment with low bacterial density. They are commonly placed on clean
superficial wounds while awaiting epithelialization. These membranes are mostly occlusive; therefore, they must be used with
caution if wounds are not clearly clean and superficial. If an occlusive membrane is placed over devitalized tissue, submembrane
purulence can occur with subsequent local and systemic sepsis.

Special Situations

Inhalation injury

The diagnosis of inhalation injury is primarily clinical, based on a history of closed-space exposure, facial burns, singed nasal
hairs, and carbonaceous debris in the mouth and pharynx or sputum. Chest radiograph findings are routinely normal until
complications (usually infection) develop. Bronchoscopy findings may include carbonaceous debris, ulceration, or erythema, but
these changes are not always apparent.

The clinical consequences of inhalation injury include upper airway edema, bronchospasm, small airway occlusion, increased
dead space and intrapulmonary shunting, decreased lung and chest wall compliance, and infection. Management is supportive
only.

Pneumonia or tracheobronchitis occurs in at least 30% of patients with inhalation injuries, due to the loss of the ciliary clearance
mechanism, small airway occlusion, alveolar flooding, and endotracheal intubation. Vigorous pulmonary toilet, with toilet
bronchoscopy in selected patients, is a very important component of therapy. The role of tracheostomy in the management of
inhalation injury is controversial. It can be very useful if particularly prolonged intubation or difficult weaning is anticipated or if
unusually thick secretions are unmanageable through an endotracheal tube. Tracheostomy in children is associated with a higher
incidence of serious structural problems that require prolonged cannulation and reconstruction and, ideally, is avoided whenever
possible.

Electrical burns

Compartment syndrome, cardiac arrhythmia, or myoglobinuria is uncommon in patients exposed to less than 500 volts, although
patients sustaining midrange injuries (200-1000 V) can have destructive local injuries. High-voltage injuries are commonly
associated with loss of consciousness, falls, fractures, myoglobinuria, compartment syndrome, and arrhythmia, and these
individuals should be treated as trauma patients.

Chemical burns

Treatment of chemical exposures should begin with immediate removal of clothing and chemicals. First responders need to protect
themselves from injury. Copious irrigation with tap water should then be performed for at least 30 minutes. Alkaline substances,
less soluble in water, often take longer to clear. Consultation with personnel at the poison control center should be considered
when evaluating anyone with a chemical burn. Adequate ocular irrigation can be facilitated by topical ocular anesthetics. With
larger injuries, fluid resuscitation may be required. Some agents are associated with irritating fumes, which can result in airway
compromise.

Toxic epidermal necrolysis

Toxic epidermal necrolysis is a systemic process triggered by a medication or viral syndrome that results in a separation at the
dermal-epidermal junction. Both a cutaneous wound and a visceral wound develop, with variable degrees of dermal, mucosal, and
conjunctival involvement. Endotracheal intubation is often required for airway protection. Wound care should be directed to prevent
desiccation and superinfection, and nutritional support is important.

Facial burns
Especially in adolescents and adults, the deep sweat and sebaceous glands of the central face make it likely that most second-
degree burns will heal well with adequate topical wound care. Many reasonable management options are available, including
topical silver sulfadiazine or bland antibiotic ointments. Burns around the eyes can be dressed with topical ophthalmic antibiotic
ointments. If grafting is a possibility, reserve thick donor skin with optimal color match for facial resurfacing. Often, the "blush"
areas, such as the upper back and shoulders, make good facial donor sites.

The most important point of early management of deeply burned ears is prevention of auricular chondritis. This is a serious
complication in which the cartilage becomes infected and quickly liquefies. Twice-daily cleansing and the application of topical
mafenide acetate, which penetrates the eschar, can minimize the condition. Subsequent management of the ear is based on the
depth of injury.

Deep corneal burns are obvious during the physical examination. The cornea has a clouded appearance. More subtle injuries can
be detected only with topical fluorescein application. After facial edema resolves, lid retraction may occur with variable degrees of
exposure of the globe or ectropion. When this is relatively mild, no intervention is required beyond ocular lubricants. Should
keratitis occur, early lid release is advised.

Hand burns

Hand burns assume a high priority from the onset of care. During the first 24-48 hours, adequate blood flow must be ensured.
Regularly monitor consistency, temperature, and the presence of pulsatile flow (detectable using Doppler studies of the digital
pulp). If blood flow is questionable, perform escharotomy or fasciotomy.

Splint hands in a position of function, ie, the metatarsophalangeal joints at 70-90°, interphalangeal joints in extension, first web
space open, and wrist at 20° of extension. Elevate the hands to minimize edema, and have the patient perform range-of-motion
exercises with a therapist twice daily. Deep dermal and full-thickness burns should undergo early excision and sheet autograft
closure. Perform hand therapy throughout the healing period, stopping only in the few days immediately after grafting. If this is not
performed, suboptimal long-term function results (see the image below).

Initial evaluation and management of the burn patient. If hand positioning and therapy are ignored while
overlying burns heal, poor long-term function may result.
Rehabilitation

The final phase of burn care is rehabilitation and reconstruction. As survival has improved, this field has evolved rapidly, becoming
highly specialized. Therapy should begin in the critical care setting; priorities include ranging, splinting, and antideformity
positioning. Ranging is ideally performed twice daily, with the therapist taking all joints through a passive of range of motion. These
activities help prevent the occurrence of many common contractures. As the seriously burned patient begins to recover, priorities
include continuing passive ranging, increasing active ranging and strengthening, minimizing edema, pursuing activities of daily
living, and preparing for work or play and school.

Important aspects of rehabilitation after discharge include ongoing and progressive ranging and strengthening, postoperative
therapy after reconstructive operations, and scar management. The most difficult hypertrophic scarring is seen in deep dermal
burns that heal spontaneously in less than 3 weeks. Therapies to minimize hypertrophic scarring are begun as soon as burns are
well healed and include scar massage, compression garments, topical silicone, steroid injections, and management of pruritus.

If they participate in a coordinated multidisciplinary burn aftercare program, most patients have satisfying long-term outcomes.

Multimedia
 Media file 1: Initial evaluation and management of the burn patient. Burn size is best estimated
using a chart that corrects for changes in body proportion with aging.

(Enlarge Image)

Initial evaluation and management of the burn patient. Burn size is best estimated using a chart that corrects for
changes in body proportion with aging.
Media file 2: Initial evaluation and management of the burn patient. Second-degree burns
are often red, wet, and very painful. Their depth, ability to heal, and tendency to result in
hypertrophic scar formation vary enormously.

(Enlarge Image)

Initial evaluation and management of the burn patient. Second-degree burns are often red, wet, and very painful.
Their depth, ability to heal, and tendency to result in hypertrophic scar formation vary enormously.
Media file 3: Initial evaluation and management of the burn patient. Third-degree burns
are usually leathery in consistency, dry, and insensate. These wounds do not heal.

(Enlarge Image)

Initial evaluation and management of the burn patient. Third-degree burns are usually leathery in consistency,
dry, and insensate. These wounds do not heal.
Media file 4: Initial evaluation and management of the burn patient. Management of burn
blisters is controversial. Burn blisters occasionally obscure the presence of full-thickness
wounds.

(Enlarge Image)

Initial evaluation and management of the burn patient. Management of burn blisters is controversial. Burn blisters
occasionally obscure the presence of full-thickness wounds.
 Media file 5: Initial evaluation and management of the burn patient. Burn wound cellulitis
manifests with increasing erythema, swelling, and pain in uninjured skin around the
periphery of a wound.

(Enlarge Image)

Initial evaluation and management of the burn patient. Burn wound cellulitis manifests with increasing erythema,
swelling, and pain in uninjured skin around the periphery of a wound.
Media file 6: Initial evaluation and management of the burn patient. Invasive burn wound
infection implies that bacteria or fungi are proliferating in eschar and invading underlying viable
tissues. These wounds display a change in color, new drainage, and often a foul odor. These
infections are life-threatening.

(Enlarge Image)

Initial evaluation and management of the burn patient. Invasive burn wound infection implies that bacteria or
fungi are proliferating in eschar and invading underlying viable tissues. These wounds display a change in color,
new drainage, and often a foul odor. These infections are life-threatening.
Media file 7: Initial evaluation and management of the burn patient. If hand positioning
and therapy are ignored while overlying burns heal, poor long-term function may result.

(Enlarge Image)

Initial evaluation and management of the burn patient. If hand positioning and therapy are ignored while
overlying burns heal, poor long-term function may result.
Media file 8: Initial evaluation and management of the burn patient. Estimating the burn area in an adult
patient.

(Enlarge Image)

Initial evaluation and management of the burn patient. Estimating the burn area in an adult patient.
 Media file 9: Initial evaluation and management of the burn patient. Estimating the burn
area in a child.

(Enlarge Image)

Initial evaluation and management of the burn patient. Estimating the burn area in a child.
Media file 10: Initial evaluation and management of the burn patient. Escharotomy incisions.

(Enlarge Image)

Initial evaluation and management of the burn patient. Escharotomy incisions.

Media file 11: Partial-thickness burn.

(Enlarge Image)

Partial-thickness burn.
Media file 12: A 2-year-old child with a scald burn to the hand.

(Enlarge Image)

A 2-year-old child with a scald burn to the hand.

Media file 13: Proper functional positioning for splinting of serious hand burns is the
metacarpophalangeal joints are at 70-90° of flexion, the interphalangeal joints are in
extension, the wrist is at 20° of extension, and the first web space is open.

(Enlarge Image)

Keywords
burn, heat injury, electrical injury, lightening injury, chemical injury, thermal injury, electric shock, high-voltage injury, first-degree
burn, second-degree burn, third-degree burn, 1st degree burn, 2nd degree burn, 3rd degree burn, escharotomy