Burn

A burn is an injury to skin, or other tissues, caused by heat, electricity, chemicals, friction, or ionizing radiation (such as sunburn, caused by ultraviolet radiation).<ref name="TBCChp4">Template:Cite book</ref><ref>Template:Cite book</ref> Most burns are due to heat from hot fluids (called scalding), solids, or fire.<ref name="WHO2014">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Burns occur mainly in the home or the workplace. In the home, risks are associated with domestic kitchens, including stoves, flames, and hot liquids.<ref name="WHO2016" /> In the workplace, risks are associated with fire and chemical and electric burns.<ref name="WHO2016" /> Alcoholism and smoking are other risk factors.<ref name="WHO2016" /> Burns can also occur as a result of self-harm or violence between people (assault). <ref name="WHO2016" />

Burns that affect only the superficial skin layers are known as superficial or first-degree burns.<ref name=Tint2010/><ref name=EMP2009/> They appear red without blisters, and pain typically lasts around three days.<ref name=Tint2010/><ref name=EMP2009>Template:Cite journal</ref> When the injury extends into some of the underlying skin layer, it is a partial-thickness or second-degree burn.<ref name=Tint2010/> Blisters are frequently present and they are often very painful.<ref name=Tint2010/> Healing can require up to eight weeks and scarring may occur.<ref name=Tint2010/> In a full-thickness or third-degree burn, the injury extends to all layers of the skin.<ref name=Tint2010/> Often there is no pain and the burnt area is stiff.<ref name=Tint2010/> Healing typically does not occur on its own.<ref name=Tint2010/> A fourth-degree burn additionally involves injury to deeper tissues, such as muscle, tendons, or bone.<ref name=Tint2010>Template:Cite book</ref> The burn is often black and frequently leads to loss of the burned part.<ref name=Tint2010/><ref>Template:Cite book</ref>

Burns are generally preventable.<ref name=WHO2016>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Treatment depends on the severity of the burn.<ref name=Tint2010/> Superficial burns may be managed with little more than simple pain medication, while major burns may require prolonged treatment in specialized burn centers.<ref name=Tint2010/> Cooling with tap water may help pain and decrease damage; however, prolonged cooling may result in low body temperature.<ref name=Tint2010/><ref name=EMP2009/> Partial-thickness burns may require cleaning with soap and water, followed by dressings.<ref name=Tint2010/> It is not clear how to manage blisters, but it is probably reasonable to leave them intact if small and drain them if large.<ref name=Tint2010/> Full-thickness burns usually require surgical treatments, such as skin grafting.<ref name=Tint2010/> Extensive burns often require large amounts of intravenous fluid, due to capillary fluid leakage and tissue swelling.<ref name=EMP2009/> The most common complications of burns involve infection.<ref name=TBCChp3>Template:Cite book</ref> Tetanus toxoid should be given if not up to date.<ref name=Tint2010/>

In 2015, fire and heat resulted in 67 million injuries.<ref name=GBD2015Pre>Template:Cite journal</ref> This resulted in about 2.9 million hospitalizations and 176,000 deaths.<ref name=GBD2015De>Template:Cite journal</ref><ref name=GBD2016>Template:Cite journal</ref> Among women in much of the world, burns are most commonly related to the use of open cooking fires or unsafe cook stoves.<ref name=WHO2016/> Among men, they are more likely a result of unsafe workplace conditions.<ref name=WHO2016/> Most deaths due to burns occur in the developing world, particularly in Southeast Asia.<ref name=WHO2016/> While large burns can be fatal, treatments developed since 1960 have improved outcomes, especially in children and young adults.<ref name=TBCChp1>Template:Cite bookTemplate:Dead link</ref> In the United States, approximately 96% of those admitted to a burn center survive their injuries.<ref name=ABA2012>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The long-term outcome is related to the size of burn and the age of the person affected.<ref name=Tint2010/> Template:TOC limit

History

File:Guillaume Dupuytren.jpg

Guillaume Dupuytren (1777–1835), who developed the degree classification of burns

Cave paintings from more than 3,500 years ago document burns and their management.<ref name=TBCChp1/> The earliest Egyptian records on treating burns describes dressings prepared with milk from mothers of baby boys,<ref name="Pećanac-">Template:Cite journal</ref> and the 1500 BCE Edwin Smith Papyrus describes treatments using honey and the salve of resin.<ref name=TBCChp1/> Many other treatments have been used over the ages, including the use of tea leaves by the Chinese documented to 600 BCE, pig fat and vinegar by Hippocrates documented to 400 BCE, and wine and myrrh by Celsus documented to the 1st century CE.<ref name=TBCChp1/> French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s.<ref name=David2012>Template:Cite book</ref> Guillaume Dupuytren expanded these degrees into six different severities in 1832.<ref name=TBCChp1/><ref>Template:Cite book</ref>

The first hospital to treat burns opened in 1843 in London, England, and the development of modern burn care began in the late 1800s and early 1900s.<ref name=TBCChp1/><ref name=David2012/> During World War I, Henry D. Dakin and Alexis Carrel developed standards for the cleaning and disinfecting of burns and wounds using sodium hypochlorite solutions, which significantly reduced mortality.<ref name=TBCChp1/> In the 1940s, the importance of early excision and skin grafting was acknowledged, and around the same time, fluid resuscitation and formulas to guide it were developed.<ref name=TBCChp1/> In the 1970s, researchers demonstrated the significance of the hypermetabolic state that follows large burns.<ref name=TBCChp1/>

The "Evans formula", described in 1952, was the first burn resuscitation formula based on body weight and surface area (BSA) damaged. The first 24 hours of treatment entails 1ml/kg/% BSA of crystalloids plus 1 ml/kg/% BSA colloids plus 2000ml glucose in water, and in the next 24 hours, crystalloids at 0.5 ml/kg/% BSA, colloids at 0.5 ml/kg/% BSA, and the same amount of glucose in water.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two or three days, followed by peeling of the skin over the next few days.<ref name=EMP2009/><ref name=TBCChp10/> Individuals with more severe burns may indicate discomfort or complain of feeling pressure rather than pain. Full-thickness burns may be entirely insensitive to light touch or puncture.<ref name=TBCChp10/> While superficial burns are typically red in color, severe burns may be pink, white or black.<ref name=TBCChp10/> Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred, but these findings are not definitive.<ref name=Schw2010/> More worrisome signs include: shortness of breath, hoarseness, and stridor or wheezing.<ref name=Schw2010/> Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all children.<ref name=Itchy2009>Template:Cite journal</ref> Numbness or tingling may persist for a prolonged period of time after an electrical injury.<ref name=RosenChp140/> Burns may also produce emotional and psychological distress.<ref name=Epi2011/> Template:Anchor

Type<ref name=Tint2010/>	Layers involved	Appearance	Texture	Sensation	Healing time	Prognosis and complications	Example
Superficial (first-degree)	Epidermis<ref name=EMP2009/>	Red without blisters<ref name=Tint2010/>	Dry	Painful<ref name=Tint2010/>	5–10 days<ref name=Tint2010/><ref name=AFP2012/>	Heals well.<ref name=Tint2010/>	A sunburn is a typical first-degree burn.
Superficial partial thickness (second-degree)	Extends into superficial (papillary) dermis<ref name=Tint2010/>	Redness with clear blister.<ref name=Tint2010/> Blanches with pressure.<ref name=Tint2010/>	Moist<ref name=Tint2010/>	Very painful<ref name=Tint2010/>	2–3 weeks<ref name=Tint2010/><ref name=TBCChp10/>	Local infection (cellulitis) but no scarring typically<ref name=TBCChp10>Template:Cite book</ref>	Second-degree burn of the thumb
Deep partial thickness (second-degree)	Extends into deep (reticular) dermis<ref name=Tint2010/>	Yellow or white. Less blanching. May be blistering.<ref name=Tint2010/>	Fairly dry<ref name=TBCChp10/>	Pressure and discomfort<ref name=TBCChp10/>	3–8 weeks<ref name=Tint2010/>	Scarring, contractures (may require excision and skin grafting)<ref name=TBCChp10/>	Second-degree burn caused by contact with boiling water
Full thickness (third-degree)	Extends through entire dermis<ref name=Tint2010/>	Stiff and white/brown.<ref name=Tint2010/> No blanching.<ref name=TBCChp10/>	Leathery<ref name=Tint2010/>	Painless<ref name=Tint2010/>	Prolonged (months) and unfinished/incomplete<ref name=Tint2010/>	Scarring, contractures, amputation (early excision recommended)<ref name=TBCChp10/>	Eight day old third-degree burn caused by motorcycle muffler.
Fourth-degree	Extends through entire skin, and into underlying fat, muscle and bone<ref name=Tint2010/>	Black; charred with eschar	Dry	Painless	Does not heal; Requires excision<ref name=Tint2010/>	Amputation, significant functional impairment and, in some cases, death.<ref name=Tint2010/>	4th-degree electrical burn

Cause

Burns are caused by a variety of external sources classified as thermal (heat-related), chemical, electrical, and radiation.<ref>Template:Cite book</ref> In the United States, the most common causes of burns are: fire or flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%).<ref name=ABA2012pgi>National Burn Repository Pg. i</ref> Most (69%) burn injuries occur at home or at work (9%),<ref name=ABA2012/> and most are accidental, with 2% due to assault by another, and 1–2% resulting from a suicide attempt.<ref name=Epi2011/> These sources can cause inhalation injury to the airway and/or lungs, occurring in about 6%.<ref name=TBCChp3/>

Burn injuries occur more commonly among the poor.<ref name=Epi2011/> Smoking and alcoholism are other risk factors.<ref name=WHO2014/> Fire-related burns are generally more common in colder climates.<ref name=Epi2011/> Specific risk factors in the developing world include cooking with open fires or on the floor<ref name=TBCChp4/> as well as developmental disabilities in children and chronic diseases in adults.<ref name=LMIC2006/>

Thermal

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Template:Image frame In the United States, fire and hot liquids are the most common causes of burns.<ref name=TBCChp3/> Of house fires that result in death, smoking causes 25% and heating devices cause 22%.<ref name=TBCChp4/> Almost half of injuries are due to efforts to fight a fire.<ref name=TBCChp4/> Scalding is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature tap water in baths or showers, hot cooking oil, or steam.<ref>Template:Cite book</ref> Scald injuries are most common in children under the age of five<ref name=Tint2010/> and, in the United States and Australia, this population makes up about two-thirds of all burns.<ref name=TBCChp3/> Contact with hot objects is the cause of about 20–30% of burns in children.<ref name=TBCChp3/> Generally, scalds are first- or second-degree burns, but third-degree burns may also result, especially with prolonged contact.<ref name=Mag2008/> Fireworks are a common cause of burns during holiday seasons in many countries.<ref>Template:Cite book</ref> This is a particular risk for adolescent males.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> In the United States, for non-fatal burn injuries to children, white males under the age of 6 comprise most cases.<ref name=":0">Template:Cite journal</ref>  Thermal burns from grabbing/touching and spilling/splashing were the most common type of burn and mechanism, while the bodily areas most impacted were hands and fingers followed by head/neck.<ref name=":0" />

Chemical

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Chemical burns can be caused by over 25,000 substances,<ref name=Tint2010/> most of which are either a strong base (55%) or a strong acid (26%).<ref name=Hard2012>Template:Cite journal</ref> Most chemical burn deaths are secondary to ingestion.<ref name=Tint2010/> Common agents include: sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover, among others.<ref name=Tint2010/> Hydrofluoric acid can cause particularly deep burns that may not become symptomatic until some time after exposure.<ref name=HF2008>Template:Cite journal</ref> Formic acid may cause the breakdown of significant numbers of red blood cells.<ref name=Schw2010/>

Electrical

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Electrical burns or injuries are classified as high voltage (greater than or equal to 1000 volts), low voltage (less than 1000 volts), or as flash burns secondary to an electric arc.<ref name=Tint2010/> The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).<ref name=TBCChp3/><ref>Template:Cite journal</ref> Lightning may also result in electrical burns.<ref>Template:Cite journal</ref> Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.<ref name=RosenChp140/> Mortality from a lightning strike is about 10%.<ref name=RosenChp140/>

While electrical injuries primarily result in burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions.<ref name=RosenChp140/> In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone.<ref name=RosenChp140/> Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest.<ref name=RosenChp140/>

Radiation

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Radiation burns may be caused by protracted exposure to ultraviolet light (such as from the sun, tanning booths or arc welding) or from ionizing radiation (such as from radiation therapy, X-rays or radioactive fallout).<ref>Template:Cite book</ref> Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.<ref>Template:Cite journal</ref> There is significant variation in how easily people sunburn based on their skin type.<ref>Template:Cite journal</ref> Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy, redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy.<ref name=RosenChp144>Template:Cite book</ref> Redness, if it occurs, may not appear until some time after exposure.<ref name=RosenChp144/> Radiation burns are treated the same as other burns.<ref name=RosenChp144/> Microwave burns occur via thermal heating caused by the microwaves.<ref name=Micro2001/> While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.<ref name=Micro2001>Template:Cite book</ref>

Non-accidental

In those hospitalized from scalds or fire burns, 3Template:En dash10% are from assault.<ref name=Peck2012/> Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes.<ref name=Peck2012/> An immersion injury or immersion scald may indicate child abuse.<ref name=Mag2008>Template:Cite journal</ref> It is created when an extremity, or sometimes the buttocks are held under the surface of hot water.<ref name=Mag2008/> It typically produces a sharp upper border and is often symmetrical,<ref name=Mag2008/> known as "sock burns", "glove burns", or "zebra stripes" - where folds have prevented certain areas from burning.<ref name=Scielo2011>Template:Cite journal</ref> Deliberate cigarette burns most often found on the face, or the back of the hands and feet.<ref name=Scielo2011/> Other high-risk signs of potential abuse include: circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse.<ref name=TBCChp61/>

Bride burning, a form of domestic violence, occurs in some cultures, such as India where women have been burned in revenge for what the husband or his family consider an inadequate dowry.<ref>Template:Cite journal</ref><ref>Template:Cite book</ref> In Pakistan, acid burns represent 13% of intentional burns, and are frequently related to domestic violence.<ref name=TBCChp61>Template:Cite book</ref> Self-immolation (setting oneself on fire) is also used as a form of protest in various parts of the world.<ref name=Epi2011/>

Pathophysiology

File:Burn Degree Diagram.svg

Three degrees of burns

At temperatures greater than Template:Convert, proteins begin losing their three-dimensional shape and start breaking down.<ref name=Rosen2009>Template:Cite book</ref> This results in cell and tissue damage.<ref name=Tint2010/> Many of the direct health effects of a burn are caused by failure of the skin to perform its normal functions, which include: protection from bacteria, skin sensation, body temperature regulation, and prevention of evaporation of the body's water. Disruption of these functions can lead to infection, loss of skin sensation, hypothermia, and hypovolemic shock via dehydration (i.e. water in the body evaporated away).<ref name=Tint2010/> Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.<ref name=Tint2010/>

In large burns (over 30% of the total body surface area), there is a significant inflammatory response.<ref name=Roj2012>Template:Cite journal</ref> This results in increased leakage of fluid from the capillaries,<ref name=Schw2010/> and subsequent tissue edema.<ref name=Tint2010/> This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated.<ref name=Tint2010/> Poor blood flow to organs like the kidneys and gastrointestinal tract may result in kidney failure and stomach ulcers.<ref>Template:Cite book</ref>

Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years.<ref name=Roj2012/> This is associated with increased cardiac output, metabolism, a fast heart rate, and poor immune function.<ref name=Roj2012/>

Diagnosis

Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.<ref name=Tint2010/> It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary.<ref name=Schw2010/> In those who have a headache or are dizzy and have a fire-related burn, carbon monoxide poisoning should be considered.<ref name=CEM2012/> Cyanide poisoning should also be considered.<ref name=Schw2010>Template:Cite book</ref>

Size

File:Wallace rule of nines-en.svg

Burn grade is determined through, among other things, the size of the skin affected. The image shows the makeup of different body parts, to help assess burn size.

The size of a burn is measured as a percentage of total body surface area (TBSA) affected by partial thickness or full thickness burns.<ref name=Tint2010/> First-degree burns that are only red in color and are not blistering are not included in this estimation.<ref name=Tint2010/> Most burns (70%) involve less than 10% of the TBSA.<ref name=TBCChp3/>

There are a number of methods to determine the TBSA, including the Wallace rule of nines, Lund and Browder chart, and estimations based on a person's palm size.<ref name=EMP2009/> The rule of nines is easy to remember but only accurate in people over 16 years of age.<ref name=EMP2009/> More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children.<ref name=EMP2009/> The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA.<ref name=EMP2009/>

Severity

American Burn Association severity classification<ref name=CEM2012/>

Minor	Moderate	Major
Adult <10% TBSA	Adult 10–20% TBSA	Adult >20% TBSA
Young or old < 5% TBSA	Young or old 5–10% TBSA	Young or old >10% TBSA
<2% full thickness burn	2–5% full thickness burn	>5% full thickness burn
	High voltage injury	High voltage burn
	Possible inhalation injury	Known inhalation injury
	Circumferential burn	Significant burn to face, joints, hands, or feet
	Other health problems	Associated injuries

To determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate, and minor. This is assessed based on a number of factors, including total body surface area affected, the involvement of specific anatomical zones, the age of the person, and associated injuries.<ref name=CEM2012/> Minor burns can typically be managed at home, moderate burns are often managed in a hospital, and major burns are managed by a burn center.<ref name=CEM2012>Template:Cite book</ref> Severe burn injury represents one of the most devastating forms of trauma.<ref>Barayan D, Vinaik R, Auger C, Knuth CM, Abdullahi A, Jeschke MG. Inhibition of Lipolysis With Acipimox Attenuates Postburn White Adipose Tissue Browning and Hepatic Fat Infiltration. Shock. 2020;53(2):137-145. doi:10.1097/SHK.0000000000001439, 10.1097/SHK.0000000000001439</ref> Despite improvements in burn care, patients can be left to suffer for as many as three years post-injury.<ref>Jeschke MG, Gauglitz GG, Kulp GA, Finnerty CC, Williams FN, Kraft R, Suman OE, Mlcak RP, Herndon DN: Long-term persistence of the pathophysi-ologic response to severe burn injury.PLoS One6:E21245, 2011.</ref>

Prevention

Historically, about half of all burns were deemed preventable.<ref name=TBCChp4/> Burn prevention programs have significantly decreased rates of serious burns.<ref name=Rosen2009/> Preventive measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing.<ref name=TBCChp4/> Experts recommend setting water heaters below Template:Convert.<ref name=TBCChp3/> Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves.<ref name=Rosen2009/> While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit<ref>Template:Cite book</ref> with recommendations including the limitation of the sale of fireworks to children.<ref name=TBCChp3/>

Management

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.<ref name=EMP2009/> If inhalation injury is suspected, early intubation may be required.<ref name=Schw2010/> This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospital.<ref name=Schw2010/> As burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years.<ref>Template:Cite book</ref> In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.<ref name=Epi2011/> With major burns, early feeding is important.<ref name=Roj2012/> Protein intake should also be increased, and trace elements and vitamins are often required.<ref>Template:Cite journal</ref> Hyperbaric oxygenation may be useful in addition to traditional treatments.<ref>Template:Cite journal</ref>

Intravenous fluids

In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given.<ref name=EMP2009/> In children with more than 10–20% TBSA (Total Body Surface Area) burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow.<ref name=EMP2009/><ref name=Enoch2009>Template:Cite journal</ref><ref>Template:Cite journal</ref> This should be begun pre-hospital if possible in those with burns greater than 25% TBSA.<ref name=Enoch2009/> The Parkland formula can help determine the volume of intravenous fluids required over the first 24 hours. The formula is based on the affected individual's TBSA and weight. Half of the fluid is administered over the first 8 hours, and the remainder over the following 16 hours. The time is calculated from when the burn occurred, and not from the time that fluid resuscitation began. Children require additional maintenance fluid that includes glucose.<ref name=Schw2010/> Additionally, those with inhalation injuries require more fluid.<ref>Template:Cite book</ref> While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental.<ref>Template:Cite journal</ref> The formulas are only a guide, with infusions ideally tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children and mean arterial pressure greater than 60 mmHg.<ref name=Schw2010/>

While lactated Ringer's solution is often used, there is no evidence that it is superior to normal saline.<ref name=EMP2009/> Crystalloid fluids appear just as good as colloid fluids, and as colloids are more expensive they are not recommended.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Blood transfusions are rarely required.<ref name=Tint2010/> They are typically only recommended when the hemoglobin level falls below 60-80 g/L (6-8 g/dL)<ref>Template:Cite journal</ref> due to the associated risk of complications.<ref name=Schw2010/> Intravenous catheters may be placed through burned skin if needed or intraosseous infusions may be used.<ref name=Schw2010/>

Wound care

Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia.<ref name=Tint2010/><ref name=EMP2009/> It should be performed with cool water Template:Convert and not ice water as the latter can cause further injury.<ref name=EMP2009/><ref name=Rosen2009/> Chemical burns may require extensive irrigation.<ref name=Tint2010/> Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second-degree burns should be re-evaluated after two days.<ref name=Rosen2009/>

In the management of first and second-degree burns, little quality evidence exists to determine which dressing type to use.<ref name="The Cochrane Database of Systematic Reviews">Template:Cite journal</ref> It is reasonable to manage first-degree burns without dressings.<ref name=Rosen2009/> While topical antibiotics are often recommended, there is little evidence to support their use.<ref name=Anti2010/><ref>Template:Cite journal</ref> Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time.<ref name="The Cochrane Database of Systematic Reviews" /><ref>Template:Cite journal</ref> There is insufficient evidence to support the use of dressings containing silver<ref>Template:Cite journal</ref> or negative-pressure wound therapy.<ref>Template:Cite journal</ref> Silver sulfadiazine does not appear to differ from silver containing foam dressings with respect to healing.<ref>Template:Cite journal</ref>

Medications

Burns can be very painful and a number of different options may be used for pain management. These include simple analgesics (such as ibuprofen and acetaminophen) and opioids such as morphine. Benzodiazepines may be used in addition to analgesics to help with anxiety.<ref name=Rosen2009/> During the healing process, antihistamines, massage, or transcutaneous nerve stimulation may be used to aid with itching.<ref name=Itchy2009/> Antihistamines, however, are only effective for this purpose in 20% of people.<ref>Template:Cite journal</ref> There is tentative evidence supporting the use of gabapentin<ref name=Itchy2009/> and its use may be reasonable in those who do not improve with antihistamines.<ref name=TBCChp64>Template:Cite book</ref><ref>Template:Cite journal</ref> Intravenous lidocaine requires more study before it can be recommended for pain.<ref>Template:Cite journal</ref>

Intravenous antibiotics are recommended before surgery for those with extensive burns (>60% TBSA).<ref name=TBCChp31>Template:Cite book</ref> Template:As of, guidelines do not recommend their general use due to concerns regarding antibiotic resistance<ref name=Anti2010>Template:Cite journal</ref> and the increased risk of fungal infections.<ref name=Schw2010/> Tentative evidence, however, shows that they may improve survival rates in those with large and severe burns.<ref name=Anti2010/> Erythropoietin has not been found effective to prevent or treat anemia in burn cases.<ref name=Schw2010/> In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically.<ref name=HF2008/> Recombinant human growth hormone (rhGH) in those with burns that involve more than 40% of their body appears to speed healing without affecting the risk of death.<ref>Template:Cite journal</ref> The use of steroids is of unclear evidence.<ref>Template:Cite journal</ref>

Allogeneic cultured keratinocytes and dermal fibroblasts in murine collagen (Stratagraft) was approved for medical use in the United States in June 2021.<ref name="FDA PR 20210615">Template:Cite press release</ref>

Surgery

Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible.<ref>Template:Cite book</ref> Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy.<ref name=Surgery2009/> This is done to treat or prevent problems with distal circulation, or ventilation.<ref name=Surgery2009>Template:Cite journal</ref> It is uncertain if it is useful for neck or digit burns.<ref name=Surgery2009/> Fasciotomies may be required for electrical burns.<ref name=Surgery2009/>

Skin grafts can involve temporary skin substitutes, derived from animal (human donor or pig) skin or synthesized. They are used to cover the wound as a dressing, preventing infection and fluid loss, but will eventually need to be removed. Alternatively, human skin can be treated to be left on permanently without rejection.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

There is no evidence that the use of copper sulphate to visualise phosphorus particles for removal can help with wound healing due to phosphorus burns. Meanwhile, absorption of copper sulphate into the blood circulation can be harmful.<ref>Template:Cite journal</ref>

Alternative medicine

Honey has been used since ancient times to aid wound healing and may be beneficial in first- and second-degree burns.<ref>Template:Cite journal</ref> There is moderate evidence that honey helps heal partial thickness burns.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> The evidence for aloe vera is of poor quality.<ref name=Aloe2012/> While it might be beneficial in reducing pain,<ref name=AFP2012>Template:Cite journal</ref> and a review from 2007 found tentative evidence of improved healing times,<ref>Template:Cite journal</ref> a subsequent review from 2012 did not find improved healing over silver sulfadiazine.<ref name=Aloe2012>Template:Cite journalTemplate:Dead link</ref> A 2014 review found only three randomized controlled trials for the use of plants for burns, two for aloe vera and one for oatmeal.<ref>Template:Cite journal</ref> The number of randomized control trials for aloe vera had increased to nine by 2024, when a review found a significant improvement in healing time but not pain relief.<ref>Template:Cite journal</ref>

There is little evidence that vitamin E helps with keloids or scarring.<ref name=Juck2009/> Butter is not recommended.<ref>Template:Cite book</ref> In low income countries, burns are treated up to one-third of the time with traditional medicine, which may include applications of eggs, mud, leaves or cow dung.<ref name=LMIC2006>Template:Cite journal</ref> Surgical management is limited in some cases due to insufficient financial resources and availability.<ref name=LMIC2006/> There are a number of other methods that may be used in addition to medications to reduce procedural pain and anxiety including virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.<ref name=TBCChp64/>

Patient support

Burn patients require support and care – both physiological and psychological. Respiratory failure, sepsis, and multi-organ system failure are common in hospitalized burn patients. To prevent hypothermia and maintain normal body temperature, burn patients with over 20% of burn injuries should be kept in an environment with the temperature at or above 30 degree Celsius.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>Template:Better source needed

Metabolism in burn patients proceeds at a higher than normal speed due to the whole-body process and rapid fatty acid substrate cycles, which can be countered with an adequate supply of energy, nutrients, and antioxidants. Enteral feeding a day after resuscitation is required to reduce risk of infection, recovery time, non-infectious complications, hospital stay, long-term damage, and mortality. Controlling blood glucose levels can have an impact on liver function and survival.

Risk of thromboembolism is high and acute respiratory distress syndrome (ARDS) that does not resolve with maximal ventilator use is also a common complication. Scars are long-term after-effects of a burn injury. Psychological support is required to cope with the aftermath of a fire accident, while to prevent scars and long-term damage to the skin and other body structures consulting with burn specialists, preventing infections, consuming nutritious foods, early and aggressive rehabilitation, and using compressive clothing are recommended.

Prognosis

Prognosis in the US<ref name=ABA2012pg10>National Burn Repository, Pg. 10</ref>

Template:Abbr	Mortality
0–9%	0.6%
10–19%	2.9%
20–29%	8.6%
30–39%	16%
40–49%	25%
50–59%	37%
60–69%	43%
70–79%	57%
80–89%	73%
90–100%	85%
Inhalation	23%

The prognosis is worse in those with larger burns, those who are older, and females.<ref name=Tint2010/> The presence of a smoke inhalation injury, other significant injuries such as long bone fractures, and serious co-morbidities (e.g. heart disease, diabetes, psychiatric illness, and suicidal intent) also influence prognosis.<ref name=Tint2010/> On average, of those admitted to burn centers in the United States, 4% die,<ref name=TBCChp3/> with the outcome for individuals dependent on the extent of the burn injury. For example, admittees with burn areas less than 10% TBSA had a mortality rate of less than 1%, while admittees with over 90% TBSA had a mortality rate of 85%.<ref name=ABA2012pg10/> In Afghanistan, people with more than 60% TBSA burns rarely survive.<ref name=TBCChp3/> The Baux score has historically been used to determine prognosis of major burns. However, with improved care, it is no longer very accurate.<ref name=Schw2010/> The score is determined by adding the size of the burn (% TBSA) to the age of the person and taking that to be more or less equal to the risk of death.<ref name=Schw2010/> Burns in 2013 resulted in 1.2 million years lived with disability and 12.3 million disability adjusted life years.<ref name=GBD2016/>

Complications

A number of complications may occur, with infections being the most common.<ref name=TBCChp3/> In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure.<ref name=TBCChp3/> Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.<ref>Template:Cite book</ref> Pneumonia occurs particularly commonly in those with inhalation injuries.<ref name=Schw2010/>

Anemia secondary to full thickness burns of greater than 10% TBSA is common.<ref name=EMP2009/> Electrical burns may lead to compartment syndrome or rhabdomyolysis due to muscle breakdown.<ref name=Schw2010/> Blood clotting in the veins of the legs is estimated to occur in 6 to 25% of people.<ref name=Schw2010/> The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.<ref name=Roj2012/> Keloids may form subsequent to a burn, particularly in those who are young and dark skinned.<ref name=Juck2009>Template:Cite journal</ref> Following a burn, children may have significant psychological trauma and experience post-traumatic stress disorder.<ref name=Psyc2009/> Scarring may also result in a disturbance in body image.<ref name=Psyc2009>Template:Cite book</ref> To treat hypertrophic scars (raised, tense, stiff and itchy scars) and limit their effect on physical function and everyday activities, silicone sheeting and compression garments are recommended.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> In the developing world, significant burns may result in social isolation, extreme poverty and child abandonment.<ref name=Epi2011/>

Epidemiology

File:Fires world map - DALY - WHO2004.svg

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In 2015 fire and heat resulted in 67 million injuries.<ref name=GBD2015Pre/> This resulted in about 2.9 million hospitalizations and 238,000 dying.<ref name=GBD2016/> This is down from 300,000 deaths in 1990.<ref>Template:Cite journal</ref> This makes it the fourth leading cause of injuries after motor vehicle collisions, falls, and violence.<ref name=Epi2011>Template:Cite journal</ref> About 90% of burns occur in the developing world.<ref name=Epi2011/> This has been attributed partly to overcrowding and an unsafe cooking situation.<ref name=Epi2011/> Overall, nearly 60% of fatal burns occur in Southeast Asia with a rate of 11.6 per 100,000.<ref name=TBCChp3/> The number of fatal burns has decreased from 280,000 in 1990 to 176,000 in 2015.<ref name=Loz2012>Template:Cite journal</ref><ref name=GBD2015De/>

In the developed world, adult males have twice the mortality as females from burns. This is most probably due to their higher risk occupations and greater risk-taking activities. In many countries in the developing world, however, females have twice the risk of males. This is often related to accidents in the kitchen or domestic violence.<ref name=Epi2011/> In children, deaths from burns occur at more than ten times the rate in the developing than the developed world.<ref name=Epi2011/> Overall, in children it is one of the top fifteen leading causes of death.<ref name=TBCChp4/> From the 1980s to 2004, many countries have seen both a decrease in the rates of fatal burns and in burns generally.<ref name=Epi2011/>

Developed countries

An estimated 500,000 burn injuries receive medical treatment yearly in the United States.<ref name=Rosen2009/> They resulted in about 3,300 deaths in 2008.<ref name=TBCChp4/> Most burns (70%) and deaths from burns occur in males.<ref name=Tint2010/><ref name=ABA2012/> The highest incidence of fire burns occurs in those 18Template:Endash35 years old, while the highest incidence of scalds occurs in children less than five years old and adults over 65.<ref name=Tint2010/> Electrical burns result in about 1,000 deaths per year.<ref name=Ed2005>Template:Cite journal</ref> Lightning results in the death of about 60 people a year.<ref name=RosenChp140>Template:Cite book</ref> In Europe, intentional burns occur most commonly in middle aged men.<ref name=Peck2012/>

Developing countries

In India, about 700,000 to 800,000 people per year sustain significant burns, though very few are looked after in specialist burn units.<ref name=Ahu2004>Template:Cite journal</ref> The highest rates occur in women 16–35 years of age.<ref name=Ahu2004/> Part of this high rate is related to unsafe kitchens and loose-fitting clothing typical to India.<ref name=Ahu2004/> It is estimated that one-third of all burns in India are due to clothing catching fire from open flames.<ref>Template:Cite book</ref> Intentional burns are also a common cause and occur at high rates in young women, secondary to domestic violence and self-harm.<ref name=Epi2011/><ref name=Peck2012>Template:Cite journal</ref>

See also

• Blister
• Frostbite
• Scalding

References

General and cited references

• Template:Cite book

External links

• WHO fact sheet on burns
• Parkland Formula
• {{#invoke:citation/CS1|citation

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