BURNS

Burns, most commonly caused by fire, can also result from chemicals, electricity, and other heat
accidents, such as scalding hot water or steam. More than 300 000 persons die each year
worldwide because of fire-related burn injuries. Many more are seriously injured, disabled, or
disfigured because of all types of burns. Risk factors for burns include cooking with an open
flame, open cooking facilities on the ground floor of a building or residence, wearing loose
clothing while cooking, smoking, alcohol use, water heaters that are set too hot, poor electrical
safety, and unsupervised children. Occupational injuries involving burns can also occur,
especially at job sites with open flames, chemicals, or superheated materials.

• Burns cause varying degrees of pain, blisters, swelling, and skin loss.
• Deep, extensive burns can cause serious complications, such as shock and severe
infections.
• Small, shallow burns may need only to be kept clean and to have an antibiotic cream
applied.
• People with deep or extensive burns may require intravenous fluids, surgery, and
rehabilitation, often at a burn center.

Burn is an injury involving the skin, including muscles, bones, nerves and blood vessels. This
results from heat, chemicals, electricity or solar or other forms of radiation.

Burns destroy skin, which controls the amount of heat our bodies retain or release, holds in
fluids, and protects us from infection. While minor burns on fingers and hands are usually not
dangerous, burns injuring even relatively small areas of skin can develop serious complications.
Burning causes blisters that will form at the place that is burned especially if it is caused by
fluids. Blisters contain lymph that should not be burst as it causes a
wound immediately after bursting it. You should treat the blisters
carefully and make sure that you are using the right kind of medicine
and if it bursts, bandage it.

The skin has an important role to play in the fluid and temperature
regulation of the body. If enough skin area is injured, the ability to
maintain that control can be lost. The skin also acts as a protective
barrier against the bacteria and viruses that inhabit the world outside
the body.

There are three layers:

1.Epidermis, the outer layer of the skin
2.Dermis, made up of collagen and elastic fibers and where nerves,
blood vessels, sweat glands, and hair follicles reside.
3.Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. This
is the layer of tissue that is most important in temperature regulation.
TYPES OF BURNS

Burns are classified based on how much of the skin’s thickness is involved. First-degree
(or superficial) burns involve only the top layer of the skin and are the least serious burn injuries.
Second-degree (or partial-thickness) burns injure deeper into the skin and cause blistering.
Third-degree (or full-thickness) burns involve all the layers of the skin, including the nerves
that supply the skin, and are extremely serious injuries. Fourth-degree burns extend into the
muscle below the skin.

Three degrees of burns

FIRST-DEGREE BURNS are usually limited to redness (erythema), a white plaque and minor
pain at the site of injury. These burns involve only the epidermis. Most sunburns can be included
as first-degree burns.

Signs:

• Red
• Painful to touch
• Skin will show mild swelling

Treatment:

 Apply cool, wet compresses, or immerse in cool, fresh water. Continue until pain
subsides.
 Cover the burn with a sterile, non-adhesive bandage or clean cloth.
 Do not apply ointments or butter to burn; these may cause infection.
 Over-the-counter pain medications may be used to help relieve pain and reduce
inflammation.
  First degree burns usually heal without further treatment. However, if a first-degree burn
covers a large area of the body, or the victim is an infant or elderly, seek emergency
medical attention.

SECOND-DEGREE BURNS manifest as erythema with superficial blistering of the skin, and
can involve more or less pain depending on the level of nerve involvement. Second-degree burns
involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer.
Deep dermal burns usually take more than three weeks to heal and should be seen by a surgeon
familiar with burn care, as in some cases severe hypertrophic scarring can result. Burns that
require more than three weeks to heal are often excised and skin grafted for best result.

Signs:

• Deep reddening of the skin

• Pain
• Blisters
• Glossy appearance from leaking fluid
• Possible loss of some skin

Treatment:

• Immerse in fresh, cool water, or apply cool compresses. Continue for 10 to 15 minutes.
• Dry with clean cloth and cover with sterile gauze.
• Do not break blisters.
• Do not apply ointments or butter to burns; these may cause infection
• Elevate burned arms or legs.
• Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches, and
cover the victim with a coat or blanket. Do not place the victim in the shock position if a
head, neck, back, or leg injury is suspected, or if it makes the victim uncomfortable.
• Further medical treatment is required. Do not attempt to treat serious burns unless you
are a trained health professional.

THIRD-DEGREE BURNS occur when the epidermis is lost with damage to the subcutaneous
tissue. Burn victims will exhibit charring and extreme damage of the epidermis, and sometimes
hard eschar will be present. Third-degree burns result in scarring and victims will also exhibit the
loss of hair shafts and keratin. These burns may require grafting. These burns are not painful, as
all the nerves have been damaged by the burn and are not sending pain signals; however, all
third-degree burns are surrounded by first and second-degree burns.

Signs:

• Loss of skin layers

• Often painless. (Pain may be caused by patches of first- and second-degree burns which
often surround third-degree burns).
• Skin is dry and leathery
• Skin may appear charred or have patches which appear white, brown or black
Treatment:

• Cover burn lightly with sterile gauze or clean cloth. (Do not use material that can leave
lint on the burn).
• Do not apply ointments or butter to burns; these may cause infection
• Take steps to prevent shock: lay the victim flat, elevate the feet about 12 inches.
• Have person sit up if face is burned. Watch closely for possible breathing problems.
• Elevate burned area higher than the victim’s head when possible. Keep person warm and
comfortable, and watch for signs of shock.
• Do not place a pillow under the victim’s head if the person is lying down and there is an
airway burn. This can close the airway.
• Immediate medical attention is required. Do not attempt to treat serious burns unless you
are a trained health professional.

OTHER CLASSIFICATIONS

• A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided

into superficial and deep categories) and "Full Thickness" relates more precisely to the
epidermis, dermis and subcutaneous layers of skin and is used to guide treatment and
predict outcome.

A description of the traditional and current classifications of burns.

Traditional
Nomenclature Depth Clinical findings Example
nomenclature

Erythema,
Superficial
first degree Epidermis involvement significant pain, lack
thickness
of blisters

Partial thickness Blisters, clear fluid,

second degree Superficial (papillary) dermis
– superficial and pain

Whiter appearance
Partial thickness or fixed red staining
third degree Deep (reticular) dermis
– deep (no blanching),
reduced sensation
Epidermis, Dermis, and
complete destruction to Charred or leathery,
Full thickness fourth degree* subcutaneous fat, eschar thrombosed blood
formation and minimal pain, vessels, insensate
requires skin grafts

How long does it take for burns to heal?

 • First-degree burns usually heal in 3 to 6 days.
• Second-degree burns usually heal in 2 to 3 weeks.
• Third-degree burns usually take a very long time to heal.

TYPES OF BURN INJURIES

Thermal Burn

Thermal burns — the most common type of burn injury — are the result of contact with heat
sources such as fire, steam, hot liquids, hot metals and hot objects. Forty-three percent of burn
center admissions are fire/flame related, 23 percent are related to scalding, and 8 percent are
linked to contact with a hot object.

Fire/Flame Injury. One civilian fire injury occurs every 30 minutes. While a brief exposure
(flash) tends to produce superficial or superficial partial thickness burns, prolonged exposure to
flames can produce deep partial thickness to full thickness burns. Many patients burned in fires
also suffer smoke inhalation injuries, which can be more serious than the burn itself.

Many recalls have been issued for defective consumer products that pose fire hazards (for
example, certain brands of candles and fire extinguishers.) Other potential causes of burn injuries
from fire include:

• Car accidents
• Industrial products
• Defective machinery
• Water heater fires
• Explosions
• Faulty electrical wiring
• Home & other structural fires
• Flammable clothing and liquids

Chemical burn

Chemical burns represent approximately 3 percent of all burn center admissions.

Chemical burns occur when certain acids, alkaloids and other caustic chemicals come
into contact with the skin. Caustic chemicals are used in agriculture and construction, as
well as in the medical and automotive industries.

Most chemicals that cause severe chemical burns are strong acids or bases.
Chemical burns can be caused by caustic chemical compounds such as sodium
hydroxide or silver nitrate, and acids such as sulfuric acid. Hydrofluoric acid can
cause damage down to the bone and its burns are sometimes not immediately evident.

Possible causes of chemical burns at home or in the workplace include:

 • Industrial products, tar, gasoline and wet pavement
• Household cleaners that contain lye (paint cleaners), sulfuric acid (toilet bowl cleaners),
phenol (deodorizers), or sodium hypochlorite (disinfectants and bleaches)
• Cosmetic products such as nail polish remover and hair dye
• Explosions and spills

Electrical burn

Electrical burns represent 4 percent of burn center admissions. Electrical burns occur when
electric current passes through the body, causing both external and internal injuries. Most of the
damage from electric current occurs beneath the surface of the skin. Factors affecting the extent
of injury include the intensity and type of current, duration of exposure, the amount of moisture
on the patient and the area of the body that the current passes through.

Low Voltage. When a low-voltage electric current (less than 500 volts) passes through the body,
it generally does not cause severe burns. However, contact with low voltage can still have
serious consequences:

• Cardiac problems, including cardiac arrest, can occur if low-voltage electricity comes
into contact with wet skin
• Muscle spasms, which can prevent the patient from "letting go" or can suffocate the
patient if the lungs spasm
• Oral burns, which are typically seen in young children who suck or bite on electrical
cords

High Voltage. High voltage burns occur when an electric current of more than 1000 volts passes
through the body. Electrical burn complications can be very serious and may include:

• Heart rhythm disturbances such as sudden cardiac arrest

• Fractures and other blunt trauma either from the force of the jolt or from resulting falls
(caused by the jolt and/or involuntary muscle contractures)
• Severe skin burns from electrical arcs, flashes and clothes catching on fire.
• Seizures/coma and permanent neurological deficits

Electrical burns can be caused by faulty electrical appliances or machinery, unintentional contact
with batteries or household wiring, and by lightening. Power sources and power lines are often
involved in high-voltage electrical burns.

Radiation burn

Radiation burns are caused by protracted exposure to UV light (as from the sun), tanning
booths, radiation therapy (as patients who are undergoing cancer therapy), sunlamps, radioactive
fallout, and X-rays. By far the most common burn associated with radiation is sun exposure,
specifically two wavelengths of light UVA, and UVB, the latter being more dangerous. Tanning
booths also emit these wavelengths and may cause similar damage to the skin such as irritation,
redness, swelling, and inflammation. More severe cases of sun burn result in what is known as
sun poisoning. Microwave burns are caused by the thermal effects of microwave radiation.

 Inhalation injuries – Inhalation injuries result from: direct inhalation of a hot air or
flame source, which will damage the upper airways; inhalation of toxic chemicals, such
as carbon monoxide, which can cause brain damage or even death; or injury from smoke
inhalation. People suffering from inhalation injuries as a result of chemical or industrial
accidents often frequently suffer from serious chemical burns.

FACTORS TO DETERMINE THE SERIOUSNESS OF BURNS

Burn Depth: The depth of injury from a burn is described as first, second, or third degree:

• First-degree burns are the most shallow (superficial). They affect only the top layer of
skin (epidermis).
• Second-degree burns (also called partial-thickness burns) extend into the middle layer of
skin (dermis). Second-degree burns are sometimes further described as superficial
(involving the more superficial part of the dermis) or deep (involving both the superficial
and the deep parts of the dermis).
• Third-degree burns (also called full-thickness) involve all three layers of skin
(epidermis, dermis, and fat layer). Usually, the sweat glands, hair follicles, and nerve
endings are destroyed as well.
• Fourth degree burns involve the thickness of the skin, and sometimes the muscles, bone
or even the tendons. It may look blackened or charred and sometimes may look white in
color. The person may not feel any pain due to nerve endings being severely damaged.

FIRST DEGREE BURN SECOND DEGREE BURN

THIRD DEGREE BURN FOURTH DEGREE BURN

Estimating the Extent of a Burn

To determine the severity of a burn,

doctors estimate what percentage of the
body's surface has second- or third-
degree burns. For adults, doctors use the
rule of nines. This method divides
almost all of the body into sections of
9% or of 2 times 9% (18%). For
children, doctors use charts that adjust
these percentages according to the
child's age (Lund-Browder charts).
Adjustment is needed because different
areas of the body grow at different
rates.

Burn Severity: Burns are classified as minor, moderate, or severe. These classifications may not
correspond to a person's understanding of those terms. For example, doctors may classify a burn
as minor even though it can cause the person significant pain and interfere with normal activities.
The severity determines how they are predicted to heal and whether complications are likely.
Doctors determine the severity of the burn by its depth and by the percentage of the body surface
that has second- or third-degree burns. Special charts are used to show what percentage of the
body surface various body parts comprise. For example, in an adult, the arm constitutes about
9% of the body. Separate charts are used for children because their body proportions are
different.

• Minor burns: All first-degree burns as well as second-degree burns that involve less than
10% of the body surface usually are classified as minor.
• Moderate and severe burns: Burns involving the hands, feet, face, or genitals, second-
degree burns involving more than 10% of the body surface area, and all third-degree
burns involving more than 1% of the body are classified as moderate or, more often, as
severe.

SIGNIFICANCE OF THE AMOUNT OF BODY AREA BURNED

In addition to the depth of the burn, the total area of the burn is significant. Burns are measured
as a percentage of total body area affected. The "rule of nines" is often used, though this
measurement is adjusted for infants and children. This calculation is based upon the fact that the
surface area of the following parts of an adult body each correspond to approximately 9% of total
(and the total body area of 100% is achieved):
•Head = 9%
•Chest (front) = 9%
•Abdomen (front) = 9%
•Upper/mid/low back and buttocks = 18%
•Each arm = 9%
•Each palm = 1%
•Groin = 1%
•Each leg = 18% total (front = 9%, back = 9%)
As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen
were burned, this would involve 55% of the body.
Only second and third degree burn areas are added together to measure total body burn area.
While first degree burns are painful, the skin integrity is intact and it is able to do its job with
fluid and temperature maintenance.
If more than15%-20% of the body is involved in a burn, significant fluid may be lost. Shock may
occur if inadequate fluid is not provided intravenously. The Parkland formula (named for the
trauma hospital in Dallas) estimates the amount of fluid required in the first few hours of care
following a burn:

As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen
were burned, this would involve 55% of the body.
Location of the burns: The seriousness of a burn depends to a large degree on the localization
of the burn, i.e. the precise area injured. The areas that need most attention are the face, the neck,
the limbs, and the perineum. Burns on the face and the neck may cause oedema in the upper
respiratory passages. Problems may also arise with regard to the patient’s appearance, as also to
functioning of the eyes, ears, nose, etc. Burns in the limbs may leave scars causing mobility
problems.The risk of infection is high when the perineum is involved, since the skin is burned
and can no longer protect the area from contamination from airborne bacteria.

Age : Burns, irrespective of their degree and extent, are more dangerous in children under 2 yr
old and in the elderly. In children, the immune system is not mature enough to withstand such a
complex situation, and the weakened organism of the elderly is also unable to handle the burn
effectively.
Burns are very common in children and the elderly - children are often attracted by dangerous
objects (matches, electric devices, chemical substances, lighters) in their ignorance of the
possibly dangerous consequences, while the elderly may not be able to react effectively to an
accident involving fire.

Co-existing illnesses : Diabetes mellitus, heart disease, pneumonia, immunosuppression, cancer,

and various other illnesses make the human organism less resistant to burns.

Presence of inhalation burns : An injury to the respiratory system may be life-threatening.

Injuries caused by inhalation of smoke are dangerous owing to the pernicious impact that
combustion products have on the mucous membrane as also to the absorption of poisonous
substances inhaled together with smoke by the mucous membrane. The most frequent form of
poisoning involves carbon monoxide, which is a product of incomplete combustion.

Co-existing injuries : A burn creates a very serious problem for the human organism. When the
burn is associated with other injuries occurring at the time of the accident or before the patient is
taken to hospital, it becomes more serious and even life-threatening.

COMPLICATIONS AND SEQUELAE

The complications and sequelae of burns depend on their gravity. Complications involving all
systems of the body may develop. The most serious complications are the following:

Complications that threaten the life of the patient directly:

1. Loss of fluids

It has already been said that a severe problem facing the patient is the loss of
fluids from the burned area. The more extensive the burn, the larger the quantity
of fluids lost.

2. Possible infection

Since the continuity of the skin in the burned area has been destroyed, the burned
area is more liable to contamination from airborne bacteria. This infection can
easily turn into septicaemia, as the organism is already affected by a serious burn
injury and is incapable of effective resistance.

3. Shock

The immediate danger after a burn injury is shock as a result of the loss of body
fluids (oligaemic shock) or of septicaemia (septic shock). The acute pain due to
the burn is one of the causes of shock.

B. Complications that do not threaten the life of the patient directly

1. Changes in the patient’s appearance
 The wrinkles and scars that form as the burn heals generate various aesthetic
problems.

2. Permanent disabilities

When the wrinkles and scars affect mobility and/or limit the patient’s movements, the
burn is responsible for functional problems or disabilities.

PHASES OF THE MANAGEMENT OF BURN INJURY

Emergent phase
- begins at the time of injury and ends with the restoration of capillary permeability, usually at
48-72 hours after the injury
- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ functioning
- includes prehospital care and emergency room care

Resuscitative phase
- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels
and the large fluid shifts have decreased
- the amount of fluid administered is based on the client’s weight and extent of injury
- most fluid replacement formulas are calculated from the time of injury and not from the time of
arrival at the hospital
- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining
vital organ perfusion

Acute phase
- begins when the client is hemodynamically stable, capillary permeability is restored, and
diuresis has begun
- usually begins 48 - 72 hours after the time of injury
- emphasis during this phase is placed on restorative therapy, and the phase continues until
wound closure is achieved
- the focus is on infection control, wound care, wound closure, nutritional support, pain
management, and physical therapy

Rehabilitative phase
- final phase of burn care
- overlaps the acute care phase and goes well beyond hospitalization
- goals of this phase are designed so that the client can gainindependence and achieve maximal
function

BURN PREVENTION:

• Do not smoke. If you do smoke, never smoke in bed. Avoid smoking while consuming
alcoholic beverages.
• Never throw a lighted cigarette or a match anywhere. Dispose of those hazards in
proper ashtrays.
 • Be very cautious around any type of open flames.
• Supervise children carefully.
• Follow electrical safety rules. Never put electrical appliances or cords in or near water.
• Do not touch downed power lines

SAFEGUARD YOUR HOME

• Install smoke alarms on each floor of your home. One alarm must be outside a bedroom
where you sleep.
• Change batteries in smoke alarms at least once a year. (Never borrow smoke alarm
batteries for other purposes).
• Keep emergency phone numbers and other pertinent information posted close to your
telephone.
• Draw a floor plan and find two exits from each room. Windows can serve as emergency
exits.
• Practice getting out of the house through the various exits.
• Designate a meeting place at a safe distance outside the home.
• Respond to every alarm as if it were a real fire.
• Call the fire department after escaping. Tell them your address and do not hang up until
you are told to do so. Let them know if anyone is trapped inside.
• Never go back into a burning building to look for missing people, pets, property, etc.
Wait for firefighters.

HOTEL AND WORKPLACE FIRE SAFETY

• Become familiar with exits and posted evacuation plans each time you enter a building.
• Learn the location of all building exits. You may have to find your way out in the dark.
• Ensure that fire exits are unlocked and clear of debris.
• All buildings, whether homes, workplaces or hotels, should have working smoke alarm
systems. Make sure you know what the alarm sounds like.
• Respond to every alarm as if it were a real fire. If you hear an alarm, leave immediately
and close doors behind you as you go.
• Establish an outside meeting place where everyone can meet after they have escaped.
• Call the fire department after escaping. Tell them your address and do not hang up until
you are told to do so. Let them know if anyone is trapped inside.
• Never go back into a burning building to look for missing people, pets, property, etc.
Wait for firefighters.

IF YOU ARE TRAPPED IN A BURNING BUILDING

• Smoke rises, so crawl low to the ground where the air will be cleanest.
• Get out quickly if it is safe to leave. Cover your nose and mouth with a cloth (moist if
possible).
 • Test doorknobs and spaces around doors with the back of your hand. If the door is warm,
try another escape route. If it is cool, open it slowly. Check to make sure your escape path
is clear of fire and smoke.
• Use the stairs. Never use an elevator during a fire.
• Call the fire department for assistance if you are trapped. If you cannot get to a phone,
yell for help out the window. Wave or hang a sheet or other large object to attract
attention.
• Close as many doors as possible between yourself and the fire. Seal all doors and vents
between you and the fire with rags, towels, or sheets. Open windows slightly at the top
and bottom, but close them if smoke comes in.

BURN TREATMENT
Treating burns depends on the severity of the burn, the type of burn, and the
amount of body tissue involved. Persons who have large surface areas of their body
burned have a poorer prognosis (chance of surviving and doing well after an injury).
Burn treatments include fluids (given intravenously for serious burns), pain management,
surgical debridement (removal of dead tissue) for third-degree or fourth-degree burns,
intensive care (often in a specialized burn treatment intensive care unit), and skin
grafting. For persons who have serious burn injuries, physical therapy is often used in
addition to other treatments to aid recovery and prevent complications such as
contracture (where the burned skin and body tissue become very difficult to move).

What you do to treat a burn in the first few minutes after it occurs can make a huge difference in
the severity of the injury.

CONSIDERATIONS

• Before giving first aid, evaluate how extensively burned the person is and try to
determine the depth of the most serious part of the burn. Then treat the entire burn
accordingly. If in doubt, treat it as a severe burn.

• By giving immediate first aid before professional medical help arrives, you can help
lessen the severity of the burn. Prompt medical attention to serious burns can help
prevent scarring, disability, and deformity. Burns on the face, hands, feet, and genitals
can be particularly serious.

• Children under age 4 and adults over age 60 have a higher chance of complications and
death from severe burns.

• In case of a fire, you and the others there are at risk for carbon monoxide poisoning.
Anyone with symptoms of headache, numbness, weakness, or chest pain should be tested.

IMMEDIATE TREATMENT FOR BURN VICTIMS

 1. “Stop, Drop, and Roll” to smother flames.
2. Remove all burned clothing. If clothing adheres to the skin, cut or tear around burned
area.
3. Remove all jewelry, belts, tight clothing, etc., from over the burned areas and from
around the victim’s neck. This is very important; burned areas swell immediately.

TIPS:

1. Burns cause swelling. Burns of the face and neck can sometimes swell enough to cause
difficulty breathing (see illustration). If that happens, call 911 immediately.

2. Burns that completely circle the hands or feet may cause such severe swelling that blood
flow is restricted. If swollen or tight hands and feet become numb and tingly, blue, cold, or
"fall asleep," then call 911 immediately.

3. While the burn is healing, wear loose natural clothing like silks or light cottons. Harsher
fabrics will irritate the skin even more.

4. Burns destroy skin and the loss of skin can lead to infection, dehydration and
hypothermia (loss of body heat). Make sure that burn victims get emergency medical help if
experiencing any of the following:

 dizziness or confusion
 weakness
 fever or chills
 shivering
 cold sweats

DO NOT

• Do NOT apply ointment, butter, ice, medications, cream, oil spray, or any household
remedy to a severe burn.

• Do NOT breathe, blow, or cough on the burn.

• Do NOT disturb blistered or dead skin.

• Do NOT remove clothing that is stuck to the skin.

• Do NOT give the person anything by mouth, if there is a severe burn.

• Do NOT immerse a severe burn in cold water. This can cause shock.

• Do NOT place a pillow under the person's head if there is an airways burn. This can close
the airways.
TREATMENT

A burn is an injury that in most cases leaves no disability, provided it is properly treated.
On the contrary, if treated inadequately or not following standard rules and principles, a burn can
seriously threaten not only the patient’s life but also his or her rehabilitation in society and at
work because of malformations and disabilities.18

There are two ways of treating a burn patient. The first way is to provide first-aid
treatment on the spot, i.e. where the accident took place, and to transfer the burn patient to
hospital only if the burn is extensive. The second way is to move the patient to a specialist burns
centre immediately in order to treat the burn injury systemically and topically, given the
availability of the necessary equipment and specialist knowledge.19,20

FIRST-AID TREATMENT IN BURNS

The treatment of burns caused by heat or electricity starts with the application of cold water in
order to cool destroyed tissues and to minimize damage to them.9,21,22

This treatment is not administered in extensive or third-degree burns, as cold water may
aggravate the state of shock.

1. If the patient has suffered burns in the face or has inhaled smoke or hot air in a burning
building, the burn is regarded as an inhalation burn that requires assessment by a
physician.
2. We immerse the burned area immediately in cold running water. We place it under a tap
or in a bucket of water, or we apply cold-water compresses (but not ice) to the burned
area.
3. We continue to cool the burned area with cold water for about 5 minutes or until the pain
diminishes. We then dry the area gently with a clean towel and dress it with a sterile or
clean, dry cloth.
4. Look for blistering, sloughing, or charred (blackened) skin. Blistering or sloughing (skin
coming off) means the top layer of skin is completely damaged and complications are
likely. Charring indicates even deeper damage to all three layers of skin. We do not prick
blisters or otherwise interfere with the burned area.
5. We do not remove clothing adhering to the wound. We remove any watches, bracelets,
rings, belts, or constricting clothing from the affected area before it begins to swell.
6. We do not apply butter, oil, or creams to the wound. We use analgesic drugs, ointments,
or sprays only in first-degree burns or according to medical instructions.
7. We do not press the burned area.
8. In electrical burns, we look for the entrance and exit points of the electric current.
9. In chemical burns, we do not use other materials to neutralize the chemicals without
detailed medical instructions. However:
o we remove contaminated clothing and the patient’s shoes and socks;
o we douse the victim with cold water and keep washing off the burned area with
running water for at least 5 minutes;
o we relieve pain with cold-water compresses;
 o we cover wounds with a damp bandage;
o we require evaluation by a physician even when the burn is not extensive.
10. When people’s clothing is on fire, they should not start running as this will only cause the
fire to expand. Also, people should not stand upright as this facilitates inhalation of
smoke and their hair may catch fire. In such moments, people should be laid on the
ground, where it is easier to wrap them in a blanket, douse them with cold water, or roll
them over in order to extinguish the fire. We should then remove any clothing still
burning and anything that could retain heat. We should also ensure that any clothing
adhering to the wound is not removed.
11. In extensive burns, the victim is wrapped in a clean sheet and transferred to hospital.
12. In face burns, extensive first-degree burns, second-degree burns in the limbs or perineum,
burns in more than 10-15% TBSA, and all third-degree burns, we require evaluation by a
physician.

For minor burns, including first-degree burns and second-degree burns limited to an area
no larger than 3 inches (7.5 centimeters) in diameter, take the following action:

Cool the burn. Hold the burned area under cold running water for at least five minutes, or until
the pain subsides. If this is impractical, immerse the burn in cold water or cool it with cold
compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don't put
ice on the burn.

 Cover the burn with a sterile gauze bandage. Don't use fluffy cotton, which may irritate the
skin. Wrap the gauze loosely to avoid putting pressure on burned skin. Bandaging keeps air off
the burned skin, reduces pain and protects blistered skin.

 Take an over-the-counter pain reliever. These include aspirin, ibuprofen (Advil, Motrin,
others), naproxen (Aleve) or acetaminophen (Tylenol, others). Never give aspirin to children or
teenagers. Once the skin has cooled, moisturizing lotion also can help.

Minor burns usually heal without further treatment. They may heal with pigment changes,
meaning the healed area may be a different color from the surrounding skin. Watch for signs of
infection, such as increased pain, redness, fever, swelling or oozing. If infection develops, seek
medical help. Avoid re-injuring or tanning if the burns are less than a year old — doing so may
cause more extensive pigmentation changes. Use sunscreen on the area for at least a year.

Make sure the person is up to date on tetanus immunization.

Caution
 Don't use ice. Putting ice directly on a burn can cause frostbite, further damaging your skin.
 Don't apply butter or ointments to the burn. This could prevent proper healing.
 Don't break blisters. Broken blisters are vulnerable to infection.

FOR MAJOR BURNS

The most serious burns are painless, involve all layers of the skin and cause permanent tissue
damage. Fat, muscle and even bone may be affected. Areas may be charred black or appear dry
and white. Difficulty inhaling and exhaling, carbon monoxide poisoning, or other toxic effects
may occur if smoke inhalation accompanies the burn or major burns, dial 911 or call for
emergency medical assistance. Until an emergency unit arrives, follow these steps:

• If someone is on fire, tell the person to stop, drop, and roll. Wrap the person in thick
material to smother the flames (a wool or cotton coat, rug, or blanket). Wet the person
with water.

• Make sure that the person is no longer in contact with flaming materials. However, do
NOT remove burned clothing that is stuck to the skin.

• Make sure the person is breathing. If breathing has stopped, or if the person's airways are
blocked, open the airways. If necessary, begin rescue breathing and CPR.

• Cover the burn area with a dry sterile bandage (if available) or clean cloth. A sheet will
do if the burned area is large. Do NOT apply any ointments. Avoid breaking burn
blisters.

• If fingers or toes have been burned, separate them with dry, sterile, non-adhesive
dressings.

• Elevate the body part that is burned above the level of the heart. Protect the burn area
from pressure and friction.

• Take steps to prevent shock. Lay the people flat, elevate the feet about 12 inches, and
cover the person with a coat or blanket. However, do NOT place the person in this shock
position if a head, neck, back, or leg injury is suspected or if it makes the person
uncomfortable.

• Continue to monitor the person's vital signs until medical help arrives. This means pulse,
rate of breathing, and blood pressure.

CHEMICAL BURNS: FIRST AID

If a chemical burns the skin, follow these steps:

1.Remove the cause of the burn by flushing the chemicals off the skin surface with cool, running
water for 20 minutes or more. If the burning chemical is a powder-like substance, such as lime,
brush it off the skin before flushing.
2.Remove clothing or jewelry that has been contaminated by the chemical.
3.Apply a cool, wet cloth or towel to relieve pain.
4.Wrap the burned area loosely with a dry, sterile dressing or a clean cloth.
5.Rewash the burned area for several more minutes if the person experiences increased burning
after the initial washing.
MINOR CHEMICAL BURNS USUALLY HEAL WITHOUT FURTHER TREATMENT.
SEEK EMERGENCY MEDICAL ASSISTANCE IF:

 The victim has signs of shock, such as fainting, pale complexion or breathing in a notably
shallow manner.
 The chemical burn penetrated through the first layer of skin, and the resulting second-degree
burn covers an area more than 3 inches (7.5 centimeters) in diameter.
 The chemical burn occurred on the eye, hands, feet, face, groin or buttocks, or over a major
joint.
 The victim has pain that cannot be controlled with over-the-counter pain relievers such as
acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin, others).

TREATMENT OF BURN PATIENTS IN THE EMERGENCY DEPARTMENT

A. The treatment of burns in the Emergency Department includes the following actions, in
order of precedence.23,24
1. Checking of respiratory passages

The respiratory passages must be checked to ensure that the patient is properly
oxygenated. Close observation of the victim can prevent suffocation.25,26

2. Placement of phlebocatheter

A vein chosen for intravenous fluid replacement should be able to accept large
quantities of fluids (15-20 l per 24 h in extensive burns). The drip inserted into the
vein should not pass through the affected area; it is recommended that it should be
placed in the neck (subclavicle), in the arm, or in the crural vein, in order to avoid
thrombophlebitis.

3. Record of vital signs

Pulse, arterial pressure, temperature, and respiration frequency (danger of

dyspnoea) should be carefully recorded in order to evaluate the patient’s general
state.

4. Record of the patient’s case-history (information from the patient directly or

accompanying persons)

The patient’s name and age are recorded, as well as the causes of the burn,
including the conditions in which the accident took place, so that the patient can
be properly treated. It is of the utmost importance for the physician to know if the
patient is suffering from any disease (nephropathy, allergy, heart disease, diabetes
mellitus), if first-aid treatment was given, and if the patient takes drugs, has ever
suffered from allergies caused by a drug, or has suffered any other injury apart
from the burn (e.g. a fracture).
 5. Relief of pain, and administration of painkillers or intravenous morphine1,27
6. Prevention of shock and anti-shock therapy
7. Placement of a urocyst catheter.

It is necessary to know the quantity and the specific gravity of the urine excreted
by the patient.

8. Placement of a Levin rhinogastric tube

In modern practice, the rhinogastric tube is placed as soon as the patient is

admitted to hospital in order to allow proper feeding. In the past, it was placed in
order to divert gastric fluids.

9. Quantitative evaluation of the burned surface

To evaluate the quantity of the burned surface, all burned areas are added
together, irrespective of their depth.

10. Qualitative evaluation of the burned surface

The depth of the burn cannot always be evaluated precisely when the patient is
admitted to hospital. The depth of the burned area should therefore be re-assessed
on the second or third day post-burn. Qualitative evaluation includes sensibility of
the burned area, erythema, formation of blisters, and the extent of oedema.

11. Laboratory tests

This entails haematocrit, electrolytes, blood air, and urine specific gravity. During
the first days after the accident, the tests should be repeated every 2-4 h. Urea,
blood sugar, creatine, albumin, liver function, and blood group should be
carefully recorded.

12. Electrocardiogram

Thorax radiography is necessary.

13. Check of patient’s psychological state

Steps should be taken to limit the patient’s psychological and emotional reactions
(e.g. pain, anxiety).28

The purpose of the clinical and laboratory check of the burn patient during the
first two days after the accident is to evaluate the effectiveness of treatment and to
diagnose complications as soon as possible.

B. IMMEDIATE TREATMENT OF BURN INJURIES

 When a burn patient is admitted to hospital, any watches, bracelets, etc. are removed
from the burned area before it begins to swell. All clothing that constricts the body is
removed, in order not to compress the burned area and to prevent it from adhering to the
wound.

The burned area is treated in aseptic conditions, with large quantities of cold sterile water,
antiseptic solution (NaCl), iodide soap, or Betadin. The lather produced by the antiseptic
solution is cleansed with physiological saline, the dead tissues are removed, and the
blisters are emptied.

In chemical burns, the burned area should be scrupulously cleaned and, depending on the
particular caustic chemical that caused the accident, water or any other suitable solution
should be used.

We then check haematosis of the limbs, inspecting the arteries or using a Doppler. The
vitality of the skin, as also of the perichondrium of the lobe and the nose are also
checked. If haematosis is not considered to be satisfactory, or if there is extensive
oedema, a section is recommended.

Once the method of treatment is selected (open, closed, or surgical), an antibacterial drug
or a combination of various drugs is applied to the burned area. Before selecting the
antibacterial drug, we consider the wound’s bacterial flora, its virulence and absorbency,
and the drug’s reaction in the tissues.

The first purpose of systemic therapy is to prevent the patient’s death; healing of the
wounds will follow.

In all cases of burn injury, antibiotic drugs are prescribed to protect the burned area from
infection.

Plastic surgery may be necessary to minimize scars and wrinkles, and generally to
improve the appearance of the patient’s skin and limb mobility.

Daily physiotherapy, starting immediately after the accident, contributes greatly to the
maintenance of limb function after burn injury.

THERAPY

Therapy affects the recovery of burn injuries. The immediate application of appropriate therapy,
plus proper nursing care, influences the final prognosis. Any delay in treatment may complicate
the patient’s recovery. Delay reduces the possibilities of making a sound prognosis and increases
the risk of death.

The therapy applied to burn patients depends on the extent, depth, and localization of the burn.
Burns affecting up to 15% TBSA in adults and 10% TBSA in children do not require hospital
treatment, provided that the burn is not in the face, neck, limbs, or perineum. After cleaning of
the affected area and the administration of injections for tetanus, it is recommended that the
patient should be given analgesic drugs and fluids by mouth. The quantity of urine excreted
should be recorded. Treatment is given in the out-patients’ department.1

Burns in more than 15% TBSA require treatment in the plastic surgery department. The sooner
systematic treatment of the burned area begins, the fewer complications there will be and the
greater the chances of recovery.

Complications may occur during the treatment of burn injuries, although they heal quickly.
Burns constitute an injury to the skin, and the utmost attention is necessary when nursing a burn
patient.

It should be borne in mind that a burn is an accident and is therefore to a large degree
preventable. Most burn accidents happen in the home and only occasionally at work (e.g. in
factories).

The following points should be taken into account:

• Small children under 4 years old are exposed to various dangers when exploring their
environment. Stoves, heaters, radiators, lighters, matches, electric current and cables,
pans with boiling water, etc. attract children, as they are unaware of the potential danger.
Parents should go to great lengths to ensure that children do not touch such items and do
not have access to them. Automatic fuses are necessary.
• Older people tend to forget electric appliances on or pans with boiling fat. It is
recommended that they should not occupy themselves in potentially dangerous household
tasks.
• Everyone should take care in the use of any energy source that can cause thermal injuries
and avoid exposure to unnecessary danger.
• We should never forget that burns are also caused by protracted exposure to the sun.