burn

(bŭrn)

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Tissue injury resulting from excessive exposure to thermal, chemical, electrical, or radioactive agents.

INCIDENCE
Burns are among the most common kinds of traumatic injury. The incidence of burns in the U.S. is approx. 1.4 per 1,000,000 per year, according to the World Health Organization. Approx. 50,000 Americans are hospitalized annually after severe burn injuries.

CAUSES
Burns may result from ultraviolet radiation, bursts of steam, explosions, heated liquids and metals, chemical fires, electrocution, or direct contact with flame or flammable clothing.

SYMPTOMS AND SIGNS
The effects may be local, resulting in cell injury or death, or both local and systemic, involving primary shock (which occurs immediately after the injury and is rarely fatal) or secondary shock (which develops insidiously following severe burns and is often fatal). Burns are usually classified as:

First degree: a superficial burn in which damage is limited to the outer layer of the epidermis and is marked by redness, tenderness, and mild pain. Blisters do not form, and the burn heals without scar formation. A common example is sunburn.

Second degree: a burn that damages partial thickness of the epidermal and some dermal tissues but does not damage the lower-lying hair follicles, sweat, or sebaceous glands. The burn is painful and red; blisters form, and wounds may heal with a scar.
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SECOND DEGREE BURN

Third degree: a burn that extends through the full thickness of the skin and subcutaneous tissues beneath the dermis. The burn leaves skin with a pale, brown, gray, or blackened appearance. The burn is painless because it destroys nerves in the skin. Scar formation and contractures are likely complications.

Fourth degree: a burn that extends through the full thickness of the skin and into underlying bone, fat, muscles, and tendons. Third- and fourth-degree burns are best managed at specialized burn centers.
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BURNS

COMPLICATIONS
Sloughing of skin, gangrene, scarring, erysipelas, nephritis, pneumonia, immune system impairment, or intestinal disturbances are possible complications. Shock and infection must always be anticipated with higher-degree or larger burns. The risk of complication is greatest when more than 25% of the body surface is burned.

TREATMENT
The first responsibility in the care of the burn patient is to assess the patency of the airway and to ensure that breathing is unimpaired. If smoke inhalation or airway injury is suspected, intubation should be performed before edema makes this impossible. Airway injury is most likely to occur after facial burns or smoke inhalation in closed spaces. A cough productive of soot or charred material increases the likelihood of inhalational injury.

The second task in burn care is to ensure cardiac output and tissue perfusion. Volume resuscitation with crystalloid is given per standard protocols; at the same time, urinary output, blood pressure and pulse, body weights, and renal function are closely monitored to ensure adequate hydration.

The immediate care of the burn itself involves the removal of any overlying clothing and jewelry and the irrigation of the affected tissues with cool water, taking care to avoid excessively cooling the body. To help prevent hypothermia and infection, cover the burn wounds with sterile dressings if available, or a clean sheet, separating burn wound surfaces. Gentle tissue débridement should be followed by application of nonadherent dressings, skin substitutes, topical antiseptics, or autografts, as dictated by circumstances. Tetanus prophylaxis is routinely given, usually with both tetanus toxoid and tetanus immune globulin.

In specific circumstances, additional interventions such as hyperbaric oxygen therapy for carbon monoxide intoxication, escharotomy for circumferential burns, antibiotic therapy for infections, pressor support for hypotension, or nutritional support may be needed.

Patients with large or complex burn injuries should be transferred to regional burn centers or to the care of surgeons with special knowledge of burn management.

PATIENT CARE
A person in burning clothing should never be allowed to run. The individual should lie down and roll. A rug, blanket, or anything within reach can be used to smother the flames. Care must be taken so that the individual does not inhale the smoke. The clothing should be cut off carefully so that the skin is not pulled away. Synthetic fabrics that have melted into the burn wound are best removed later in the emergency department or burn center. Jewelry should be removed even if not near the burn wounds due to concerns for fluid shifts and swelling. Blisters should not be opened, as this increases the chance for infection. Patients with large burn areas or third- and fourth-degree burns must receive appropriate tetanus prophylaxis.

During rehabilitation, individually fitted elastic garments are applied to prevent hypertrophic scar formation, and joints are exercised to promote a full range of motion. The patient is encouraged to increase activity tolerance, obtain adequate rest, strive for physical and emotional independence, and resume vocational and social functioning. Referrals for occupational therapy, psychological counseling, support groups, or social services are often necessary. Reconstructive and cosmetic surgery may be required. Support groups and services are available to assist the patient with life adjustments.

Patients' previous psychological states may predispose them to injury and may have an adverse effect on recovery. Patients with burn injuries demonstrate a wide range of emotional responses including anger, frustration, irritability, and psychological states (delirium, anxiety, depression, and grief). Posttraumatic stress disorder (PTSD) may occur after a burn injury. Often, the PTSD patient will need help from primary or specialized care providers to recover psychologically. Explain patient needs and care concerns to the family to help alleviate their cares, concerns, and varied psychological responses. Involve them in patient care as permissible. Family members should be encouraged to sit with the patient, and to touch, speak to, read to, and otherwise communicate. Providing patients with a sense of purpose will help relieve feelings of helplessness and will provide both patient and family with more comfortable memories.

The provision of optimal nutrition to burn patients is an important component of recovery. Because of protein losses, the total protein consumed by a burn patient should be at least 2.5 g/kg of body weight daily. Total caloric needs may exceed 30 kcal/kd/daily. The risk of infections may be reduced by the provision of dietary supplements, esp. arginine and glutamine.

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