BURNS
A Complete Presentation for Medical College
Based on SRB Manual of Surgery and S Das Clinical Surgery
DEFINITION
Burns (Combustio) are tissue damage arising from thermal, chemical, electrical, or radiation
exposure[41]. Burns represent tissue injury resulting from skin contact with a heat source or
energy transfer to the body[36][62].
TYPES OF BURNS
1. Thermal Burns [55][57]
Hot liquids (scalds) - most common in young children
Steam burns
Hot metals and contact burns
Flames - leading cause in older adults
Hot gases
2. Chemical Burns [40][55]
Acids (sulfuric, hydrochloric)
Alkalis (sodium hydroxide, lime)
Organic solvents
Industrial chemicals
3. Electrical Burns [35][43]
Low voltage (household current)
High voltage (power lines)
Lightning strikes
Arc burns
4. Radiation Burns [55][57]
Ultraviolet radiation (sunburn)
X-rays and therapeutic radiation
Nuclear radiation
5. Friction Burns [55]
Rope burns
Treadmill injuries
Road rash
BURN CLASSIFICATION BY DEPTH
Traditional Classification [26][31][59]
First-Degree Burns (Superficial)
Depth: Epidermis only[31]
Appearance: Red, dry, no blisters[31]
Pain: Painful[26]
Healing: 3-7 days without scarring[31]
Example: Mild sunburn[26]
Second-Degree Burns (Partial Thickness)
Superficial Partial Thickness[26]
Affects superficial dermis
Red to pale pink[119]
Small blisters present[26]
Capillary refill: Brisk 1-2 seconds[119]
Very painful[26]
Heals in 7-14 days[23]
Deep Partial Thickness[26]
Involves deeper dermis
Blotchy red to white[119]
Large blisters or no blisters[26]
Capillary refill: Sluggish >2 seconds[119]
Less painful[26]
Heals in 3-6 weeks[62]
Third-Degree Burns (Full Thickness)
Depth: All layers of skin[31][59]
Appearance: White, brown, black, charred or leathery[31][59]
Sensation: Anesthetic (painless)[59]
Capillary refill: Absent[119]
Healing: Requires skin grafting[59]
Fourth-Degree Burns
Depth: Through skin into muscle, fascia, bone[31][59]
Appearance: Charred, exposed deeper structures[31]
Treatment: Extensive debridement and reconstruction[59]
PATHOPHYSIOLOGY OF BURNS
Jackson's Burn Wound Model [114]
1. Zone of Coagulation (innermost)
Irreversible tissue death
No viable tissue remains
2. Zone of Stasis (middle)
Potentially viable tissue
Target of therapeutic intervention
Can be salvaged with proper care
3. Zone of Hyperemia (outermost)
Inflammatory response
Returns to normal within hours
Systemic Effects [56][58]
Cardiovascular Changes
Burn Shock: Combination of distributive, hypovolemic, and cardiogenic shock[58]
Increased capillary permeability leading to fluid shift[56]
Decreased cardiac output[56]
Increased systemic vascular resistance[58]
Fluid and Electrolyte Changes
Massive fluid loss due to increased permeability[56]
Hypovolemia and hemoconcentration[56]
Intravascular depletion with interstitial edema[58]
Protein loss through burn wounds[56]
Metabolic Changes
Hypermetabolic response[63]
Increased oxygen consumption (up to 2-fold)[63]
Catecholamine surge[63]
Muscle wasting and negative nitrogen balance[63]
BURN ASSESSMENT
Total Body Surface Area (TBSA)
Rule of Nines [64][88][119][122]
Adults (≥14 years):
Head and neck: 9% (4.5% anterior, 4.5% posterior)
Each arm: 9% (4.5% anterior, 4.5% posterior)
Anterior trunk: 18%
Posterior trunk: 18%
Each leg: 18% (9% anterior, 9% posterior)
Perineum: 1%
Total: 100%
Children (1-14 years):
For every year of life, take 1% from head and add 0.5% to each leg[119]
Infants (<1 year):
Head: 18%
Each arm: 9%
Anterior trunk: 18%
Posterior trunk: 18%
Each leg: 13.5%
Perineum: 1%
Palmar Method [119][122]
Patient's palm (including fingers) = 1% TBSA
Useful for estimating smaller burns
Use patient's palm, not examiner's
Burn Severity Classification [59]
Severe Burns
Adults:
TBSA >20%
Third-degree burn >5%
Smoke inhalation
Burns to face, hands, feet, perineum
Electrical/chemical burns
Children:
TBSA >10%
Third-degree burn >5%
Age <1 year
Circumferential burns
Moderate Burns
Adults:
TBSA 10-20%
Third-degree burn 3-5%
Age >75 years
Minor Burns
Adults:
Second-degree <10% TBSA
Third-degree <3% TBSA
No circumferential burns
INITIAL MANAGEMENT
Primary Survey (ABCDE)
1. Airway: Assess for inhalation injury
2. Breathing: Check respiratory function
3. Circulation: Evaluate for shock
4. Disability: Neurological assessment
5. Exposure: Complete burn assessment
Immediate Care
1. Stop the burning process
2. Cool water irrigation (10-20 minutes)
3. Remove jewelry and clothing
4. Cover with clean, dry cloth
5. Pain management
6. Tetanus prophylaxis
FLUID RESUSCITATION
Parkland Formula [64][65][88][91]
4 ml × weight (kg) × %TBSA burn = Total fluid in first 24 hours
Administration Schedule:
First 8 hours: Half of total volume from time of burn
Next 16 hours: Remaining half of total volume
Fluid Type:
Lactated Ringer's solution (isotonic crystalloid)
Warm fluids to prevent hypothermia
Monitoring:
Urine output: 0.5-1 ml/kg/hour (adults)
Blood pressure and heart rate
Mental status
Peripheral perfusion
Modifications [66][68]
Obese patients: May require formula adjustment
Children: Modified Parkland (3 ml/kg/%TBSA)
Elderly: Careful monitoring for fluid overload
WOUND MANAGEMENT
Debridement [123]
1. Mechanical debridement
Removal of loose, necrotic tissue
Daily wound cleaning
2. Surgical debridement
Tangential excision
Fascial excision for deep burns
Dressings [95][100][114]
Superficial Burns
Emollients and moisturizers
Non-adherent dressings
Partial Thickness Burns
Silver sulfadiazine (SSD)
Hydrogels[95][117]
Hydrocolloids
Foam dressings
Full Thickness Burns
Antimicrobial dressings
Temporary skin substitutes
Preparation for grafting
Advanced Dressing Options
Silver-impregnated dressings[100]
Negative Pressure Wound Therapy (NPWT)[96][99]
Hydrogel dressings[102][117]
Collagen-based dressings[100]
SURGICAL MANAGEMENT
Escharotomy [83][86][89][92]
Indications:
Circumferential full-thickness burns
Compartment syndrome (pressure >30 mmHg)
Absent distal pulses
Oxygen saturation <95% distally
Respiratory compromise (chest/neck burns)
Technique:
Incise eschar down to fat
Avoid deep fascia
Use electrocautery for hemostasis
Common sites: extremities, chest, abdomen
Fasciotomy [83][86]
Required for compartment syndrome
Incision through deep fascia
Usually combined with escharotomy
Skin Grafting [94][96][97]
Types:
1. Split-thickness skin grafts (STSG)
Most common for burns
0.008-0.012 inches thick
2. Full-thickness grafts
For smaller, functional areas
Better cosmetic results
Graft Care:
Immobilization for 3-5 days
Negative pressure dressing[96]
Monitor for hematoma/seroma
Early mobilization after take
COMPLICATIONS
Early Complications
Burn Shock [56][58]
Hypovolemic component: Fluid loss
Distributive component: Vasodilation
Cardiogenic component: Myocardial depression
Respiratory Complications
Inhalation injury
Pneumonia
Adult respiratory distress syndrome (ARDS)
Renal Complications [70]
Acute renal failure
Myoglobinuria (electrical burns)
Hemoglobinuria
Late Complications
Infection and Sepsis [84][87][90]
Burn wound infection
Sepsis - leading cause of death[84]
Multi-organ dysfunction syndrome (MODS)[84]
Signs of Burn Sepsis:
Fever >38.5°C or <36°C
Tachycardia >110 bpm
Tachypnea >25/min
Change in wound appearance
Increased fluid requirements
Hypertrophic Scarring and Contractures [123]
Risk factors: Healing >21 days, deep burns
Prevention: Pressure therapy, splinting, physiotherapy
Treatment: Scar revision, laser therapy
REHABILITATION [115][118][121]
Physiotherapy Goals
1. Prevent contractures
2. Maintain range of motion
3. Restore function
4. Scar management
Interventions [118]
Positioning in anti-deformity positions
Splinting during acute phase
Range of motion exercises
Stretching protocols
Scar massage
Pressure therapy
Rehabilitation Timeline
Acute phase: Positioning, gentle ROM
Post-grafting: Immobilization 3-5 days, then mobilization
Long-term: Aggressive therapy, scar management
SPECIAL CONSIDERATIONS
Pediatric Burns [67][99][102]
Higher fluid requirements per kg
Thinner skin - deeper injuries
Higher risk of hypothermia
Modified Parkland formula: 3 ml/kg/%TBSA
Electrical Burns [118]
Entry and exit wounds
Deep tissue damage
Cardiac monitoring required
Compartment syndrome risk
Rhabdomyolysis and kidney injury
Chemical Burns [40]
Continuous irrigation until pH normal
Remove contaminated clothing
Alkali burns - more severe than acid
Specific antidotes for some chemicals
PROGNOSIS
Factors Affecting Outcome
1. Age of patient
2. Extent of burn (TBSA)
3. Depth of burn
4. Presence of inhalation injury
5. Pre-existing medical conditions
6. Time to treatment
Mortality Predictors
Age >60 years
TBSA >40%
Inhalation injury
Full-thickness burns
PREVENTION
Primary Prevention
1. Smoke detectors in homes
2. Safe cooking practices
3. Water heater temperature <49°C (120°F)
4. Electrical safety
5. Chemical storage safety
6. Fire safety education
Secondary Prevention
Proper first aid
Early medical attention
Appropriate referral to burn centers
BURN CENTER REFERRAL CRITERIA
American Burn Association Criteria
1. Partial-thickness burns >10% TBSA
2. Full-thickness burns any size
3. Burns to face, hands, feet, genitalia, perineum, major joints
4. Electrical burns
5. Chemical burns
6. Inhalation injury
7. Circumferential burns
8. Burns with trauma
9. Pre-existing medical conditions
CONCLUSION
Burns represent a complex medical challenge requiring multidisciplinary management. Early
recognition, appropriate fluid resuscitation, wound care, and rehabilitation are crucial for optimal
outcomes. Understanding burn pathophysiology, classification systems, and treatment principles
is essential for medical professionals managing these injuries.
The integration of traditional surgical principles from texts like SRB Manual of Surgery and S Das
Clinical Surgery with modern evidence-based practices provides the foundation for
comprehensive burn care. Continuous advances in wound care technology, surgical techniques,
and rehabilitation protocols continue to improve patient outcomes and quality of life.
Key References: SRB Manual of Surgery, S Das Clinical Surgery, and contemporary burn care
literature.
