When to treat or refer a burn-injured patient

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Burns

	Second-degree burns (shown here) form blisters and have associated skin sloughing.
Second-degree burns (shown here) form blisters and have associated skin sloughing.

At a glance

  • First-degree burns involve only the top layer of skin and generally heal in less than one week. Sunburn is a common cause of this type of burn.
  • Involving both the epidermis and the papillary dermis, superficial second-degree burns will usually heal in one to two weeks with no significant scarring.
  • Unless treated with early excision and grafting, third-degree burns pose a high risk for infection and scarring, as well as death.
  • Because burn-injured areas develop significant edema rather quickly, careful assessment and attention to airway management is essential.

Whether practicing in a hospital outpatient clinic, a freestanding urgent-care center, a private office, or an emergency department, at some point it is likely you will be challenged with treating a person with a burn injury. Several questions may arise when confronted with a burn-injured patient. When should you become concerned? How can you tell if this situation warrants immediate action? When should you treat a burn injury or refer the individual to another specialist or to a burn center?

A number of situations can cause a burn injury. Often, depending on the mechanism of injury, very specific treatment must be applied to provide appropriate care. The most common causes of burn injury are house fires, automobile accidents, scalding incidents, product-related thermal burns, electrical accidents, or chemical-related burns.

Injury statistics and incidence rates

Statistical data indicate that approximately 450,000 people annually receive treatment for a burn injury in a number of different settings. It is estimated that nearly 45,000 of these patients are hospitalized as a result of their injury, with 55% of these being admissions to the 125 hospitals nationally known for their specialized facilities for burn care (burn centers).

The majority of fire-related deaths (70%) are due to smoke inhalation, with the remaining 30% resulting from the actual flame. Children aged 5 years and younger are more than twice as likely to die in a home-related fire More than half the children up to age 5 years who die from house fires are asleep, with one third of these victims being too young to react appropriately.

Of children aged 4 years and under who are hospitalized for burn-related injuries, 65% suffer scald burns and 20% have contact burns. Hot-water burns cause more deaths and hospitalizations than any other hot liquid substance.

The leading cause of home-related fires is home cooking equipment, with the most fire-related deaths in homes being caused by cigarettes or other smoking materials. The most common causes of product-related burn injuries occur from curling irons, hair curlers, room heaters, ovens, irons, gasoline, and fireworks.

Infants and children aged 5 years and under, elderly patients aged 70 years and older, and patients with multiple comorbidities are at highest risk for death as a result of their burn injuries. Larger total-body-surface-area burns are associated with more death, disability, and disfigurement.

Categorizing burn injuries

The four degrees of burn injury are: (1) first-degree burns; (2) superficial and deep second-degree (partial-thickness burns); (3) third-degree (full-thickness) burns; and (4) fourth-degree (deep full-thickness burns).

First-degree burns

Only the top layer of skin (epidermis) is involved in first-degree burns. The skin will be erythematous and remains intact. There is no associated blistering or sloughing of the skin. The skin will remain moist and will blanch, and the patient will have minimal to moderate pain. These burns generally heal in less than a week. Sunburn is a common cause of first-degree burns.

Second-degree burns

Superficial second-degree burns involve both the epidermis and the papillary dermis (Figure 1). These burns form blisters and usually have associated skin sloughing. The wound bed will appear pink or red, is moist, and does blanch. Second-degree burns are very painful, especially on areas of skin sloughing where air passes over the injury. With appropriate wound care, this type of burn will usually heal in one to two weeks without significant scarring.

Deep second-degree burns extend into the deeper reticular dermis and will generally take two to three weeks to heal if treated appropriately (Figure 2). They blister; however, the wound bed usually appears more mottled pink, beefy red, or white, and may have a buildup of proteinaceous exudate or pseudoeschar. This degree of burn will blanch poorly (or not at all) and is not as painful as more superficial burns. Patients often describe the pain as discomfort or pressure. These burns can be more difficult to heal, pose a higher risk of infection, and often require surgical excision and grafting.

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