More than 60% of the 40,000 hospitalizations for serious burn injuries each year now occur at the 125 hospitals with specialized burn centers. This percentage of specialized hospitalizations has increased steadily in the last 30 years as emergency care and transportation has improved.
Until the last decade, the goal in the treatment of severe burns was simply enabling the patient to survive. As the range of therapies has increased, and survival rates have improved, burn specialists have widened their goals. In a recent article, burn specialist Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital and Associate Professor of Surgery, in the Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School wrote that the goal of burn treatment is to reintegrate the burn patient into the community.
Working towards this goal means that the tasks of the burn care treatment team have broadened well beyond wound closure. This effort involves three broad aspects: rehabilitation, reconstruction, and reintegration. An active focus on long-term rehabilitation goals must be part of the treatment plan from the beginning of acute care.
Stabilizing the patient
The first tasks after a serious burn injury involve stabilizing the patient: providing fluids, usually intravenously, to reduce shock and prevent dangerous drops in blood pressure, and monitoring the patient’s breathing, assisting if necessary. The skin is the body’s principal barrier against infection, and after a serious burn injury, the victim is at significant risk for infection. Immediate treatment aims at preventing infection with IV antibiotics and antibiotics in cream or ointment form applied directly to the burned areas.
Even while a patient is still critically ill and in the ICU, rehabilitation goals are part of the treatment. The aim is to limit loss of range of motion, ROM, to reduce edema, the presence of excess fluid in tissues which contributes to joint stiffening, and to use positioning and splinting to prevent contractures. This process generally involves twice-a-day therapy sessions timed when anesthetics are strongest, so that aggressive joint ROM therapy can occur.
This treatment occurs at a time when the burn patient’s survival may be uncertain. The burn injury survivor will experience anxiety, fear, pain, delirium, sleep deprivation, and confusion, which must be managed by the ICU team and psychiatric consultants.
As the patient stabilizes, the burn treatment team begins a careful assessment of the extent of the burn damage, and plans the course of treatment.
Burns are classified by the cause and the severity of the burn.
Thermal – including flame, radiation, or excessive heat from fire, steam, and hot liquids and hot objects.
Chemical, including acids, and caustics and other bases.
Electrical, by lightning and electric current.
Light, burns caused by intense light sources or ultraviolet light, including sunlight.
Radiation from nuclear sources or ultraviolet light
Burn care specialists and first responders are trained never to assume the source of a burn. They must ask questions and be sure.
Severity of the burn by degrees
First degree burns, the commonest, and least damaging burns are superficial injuries that involve only the epidermis or outer layer of skin. The skin is reddened and extremely painful. The burn will heal on its own without scarring within two to five days. There may be peeling of the skin and some temporary discoloration.
Second degree burns occur when the first layer of skin is burned through and the second layer, the dermal layer, is damaged but the burn does not pass through to underlying tissues. The skin appears moist and there will be deep intense pain, reddening, blisters and a mottled appearance to the skin. Second degree burns are considered minor if they involve less than 15 percent of the body surface in adults and less than 10 percent in children. When treated with reasonable care, second degree burns will heal themselves and produce very little scarring. Healing is usually complete within three weeks.
Third degree burns involve all the layers of the skin. They are referred to as full thickness burns and are the most serious of all burns. These are usually charred black and include areas that are dry and white. While a third-degree burn may be very painful, some patients feel little or no pain because the nerve endings have been destroyed. This type of burn may require skin grafting. As third degree burns heal, dense scars form.
Assessing the severity of burns
The severity of the burn injuries is determined by these factors:
Source of the burn – a minor burn caused by nuclear radiation is more severe than a burn caused by thermal sources. Chemical burns are particularly dangerous because the chemical may still be on the skin, continuing to burn it.
Parts of the body burned – burns to the face are more severe because they can involve the eyes or airway management. Burns to hands and feet are also of special concern because they could damage movement of fingers and toes.
Degree of the burn – the degree of the burn is important because second and third degree burns expose the tissues to infection and allow infectious agents access to the circulatory system.
Extent of burned surface areas – It is important to know the percentage of the skin surface involved. Burn treatment staff calculate the total burned area by the rule of nines: the adult body is divided into regions, each of which represents nine percent of the total body surface. These regions are the head and neck, each upper limb, the chest, the abdomen, the upper back, the lower back and buttocks, the front of each lower limb, and the back of each lower limb. Together these regions comprise 99 percent of the adult body. The remaining one percent is the genital area. Infants or small children have relatively larger heads and trunks, so a slightly different calculation is used.
Age of the patient – This is important because small children and the elderly usually have more severe reactions to burns and their healing processes are somewhat different.
Pre-existing conditions – A person with respiratory illnesses, heart disorders, diabetes or kidney disease are at greater risk than a healthy person.
Serious burns are always complex injuries, and have the potential to involve muscles, bones, nerves, and blood vessels. The respiratory system can be damaged by smoke inhalation, and there are risks of airway obstruction, respiratory failure and respiratory arrest. Burns disrupt the body’s normal fluid/electrolyte balance and its ability to maintain and regulate internal temperature. Joint function, manual dexterity, and physical appearance can also be significantly affected by burns.