Burns

Definition

Burn – tissue damage caused by local exposure to high temperatures (more than 55-60 C), aggressive chemicals, electric current, light, and ionizing radiation. According to the depth of tissue damage, there are 4 degrees of burns. Extensive burns lead to the development of the so-called burn disease, a dangerous, lethal outcome due to the violation of the cardiovascular and respiratory systems, as well as the emergence of infectious complications. Local treatment of burns can be carried out using an open or closed method. If indicated, it is necessarily supplemented with anesthetic treatment – antibacterial and infusion therapy. 

Classification

By localization:

• skin burns;
• eye burns;
• inhalation injuries and respiratory burns.

In terms of the depth of the lesion:

• I degree. Incomplete damage to the superficial layer of the skin. It is accompanied by skin reddening, slight swelling, and burning pain. Recovery in 2-4 days. The burn heals without a trace.
• II degree. Complete damage to the superficial layer of the skin. It is accompanied by burning pain and the formation of small blisters. Opening the blisters exposes bright red erosions. Burns heal without scarring within 1-2 weeks.
• III degree. Damage to the superficial and deep layers of the skin.
• IIIA degree. Deep layers of the skin are partially damaged. 

It is possible to form large, fusion-prone blisters. Opening the blisters exposes a mottled wound surface consisting of white, gray, and pink areas. In dry necrosis, a thin scab resembling parchment is formed, and in wet necrosis, a moist grayish fibrin film is formed.

The injured area’s pain sensitivity is reduced. Healing depends on the number of preserved islets of intact deep skin layers at the wound bed. 

• IIIB degree. Death of all skin layers. Subcutaneous fatty tissue may be damaged.
• IV degree. Charring of the skin and underlying tissues (subcutaneous fat, bone, and muscle).

Degrees I-IIIA burns are considered superficial and can heal independently (unless secondary deepening of the wound occurs due to suppuration). IIIB and IV degree burns require necrosis removal followed by skin grafting. Accurately determining the degree of burns is possible only in a specialized medical institution.

Area affected

The severity of the burn, prognosis, and choice of treatment measures depends not only on the depth but also on the area of the burned surfaces. In traumatology, the “rule of palms” and the “rule of nines” are used to calculate the area of burns in adults. According to the “rule of palms,” the area of the palm surface of the hand approximately corresponds to 1% of the host body. According to the “rule of nines”:

• the neck and head area is 9% of the total body surface area;
• chest, 9%;
• belly – 9%;
• posterior torso – 18%;
• one upper extremity, 9%;
• one thigh, 9%;
• one tibia along with the foot, 9%;
• external genitalia and perineum – 1%.

Prognosis

The prognosis depends on the depth and area of the burns, the general condition of the body, and the presence of concomitant injuries and diseases. The Injury Severity Index (ISI) and the Rule of Hundred (RH) are used to determine prognosis.

Injury severity index

This applies to all age groups. For injury severity index, 1% of superficial burns equals 1 unit of severity, and 1% of deep burns equals 3 units. Inhalation lesions without impaired respiratory function are equal to 15 units, and with impaired respiratory function, equal to 30 units.

Prediction:

• favorable – less than 30 units;
• relatively favorable – from 30 to 60 units;
• doubtful – 61 to 90 units;
• unfavorable – 91 and more units.

In the presence of combined lesions and severe comorbidities, the prognosis worsens by 1-2 degrees.

The rule of hundreds

It is usually used for patients over 50 years of age. Calculation formula: sum of age in years + percent burned area. Upper respiratory tract burns equate to 20% of skin lesions.

Prediction:

• favorable – less than 60;
• relatively favorable, 61-80;
• questionable, 81-100;
• unfavorable – over 100.

Local symptoms

Superficial burns up to 10-12% and deep burns up to 5-6% proceed mainly as a local process. No disturbance of other organs and systems is observed. In children, the elderly, and persons with severe comorbidities, the “boundary” between local suffering and the overall process may be halved: up to 5-6% for superficial burns and up to 3% for deep burns.

Local pathologic changes are determined by the degree of burn, the period since the injury, secondary infection, and other conditions. First-degree burns are accompanied by erythema. Burns of the II degree are characterized by blisters, and burns of the III degree are bullae. When the skin peels off, spontaneous blister opening or removal exposes erosion.

After rejecting dry and wet necrosis areas, ulcers of varying depths are formed.

General symptoms

Extensive lesions cause burn disease, which causes pathological changes in various organs and systems. In this condition, protein and water-salt metabolism is disturbed, toxins accumulate, the body’s defenses are reduced, and burn exhaustion develops. Burn disease, in combination with a sharp decrease in motor activity, can cause dysfunction of the respiratory, cardiovascular, urinary, and gastrointestinal tract.

Burn disease progresses in stages:

Stage I. Burn shock develops due to severe pain and significant fluid loss through the burn surface. It is life-threatening for the patient and lasts 12-48 hours, sometimes up to 72 hours. A short period of agitation is followed by increasing lethargy. Consciousness is confused. Unlike other types of shock, blood pressure rises or remains within normal limits. The pulse rate increases and urine output decreases. 

Stage II. Burn toxemia. It occurs when tissue decay products and bacterial toxins are absorbed into the blood. Develops on the 2nd-4th day from the moment of injury. Lasts from 2-4 to 10-15 days. Body temperature is elevated. The patient is agitated, but his consciousness is confused. Possible convulsions, delirium, auditory and visual hallucinations. 

Stage III. Septicotoxemia. It is caused by a significant protein loss through the wound surface and the body’s response to the infection. Lasts from several weeks to several months. Wounds with large amounts of purulent discharge. Healing of burns is suspended, and areas of epithelialization are reduced or disappear.

Fever with large fluctuations in body temperature is characteristic. The patient is lethargic and suffers from sleep disturbance. There is no appetite. Significant weight loss is noted. Muscle atrophy, joint mobility decreases, bleeding increases and bedsores develop. Death occurs from general infectious complications (sepsis, pneumonia). With a favorable variant of the development of events, burn disease ends with recovery, during which the wounds are cleaned and closed, and the patient’s condition gradually improves.

Treatment

Closed burn treatment

First, the burn surface is treated. Foreign bodies are removed from the damaged surface, and the skin around the wound is treated with antiseptic. Large blisters are trimmed and emptied without being removed. The peeled skin adheres to the burn and protects the wound surface. The burned limb is elevated.

At the first stage of healing, drugs with analgesic and cooling effects and medicines are used to normalize tissues, remove wound contents, prevent infection, and reject. In IIIA degree burns, the scab is preserved until independent rejection. Initially, aseptic dressings are applied, and after scab rejection, ointment is applied. The purpose of local treatment of burns at the second and third stages of healing – is protection from infection, activation of metabolic processes, and improvement of local blood supply. In deep burns, stimulation of necrotic tissue rejection is carried out. Salicylic ointment and proteolytic enzymes are used to melt the scab. After cleansing the wound, skin repair is performed.

Open burn treatment

It is performed in special aseptic burn wards. Burns are treated with drying antiseptic solutions and left without dressings. In addition, burns of the perineum, face, and other areas where it is difficult to apply a bandage are usually treated openly. Antiseptic ointments are used to treat wounds in this case.

Surgical treatment

Surgical treatment of hand burns is important for restoring function and appearance after injury. In moderate to severe burns, removal of necrotized tissue and subsequent plastics may be necessary when a significant portion of the skin is damaged. The main methods are the use of autodermoplasty (skin grafting from another part of the patient’s body) and alloplasty (use of biomaterials to close the wound).

Modern technology also offers bioengineering methods, such as culturing skin cells in the laboratory to create skin flaps, which are then transplanted to the affected areas. It can speed up the healing process and improve cosmetic results, especially in extensive lesions. 

All these treatment options are available in more than 800 hospitals worldwide (https://doctor.global/results/diseases/hand-burns). For example, Hand rejuvenation with structural fat grafting can be done in these countries at following approximate prices:

Turkey $2.4 K in 32 clinics

Germany $8.7 K in 40 clinics

China $9.5 K in 6 clinics

United States $11.4 K in 19 clinics

Israel $60.5 K in 16 clinics.

Rehabilitation

Rehabilitation includes measures to restore the patient’s physical (therapeutic gymnastics, physiotherapy) and psychological state. The main principles of rehabilitation:

• early start;
• a clear plan;
• avoiding periods of prolonged immobility;
• constant increase in motor activity.

At the end of the initial rehabilitation period, the need for additional psychological and surgical care is determined.