Burns are a serious public health problem. A burn is defined as an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.
Heat burns occur when some or all of the different layers of cells in the skin are destroyed by a hot liquid (scald), a hot solid (contact burn) or a flame (flame burn). Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered as burns.
According to WHO estimates about 265 000 deaths occur each year from fires alone globally, with more deaths from scalds, electrical burns, and other forms of burns for which data are not available. The majority of these deaths occur in low- and middle-income countries, with almost half occur in the WHO South-East Asia Region.
Symptoms of burn depend on the depth of the burn. Burns can be divided into three types.
First degree or superficial burns involves the upper skin layer. They produce redness (erythema) and pain (tenderness). Blisters are absent. They are typically caused by exposure of the unprotected skin to solar radiation (sun burn) or to brief contact with hot substances, liquids or flash flames (scalds). First-degree burns heal within a week with no permanent changes in skin colour, texture, or thickness.
Second degree or partial thickness burns affect deeper skin layers. Symptoms are more severe and usually include blisters.
- Superficial second-degree burns take less than three weeks to heal.
- Deep second-degree burns take more than three weeks to close and are likely to form hypertrophic scars.
Third degree or full thickness burns involve all skin layers. Skin is white (appears cooked), and there may be no pain in the initial stages. Due to extensive destruction of the skin layers third-degree burn wounds cannot regenerate themselves without grafting.
Signs of inhalational burns-
- History of burns in closed space
- Deep burns to face, neck, or trunk
- Singed nasal hair
- Carbonaceous sputum ,carbon particles in oropharynx
- Change in voice with hoarseness or harsh cough
Common causes of burns may be classified as thermal or inhalational.
Heat burns occur by:
- Hot liquids (scalds) – Scalds are commonly caused by hot liquids (water, oil), steam from boiling water or heated food. Young children are mostly affected by scalds.
- Hot solids (Contact burns): Solid objects that are hot can cause contact burns, especially in children. Sources of burns from solid objects include ashes and coal, hot pressing irons, soldering equipment, cooking utensils (frying pans and pots), oven containers, light bulbs, and exhaust pipes.
- Flames: Burns can be due to leaking gas pipe or cylinder, accidents from kerosene pressure stove, lighting of crackers during “Diwali”, catching of fires in tents as pandal fires.
- Chemical burns-These are accidental burns in homes (such as from toilet cleaning agents), or as acid violence attacks (throwing of acid over somebody for seeking revenge and attempts to resolve disputes of love, land or business) and work place accidents.
- Electrical burns– Electrical burns are due to exposed “live” wires or short circuits. High tension wires close to homes, play areas and roads can lead to electrical burns.
- Inhalational burns are the result of breathing in superheated gases, steam, hot liquids or noxious products of incomplete combustion.
- They cause thermal injury to the upper airway, irritation or chemical injury to the airways from soot, asphyxiation, and toxicity from carbon monoxide (CO) and other gases such as cyanide and accompany a skin burn in approximately 20% to 35% of cases.
- Inhalational burns are the most common cause of death among people suffering fire-related burn.
Burns are more common in rural areas and urban poor of low income countries; some of the factors that are of prime concern include:
- use of cooking pots on ground level (floor cooking): toddlers and young children are at increased risk of scald burns as they can easily knock over the pots on the ground level;
- use of open wood fires;
- wearing of loose fitting cotton clothing (loose chunnis and pallus) can catch fire while cooking on an open fire (a risk factor for women in Asia); or due to faulty habits like use of clothing to hold cooking pot.
Other risk factors are:
- Exposure to fire during occupation;
- poverty, overcrowding(single room houses with kitchen adjacent to bed/play area for children)
- young girls performing household work as cooking and care of small children;
- smoking and alcohol abuse;
- inadequate safety measures for liquefied petroleum gas (LPG) and electricity;
- underlying medical conditions such as epilepsy, physical and cognitive disabilities.
Burns can occur in home and workplace. Children and women are usually burned in homes in their kitchens from hot liquids, flames, or from cook stove explosions. Men are mostly burned in the workplace due to fire, scalds, chemical and electrical burns.
A detailed history and physical examination are the initial steps in diagnosis.
a. History regarding cause of burns and age should be inquired as it helps in diagnosing extent and depth of burns, such as:
- Flame burns are usually full thickness burns, scald burns from hot water spilling may be superficial burns while scalds from ghee, oil are likely to be deep. Chemical and electrical burns are deep.
- Age of patients-At extremes of age (infants and older patents) burns are deep because of thinness of skin.
b. Examination: The severity of the burn is determined by burned surface area, depth of burn and other considerations. Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.
Whole body surface area is taken as 100%. Proportion of surface burn is represented as percentage(%). There are many ways to estimate the body surface area burned.
- The “Rule of 9’s” is commonly used to estimate the total body surface area (TBSA) burned in adults. In this, body is divided into 11 equal parts making this 99% and 1% is given to perineum. Therefore 9% each for the head and each upper limb; 18% each for each lower limb, front of trunk and back of trunk*.
- In newborns and children (younger than 10 years), because of the larger size of head and small body surface area of limbs, the Rule of Nine is not applicable. Lund and Browder chart can be used for the calculation of total body surface area of burns in children*.
- The “Rule of Palm” is one closed hand of an individual is equal to his 1% body surface area. (A hand consists of all the fingers and thumb brought together in extended position with palm).
Initially most of the burn patients are well oriented and may look like as if suffering from a simple injury but any burn above 5% should be taken seriously.
Burns can be classified as minor, moderate and critical burns according to severity:
- Burns less than 15% in adults and 10% in children (excluding chemical, electrical burns and burns of face, hands and perineum).
- These burns can be treated on out-patient basis.
- Burns between 15-25% in adults and 10-15% in children.
- May require hospitalization.
- Burns above 25% in adults, 15% in children and 5% in newborn and infants.
- Electrical burns
- Chemical burns
- Respiratory burns
- Burns associated with other injuries
- Orthopaedic injury
- Chest injury
- Abdominal injury
- Head injury
A burn accident can happen at any place and at any time where medical personnel are usually not around. The first aid has to be provided by the bystanders, who become the “first responders”. Extent of damage can be minimized by providing quick and proper on the site management.
On site management (first aid: Cool, Cover, Call): The basic principles of first aid remain the same for all categories of burns with some specific management for particular category. Rescuer should take care of his/ her own safety before helping burn victim.
- The victim should be removed from the burning premises.
- The victim should be asked to lie down on the floor with burning side upper most (stop drop and roll)(tough rolling is not advised by some experts as this practice can transfer the fire to previously undamaged areas and can also cause other injuries) . Lying flat prevents the flames from involving the face, head and scalp hairs and also prevents the fire from going around the body (as flames go upwards).
- Prevent the victim from running as it only fans the flames.
- If the victim is unable to walk or unconscious, drag him from burning site.
- If there is lot of smoke along with fire, the rescuer should stay low/ crawl on the floor to minimize the inhalation of the toxic fumes (as the smoke, gases and hot air tend to rise). Breathing should be done through the wet handkerchief to filter out the fumes, carbon and other toxic particles.
- Pour water in copious amounts over the victim to extinguish the flames and to reduce the temperature of the burn.
- In the absence of water any other non-inflammable clear liquid such as milk, canned drink can be used. Or
- The victim should be put on the ground with the burning side uppermost and then wrapped in a heavy cotton cloth (blanket/rug/dari/coat or any other heavy fabric).Once the fire extinguishes, the blanket should be immediately removed as it can retain the heat. (Nylon or other inflammable material should not be used for this purpose).
- Fire extinguishers can be used for putting out the fire.
- Don’t throw/apply mud/sand over the victim’s body to put out the fire.
- All the burnt clothes (including belts, socks and shoes) and the ornaments (necklace, wrist watch, bangles, bracelets, nose-rings, ear-rings, rings around the fingers and toes, anklets) should also be removed.
- Do not apply any ointments, creams, lotions, powders, grease, ghee, gentian violet, calamine lotion, toothpastes, butter, colouring and other sticky agents, over the burn wound.
- To avoid contamination, the burnt parts should be wrapped in a clean, dry sheet/cloth. Upper and lower limb injuries could be wrapped in pillow cover/plastic bags. Wrapping of wounds also reduces pain due to the air currents and provides protection during transport.
- If burn injuries occur in closed chamber, patients may develop carbon monoxide poisoning. In such cases cleaning of the throat and putting oxygen mask during transportation is required.
- Look for associated injuries (fractures or spinal injuries) and take care accordingly.
- Don’t give anything to eat and drink as this may result in vomiting.
- Formal oral analgesics are usually not given in the first aid. Reassurance and consolation to the victim and the family are important components of early care.
- Co-morbid conditions/other pre-existing conditions (such as pregnant women, alcoholism, and drug addictions) should be inquired.
- Seek immediate medical help. First 6 hours following injury are critical; transport the patient with severe burns to a hospital as soon as possible.
- In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water.
- S.A.F.E. approach is recommended. S – Shout for help, A – Assess the scene quickly, F – Free from danger of violence, E – Evaluate the casualty.
- The victims should be rushed to the nearest medical care units at the earliest.
- Switch off the power supply and victim should be removed with a non-conducting material like a dry wooden stick/pole/wooden chair.
- No such maneuver should be attempted while a person is connected to a high voltage source, as the current is likely to “arc” to the rescuer as he approaches.
- Look for airway, breathing and circulation. If there is no response or respiration, the victim most likely has suffered cardiac arrest and CPR (cardiopulmonary resuscitation) should be started immediately at the site.
- Look for associated injuries.
- Call for help immediately.
- The victims of lightning injuries are managed in the same way as those of electrical injuries. These patients can withstand apnoea (cessation of breathing) for very long periods of time. Sometimes prolonged resuscitation with cardiac massage and ventilation is required.
a. Initial management includes assessment and maintenance of following parameters with ABCDE approach:
- Airway assessment and management in case of inhalational burns (burns in closed space, deep dermal burns to face, neck, or trunk, singed nasal hair ,carbon particles in oropharynx).
- Breathing: beware of inhalation and rapid airway compromise.
- Circulation: ensure fluid replacement by securing wide bore intravenous line through which Ringer lactate solution can be given rapidly. Oral fluids such as ORS (Oral rehydration solution) may be given after initial resuscitation.
- Disability: evaluation for neurological deficit or any gross disability. Compartment syndrome occurs when excessive pressure builds up inside an enclosed space in the body. The legs, arms, and abdomen are mostly affected by compartment syndrome. Treatments for compartment syndrome focus on reducing the dangerous pressure in the body compartment. Dressings, casts, or splints that are constricting the affected body part must be removed.
- Exposure: (Percentage area of burn), the whole of a patient should be examined (including the back) to get an accurate estimate of the burn area and to check for any concomitant injuries.
b. In all cases, tetanus prophylaxis should be administered.
c. Wound care:
- Adherent necrotic (dead) tissue should be cleaned.
- After debridement, the burn should be cleansed with either 0.25% (2.5 g/litre) chlorhexidine solution or 0.1% (1 g/litre) cetrimide solution, or with mild water based antiseptic. (Do not use alcohol-based solutions).
- A thin layer of antibiotic cream (silver sulfadiazine) should be applied.
- The burn area is dressed with petroleum gauze and dry gauze thick enough to prevent seepage to the outer layers.
d. Systemic antibiotics are given to treat and prevent wound infections.
e. Proper nutrition with adequate supply of energy and proteins should be given to patients.
f. Specialized care may be provided during healing process in the form of skin grafts or surgical release of contractures due to scars.
- Stop the burning process by removing clothing, jewelry and irrigating the burns.
- In electrical burns, put the main switch off as quickly as possible and use a wooden scale or rod wooden chair to push the victim away from electricity. (No such maneuver should be attempted while a person is connected to a high voltage source, as the current is likely to “arc” to the rescuer as he approaches)
- Extinguish flames by pouring plain water; if water is not available by applying a blanket and removing the blanket as soon as the flames are put off.
- In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water.
- Use cool running water to reduce the temperature of the burn.
- Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate facility for medical care.
- Take care of fractures and probable injuries during transportation.
- Ensure A-Airway, B-Breathing & C-Circulation before transportation to higher center.
- Do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals etc.)
- Do not apply ice because it may further damage the injured tissues.
- Avoid prolonged cooling with water because it may cause hypothermia (low temperature).
- Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn or any other material.
- Do not open blisters with needle or pin, until topical antimicrobials can be applied, such as by a health-care provider.
Specific recommendations/precautions to prevent burn injuries by individuals, communities -Primary prevention:
- Enclose fires and limit the height of open flames in domestic environments. Cooking on floor should be avoided.
- Restrain playing of toddlers in kitchen/cooking area.
- Watch the child constantly especially around gas burners, stoves, ovens, microwaves, heaters and other appliances.
- Turn pot handles toward the back or center of the stove to prevent tipping.
- Never cook while holding a child.
- Carefully use electrical appliances and switch off all electrical appliances when not in use.
- Avoid use of unauthorized gas cylinders & kerosene stove/chulha. Use safe stoves and lamps.
- Avoid loose clothing while cooking. Tie up loose saree end (pallu) or stole (chunni) properly.
- Never hold a cup of hot liquid near infant/toddlers.
- Check the temperature of water before bath.
- Beware of high tension wires passing over terrace or balcony and do not keep open electrical wires at home.
- Supervise children while lighting fire crackers.
- Do not hold the cracker while bursting.
- Don’t point the burning fireworks towards you/others.
- Don’t fiddle with un-burnt crackers.
- Always light or burst crackers in open area /ground.
- Acid-throwing: Intensified legal reforms to the crime, restricted availability of acid and chemicals for general public and changing attitude of society so that person attacking in this way is no longer acceptable may be the effective steps in prevention. Handle chemicals (acids) carefully.
- Promote fire safety education and the use of smoke detectors/smoke alarms, fire sprinklers, and fire-escape systems in homes/buildings. Smoke alarms provide an early warning system; alerting people and allowing them time to escape before the fire spreads.
- Improve treatment of medical conditions such as epilepsy.
- Get inside a home, building (away from doors and windows, metal objects such as pipes, sinks, radiators, and plugged-in electrical appliances),
- When outside and unable to find shelter, maintain distance from tall trees.
- Lightning can travel through water, therefore avoid swimming, boating and bathing during a thunderstorm
Secondary Prevention: Both pre-hospital and hospital care play an important role in the management of burn patients by preventing deaths and disability.
- First aid: Education and sensitization of individuals/communities on the site management in the form of first aid can further help in early recovery of the burn patients.
- Better hospital care: These include better initial treatment to prevent shock and breathing problems, better infection control, increased use of skin grafts and assuring adequate nutrition. These measures can minimize the burden of death, disability and suffering from burns.
- Rehabilitation- Burn survivors are often left with disability and disfigurement that interferes with their future life. Rehabilitation measures such as physical therapy and addressing psychological issues can assure a better life in burn survivors.