Burns occur when the skin comes into contact with a heat source or caustic substance, commonly fire or flames, boiling liquid, hot objects, electrical current, or chemical agents.¹ Different mechanisms of injury that can cause a burn include scalding, fire, chemical exposure, electrical exposure, and radiation.² The extent of injuries that can occur from a burn is highly variable, and morbidity and mortality tend to increase as the surface area of the burn increases.³ Proper classification of burns is essential in guiding the initial management of the burn wound and achieving optimal outcomes. Burn severity is classified by four progressive depths of tissue injury in combination with total body surface area (TBSA) affected. The location on the body, the degree of temperature, and the duration of exposure are all contributing factors to the severity of a burn.² Age and comorbidities may also have an impact on burn severity.

Minor Burns

Superficial Burns

Superficial burns involve damage only to the epidermis, with no blistering. They can occur anywhere on the body and may be red, tender, and painful. Healing typically occurs within several days with no scarring. The risk of infection is minor. Medical treatment is often not necessary for a superficial burn. Caring for a superficial burn injury is straightforward and often includes the following actions⁴:

• Immediately after injury, hold the burn under cool running water until the pain subsides.
• Use a cold compress to keep the burn cool.
• If the pain persists, acetaminophen, ibuprofen, or naproxen may be administered to provide pain relief.
• Cover the burn with a moist bandage, or apply a petroleum-based (non-fragranced) ointment several times daily to promote healing.
• Refrain from using oils, lotions, or creams for several days until healing occurs.

Partial-Thickness Burns

Partial-thickness burns damage the outer layer of skin (epidermis) and the layer underneath (dermis). Partial-thickness burns can be either superficial, involving only the epidermis and papillary dermis, or deep, reaching into the reticular dermis and dermal appendages. Superficial partial-thickness burn injuries appear pink and moist, and they can also have fluid-filled blisters. Superficial partial-thickness burns usually heal within two to three weeks, often without scarring.²

Management of Burn Injuries

Deep partial-thickness burn injuries appear deep red and may contain some white tissue, with slow capillary refill. Thick-walled blisters are commonly present. Topical antimicrobials may be indicated to prevent infection in these injuries. They generally heal within three to six weeks, although they may leave a hypertrophic scar.² It may not be necessary to contact emergency services after a partial-thickness burn injury has been sustained, although it is advisable that the individual follow-up with a provider familiar with burn care to determine optimal treatment. When caring for patient with a partial-thickness burn, it is crucial to remember a few things⁴:

• Do not apply ice; use only cool water or a cold compress to cool the burn.
• Do not break any blisters or add ointments because these actions can increase the risk of infection.
• If it appears that the individual may go into shock, lay them flat, with their feet and the burn area slightly elevated.
• A clinical examination will determine course of treatment, including antibiotics and analgesics as indicated.

Major Burns

Full-Thickness Burns

Full-thickness burns completely destroy the epidermis, dermis, and capillary network. The burn may appear white and leathery or black and burned. The patient may feel extreme pain, or the skin may be numb. Frequently, skin grafting is necessary to resurface the injured area.² Contacting emergency services and obtaining medical care quickly are crucial for full-thickness burns. Immediate further steps include the following:

• Protect the burn area by covering it with a sterile bandage. If one is not available, a sheet or other material that will not leave lint in the wound may be used.
• Separate burned fingers and toes.
• Do not soak the wound in water or apply any creams or ointments because this can increase the risk of infection.
• To prevent the person from going into shock:
  • Lay them flat. Do not use a pillow when their airway may be affected because it can cause the airway to close. If they have a facial burn, have them sit in an upright position.
  • Elevate the feet and the burn area above heart level, if possible.
  • Check pulse and monitor breathing until medical assistance arrives.
• A health care provider may perform a focused assessment and administer oxygen, fluids, and analgesics for treatment

Conclusion

Burns are relatively common injuries in emergency and urgent care clinical settings, and severe burns have the potential to cause significant morbidity and mortality. Treatments, whether for major or minor burns, are determined based on the extent (depth) and severity (TBSA) of the burn, thus making it is essential to classify these wounds accurately.

References

1. Warby R, Maani CV. Burns classification. StatPearls. 2019. https://www.ncbi.nlm.nih.gov/books/NBK539773/. Accessed December 5, 2019.

2. Vorstenbosch J. Thermal burns. MedScape. 2019. https://emedicine.medscape.com/article/1278244-overview#a1. Accessed December 5, 2019.

3. Vivo C, Galeiras R, del Caz MD. Initial evaluation and management of the critical burn patient. Med Intensiva. 2016;40(1):49-59.

4. Thermal burns treatment. WebMD. https://www.webmd.com/first-aid/thermal-heat-or-fire-burns-treatment#1. Accessed December 5, 2019.