Burn Injuries

Burns are a traumatic injury to the flesh or skin. Most people experience superficial or first-degree burns—the type of burn caused by touching a hot stove, an iron or getting a minor sunburn—at some point during their life. In most cases, superficial burns are not a cause for significant concern, and the pain associated with them can usually be managed with over-the-counter pain relievers. However, burns extending below the superficial layer of skin are far more serious and can result in severe and prolonged pain, blistering, scarring and disfigurement, as well as disability and death. These burns, classified as “Moderate” and “Major”—or 2nd, 3rd and 4th degree—require immediate medical attention and may involve extensive hospitalization and rehabilitation treatment.

Last year almost half a million people in this country sought professional medical care for burn injuries. For people under the age of 40, burns are the second-leading cause of trauma-related death following motor vehicular accidents, and the third most common cause of death overall. Extensive burns are regarded as being among the most devastating type of injuries a person can sustain and still hope to survive. Recent medical advances in the field of trauma medicine in this country have increased the survival rate from burn injuries to 96%.

Yet when talking about burn injuries, it is important to distinguish between “survival” and “recovery”. A person who survives extensive burns is apt to be left with scarring and disfigurement affecting his/her physical functions as well as cosmetic appearance. The ability to “recover” in the sense of being fully restored to pre-injury condition, capable of resuming an active life in society, may entail a long, costly, difficult and painful healing process. In some cases, full recovery may not be possible or realistic based on burn severity and the lingering effects associated with the physical and emotional trauma.

There are relatively few statistics pinpointing the number of burn victims incapable of regaining their former life status, but what is known about prognosis for recovery points to the critical importance of not wasting time in seeking appropriate medical care. Namely, the sooner a burn victim receives best medical care, the greater chance he/she has of achieving optimal physical and psychological health outcomes, with fewer difficulties, in the long-term.

The costs of sustaining a burn injury can be overwhelming in terms of the physical, emotional and financial burden it places on the victim. If you have suffered a burn injury resulting from the actions or negligence of another, you are entitled to reimbursement for the harms and losses you and your loved ones have suffered.

Sources of Burns and Common Causes

There are numerous sources of burns, including:

  • Heat Burns caused by fire, steam, hot objects and hot liquids. Fire is the most common cause of burn injuries in this country, with scalding being most common among children, the disabled and the elderly.
  • Electrical Burns resulting from contact with electrical sources or lightening.
  • Chemical Burns caused by household or industrial chemicals: liquids, solids or gas.
  • Radiation Burns caused by the sun, tanning booths, sunlamps, X-rays and radiation therapy.
  • Friction Burns caused by contact with hard or abrasive surfaces, such as the “road rash”/abrasions motorcyclists or bicyclists may suffer in an accident.
  • Cold Burns caused by the skin’s exposure to wet, windy or cold conditions. Frostbite is one of the most common types of cold burns.

The vast majority of burns are accidental in nature, and in many cases, these injuries are highly preventable. With the implementation of numerous burn prevention programs and measures in recent years—mandated installation of smoke detectors and sprinkler systems, smoking ban ordinances, stiffer requirements regulating electrical and building design and construction, the introduction of fire-resistant clothing and textiles, heat-sensing controls for regulating water heat, etc.—the incidence of serious burns has declined dramatically.

Types of Burns and Symptoms

Burn injuries are classified by severity into four types. They are:

  • First Degree Burn: affects only the outermost layer of skin, known as the epidermis. The injured skin appears red without blisters and is dry to the touch. First degree burns typically heal within 10 days. They are painful but usually can be effectively managed with over-the-counter pain relievers. Home remedies of ice and butter, once widely used to treat milder burns, are not recommended and may cause further damage.
  • Second Degree/Superficial Partial Thickness Burns: extend beyond the superficial layer of skin to the uppermost dermis, the layer of skin lying between the epidermis and subcutaneous tissues, a layer of connective tissues that serves essential functions of insulating and storing energy for the body. The injury site is typically red with clear blisters and blanches with pressure. Unlike a first degree, second degree burns are moist and weep, tend to be very painful and may take as long as three weeks to heal. Complications may include localized infection and some change in skin pigmentation, but typically these burns do not cause scarring. Medical attention may be required, especially if the victim is a child, elderly, disabled or otherwise immune-suppressed.
  • Second Degree/Deep Partial Thickness Burns: penetrate the reticular dermis, the “basement” of the epidermis. The reticular dermis is comprised of highly specialized connective tissues that give skin its unique properties of elasticity and strength. This layer also contains critical receptor cells for touch and sensing heat as well as glands, lymphatic and blood vessels that nourish and remove waste for the epidermal and dermal cells. The burn site is likely to be appear discolored and patchy with variable color: yellow, red or a waxy white. There is less blistering, but the blisters accompanying this type of burn are typically open. A deep partial thickness burn does not blanch. Burn victims are responsive to pressure only; they do not feel the pain of a more superficial wound. A second degree/deep partial thickness burn is very serious and demands immediate medical attention. It can cause scarring and contracture of tissues, requiring surgical removal or excision of the damaged skin and sometimes skin transplantation, known as skin grafts. The healing process is painful and may take up to 2-3 months.
  • Third Degree/Full Thickness Burn: extends throughout the entire dermis. The burn site is white or brown in coloration with no blanching, and the skin is leathery to the touch. Despite the severity of the injury, the victim feels no pain. This is because the burn has killed the nerves that sense touch and pain. Third degree burns are life threatening and demand immediate medical intervention and specialized intensive treatment, such as in a burn center. Surgical excision of damaged or dead skin is recommended as early as possible to prevent infection or deep and unstable scarring. Amputation may be necessary if there is extensive and unrecoverable damage to a limb. Healing from a third degree burn may take months, if not years. When burn victims suffer third degree burns affecting more than 2% of the full body surface, complete recovery is not possible. The victim will suffer lifelong effects, including scarring, pain and loss of functional capacity.
  • Fourth Degree Burn: extends through all layers of skin and penetrates the underlying fat, muscles and bones. The skin is black, inelastic and may slough off. The wound is dry and painless. Such burns require excision of damaged and dead skin as soon as possible. Fourth degree burns pose an immediate threat to life and may result in amputation, significant disability, and death. The healing process take years and is never complete as the severity of injury results in permanent disability and extensive scarring.

In recent years, the American Burn Association has developed a grading system for burns to help physicians determine the need for admission to a specialized burn unit. Burns are classified as Minor, Moderate and Major and assessed on the basis of several criteria; including total body surface area affected and associated injuries as well as the general health and age of the burn victim.

Treatment:  Immediate First Aid Steps

Treatment of burns depends on wounds and severity.  The table below provides information on immediate first aid for burns.

Burn Type

Burn Source

Recommended First Aid

Minor

Heat/Flames

Rinse with cool but not ice cold water as frigid temperatures can result in further damage to the injured area. Blisters should be left intact and are best evaluated by a doctor. Use over-the-counter medications as directed for pain relief.

Minor

Heat/Liquid Scald

Run cool water over the burn for 10 to 20 minutes. Do not use ice.

Minor

Cold

Immerse affected areas in warm—but not hot—water and/or cover with warm blankets or clothing. For smaller parts of the body, such as ears, fingers, nose and toes, blow warm air onto the injury site.

Electrical

After separating the person from the electrical source, check for breathing and heartbeat and call 911.

Chemical

First determine what chemical or substance may have caused the burn. Call your local Poison Control Center or National Poison Control Hotline (1-800-222-1222) for information on how to treat the specific burn.

Minor

Hot Tar or Plastic

Immediately run cold water over the hot tar or plastic to cool the tar or plastic and to keep it from continuing to burn the skin.

After immediately treating the burn, the next step is to check for the possibility of other injuries. Remove any clothing at the burn site, but do not attempt to pull clothing off of the wound if stuck. Cut around the stuck fabric, removing the loose cloth. Remove all jewelry as burns can cause significant swelling making it difficult to get off later on.

If the decision is made to seek medical attention, put a dry, clean cloth over the burn site to reduce the risk of infection. Do NOT put any salve or medication on the area so that the doctor can properly evaluate the wound. ALWAYS ERROR ON THE SIDE OF CAUTION: IF YOU ARE UNSURE OF BURN SEVERITY, SEEK MEDICAL ATTENTION IMMEDIATELY!

Pathophysiology of Burn Injuries

A burn causes cell and tissue damage, disrupting virtually all components vital for maintaining normal function of the skin. Touch, sensation, the ability to regulate water loss and to maintain a normal body temperature are impeded or lost. altogether As cell membranes break down, the cells lose potassium and begin absorbing water and sodium. The body reacts to the injury with an overwhelming inflammatory response. Fluids leak from the capillaries into surrounding tissue, resulting in swelling. This in turn causes blood volume loss, with the remaining blood becoming increasingly concentrated. Blood flow to essential organs, such as the kidneys and the gastrointestinal tract, may be disrupted and result in kidney (renal) failure and/or stomach ulcers. Stress hormone levels, necessary for survival and responsible for the flight-or-fight instinct, may increase dramatically, with pronounced deleterious effect on cardiac, circulatory, blood sugar, kidney and liver functions.

Treatment of Moderate to Major Burn Injuries

Burn victims with moderate to major wounds need immediate medical intervention due to the high risk for experiencing shock. They are best cared for in a burn unit of a hospital or a burn center equipped to provide the specialized treatment they need. Treatment begins with assessment of the person’s airway, breathing and circulation. Victims of fire may have suffered smoke and heat inhalation injuries requiring intubation, the insertion of a tube for opening a swollen airway and/or clearing it of fluids and other inhaled debris. The most common cause of smoke inhalation is fire resulting from a motor vehicular accident.

After ensuring an adequate airway, the depth and extent of the injuries are assessed. Absence of pain and visible wounds are not good criteria for gauging wound severity. The absence of pain, as discussed earlier, can signify the burn has destroyed nerves; electrical and smoke inhalation injuries extend internally and may not be readily detectable. The patient should be checked for other injuries, such as fractures and treated accordingly. All patients with moderate to major burns should undergo immediate evaluation for carbon monoxide and cyanide poisoning and if diagnosed, treated according to standard protocol.

The immediate administration of intravenous fluids or “fluid therapy” is key to stabilizing the patient, reducing the potential for complications and increasing the prognosis for survival. How much fluid to give a patient, though, is not entirely clear. Fluid therapy must take several factors into consideration, including the depth and extent of the burns, age, whether there are pre-existing conditions that could compromise cardiopulmonary function, the potential for smoke inhalation injury (requiring additional fluids), etc. Patients must be constantly monitored to make sure that the fluid amounts administered are neither overloading their system nor insufficient for recovery.

The primary goal for treatment is to close the wound site as soon as possible to reduce the potential for infection and scarring. Hydrotherapy is routine, with the objective of removing dead or extensively damaged tissue while leaving newly-formed skin intact. Topical agents are used to prevent bacteria and fungal infection. Patients with full-thickness burns require the prompt surgical removal of dead skin and the replacement of skin with skin grafts. Limbs and body parts assessed as being non-viable may have to be amputated in order to prevent widespread infection, sepsis, and the potential for hemorrhage caused by dying blood vessels. Patients with smoke inhalation injuries may have to be placed on a mechanical ventilator to ensure adequate oxygenation and ventilation.

For further discussion of acute care management of moderately to severely burned patients, see Critical Care of the Burn Patient: the First 48 Hour by Barbara A. Latenser, MD, FACS.

Pain Management

Burn patients are apt to experience significant pain as they undergo various procedures and constant manipulation of their wounds. Intravenous opioids, long-acting analgesics, anesthesia and relaxants may be used to make the patient as comfortable as possible. Medications have to be administered intravenously, orally, or rectally due to the compromised absorption with injections.

Rehabilitation

Rehabilitation is an essential part of the burn patient’s treatment and recovery. Most people assume that rehabilitation of the burn victim would begin after the healing of the wounds and skin grafts when the patient is not in such acute discomfort. This is a common misconception. Rehabilitation should begin at the moment of admission and often extends for months and sometimes even years. Any delay in starting rehabilitation can result in greater complications, including a higher risk for irreversible and deforming contractures, impaired mobility and daily functioning, extensive and unstable scarring as well as the loss of independence.

Rehabilitation involves a multi-disciplinary approach geared to treating the physical, psychological and social components of recovery as patients are apt to experience significant difficulties in one or more of these critical areas. The family may be involved with rehabilitation treatment if deemed appropriate by the patient and his/her care team.

The goal of rehabilitation is to minimize the debilitating effects of the burn injury by helping the patient to maintain the greatest range of motion possible, reduce the potential for the development and impact of contractures related to scarring, maximize functional ability, restore emotional well-being and assist with re-integration into society.

Rehabilitation Therapies

Rehabilitation requires the coordinated and dedicated efforts of professionals from several fields—physicians, psychologists, family counselors, social workers, spiritual counselors, physical therapists, occupational therapists, respiratory therapists, physiotherapists, recreational therapists, nutritionists, vocational counselors—to assist the patient in reaching optimal recovery. Rehabilitation of the burn patient represents a continuum of coordinated care, from the point of admission throughout the lengthy process of recovery, often extending well after discharge. Rehabilitation therapies of the severely burned patient are likely to include:

  • Effective pain management.
  • Postural control to assist breathing, reduce the risk of pneumonia, reduce swelling and maintain as much of the patient’s functional range of motion as possible.
  • Clinical treatment and counseling for helping manage the emotional impact of the trauma as well as to alleviate or reduce common feelings of depression, hopelessness, loss of self-esteem and anxiety over the disfigurement of contractures and scarring, disability and the loss of function, including possible loss of independence.
  • Anti-contracture positioning and splinting to facilitate tissue length and optimize range of motion.
  • Family support and counseling to enlighten family members regarding the benefits of therapy, what to expect regarding the patient’s prognosis, and how to best assist the patient once home.
  • Stretching and exercise to assist the patient with regaining optimal range of motion, flexibility, coordination, balance, respiratory and cardiovascular capacity and daily functioning.
  • Massage and moistening to moisturize and stabilize scars and new skin while providing traumatized patients with the reassurance of compassionate touch.
  • Pressure therapy to reduce scarring.
  • Activities of Daily Living (ADL) to encourage patients to return to the routine of their daily activities as soon as possible and to resume their pre-injury role in society.
  • Social rehabilitation

For an excellent article and further discussion on rehabilitation strategies, read: Rehabilitation of the Burn Patient by Fiona Proctor.

Common Complications

The devastating effects of thermal burns, caused by fire, steam, hot objects and hot liquids are not just confined to the skin, but compromise the entire being, damaging all organs and systems. Complications secondary to the burn wound itself frequently arise. Organs most commonly affected by burns include the lungs, heart and circulatory system, kidneys, the liver, and blood coagulation systems. There are many numerous factors influencing the body’s dysfunctional and systemic response to a burn injury, the most important being decreased blood flow and cardiac output and respiratory failure. Some of the more common complications associated with burns are:

  • Infection: Infection is the most common complication of burns. Serious thermal injuries ravage the immune system, increasing the patient’s vulnerability to infection. Early removal of dead skin can reduce the potential for massive infection or sepsis, a life-threatening inflammatory response affecting the whole body.
  • Respiratory Failure: Respiratory failure, commonly seen with chemical burns and smoke inhalation injuries, can be caused by numerous factors, including injuries to the head, neck and lungs, fluid overload of the system, inflammatory swelling of airways and pneumonia. Burn patients showing signs of respiratory failure are provided with oxygen and fluid therapies and may be placed on a mechanical ventilator as a lifesaving measure.
  • Pneumonia: Burn trauma not only affects the skin but also the lower airways, particularly in patients with inhalation injuries. Patients requiring mechanical ventilation are at especially high risk for developing pneumonia. Pneumonia is treated in a manner consistent with standard protocol: antibiotics, postural therapy and frequent turning of the body.
  • Cardiac Stress and Heart Failure: Cardiac stress is one of the chief complications of burn injuries and results from increased cardiac output, poor circulation, rapid heart rate, blood loss, and poor delivery of oxygen to the heart. Studies have shown that the cardiac stress produced as a result of burn injuries persists for two years after the injury, increasing the patient’s risk of stroke.
  • Renal Failure: Renal or kidney failure is a leading cause of serious complications and death in burn patients. The kidneys rely on adequate blow flow to flush the body of waste and to regulate the body’s critical balance of salt and water. Without adequate blood flow to the kidneys, toxic waste can build up in the kidneys causing them to fail. Another factor leading to acute renal failure is dehydration. Healthy skin prevents the loss of bodily fluids. Damaged skin allows fluids to rapidly escape the body through evaporation, and the kidneys can shut down due to dehydration. This is why giving intravenous fluids to burn victims immediately is of critical importance.
  • Blood Clots and Aneurysms: Frequently in cases where an electrical current has passed through the body or there are extensive burns, blood vessels may explode from the heat or die due to being irrevocably damaged. When this happens, blood clots can form and obstruct blood flow to vital organs as well as to the arms and legs. In such cases, limbs can die quickly and require lifesaving amputation.
  • Hemorrhage: Blood vessels that have been destroyed can also “bleed out” causing profuse and uncontrolled internal bleeding.
  • Hypermetabolism: Hypermetabolism in burn patients results from a combination of several factors, including raised body temperature, an increased heart rate as the heart attempts to compensate for the prolific and rapid loss of blood and bodily fluids, loss of body proteins as cell membranes break down, the risk of increased infections, and increased levels of stress hormones released in response to stimulating the fight-and-flight instinct. Recent studies have shown that increased levels of these hormones may result in a hypermetabolic state that persists for years, characterized by a fast heart rate and increased cardiac output, a higher basal metabolism and poor immune function.

Preventable Complications

While complications caused by the injuries’ profound impact on the body’s major organs and systems should be anticipated, there are some foreseeable complications that can be prevented through the use of standard medical intervention as well as vigilant monitoring. These include Hypothermia, Compartment Syndromes, Deep Venous Thrombosis, Heparin-Induced Thrombocytopenia, Neutropenia, Stress Ulcers and Adrenal Insufficiency.

Scarring and Contractures

Even with the best care, scarring is an unavoidable consequence of burn injury. With the exception of superficial dermal burns, all deeper burn wounds heal through the natural process of scarring. The extent and magnitude of scarring corresponds directly to the severity of the burn.

Most people assume that the main impact of burn scars is confined to the psychological agony of the patient’s altered appearance, but this is inaccurate. Scars can become malignant and result in contractures and loss of physical function, cell break down resulting in skin ulceration and cause deep emotional trauma persisting for an entire lifetime.

Scarring and its complications can be minimized through the use of various clinical strategies, including physical therapy techniques, such as splinting and positioning; pressure therapy, medications and moisturizing to relieve itching and to make the scar more supple, surgical excision and dermabrasion, avoiding sunlight to prevent discoloration of the scar, use of silicone gel sheets, and skin grafts. However, skin grafts,–while lifesaving—are still perceived as unsightly “scars” by most burn victims.

Despite advances in burn treatment and plastic surgery, many burn patients end up with scar contractures. Contractures represent a shortening of muscles/tendons and neurovascular (nerves/blood vessels) structures or an area of skin loss that can cause decreased range of motion, a loss of flexibility and significant physical disability. Contractures can result from either the initial burn injury or from scarring and contracture of the skin over a period of years.

Physical therapy can help immensely in preventing contractures, but sometimes surgery is necessary to release dislocated joints that have caused tightness and decreased mobility of joint capsules and ligaments. Physical therapy and surgical treatment of scars and contractures must be carefully evaluated in light of numerous medical considerations, including the imminent danger that the scar might pose to vital organs; the maturity and stability of the scar, the extent of neuromuscular and vascular involvement, the severity of the disability caused by contracture and the need for follow-up skin grafts. Severe and incapacitating contractures may not respond to non-operative physical therapy measures.

Scars can have a profound and agonizing impact on a patient’s self-image and create a low quality of life due to depression, anxiety, low self-esteem, a reluctance to re-integrate into society, feelings of hopelessness, shame, fear and self-loathing. Group, individual and family counseling, provided by a skilled therapist experienced in dealing with trauma patients and their families, coupled with the use of antidepressant and anti-anxiety medications, have been shown to have a positive effect on depression. Other therapies, including cognitive-behavioral, social skills training and community interventions, can also help increase the patient’s sense of self-worth and acceptance. Nonetheless, the emotional and physical pain caused by scarring, disfigurement, disability and deformity for the severely burned patient are ongoing, and the process of healing and true recovery never ending.

Contact The Dixon Injury Firm To Discuss Your Burn Injury

If you or a loved one has suffered burn injuries due to the actions or negligence of another, it is important to consult with a burn injury attorney who has handled burn injuries in personal injury cases before settling your case. Many burn injury victims are not aware they are entitled to reimbursement for all aspects of their injuries, not just the cost of treatment and rehabilitation. In addition, if you are forced to undergo a surgery as the result of an injury which is not your fault, scarring from incision wounds should also be reimbursed.

To make sure you receive full reimbursement for your injuries, preparation is key. Contact The Dixon Injury Firm to discuss your rights of reimbursement and ensure you are seeking the full value of your injury. Experienced personal injury lawyers are available 24 hours a day, 7 days a week to answer your questions by calling (314) 409-7060 or toll free 855-40-CRASH. All consultations are FREE.