Burns: general information

Burns are damage to the skin and other soft tissues caused by thermal, radiation, chemical, or electrical effects. Burns are classified by depth (first degree, affecting part of the dermis and the entire thickness of the dermis) and the percentage of affected skin areas of the total body surface area. Complications include hypovolemic shock, rhabdomyolysis, infection, scarring, and joint contractures. Patients with large burns (more than 15% of the body surface area) require adequate fluid replacement. Burns are treated with local application of antibacterial drugs, regular sanitation, and, in some cases, skin grafting. Joint burns require movement development and splinting.

ICD-10 code

Burns depend on the area and depth of the lesion. According to the location of the burns and the nature of the damaging factor, the following are distinguished:

• T20.0-7 head and neck.
• T21.0-7 of the body.
• T22.0-7 regions of the shoulder girdle and upper limb, excluding the wrist and hand.
• T23.0-7 wrists and hands.
• T24.0-7 hip joint and lower limb, excluding ankle and foot.
• T25.0-7 ankle and foot area.
• T26.0-9 limited to the area of the eye and its adnexa.
• T27.0-7 respiratory tract.
• T28.0-9 other internal organs.
• T29.0-7 multiple body areas.
• TZ0.0-7 unspecified localization.

In the United States, burns kill about 3,000 people each year and cause about 1 million medical treatment.

Burns are a very common type of traumatic injury, occupying second place in the overall structure of injuries. Thus, in Russia, more than 300 thousand cases are registered annually. The frequency of burns also increases in the conditions of modern wars. 30% of victims require inpatient treatment. Despite certain successes achieved over the past 20-25 years in the treatment of burns, the mortality rate remains quite high and exceeds 8%. In connection with the above, the problem of thermal injuries is given great importance, it is the subject of close attention of both scientists and practicing doctors.

Depending on the nature of the damaging agent, thermal, chemical and electrical burns are distinguished. The first are the most common.

Chemical burns are caused by strong acids and bases (nitric, sulfuric; hydrochloric, acetic acids, caustic potassium and sodium, quicklime, etc.) - Most often, burns occur on exposed surfaces of the body, but when taken internally, burns of internal organs may also develop (for example, taking acetic acid with a suicidal attempt). Acids, as a rule, form superficial burns with the formation of a dry scab. Alkaline burns are usually deeper and form a wet scab. Blisters do not form with chemical burns. Burn disease does not develop, but when exposed to toxic and aggressive environments, poisoning of the body may be observed.

Degrees of burns

In Russia, burns are classified by the depth of tissue damage (adopted in 1960 at the XXVII Congress of Surgeons). According to this classification, the following degrees of burns are distinguished:

• Stage I is characterized by the occurrence of edema and hyperemia of the skin of varying severity. The latter lasts from several hours to 2-5 days and ends with the rejection of the epidermis.
• The second degree is characterized by the appearance of blisters filled with a light yellow transparent liquid, when the integrity of which is violated, a pink wound surface is exposed, sensitive to touch. The depth of the lesion is the death and detachment of the epidermis to the basal (germ) layer. Burns heal within 7-12 days.
• IIIA degree is characterized by superficial skin necrosis, which is represented by a wound surface of pale pink or whitish color with reduced sensitivity. Subsequently, after 2-3 days, a thin light-brown scab is formed. Such burns heal due to the preserved epithelial elements of skin appendages (hair follicles, sweat and sebaceous glands, their excretory ducts) in a period of 21 to 35 days.
• Stage IIIB is characterized by necrosis of all layers of the skin and subcutaneous fat along with epithelial elements, while the burns are represented by a deathly pale wound surface, insensitive to a needle prick or touch of an alcohol ball.
• IV degree is characterized by necrosis of all layers of the skin and underlying tissues (fascia, muscles, tendons, bones). As with IIIB degree, a dense scab of dark brown or black color with thrombosed veins in its thickness forms at the site of the burn, and edema of the surrounding tissues is pronounced.

Burns of I, II, IIIA degrees are considered superficial; under the influence of conservative treatment, the affected areas epithelialize at different times after the injury (from 2-4 days to 3-5 weeks). Burns of IIIB and IV degrees are classified as deep - if their area is large enough, then spontaneous healing is impossible, they require surgical treatment.

Diagnosis of the depth of skin burn damage often causes difficulties. This is especially true for burns of grades IIIA and IIIB. Anamnestic data helps to clarify the diagnosis. If the victim's condition allows, the circumstances of the injury, the nature of the damaging agent, and the duration of its exposure are clarified. It is known that burns from boiling water and steam are often superficial. However, in situations where a person falls into a container with boiling water or another hot liquid with a long exposure to the thermal agent, one should suspect the presence of a deep lesion. The same applies to burns caused by flame. If burns from an arc or from the ignition of flammable liquids are usually superficial due to the short duration of action, then burns caused by burning clothes on a person are always deep.

The depth of the burn depends on the level of tissue heating: if the temperature of the damaging agent does not exceed 60 °C, wet or liquefaction necrosis occurs, which is typical for prolonged exposure to boiling water. With more intense heating by high-temperature agents (flame), dry or coagulation necrosis develops. Extensive burns have an intensity of tissue heating in different areas that is not the same, so the victim is more often found to have burns of different degrees: in the center of the wound - IIIB-IV degree, as it moves away from it - IIIA, then II and I.

It is often difficult to differentiate grade IIIA burns from grade IIIB burns in the first days after injury. In these cases, the diagnosis is clarified later (7-10 days later) after the removal of non-viable tissue. Grade IIIA burns are characterized by insular epithelialization, while grade IIIB burns are characterized by filling of the wound defect with granulation tissue.

Determining pain sensitivity (a needle prick or touching the wound surface with a ball soaked in ethanol) helps to clarify the depth of the lesion: with superficial burns this causes pain, but not with deep burns.

Determining the burn area is of great importance in diagnostics. The most common methods are the "rule of nine" and the "palm rule". In case of extensive lesions, it is more appropriate to use the first one, according to which the area of each anatomical region as a percentage of the entire body surface is a multiple of 9. The following areas are distinguished: head and neck, arm, front surface of the chest, back, abdomen, lower back and buttocks, thigh, shin and foot, each equal to 9%; the perineum and genitals make up 1% of the body surface. In case of limited lesions, the "palm rule" is used, according to which its area in an adult is about 1% of the body surface. Using these rules, it is possible to calculate the burn area quite accurately, especially since in case of extensive burns exceeding 30% of the body surface, an error in measurement of +5% can be neglected, since such a discrepancy will not have a significant effect on the tactics of general treatment.

In children, age characteristics are taken into account to determine the area of the burn.

The most accurate and objective method for determining the severity of a condition based on physical examination data is the calculation of the Frank index, according to which 1% of a superficial burn is conventionally taken as one, and 1% of a deep burn as three.

If the sum is from 30 to 70 units, the patient's condition is moderate, from 71 to 130 - severe, from 131 and more - extremely severe. In case of concomitant inhalation trauma, 15 units are added to the Frank index for mild damage, 30 - moderate, 45 - severe.

Limited burns are accompanied mainly by local disorders, and with extensive burns, a complex of general and local disorders occurs in the body of the affected person, causing burn disease. It develops with superficial burns of more than 20-25% of the body surface or with deep burns - more than 10%. The severity of the course, complications and outcome are directly proportional to the area of deep burns. In children and elderly and senile patients, burn disease can develop with a smaller area of damage.

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Determining the area of the burn

Three methods are used to determine the area of the burn.

1. Glumov's method (palm rule) is based on the fact that the human palm makes up 1% of the body's area.
2. Wallace's method (rule of nine) is based on Glumov's method, since individual parts of the adult human body are multiples of 9% of the total body area: head and neck - 9%, upper limb - 9%, lower limb - 18%, front surface of the body - 18%, back surface of the body - 18%, perineum and palm - 1%.
3. G. Vilyavin's method (filling in sketches) is based on a graphic image of a burn on a 1:100 or 1:10 diagram of a person, reflecting the extent and depth (each degree of burn is reflected in a separate color).

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Further management

Patients who have suffered extensive (more than 20% of the body surface) deep burns, after discharge from the hospital, need observation by a burn specialist, sanatorium-resort and physiotherapeutic treatment, and exercise therapy. Many of them need reconstructive and restorative surgeries.

Approximate periods of incapacity for work

The periods of incapacity for work vary widely: from 7-10 days for first-degree burns over a limited area to 90-120 days for deep burns over an area of more than 20% of the body surface.

Most patients who receive deep burns covering 25-30% of their body surface become disabled.

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What is the prognosis for burns?

The prognosis and outcome of the lesion are determined after assessing the area of superficial and deep burns and clarifying the diagnosis. The simplest prognostic method for determining the severity of a burn is the "hundred rule". If the sum of the age in years and the total area of the lesion as a percentage is equal to or exceeds 100, the prognosis is considered unfavorable, from 81 to 100 - questionable, from 60 to 80 - relatively unfavorable, up to 60 - favorable.