Burn injuries are among the leading causes of accidental death. Every year, more than 1 million people in the United States suffer burn injuries, and approximately 50,000 people require hospitalization. Hospital stays may be long–term and may involve multiple surgical procedures.

Serious burns are complex injuries that may affect skin, muscles, tendons, bones, nerves, and blood vessels. Skin damage impairs the body's normal fluid and chemical balance, heat regulation, and ability to fight infection. Long–term effects include diminished muscle and joint function and physical appearance. Involvement of the respiratory system can lead to airway obstruction and death. Even minor burns can worsen diseases such as diabetes, hypertension, and heart disease. Patients may suffer long–lasting emotional, sexual, and psychological problems.

Risk Factors

• Careless smoking: Cigarettes are the leading cause of house fires.
• Absent or nonfunctioning smoke detectors: The presence of a functioning smoke detector decreases risk of death by fire by 60 percent.
• Use of wood stoves
• Age: Children under 4 who are poorly supervised are at particular risk.
• Gender: Males are more than twice as likely to suffer burn injuries.
• Exposed heating sources or electrical cords
  
• Unsafe storage of flammable or caustic materials
  
• Water heaters set above 120°F
• Microwave heated foods and containers
• Substandard or older housing
• Substance abuse: Use of alcohol and illegal drugs increases risk.

Burns: Diagnosis and Treatment

Diagnosis

• A detailed history and physical examination is the first step. The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection. Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.
• Burns are classified based on the depth and extent of skin damage, degree of pain, and swelling:
  
  • Partial Thickness Burns. First–degree burns affect only the outer skin layer (epidermis) and are characterized by redness or discoloration, mild swelling, and pain. Sun overexposure is a common cause. Injuries heal in three to six days.
    
    Second–degree burns affect the epidermis and various portions of the lower skin layer (dermis), causing a red appearance and blisters. Fluid is lost through damaged skin, and the burns are painful and tender. These injuries require one to three weeks or more to heal. Scarring is uncommon, but there can be long–term skin color changes, although most color changes fade over time.
  • Full Thickness Burns. Burns that penetrate beyond the epidermis and dermis may affect fat (third–degree burn), and muscle, tendon, and bone (fourth–degree burn). Injuries may have a charred appearance and contain white, brown, or black patches. Patients may have severe pain, but the burns are often non–tender because the nerve endings are destroyed. However, partial thickness burns often surround full thickness burns and will be painful. Healing occurs only at the wound edges, and scarring is significant, unless skin grafting is done.
• Biopsy is rarely needed to verify infection.

Treatment

• Burn patients require specialized care and support. The level of care required is based on the location, depth, and percentage of total body surface area affected by the burn.  
• Burns should be thoroughly cleaned to prevent infection, and sterile dressings should be applied. Tetanus vaccination and pain medications should be administered as needed.
• Minor burns are immersed in cool water if possible, or a cool moist cloth can be applied until pain subsides. Very cold water or ice should not be used, as they may damage skin.
  
  Once a minor burn is completely cooled, a fragrance–free lotion or moisturizer can be used to prevent drying. Additional topical treatments may also be helpful, including aloe vera gel or petroleum jelly.
• Partial thickness burns may be treated with bacitracin ointment (Baciquent), collagenase ointment (Santyl), silver sulfadiazine (Silvadene cream), or surgery. Elevation of the burned area above heart level aids healing.

Burns: Nutritional Considerations

• Increased calorie requirements: Burn patients have an increased metabolic rate. As a result, their calorie needs may exceed 5,000 calories per day. Significant weight loss is preventable by nutritional support with increased calories. In some cases, tube feeding may be necessary, particularly in burns involving the face and in inhalation injuries.
  
  A high–protein, high–carbohydrate, low–fat diet is recommended.
  Low–fat diets may result in less muscle loss and more improvement in weight, fewer infections, and shortened hospitalization time. However, the benefit of a high–carbohydrate formula must be balanced with the risk for high blood sugar.
• Fluid needs: Because of the damaged skin barrier, significant water loss can occur. Patients with advanced burns require continuous intravenous fluids to maintain hydration.
• Vitamin supplements: Levels of the vitamins A and E and carotenoids (e.g., beta–carotene) may be low in burn patients. Further, vitamin D synthesis is impaired, which may result in poor bone mineral density. Consequently, supplementation with the recommended dietary allowance has been suggested for patients with significant burns.  
• Mineral supplements: Patients with major burns suffer deficiencies of various minerals, including zinc, selenium, and copper. In one study, the addition of mineral supplementation in hospitalized burn patients was associated with a significant decrease in the number of pneumonia infections and with a shorter hospital stay.