Burn Treatment

Tissue damage caused by factors such as heat, electricity, chemicals, boiling water and flame is called a burn. The skin is not the only place that a burn affects. Burn is a systemic trauma that affects the whole organism. The extent of tissue destruction as a result of the burn varies depending on the size of the burned area and the persistence of the factor that caused the burn. Wounds resulting from burns are grouped according to the depth and width of the burn.

Classification by Depth of Burn:

FIRST DEGREE BURNS

First degree burn: The upper layer of the skin (epidermis) is intact, there is redness, e.g. sunburns.

SECOND DEGREE BURNS

Second-degree burn: If the integrity of the upper layer of the skin (epidermis) is impaired, if it is limited to the upper layers of the lower layer (dermis), a  superficial  second-degree burn occurs,  if the lower layers of the lower layer of the skin (dermis) are involved, a  deep second-degree burn has occurred. Superficial 2nd degree burns are very painful, while deep 2nd degree burns are less painful and blunt pressure sensation is dominant.

THIRD DEGREE BURNS

Third degree: All layers of the skin (epidermis + dermis) are involved. The skin is hard, flat, pale, painless, thrombosed veins are observed, there is a classic burn eschar.

Fourth degree: All layers of the skin, subcutaneous fat and deep structures (muscle, tendon, etc.) are involved, there is a charred appearance.

 Classification of Burn According to Width:

1. Minor burns:

• 2nd degree burns of 15% or less in adults,
• 10% or less 2nd degree burns in children
• 2% or less of 3rd degree burns in adults or children.

2. Moderate burns:

• 2nd degree burns between 15 and 25% in adults,
• 2nd degree burns between 10-20% in children,
• 2–10% 3rd degree burns in adults or children.

3. Major burns:

• 2nd degree burns more than 25% in adults,
• 2nd degree burns more than 20% in children,
• More than 10% third degree burns in adults or children
• inhalation burns,
• electrical burns,
• Burns accompanied by another trauma (head trauma, intra-abdominal injury, fractures, etc.),
• Burn injury during pregnancy
• Presence of concomitant disease that brings additional risk to the burn (DM, steroid use, immunosuppression, etc.).
• Burns of eyes, ears, face, hands, feet, large joints and genital area. The burns of these areas are “ special area burns”  and should be treated in an experienced center.

Treatment

In first degree burns

No closure or superficial antibacterial agent is needed.
Moisturizing creams or ointments are sufficient. These agents will reduce the inflammation and pain sensation caused by the drying and stretching of the skin. Painkillers can be given to the patient.
In extensive first-degree burns, the patient can be hospitalized for pain and hydration management, if necessary.

In second degree burns

For superficial burns:
Paraffin-impregnated fabrics will not stick to the wound and will reduce pain during dressing changes.
Polyurethane film layers can also be used in cosmetically visible areas.
If these are not available,  dressing with gauze pads impregnated with paraffin or oily ointments (eg, 0.2% Nitrofurazone ointment) is appropriate.
Treatment of water vesicles (Bulla): Small-sized and not thought to burst uncontrollably, water vesicles can be left in place. Large water sacs should be emptied or removed and followed up with dressing.
In deep burns:
Antibiotic creams can be applied directly (eg silver sulfadiazine, mupirocin, nitrofurazone) or under paraffin-impregnated gauze.
If wound healing is delayed and exceeds three weeks, discoloration, hypertrophic scarring, keloid formation and/or contracture may develop, so it is appropriate to transport patients to burn units/centers without delay.

Third and fourth degree burns:

Spontaneous removal of eschar occurs with enzymatic products of the underlying bacteria. Eschar does not separate spontaneously in sterile full-thickness burns. Spontaneous detachment of the eschar is a sign that the wound is infected.

CHEMICAL BURNS

Chemical burns are evaluated in two main groups as acid and alkali. It should not be forgotten that especially alkaline burns have the ability to progress to deep tissues by causing liquefaction necrosis.

General Treatment Principles:

Clothing should be removed as soon as possible.
Contaminated areas should be washed with water. To prevent hypothermia, it should be washed with body temperature water at room temperature. Washing is continued for up to 60 minutes, if necessary, under running water of drinkable consistency. For the termination of washing, the  patient's definition of decrease or disappearance of pain  can be accepted as the end point.
Neutralizing agents should not be used. This may cause the combustion to deepen due to the chemical reaction itself and the heat to be generated.
It may be inconvenient to wash with water in burns caused by chemical dusts. Because water can activate the chemical agent in powder form. In such cases, the chemical dust should first be cleaned with a brush, dry cloth or vacuum cleaner and then washed with plenty of water.
If damage has occurred to the eyes, the eyes should be washed for a long time and with plenty of water. These patients should be consulted with an ophthalmologist.

RADIATION BURNS

Local radiation burn caused by high radiation doses (8-10 Gy) is similar to thermal burns, except for a delay that can last from a few days to weeks. Treatment-resistant and progressive pain is a typical finding and creates an intractable problem in the treatment of the patient.

 ELECTRIC BURNS

Although low-voltage electrical burns are considered below 1000 volts and high-voltage electrical burns above 1000 volts; Since electrical burns between 250 volts and 1000 volts may develop unconsciousness, compartment syndrome, myoglobinuria/hemoglobinuria, these patients should be followed up like high voltage electrical burns. These patients should be followed closely in terms of kidney damage and heart rhythm disorders due to muscle breakdown, as well as burns.

BURN sequelae

Burn contractures are the most common burn sequelae. After the burn heals (especially in 2nd degree deep and 3rd degree burns), the healed area is not as flexible and healthy as normal healthy skin. For this reason, in the following process, the burned area may show severe shrinkage. This tension resulting from contraction is called contracture. When the contracture occurs in the joint areas, there is limitation of movement in the joint areas as the contracture also affects the underlying tissues. Contracture lines on the face, on the other hand, cause serious deformities and loss of function as they will create a pulling line in the eyelid, lip, ear and other structures. Contractures caused by burns or other causes can be surgically corrected without delay. In case of delay, the desired benefit from the treatment may not be fully achieved.