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Iqra Mazhar

Thermal burns from hot metals, steam, or liquids raise the temperature of skin tissues. They are diagnosed by thermal burns symptoms, like burning face and blisters.

Thermal Burns 101

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Introduction

John Wesley once said. &ldquo;Light yourself on fire &hellip; and people will come from miles to watch you burn&rdquo;. He surely meant it in a larger-than-life, meaningful manner while describing passion in all its glory.&nbsp;

&nbsp;

Even a minor cut would make a majority of people bawl their eyes out and they would want someone to look after it tenderly, to treat it properly. However, none of those injuries could compare to what a (thermal) burn feels like. That&rsquo;s an entire organ &ndash; or even a part of it &ndash; on fire.&nbsp;

&nbsp;

Yes, an organ; that&rsquo;s what the human skin is. In fact, the skin is the largest organ of the human body. And thermal burns are basically skin injuries caused by an excessive exposure of heat from hot surfaces, hot liquids, steam, or, the most obvious, fire. There&rsquo;s the physical trauma the person has to deal with and then there&rsquo;s the mental trauma. And with delayed treatment, the incident can even become life-threatening.

&nbsp;

However, with the right treatment at the right time, recovery is possible. Most of the burns are not major and can be managed in the outpatient department at any local hospital. Around 6.5% of all the burn victims need to be treated in a specialized burn center<a href="#accordion">[1]</a>. The need to transfer and offer treatment exclusively at burn centers depends on how much of the body surface area is affected, the depth of the ensuing burn injuries, and any personal parameters such as age or existing comorbidities<a href="#accordion">[1]</a>. 
&nbsp;

Understanding Thermal Burns

According to the statistics<a href="#accordion">[1]</a>:

<ul>
	<li>Around 450,000 patients reportedly receive treatment for burns every year</li>
	<li>Around 30,000 require to be admitted to a burn center</li>
	<li>About 86% of the burns are thermal burns &ndash; 43% from fire, 34% from scalds, and 9% from hot objects</li>
	<li>About 4% of the burns are electrical burns&nbsp;</li>
	<li>About 3% of the burns are chemical burns&nbsp; 
	&nbsp;</li>
</ul>

Every year, around 3,400 patients lose their lives to burns or burn-related complications, like inhalation of smoke, carbon monoxide or cyanide poisoning, organ failure, or an infection. What&rsquo;s more, approximately 72% of these fatalities occur from residential fires<a href="#accordion">[1]</a>.&nbsp; 
&nbsp;

Thermal burns are<a href="#accordion">[1][2]</a>:

<ul>
	<li>The 4th leading cause of deaths due to trauma&nbsp;</li>
	<li>The 2nd leading cause of deaths due to accidents in children aged between 1 and 4&nbsp;</li>
	<li>The major cause of all the burn injuries in the United States&nbsp;</li>
</ul>

&nbsp;

Nevertheless, the survival rate for any types of burns is about 97% and the fatalities due to burns have massively declined&nbsp; by nearly 75%&nbsp; when compared to the 1960s<a href="#accordion">[1]</a>. 
&nbsp;

There are 2 types of thermal injuries based on their sources: 
&nbsp;

1. Dry Sources

<ul>
	<li>Fire</li>
	<li>Hot metal or glass 
	&nbsp;</li>
</ul>

2. Wet Sources&nbsp;

<ul>
	<li>Water or oil</li>
	<li>Hot steam</li>
</ul>

&nbsp;

So, it is not only the physical fire that people need to beware of, it&rsquo;s also the smoke. For instance, inhaling smoke, steam or superheated air can easily burn the airways. 
&nbsp;

The symptoms of a thermal burn also depend upon the exact location of the injury and the severity (or degree) of the burn. They include:

<ul>
	<li>Pain</li>
	<li>Blisters</li>
	<li>Swelling</li>
	<li>Discoloration of the skin (red, white, or black)</li>
	<li>Peeling off of the skin 
	&nbsp;</li>
</ul>

In case of an inhalation injury or airway burn, symptoms include:

<ul>
	<li>Burns present on the head, face, neck, eyebrows, or nose hairs</li>
	<li>Burned lips and mouth</li>
	<li>Cough</li>
	<li>Shortness of breath or wheezing (breathing with a whistle or rattle sound)</li>
	<li>Dark, black-stained mucus</li>
	<li>Voice change 
	&nbsp;</li>
</ul>

Note:&nbsp;Call the emergency medical services immediately if any of the symptoms listed below present after a thermal burn:

<ul>
	<li>Symptoms of an airway burn</li>
	<li>A burn injury to the face</li>
	<li>Burn injury to a baby or an aged person</li>
	<li>Little or no pain at all in the burn area as this indicates a nerve injury</li>
	<li>Burn larger than 3 inches&nbsp;</li>
	<li>Pus oozing from the burn injury</li>
	<li>Pain worsening with time&nbsp;</li>
	<li>Alteration in the thickness of the burn injury</li>
	<li>Foul smelling wound(s)</li>
	<li>Fever</li>
	<li>Shock (e.g., pale and clammy skin, weakness, blue skin or fingernails, confusion) 
	&nbsp;</li>
</ul>

Burns are further classified by doctors on the basis of the depth of the injury to the skin. This is described as &ldquo;degrees of burn&rdquo;<a href="#accordion">[2]</a>: 
&nbsp;

<h5>1. First-Degree Thermal Burns</h5>

First-degree burns are also referred to as &ldquo;superficial burns&rdquo; as they involve the top most layer of our skin, i.e., epidermis. This type of burn causes redness, swelling and is easily treatable. 
&nbsp;

<h5>2. Second-Degree Thermal Burns</h5>

Second-degree burns are a bit more serious than the first degree burns and are termed as &ldquo;partial thickness burns.&rdquo; A second-degree burn injury affects the epidermis and the layer right under it, which is called the dermis. This type of burn makes the skin blister and, with time, these blisters actually pop open, giving the skin a wet appearance. Moreover, second-degree burns even leave scars. These burns are more painful and take longer to heal.&nbsp; 
&nbsp;

<h5>3. Third-Degree Thermal Burns</h5>

Third-degree burns affect all the 3 layers of the skin, i.e., epidermis, dermis, and hypodermis. Due to the complete involvement of the layers, this type of burn is also called &ldquo;full thickness burn.&rdquo; Third-degree burns have the potential to make the skin look white or black, and even dry and leathery. Moreover, there&rsquo;s too little or zero sensation of pain because of the extensive nerve damage.&nbsp;

&nbsp;

It&#39;s necessary to get a skin graft surgery for third-degree burns as without it they can cause extreme scarring<a href="#accordion">[3]</a>. 
&nbsp;

The severity of the burns helps determine the kind of treatment required. This involves estimating the percentage of the body that has been affected by the burn and also its depth. Burns are classified as<a href="#accordion">[3]</a>: 
&nbsp;

1. Minor: First- and second- degree burns that cover less than 10% of the body are referred to as minor; patients rarely need hospitalization.

2. Moderate: Second-degree burns, which cover about 10% of the body and are classified as moderate, can range from moderate to severe if the burns are present on the hands, feet, face or genitals.

3. Severe: Third-degree burns, which cover more than 1% of the entire body, are considered severe. 
&nbsp;

There&rsquo;s no doubt that moderate to severe burns require serious medical attention. This includes<a href="#accordion">[1]</a>:

<ul>
	<li>Fluid resuscitation&nbsp;</li>
	<li>Oxygen&nbsp;</li>
	<li>Cardiac monitoring</li>
	<li>Nasogastric tube (a tube to collect secretions from the stomach into a bag via nose)</li>
	<li>Foley catheter (a tube that collects urine in a bag)&nbsp;</li>
	<li>Intravenous pain medication</li>
	<li>A tetanus booster&nbsp;</li>
	<li>Immediate transfer to a burn center as soon as stabilized 
	&nbsp;</li>
</ul>

The treatment of the burn injury has to begin on site to avoid severe complications. Emergency medical services (EMS) assesses for any inhalation injury by checking whether the nasal hairs are burnt or not, whether there are any burns on the nose and mouth, any respiratory distress or sooty/black sputum.&nbsp;

&nbsp;

In case of respiratory distress (troubled breathing), EMS intubates the patient at the site to preserve efficient breathing. More importantly, intravenous fluids are started, especially for adults, along with cooling treatment (ice packs) to help relieve the pain.

&nbsp;

Following that, the source is removed from the site as quickly as possible, while ensuring that there is minimum contact of the hot items with the burned skin. If the affected area is small, it can be quickly cooled down with liquids like tap water or saline solution. However, it&rsquo;s not advisable to try the same for larger burns because this can lead to hypothermia, a condition where the body temperature gets too loe<a href="#accordion">[1]</a>. 
&nbsp;

Superficial burns, in particular, are treated with:

<ul>
	<li>Over-the-counter painkillers&nbsp;</li>
	<li>Topical analgesics</li>
	<li>Topical aloe vera&nbsp; 
	&nbsp;</li>
</ul>

Partial-thickness and full-thickness burns are typically managed with:

<ul>
	<li>Cleansing</li>
	<li>Topical antibiotic ointments</li>
	<li>Pain medications</li>
	<li>Tetanus booster, if deemed necessary 
	&nbsp;</li>
</ul>

The healthcare practitioner on duty must rule out an inhalation injury at this stage because it can lead to an upper airway edema (swelling of the tissues due to fluid buildup) within 12-24 hours. If it exists, then intubation is recommended<a href="#accordion">[1]</a>.

&nbsp;

If the setup allows, a fiberoptic bronchoscopy should be performed, as it provides an accurate picture of the existence of an inhalation injury.&nbsp;

&nbsp;

Once the airway is corrected, the doctor will perform a vertical incision (a cut) on the patient&rsquo;s chest to allow the chest to expand freely; however, occasionally, an additional lateral (on the sides) incisions are also needed.

&nbsp;

Since the patient can be suffering from respiratory distress after the burn injury, it&rsquo;s important to check the levels of toxins such as those of carbon monoxide and cyanide. Oxygen should be provided if its levels continue to drop.&nbsp; 
&nbsp;

There is an ongoing debate as to what is the best way to treat blisters. Currently, it is agreed that<a href="#accordion">[1]</a>:

<ul>
	<li>Large blisters, tense blisters, and blisters that are across joints require debridement</li>
	<li>Small blisters and blisters that involve the palms or soles are left intact 
	&nbsp;</li>
</ul>

One method to treat partial thickness burns is to cover them with topical antibiotic creams, for example, bacitracin or a triple antibiotic ointment, followed by an absorbent dressing. Alternatively, the ointment can also be spread on the dressing and then placed on the burn.

&nbsp;

It should be noted here that dressings are supposed to be changed once or twice a day and can take 1-2 weeks to heal<a href="#accordion">[1]</a>.

&nbsp;

Once the patient is stabilized, it&rsquo;s crucial to complete the treatment with surgical debridement and grafting. 
&nbsp;

Conclusion

Silver sulfadiazine was previously a commonly used topical antibiotic ointment, but it is no longer preferred ever since it was discovered that it delays the healing process. Incase of a burn please contact your healthcare practitioner for optimal treatment.

Key Points

<ul><li>Thermal burns are basically skin injuries that are caused by an excessive exposure of heat from hot surfaces, hot liquids, steam, or fire.</li><li>Around 6.5% of all the burn victims need to be treated at a specialized burn center.</li><li>According to the statistics, around 450,000 patients reportedly receive treatment for burns every year and about 30,000 require to be admitted to a burn center.</li><li>Every year, around 3,400 patients lose their lives to burns or any burn-related complications, like inhalation of smoke, carbon monoxide or cyanide poisoning, organ failure, or an infection.</li><li>Burns has proved to be the fourth leading cause of deaths due to trauma and the second leading cause of deaths due to accidents in children who are aged between 1 and 4.</li><li>The survival rate for any type of burns is about 97%, and the fatalities due to burns have massively declined by about 75% when compared to the 1960s.</li><li>Thermal injuries can be through 2 sources – dry and wet.</li><li>Dry sources include fire, hot metal, or glass, whereas burns from a wet source include hot water or oil and hot steam.</li><li>Inhaling smoke, steam or superheated air can burn our airways.</li><li>Symptoms are usually aggravated during the first few hours or days after the injury has occurred and include pain, blisters, and swelling.</li><li>Symptoms of airway burns, in particular, include burns on the head, face, neck, eyebrows, or nose hairs, burned lips and mouth, and coughing.</li><li>It’s crucial to contact the emergency medical services immediately if the following symptoms present themselves after a thermal burn: a burn injury to the face, burn injury to a baby or an aged person, and little to no pain in the burn area.</li><li>First-degree burns are also referred to as “superficial burns” since they involve the top most layer of the skin, i.e., epidermis.</li><li>Second-degree burns are a bit more serious than the first degree burns and are termed as “partial thickness burns.”</li><li>Third-degree burns affect all the 3 layers of the skin, i.e., epidermis, dermis, and hypodermis.</li><li>Burns are also classified as minor, moderate and severe.</li><li>Treatment of the burn injury needs to begin on site to avoid severe complications.</li><li>It is important that intravenous fluids are started, especially in adults, in addition to cooling treatment (ice packs) to relieve the pain.</li><li>The initial step is to remove the source from the site as fast as possible and make sure there is no more contact of the hot items with the (burned) skin.</li><li>Superficial burns usually require over-the-counter painkillers, topical analgesics, or topical aloe vera to soothe the pain site.</li><li>A healthcare practitioner must rule out an inhalation injury during treatment at the Emergency Department because it can lead to an upper airway edema (swelling of the tissues due to fluid buildup) within 12-24 hours; they also need to recommend if there is any need for intubation.</li><li>Respiratory distress is a common risk of a burn injury, hence, levels of toxins such as carbon monoxide and cyanide need to be checked for and oxygen should be provided if its levels drop.</li></ul>