II. Epidemiology

  1. U.S. Incidence of Burn Injury
    1. Emergency Department visits: 500,000 per year
    2. Hospitalizations: 40,000 per year (60% require burn center admission)
  2. Ages at higher risk of Burn Injury (bimodal distribution)
    1. Children
    2. Older adults

III. Causes

  1. Scald Burn (80% of burns in young children)
    1. Hot liquids pulled off the counter
  2. Flame-related burns (more common in school age children and teens)
    1. Lighters
    2. Lighter fluid
    3. Fireworks
    4. Gasoline

IV. Pathophysiology

  1. Deep dermal injury
    1. Disrupts elasticity, mechanical barrier protection and vascular supply
    2. Results in scarring and Non-Healing Wounds

V. Precautions

  1. Consider physical abuse
    1. Intimate Partner Violence
    2. Elder Abuse
    3. Nonaccidental Trauma in children with Burn Injury
      1. Physical abuse accounts for 5-6% of Burn Injury <12 years old
      2. Social workers typically review pediatric burns at burn centers and pediatric hospitals
      3. Involve child protective services and pediatric specialty center evaluation if suspected abuse
      4. Consider in delayed presentation, parental indifference and inconsistent history
      5. Consider in burns to hands or feet, buttocks or posterior legs
      6. Consider in well demarcated burns or linear or patterned burns
      7. Consider in symmetric burns and in those that do not spare the flexor crease
  2. Evaluate for other Traumatic Injury
    1. See Secondary Survey
    2. Closed Head Injury
    3. Eye Trauma
    4. Chest Trauma
    5. Abdominal Trauma
    6. Musculoskeletal Trauma

VI. Types

  1. Electrical Injury
  2. Lightning Injury
  3. Chemical Toxin
  4. Fire-Related Injury
    1. Thermal Burn
      1. Contact with hot surface and scald burns from liquid (>111 F, 43 C) account for 85% of pediatric burns
    2. Smoke Inhalation
      1. Occurs in 5-35% of hospitalized Burn Injury patients
    3. Acute airway compromise (airway edema)
    4. Carbon Monoxide Poisoning
    5. Cyanide Poisoning

VII. Signs: Burn Degree

  1. Precaution
    1. Conversion to deeper burn may occur over ensuing days after initial injury
  2. First degree (Superficial burn)
    1. Not included in burn total body surface area involvement
    2. Pathophysiology
      1. Damage limited to Epidermis
    3. Findings
      1. Dry Skin erythema that when touched, is painful and blanches (e.g. Sunburn)
      2. No Blisters
    4. Causes
      1. Severe UV light exposure (Sunburn)
      2. Minor Thermal Injury
    5. Course
      1. Healing occurs in 3-6 days (up to 5-10 days) without scarring
  3. Second degree (Partial thickness burn)
    1. Superficial partial thickness
      1. Pathophysiology
        1. Involves all of the Epidermis
        2. Also involves superficial Dermis (upper layers of papillary Dermis)
        3. Skin capillaries remain intact (distinguishes from deep partial thickness injury)
      2. Findings
        1. Wet, weaping lesions with clear Blisters
        2. Erythematous, soft skin that blanches with pressure
        3. When touched, skin is hypersensitive and painful
      3. Course
        1. Healing occurs within 14-21 days
        2. Scarring is possible but uncommon (deeper structures including stem cells are spared)
    2. Deep partial thickness
      1. Pathophysiology
        1. Involves all of the Epidermis
        2. Also involves deeper Dermis (lower layers of reticular Dermis)
      2. Findings
        1. Drier lesions than with superficial partial thickness
        2. White or pale to Yellow Skin that when touched does not blanch (or has decreased blanching)
        3. Hemorrhagic Blisters may be present
        4. Painful despite reduced Sensation to touch
        5. Skin is slightly tense (less soft than in superficial partial thickness burns)
      3. Course
        1. Healing typically takes >21 days
        2. Scarring and contractures are common complications (involves stem cells, follicles, glands)
        3. Benefits from early evaluation by burn surgeon early operative management
  4. Third degree (Full thickness)
    1. Pathophysiology
      1. Kills all skin layers (involves all of Dermis)
      2. Also involves underlying subcutaneous fat and connective tissue
    2. Findings
      1. Waxy, dark-brown to black, tan or white skin
      2. Skin is stiff and leatherlike (contrast with soft skin of superficial burns)
      3. Bright red burns without blanching or Sensation are Third Degree Burns (contrast with pink Second Degree Burns)
      4. No Sensation to touch
      5. No Capillary Refill
    3. Course
      1. Burn center evaluation indicated in all cases
      2. Typically do not heal without skin grafting
      3. Contractures are a common complication
  5. Fourth degree
    1. Destroys all skin layers
    2. Also involves Muscle, tendon or bone

VIII. Signs: Estimating Surface Area with Rule of 9's

  1. Precautions
    1. Estimate burn area only based on second and Third Degree Burns
      1. First Degree Burns do not count for calculation (Sunburn-like red, closed injury areas)
    2. Exercise caution in burn area calculation in children (overestimated by >200%)
      1. Can substantially affect fluid Resuscitation volume calculation (Parkland Formula)
      2. Goverman (2015) J Burn Care Res 36(5): 574-9 +PMID:25407387 [PubMed]
    3. Lund and Bowder Chart offers a more accurate assessment of burn area
      1. https://en.wikipedia.org/wiki/Lund_and_Browder_chart
      2. Murari (2019) Acute Crit Care 34(4): 276-81 +PMID:31795625 [PubMed]
  2. Infant Rule of 9s
    1. er_burn_ruleOf9_infant.png
    2. Head: 18%
    3. Torso Back: 18%
    4. Torso Front: 18%
    5. Leg Left: 14%
    6. Leg Right: 14%
    7. Arm Left: 9%
    8. Arm Right: 9%
  3. Adult Rule of 9s
    1. er_burn_ruleOf9_adult.png
    2. Torso Front: 18%
    3. Torso Back: 18%
    4. Leg Left: 18%
    5. Leg Right: 18%
    6. Head: 9%
    7. Arm Left: 9%
    8. Arm Right: 9%
    9. Genitalia: 1%
    10. Size of patients palm
      1. Entire palm and fingers: 1% TBSA (inaccurate in obese patients)
      2. Palm only: 0.5% TBSA

IX. Evaluation: Minor burn criteria

  1. Burn is not circumferential
  2. Burn is only injury
  3. Burn does not involve high risk areas
    1. Across major joints
    2. Face
    3. Hands or feet
    4. Perineum or genitalia
  4. Partial thickness burn surface area is limited (Second Degree Burn area)
    1. Ages 10 to 50 years old: Burn area <10%
    2. Age under 10 or over age 50 years old: Burn area <5% (<2% third degree, full thickness)

X. Management

XI. Prevention: General

  1. See Sunscreen
  2. Avoid Smoking inside the home

XII. Prevention: Burns in Children

  1. Consider Nonaccidental Trauma, Intimate Partner Violence or Elder Abuse (see precautions as above)
  2. Bath
    1. Test bathwater before placing child in bath
    2. Set hot water heater to lowest setting (below 120 degrees F)
    3. Monitor children continuously when in the bath or near faucets
  3. Kitchen
    1. Preferentially use the back Burners of the stove when cooking in the presence of children
  4. Household
    1. Test smoke alarms on a regular basis
    2. Monitor children when near fireplace
    3. Keep children away from matches, fireworks, gasoline and explosives
    4. Keep children away from hot objects
      1. Never hold children while working with hot objects

XIII. Prognosis: Increased mortality risk factors

  1. Age >60 years
  2. Associated Smoke Inhalation

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Burn injury (C0006434)

Definition (MEDLINEPLUS)

A burn is damage to your body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns. Another kind is an inhalation injury, caused by breathing smoke.

There are three types of burns:

  • First-degree burns damage only the outer layer of skin
  • Second-degree burns damage the outer layer and the layer underneath
  • Third-degree burns damage or destroy the deepest layer of skin and tissues underneath

Burns can cause swelling, blistering, scarring and, in serious cases, shock and even death. They also can lead to infections because they damage your skin's protective barrier. Antibiotic creams can prevent or treat infections. After a third-degree burn, you need skin or synthetic grafts to cover exposed tissue and encourage new skin to grow. First- and second-degree burns usually heal without grafts.

NIH: National Institute of General Medical Sciences

Definition (SCTSPA) Lesión genérica por quemadura, incluidas las producidas por calor excesivo, así como por cauterización, fricción, electricidad, radiación, luz solar y otras causas
Definition (SNOMEDCT_US) Generic burn injury, including that due to excessive heat, as well as cauterization, friction, electricity, radiation, sunlight, and other causes
Definition (NCI) A traumatic injury involving interruption of tissue cohesiveness that results from exposure to caustic chemicals, extreme heat, extreme cold or excessive radiation.
Definition (NCI_CTCAE) A finding of impaired integrity to the anatomic site of an adverse thermal reaction. Burns can be caused by exposure to chemicals, direct heat, electricity, flames and radiation. The extent of damage depends on the length and intensity of exposure and time until provision of treatment.
Definition (NCI_FDA) Injury to tissues caused by contact with dry heat, moist heat, flames, chemicals, electricity, friction or radiant and electromagnetic energy. A first degree burn is associated with redness, a second degree burn with vesication and a third degree burn with necrosis through the entire skin.
Definition (MSH) Injuries to tissues caused by contact with heat, steam, chemicals (BURNS, CHEMICAL), electricity (BURNS, ELECTRIC), or the like.
Definition (CSP) damage inflicted on any part of an organism as the direct or indirect result of exposure to steam, chemicals, heat, flame, electricity or the like, with or without disruption of structural continuity; for burns due to overexposure to the sun use SUNBURN.
Concepts Injury or Poisoning (T037)
MSH D002056
ICD9 949.0, 940-949.99
ICD10 T20-T31.9 , T30.0
SnomedCT 157629005, 212129000, 212138003, 212139006, 269386003, 211657006, 48333001, 125666000
LNC LP7090-6, MTHU007829, LA7318-4
English Burn injury, Burns, BURN, Burn of unspecified site, unspecified degree, Burns NOS, Burn - unspecified, burns (physical finding), burns, burn, burn (diagnosis), Burn NOS, Burns [Disease/Finding], burning disorders, burn injury, burning injuries, burns injuries, burn injuries, burns injury, burned, burnings, burning lesions, burn lesion, Burn Wound, Burn - unspecified (disorder), Burns NOS (disorder), BURN(S), Burn, Burn - lesion, Burn (disorder), Burn injury (morphologic abnormality), Burn injury, NOS, Burn, NOS, BURNS
French BRULURE, Brûlures SAI, Brûlure, Brûlure de site non précisé, de degré non précisé, Brûlures
Dutch brandwonden NAO, brandwond van niet-gespecificeerde plaats, niet-gespecificeerde graad, brandwond, Brandwond, Brandwonden, Wond, brand-, Wonden, brand-
German Verbrennung, Verbrennungen NNB, Vergrennung an einer unspezifischen Stelle, unspezifischer Grad, Verbrennungen
Italian Ustioni NAS, Ustione, Ustione in sede non specificata di grado non specificato, Ustioni
Portuguese Queimadura de localização NE de grau NE, Queimadura, Queimaduras NE, QUEIMADURA, Queimaduras
Spanish Quemadura de localización no especificada, grado no especificado, Quemaduras NEOM, Quemadura, quemadura - no especificada (trastorno), quemadura - no especificada, quemaduras, SAI (trastorno), Burns NOS, quemaduras, SAI, Burn - unspecified, lesión traumática por quemadura (anomalía morfológica), lesión traumática por quemadura, quemadura (trastorno), quemadura - lesión, quemadura, Quemaduras
Japanese 熱傷NOS, 熱傷, 熱傷、程度不明, ネツショウNOS, ネッショウ, ネッショウNOS, ネッショウテイドフメイ
Swedish Brännskador
Czech popálení, opaření, Popálenina, Popálenina blíže neurčeného stupně, blíže neurčeného místa, Popáleniny NOS, spáleniny, poleptání, popáleniny
Finnish Palovammat
Polish Oparzenia
Hungarian Nem meghatározott lokalizációjú és nem meghatározott fokú égés, Égések k.m.n., Égés
Norwegian Brannskader, Forbrenninger, Brannsår, Combustio

Ontology: Thermal injury (C0332685)

Definition (SCTSPA) Lesión traumática debida a calor intenso
Definition (SNOMEDCT_US) Injury due to increased heat
Definition (CSP) damage inflicted on any part of an organism as the direct or indirect result of exposure to a high temperature, with or without disruption of structural continuity.
Concepts Injury or Poisoning (T037)
SnomedCT 161006
English heat injury, thermal injuries, heat injuries, thermal injury, injuries heat, injuries thermal, Heat injury, Thermal injury (morphologic abnormality), Thermal injury, Heat injury, NOS, Thermal injury, NOS
Spanish injuria por calor, injuria térmica, lesión por calor, lesión traumática térmica (anomalía morfológica), lesión traumática térmica

Ontology: First degree burn (C0332686)

Definition (NCI_FDA) A burn that only affects the outer layer of skin causing pain, redness, and swelling.
Definition (NCI) A painful injury to the epidermis due to chemical, friction, radiation or thermal exposure. The affected area appears red and blanches when touched.
Concepts Injury or Poisoning (T037)
ICD9 949.1
ICD10 T30.1
SnomedCT 269248005, 212131009, 77140003, 403190006
English Erythema due to burn (first degree), unspecified site, Burn of first degree, body region unspecified, Superficial burn NOS, first degree burns, first degree burns (diagnosis), superficial (first degree) burns, Burns first degree, First degree burns, First-Degree Burn, 1st degree burn NOS, Erythema, body region unspecified, burns superficial, superficial burn, burn degree first, first degree burn, burns degree first, Erythema [first degree], unspecified site, Erythema due to burn [first degree], unspecified site, (First degree burn) or (superficial burn NOS), Superficial burn NOS (disorder), (First degree burn) or (superficial burn NOS) (disorder), First Degree Burn, FIRST-DEGREE BURN, Burn erythema, Erythema caloricum, First degree burn injury, Superficial burn, First degree burn, First degree burn (disorder), First degree burn injury (morphologic abnormality), Erythema due to first degree burn, unspecified site, Erythema due to burn, unspecified site
Italian Ustioni di primo grado, Ustione superficiale, Eritema secondario ad ustione (primo grado), sede non specificata
Dutch erytheem door brandwond (eerste graad), niet-gespecificeerde plaats, brandwond oppervlakkig, eerstegraadsbrandwonden, Brandwond van eerste graad, lichaamsregio niet gespecificeerd, brandwonden eerste graad
French Erythème lié à une brûlure (premier degré), site non précisé, Brûlure superficielle, Brûlures du premier degré
German Erythem verursacht durch Verbrennung (ersten Grades), unspezifische Stelle, oberflaechliche Verbrennung, Verbrennung 1. Grades, Koerperregion nicht naeher bezeichnet, Verbrennungen ersten Grades
Portuguese Eritema por queimadura (1º grau) de local NE, Queimadura superficial, Queimaduras do 1º grau
Spanish Eritema por quemadura (de primer grado), localización no especificada, Quemadura superficial, quemadura superficial, SAI (trastorno), quemadura superficial, SAI, eritema calórico, eritema por quemadura, quemadura de primer grado (anomalía morfológica), quemadura de primer grado (trastorno), quemadura de primer grado, Quemaduras de primer grado
Japanese 第1度熱傷, (第1度)熱傷による紅斑、部位不明, 表在性熱傷, ダイ1ドネッショウニヨルコウハンブイフメイ, ダイ1ドネッショウ, ヒョウザイセイネッショウ
Czech Povrchová popálenina, Popáleniny prvního stupně, Popálenina prvního stupně, erytém blíže neurčeného místa
Korean 상세불명 신체 부위의 1도 화상
Hungarian Felületes égés, Első fokú égések, Nem meghatározott lokalizációjú, égés okozta (első fokú) erythema

Ontology: Second degree burn (C0332687)

Definition (NCI) An injury that includes the entire epidermis and upper layers of the dermis due to a chemical, friction, radiation or thermal exposure. The affected area appears as moist red or white skin that does not blanch. Often it is painful with the presence of blisters.
Definition (NCI_FDA) A partial thickness burn that affects both the outer and underlying layer of skin causing pain, redness, swelling and blistering.
Concepts Injury or Poisoning (T037)
ICD9 949.2
SnomedCT 212132002, 46541008, 403191005
English Blisters with epidermal loss due to burn (second degree), unspecified site, second degree burns (diagnosis), second degree burns, partial thickness (second degree) burns, Burns second degree, Second degree burns, Second-Degree Burn, 2nd degree burn NOS, burns degree second, burn degree second, second degree burn, burn second degree, Blisters with epidermal loss due to burn [second degree], unspecified site, Blisters, epidermal loss [second degree], unspecified site, SECOND-DEGREE BURN, Second Degree Burn, Burn blister with epidermal loss, Second degree burn injury, Second degree burn, Second degree burn (disorder), Second degree burn injury (morphologic abnormality), Blisters with epidermal loss due to second degree burn, unspecified site, Blisters with epidermal loss due to burn, unspecified site
Italian Ustioni di secondo grado, Vescicole con perdita dell'epidermide da ustione (secondo grado), sede non specificata
Dutch brandblaar met epidermale beschadiging (tweede graad) van niet-gespecificeerde plaats, tweedegraadsbrandwonden, brandwonden tweede graad
French Brûlures du second degré, Phlyctènes avec perte épidermique liées à une brûlure (second degré), site non précisé, Brûlures du deuxième degré
German Blasen mit Hautverlust durch Verbrennung (zweiten Grades), unspezifische Stelle, Verbrennungen zweiten Grades
Portuguese Bolhas com perda de epiderme por queimadura (2º grau) de localização NE, Queimaduras do 2º grau
Spanish Ampollas con pérdida epidérmica por quemadura (de segundo grado), localización no especificada, quemadura con destrucción epidérmica, quemadura con pérdida epidérmica, quemadura de segundo grado (anomalía morfológica), quemadura de segundo grado (trastorno), quemadura de segundo grado, Quemaduras de segundo grado
Japanese 第2度熱傷, (第2度)熱傷による表皮欠損を伴う水疱形成、部位不明, ダイ2ドネッショウニヨルヒョウヒケッソンヲトモナウスイホウケイセイブイフメイ, ダイ2ドネッショウ
Czech Popálenina druhého stupně, puchýře se ztrátou epidermis, blíže neurčeného místa, Popáleniny druhého stupně
Hungarian Másodfokú égések, Nem meghatározott lokalizációjú terület (másodfokú) égés okozta felhólyagosodása epiderm. hiánnyal

Ontology: Third degree burn (C0433445)

Definition (NCI) An injury that includes all skin layers into the subcutaneous tissue due to chemical, friction, radiation or thermal exposure. The affected area appears dry and thickened; damage to nerve endings usually renders the wound painless.
Definition (NCI_FDA) A full thickness burn that extends into deeper tissues causing white or blackened and charred skin that may be numb.
Concepts Injury or Poisoning (T037)
SnomedCT 212135000, 269250002, 80247002, 403192003
English Full thickness burn NOS, third degree burns (diagnosis), third degree burns, full thickness (third degree) burns, Burns third degree, Third degree burns, Third-Degree Burn, third degree burn, burn degree third, full thickness burn, burns full thickness, burns degree third, Full thickness burn NOS (disorder), (Third degree burn) or (full thickness burn NOS) (disorder), (Third degree burn) or (full thickness burn NOS), Third Degree Burn, THIRD-DEGREE BURN, Burn with full-thickness skin loss, Third degree burn injury, FT - Full thickness burn, Full thickness burn, Third degree burn, Third degree burn (disorder), Third degree burn injury (morphologic abnormality)
Italian Ustioni di terzo grado
Dutch derdegraadsbranwonden, brandwonden derde graad
Japanese 第3度熱傷, ダイ3ドネッショウ
Czech Popáleniny třetího stupně
Hungarian Harmadfokú égés, Harmadfokú égések
Spanish quemadura de tercer grado, SAI (trastorno), quemadura de tercer grado, SAI, quemadura con pérdida del espesor total de la piel, quemadura de tercer grado (anomalía morfológica), quemadura de tercer grado (trastorno), quemadura de tercer grado, Quemaduras de tercer grado
Portuguese Queimaduras do 3º grau
French Brûlures du troisième degré
German Verbrennungen dritten Grades

Ontology: Burn of second degree, body region unspecified (C0496071)

Concepts Injury or Poisoning (T037)
ICD10 T30.2
English Burn of second degree, body region unspecified, Burn of partial thicknes, body region unspecified
German Verbrennung 2. Grades, Koerperregion nicht naeher bezeichnet
Korean 상세불명 신체 부위의 2도 화상
Dutch Brandwond van tweede graad, lichaamsregio niet gespecificeerd

Ontology: Burn of third degree, body region unspecified (C0496072)

Concepts Injury or Poisoning (T037)
ICD10 T30.3
English Burn of third degree, body region unspecified, Burn of full thickness, body region unspecified
German Verbrennung 3. Grades, Koerperregion nicht naeher bezeichnet
Korean 상세불명 신체 부위의 3도 화상
Dutch Brandwond van derde graad, lichaamsregio niet gespecificeerd

Ontology: Thermal burn (C0701836)

Definition (SCTSPA) Quemadura debida a calor excesivo
Definition (SNOMEDCT_US) Burn injury due to excessive heat
Definition (NCI) A burn injury caused by heat or fire.
Concepts Injury or Poisoning (T037)
SnomedCT 105594005, 314534006, 48333001
Italian Ustione da calore, Ustioni da calore
English Thermal Burn, Thermal burns, thermal burn, thermal burns, THERMAL BURN, BURN, THERMAL, BURNS, THERMAL, Thermal burn, Thermal burn (disorder), Thermal burn (morphologic abnormality), Thermal burn - disorder
Japanese 熱傷, ネッショウ
Czech Tepelné popáleniny, Tepelná popálenina
Hungarian Hő okozta égés, Hő okozta égések
Spanish quemadura por agentes térmicos (anomalía morfológica), quemadura por agentes térmicos, quemadura térmica (trastorno), quemadura térmica, Quemadura térmica, Quemaduras térmicas
Portuguese Queimadura térmica, Queimaduras térmicas
Dutch brandwonden, thermische verbranding
French Brûlure thermique, Brûlures thermiques
German Thermalverbrennung, Verbrennungen durch Hitze