Advanced burn care: Types, assessment, management

Burns are a common form of injury that ranges in severity from first to fourth degree. Depending on the severity, some burns, such as small blisters, can be managed at home. However, healthcare professionals treat significant burns that are painful, extensive, or cause medical complications. Advanced burn care requires an additional layer of expertise and management.

Definition of burn care

Burn care is the medical and surgical management of injuries caused by burns that damage the skin and underlying tissue. The overarching goal of advanced burn care is to minimize tissue damage, prevent infection, and promote recovery.

Proper advanced burn care involves an interdisciplinary approach covering wound care, pain management, rehabilitation and therapy, and emotional and psychological support. Finally, advanced burn care may include skin grafting or tissue reconstruction to restore physiologic function and decrease the long-term effects of scarring.

All burns require some attention, but only some burns require medical attention. But for those who need mild or minor burn care, we also have you covered if you are looking for the basics of burn care.

Importance of advanced burn care

Advanced burn care is a crucial component of healthcare for patients who have experienced severe burns. Regarding immediate burn care, the primary treatment is to stop the burning process, prevent additional tissue damage, reduce inflammation, and manage pain.

Healthcare professionals treat significant burns with the following criteria:

• Deep or extensive burns that are larger than three inches
• Burns on the face, hands, feet, or genitals
• Any chemical or electrical burns
• Burns associated with inhalation
• Redness, fever, swelling, or discharge
• Any third or fourth-degree burn
• Significant or worsening pain

It is best to seek medical advice if you are uncertain whether a burn requires medical attention. Advanced burn care can mean the difference between life and death.

Immediate burn care

Regarding immediate burn care, the primary treatment is to stop the burning process, prevent additional tissue damage, reduce inflammation, and manage pain.

• For major burns, call emergency services immediately.
• Ensure the safety of the burned person and yourself. Switch off any power source or mitigate any flames before approaching.
• If the burn victim is not breathing or lacks a pulse, begin CPR.
• Cover the burned area with a clean and dry bandage. Do not submerge extensive burns in water.
• Elevate the wound above heart level.
• Observe for shock or arrest while you wait for EMS to arrive.

Different types of burns

Numerous different types of burns can cause significant burn injuries. This article describes radiation burns, cold burns, chemical burns, electrical burns, and thermal burns.

Radiation burns

Radiation burns occur from prolonged exposure to radiation, like ultraviolet rays or ionizing radiation. Radiation dermatitis (or burns) is a side effect of radiation therapy to treat cancer. Sunburn, x-rays, or radiation therapy can cause radiation. There are naturally occurring radioactive materials in space and in the ground.

Cold burns

Severe cold can cause significant burns that damage the tissue, often known as an “ice burn.” Causes include exposure to freezing cold air, water, ice, or objects and can damage the skin and other tissues to a significant extent.

Chemical burns

Chemical burns occur due to corrosive substances, like battery acid, alkalines, detergents, or solvents. Burns can be caused by direct contact with the skin, breathing in the fumes, or ingesting chemicals.

Electrical burns

Electrical currents, such as direct or alternating currents, cause these types of burns. Burns caused by electricity are often deep and may not be visible on the skin’s surface. Causes include live wires, lightning, or electric appliances. Beyond causing typical burn symptoms and complications, they also can cause nerve injury, heart damage, and arrhythmia.

Thermal burn

Thermal burns are the most common type of burn and occur when heat transfer raises the temperature of the tissue and kills the cells. The people most at risk for thermal burns include children, the male gender, and alcohol consumption.

Burn by Hellcanwait under license of CC BY 2.0

The severity of a thermal burn is related to the object’s heat causing the burn and the duration of the contact. Types of thermal burns include:

• Scalding (boiling) liquids
• Hot metal
• Fire or steam

Assessment of burns

Burn assessment describes the extent of skin and tissue damage caused by a burn injury. The clinician must consider several crucial aspects when assessing a burn.

Knowing the size, depth, and location of a burn is essential for determining the severity of the injury and guiding treatment decisions. Some burns result in systemic injury causing a widespread inflammatory response. For example, larger or full-thickness burns are more likely to result in complications such as infection and shock that may require more intensive treatment and monitoring.

Burn size

The size of a burn is typically measured as a percentage of the total body surface area (TBSA) that has been burned. The TBSA is calculated based on age, sex, and total body weight.

Rule of nines

513 degree of burns by OpenStax College under license of CC by 3.0

The rule of nines varies if the patient is an adult or pediatric burn care patient. The rule of nines divides the body into different regions, each accounting for a specific percentage of the TBSA. For example, while the head and neck account for 9% of the TBSA, the trunk accounts for 36%. The clinician determines the total percentage of burned TBSA by assessing each region affected by the burn.

The Lund-Browder Chart

The proportion of body surface area between children and adults is significant. Also, there is a considerable difference in head-to-body size ratios. The Lund-Browder chart provides a more accurate estimate of the TBSA burned for infants, children, and those with obesity or cachexia.

The chart is helpful to calculate the size of the burn. According to Lund-Browder, the hand represents 2% of the TBSA. It takes into account the proportions of children as they grow. It is more detailed than the rule of nines because it considers the person’s age and compares it to the typical size of body parts. While the above scales attribute a more significant percentage to specific areas of the body, particular burn locations impact care.

Burn location

The burn location significantly impacts management options and the likelihood of improvement. Burns in certain body areas are more challenging to manage and have a poorer prognosis. The places where a burn may affect treatment and outcomes include:

• Face and neck: These burns can impact breathing, swallowing, and vision. Management options include airway protection, nutritional support, and specialized wound burn care.
• Hands: These burns can be disabling and require occupational therapy as it interferes with the ability to perform everyday tasks.
• Groin: These burns can also affect urinary and reproductive function.
• Feet: Burns to the feet can impact mobility and weight bearing. Physical therapy will often be necessary, depending on the extent of damage to the nerves and vessels.

Zones of a burn

The three zones of a burn are coagulation, stasis, and hyperaemia.

• Hyperaemia causes extra blood flow in the local vessels, improving the likelihood of recovery due to increased tissue perfusion.
• Stasis means the zone experiences decreased tissue perfusion but may be salvageable with reperfusion.
• Coagulation is irreversible tissue damage and loss and the zone or point of maximum damage.

Burn depth

The medical field defines burns by the extent to which they impact local tissue. Clinicians classify burn injuries based on severity and depth. Severe burns may cause lymphoedema due to destroying the protective epidermal layer or the lymphatic vessels.

Structure of mammalian skin by Sean P Doherty is licensed under CC BY-SA 4.0

First (1st) degree burns

First-degree burns affect the epidermis or outermost layer of the skin and have mild pain and redness symptoms. They are superficial and the mildest type of burn. First-degree burn symptoms include redness, pain, and swelling. These burns can often be taken care of at home and heal within a few days.

Second (2nd) degree burns

Second-degree burns involve the epidermis, the first layer of skin, and the dermis, the second. These burns cause blisters and more intense pain than first-degree burns. These burns may require medical attention and can take weeks to heal.

Major 2nd Degree Burn by Wikimedia Commons

• Superficial partial thickness burns are second-degree burns, formerly known as 2 A burns. These wounds are painful, weep, and require wound care. Superficial partial thickness burns may scar but do not require surgical management.
• Deep partial-thickness wounds are second-degree burns, formerly known as 2B burns, which are more severe than superficial wounds, but do not weep. However, due to their depth, they affect nerve endings, including pain receptors called nociceptors. The intensity of the pain varies depending on the severity or extent of the burn. These types of burns will scar and require surgery.

Third (3rd) degree burns

While first and second-degree burns are milder and often resolve with less intervention, third-degree burns can significantly impact long-lasting health. Third-degree burns penetrate through all layers of skin and injure tissue, nerve, and even burn.

8 Day Old 3rd Degree Burn by Wikimedia Commons

A third-degree burn, also called a full-thickness burn, extends through the entirety of the dermis. It is not painful because the nerve endings are significantly damaged. Third-degree burns are at significant risk of becoming infected and requiring surgery.

Fourth-degree burns

Fourth-degree burns are the most severe type of burn, injuring deeper tissues. These burns involve damage to all layers of the skin, including tissue, muscles, and bone. In some cases, the bone or muscle is blackened and necrotic. Immediate medical attention for severe burn injuries may mitigate long-term skin damage.

The upper skull is also known as the calvaria. If a fourth-degree burn is severe enough to affect the calvaria, it can cause significant damage and defects to the bone and underlying brain tissue. This is particularly dangerous because harming the brain tissue can cause loss of function or life.

Fourth-degree calvarial burn damage may require surgery to reconstruct the skull using bone grafts or synthetic materials. The multidisciplinary team caring for calvarial burns includes burn specialists, neurosurgeons, and plastic surgeons. The recovery period is lengthy and may require ongoing rehabilitation.

Other complications of calvarial burns include:

• Infections
• Scarring
• Neurologic issues
• Psychological effects
• Chronic pain
• Increased intracranial pressure

Signs that a burn is infected

Burns damage the barrier of the skin, which protects the body. Unfortunately, the risk of infection skyrockets when there is an opening in the skin.

The signs and symptoms of infection include:

• Malodorous drainage (pus)
• A fever greater than 100.4
• Increasing pain
• Spreading or streaky redness

Infected burn care is more challenging because it requires additional wound care measures like wound cleaning and specific dressings. An infected wound requires antibiotics to treat the infection and stop it from spreading. It is important to seek medical attention if there are any signs or symptoms of infection.

Management of a burn patient

Always remember that the priority intervention is maintaining an airway, often through intubation. Other priorities involve attempting to limit tissue damage.

When managing burn patients, the interventions depend on the burn wound healing stages of care. There are four significant phases of burn care:

• Resuscitative phase: This emergent stage occurs directly after the burn injury and focuses on stabilization. The most crucial treatment for burn patients is pain management, fluid balance, and airway protection.
• Wound care phase: This stage begins after the patient is stabilized and involves managing the burn wound. The primary goals are to prevent infection, manage pain, and promote healing. Treatment involves wound cleaning, debridement, possible excision or grafting, and dressing changes.
• Rehabilitative phase: Once the wound has healed, the focus shifts to restoring function and mobility to the burned area. Treatment involves physical therapy, occupational therapy, and counseling.
• Reconstructive phase: This long-term burn care phase involves surgical management to improve the appearance and function of the burned area.

Medical management

Emergency burn care requires clinicians to be prepared and flexible. Advanced burn care can be broken into medical and surgical management.

Intravenous (IV) fluid resuscitation

Since severe burns cause significant injury resulting in a systemic response, intravascular fluid loss and fluid shifts occur. These shifts can cause hypovolemia and hypoperfusion that peaks six to eight hours after the burn. The fluid shift requires ongoing resuscitation in patients with major burn injuries and lasts about 24 hours. While intravenous fluids are preferred, research suggests oral rehydration solutions can be used for burns up to 40% TBSA. Closely monitoring vital signs to avoid fluid overload is key.

Advanced wound dressings

Wound dressings are a typical intervention for many patients across the medical field. However, advanced burn care dressings often require antimicrobial solutions to prevent infection and promote healing. The most commonly used burn wound dressing is silver sulfadiazine cream (SSD 1%), covered with fine mesh gauze.

Pain management

Effective pain management for burns is vital because burns are often excruciating. To improve the patient’s comfort, pain relief options should include drugs, nerve blocks, and alternative therapies.

Rehabilitation

While medical and surgical burn management is crucial, planning for rehabilitation after a prominent burn is vital. Rehab planning should begin at admission and continue through discharge. Multidisciplinary teams facilitate care throughout the burn continuum.

Physical therapy

Physical therapy (PT) is beneficial for those recovering from burn injuries. It improves mobility, strength, and overall function through PT exercises, range of motion (ROM), and therapy techniques.

PT often addresses contractures when the muscles, tendons, or other tissue shortens and hardens. The most common functionally limiting burn injuries are hand contractures. Contractures often lead to joint rigidity.

Occupational therapy

Patients who sustain burns to extremities or other areas that affect their ability to perform activities of daily living may require occupational therapy (OT). To regain function and independence in their daily lives, OT helps to improve these abilities.

Psychological support

Burn injuries may be traumatic and often impact affected patients’ long-term well-being and mental health. Psychological support is a key factor in advanced burn care.

Many options may improve the long-term psychological and emotional outcomes to assist patients in adjusting to this major life change, such as:

• Counseling
• Support groups
• Eye movement desensitization and reprocessing (EMDR)
• Psychotherapy

Hyperbaric oxygen therapy

Hyperbaric oxygen (HBO) therapy delivers pure oxygen through a pressurized tube or room. Proponents argue HBO therapy reduces long-term neurological complications associated with carbon monoxide poisoning⁷. Unfortunately, randomized trials demonstrated conflicting data regarding the impact on long-term cognitive function.

Hydrotherapy

Hydro- means water and therapy attempt to remediate a health problem. Hydrotherapy perfectly describes this effective and safe way to clean wounds and burned skin. Pressurized water jets can reduce pain, redness, scarring, and skin discoloration in hydrotherapy⁸.

Regenerative medicine

Regenerative medicine has the potential to transform advanced burn care by using stem cells and tissue engineering to stimulate tissue healing and regeneration. The approach reduces scarring, promotes wound healing, restores sensation in burned skin, and offers pain management options.

Surgical management

Some burns, like those with contractures or third and fourth-degree burns, may require more advanced surgical management.

Debridement

Debridement is the removal of dead tissue from a wound to promote healing. The surgical approach leaves no full-thickness burned tissue behind and debrides to viable tissue. In the case of burns, debridement provides the ability to prevent infection. Debridement may mean skin grafts or excision, based on the extent and severity of the burn⁷.

Early excision

The gold-standard treatment is early excision, decreasing pain and the risk of infection or sepsis. The optimal timing of early excision is whether a patient undergoes surgery during the first day after the burn or two to three days later following the completion of a 24-hour resuscitation. The main principle of excision and grafting is to close and stabilize the wound.

Skin grafting

Skin grafting is when the principle of excision and grafting is used to close the wound. Autografting is where the skin is transplanted from a healthy donor site to close the excised wounds rapidly. Autografting is used when the wound bed is fresh and uncontaminated.

Burned hand with cadaver skin bandage by Chris Bede under license of CC BY 2.0

Allografting is used if there are concerns about the bacterial load in the wound bed or the patient’s stability. Allografting is using skin from another person, often a cadaver, to cover the debrided wound.

Tissue expansion

Tissue expansion is ideal for secondary burn reconstruction. During tissue expansion, the procedure promotes the growth of healthy supplementary skin used to replace damaged skin. This is typically performed prior to reconstructive burn surgery.

Laser treatment

The laser treatment of a burn is a minimally invasive, low-risk approach. The laser decreases scar thickness, neuropathic pain, scar color, pliability, texture, height, and itching. There are different types of lasers used to perform the procedure.

Prevention of burns

Preventing burns requires strategies to keep everyone in the household safe. Whether you are educating patients or reading for your family, there are many steps to take.

Kitchen safety

• Protect children and yourself from hot liquids, steam, open flames, and hot surfaces.
• Keep small children away from the kitchen while the stove is on.
• Put pots on a back burner and turn the pot or utensil handle away from the edge.
• Use protective clothing like oven mitts and pot holders to remove hot objects.
• Install safety devices like protective knob covers, oven locks, and stove guards.

Electrical safety

Burned Receptacle by Karl Palutke under license of CC BY 2.0

• Use electrical appliances safely, like avoiding water while using them.
• Avoid overloading electrical outlets; never put anything else into an electrical plug.
• Check extension cords and power strips for fraying or a breach in the wiring.
• Install smoke detectors In the home.
• Do not stick forks into toasters that are turned on.
• Keep flammable materials away from heat sources.

Sun safety

• Use sunscreen with a sun protective factor (SPF) of 30 and reapply after swimming or every two hours.
• Wear sun-protective clothing like a wide-brimmed hat and long pants or shirts.
• Avoid being outside during the hours of 10 AM and 4 PM.
• Wear a swim shirt or suit with an ultraviolet protection factor (UPF) of 50.

Workplace safety

• Wear personal protective equipment (PPE), including protective clothing, gloves, eyewear, and other equipment to protect employees from hazards that can cause burns.
• Handle and store flammable materials properly.
• Use caution when working with heat sources and ensure that equipment is maintained.
• Have fire extinguishers readily available and conduct regular fire drills with a fire response plan.

Frequently asked questions (FAQs) about burn care

What is the immediate first aid for burn care?

The initial step in burn care first aid is to protect the patient’s airway and do what they can to decrease tissue damage. Clinicians take specific precautions because of the risk of disease. Initially, healthcare workers use appropriate hygiene while treating broken areas on the patient’s skin. Healthcare professionals also administer the tetanus vaccine if the patient is not current.

What types of burns cause a blistering burn?

Exposure to heat and chemicals causes blistering burns. Hot liquids, steam, and chemicals can cause the skin to blister and bubble. Nearly any type of cause for burns can blister.

What is the best treatment for severe burns?

The best treatment for severe burns depends on the severity and extent of the burnt tissue. Severe burn care involves:

• Airway protection
• Wound cleaning
• Debridement
• Skin grafts
• Pain management
• Fluid resuscitation
• Infection prevention
• Nutrition support

What are the levels of burn severity?

The levels of burn severity are first-degree, second-degree, third-degree, and fourth-degree burns.

What are the four phases of definitive burn care?

The four phases of definitive burn care include

• Resuscitative phase
• Acute phase
• Rehabilitation phase
• Reconstructive phase

How do you treat a 3rd degree burn?

Treat a third-degree burn with immediate professional medical attention. During professional burn treatment, clinicians will:

• Clean the wound
• Perform early excision or debridement
• Skin grafts
• Pain management
• Multidisciplinary support (e.g., nutritionists, plastic surgeons, physical therapists)

Summary of key points

Burns can occur in many ways with varying degrees of severity. To provide advanced burn care, you must understand the different types of burns and how to manage them. Proper burn care includes providing physical, emotional, surgical, and medical support for people afflicted with burns. However, responding with the appropriate, timely medical care is critical.

Additional resources for further reading

• The American Burn Association guidelines PDF provides advanced burn management care for those seeking more detailed burn management guidelines.
• Complicated burns require advanced burn care. Locate a medical burn center with a burn center team with specialized training in burn injuries.
• The advanced burn life support provider course is an eight-hour course for healthcare providers designed to provide educational care for the burn patient in the first 24 hours.

Works Cited

1. Schaefer TJ, Nunez Lopez O. Burn Resuscitation And Management. StatPearls. 2023. https://www.ncbi.nlm.nih.gov/books/NBK430795/

2. American Burn Association. Advanced burn life support course: Provider manual 2018 update. American Burn Association; 2022.

3. U.S. Fire Administration. Keeping kids safe from fire. https://www.usfa.fema.gov/prevention/home-fires/at-risk-audiences/children/

4. Hoss E. Burns. MedlinePlus. Updated May 31, 2022. Accessed March 24, 2023. https://medlineplus.gov/ency/article/000030.htm

5. Cleveland Clinic. Burns: Type, symptoms, & treatments. Updated August 24, 2022. Accessed March 24, 2023. https://my.clevelandclinic.org/health/diseases/12063-burns

6. John Hopkins Medicine. Burns and wounds. Accessed March 24, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/burns

7. Jeschke MG, van Baar ME, Choudhry MA, Chung KK, Gibran NS, Logsetty S. Burn injury. Nat Rev Dis Primers. 2020;6(1):11. Published 2020 Feb 13. doi:10.1038/s41572-020-0145-5

8. University of Rochester. Kessler burn & trauma center. Accessed March 24, 2023. https://www.urmc.rochester.edu/burn-trauma/burn-center/hydrotherapy.aspx

9. Klifto KM, Asif M, Hultman CS. Laser management of hypertrophic burn scars: a comprehensive review. Burns trauma. 2020;8:tkz002. Published 2020 Jan 16. doi:10.1093/burnst/tkz002