What is Burns ?
Burns are a serious public health problem. A burn is defined as an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.
Heat burns occur when some or all of the different layers of cells in the skin are destroyed by a hot liquid (scald), a hot solid (contact burn) or a flame (flame burn). Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered as burns.
According to WHO estimates about 265 000 deaths occur each year from fires alone globally, with more deaths from scalds, electrical burns, and other forms of burns for which data are not available. The majority of these deaths occur in low- and middle-income countries, with almost half occur in the WHO South-East Asia Region.
In India around 7 million people suffer from burn injuries each year with 1.4 lakh deaths and 2.4 lakh people suffer with disability. Burn death rates have been decreasing in high income countries.
Females and males show similar rates for burns in contrast to other injury patterns where rates of injury are higher in males than females. The higher risk for females is associated with open fire cooking, or unsafe cook stoves, loose clothing. Self-directed or interpersonal violence is also a factor for burn injuries.
Along with adult females, children are also vulnerable to burns. Out of 5 burn victims 4 are women and children. Burns are the fifth most common cause of non-fatal childhood injuries and 11th leading cause of death of children aged 1-9 years. Among all people globally, infants have the highest death rates from burns.
Burns are also a leading cause of morbidity; millions who survive suffer from lifelong disability and disfigurements with resulting emotional trauma and stigma.
Burns are preventable. Increased efforts in prevention and care would lead to significant reduction in burn-related morbidity, mortality and disability.
The National Programme for Prevention, Management and Rehabilitation of Burn Injuries (NPPMRBI) is an initiative by the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India to strengthen the preventive, curative and rehabilitative services for burn victims.
Burns Symptoms
Symptoms of burn depend on the depth of the burn. Burns can be divided into three types.
First degree or superficial burns involves the upper skin layer. They produce redness (erythema) and pain (tenderness). Blisters are absent. They are typically caused by exposure of the unprotected skin to solar radiation (sun burn) or to brief contact with hot substances, liquids or flash flames (scalds). First-degree burns heal within a week with no permanent changes in skin colour, texture, or thickness.
Second degree or partial thickness burns affect deeper skin layers. Symptoms are more severe and usually include blisters.
- Superficial second-degree burns take less than three weeks to heal.
- Deep second-degree burns take more than three weeks to close and are likely to form hypertrophic scars.
Third degree or full thickness burns involve all skin layers. Skin is white (appears cooked), and there may be no pain in the initial stages. Due to extensive destruction of the skin layers third-degree burn wounds cannot regenerate themselves without grafting.
Signs of inhalational burns-
- History of burns in closed space
- Deep burns to face, neck, or trunk
- Singed nasal hair
- Carbonaceous sputum ,carbon particles in oropharynx
- Change in voice with hoarseness or harsh cough
Burns Causes
Common causes of burns may be classified as thermal or inhalational.
Heat burns occur by:
- Hot liquids (scalds) - Scalds are commonly caused by hot liquids (water, oil), steam from boiling water or heated food. Young children are mostly affected by scalds.
- Hot solids (Contact burns): Solid objects that are hot can cause contact burns, especially in children. Sources of burns from solid objects include ashes and coal, hot pressing irons, soldering equipment, cooking utensils (frying pans and pots), oven containers, light bulbs, and exhaust pipes.
- Flames: Burns can be due to leaking gas pipe or cylinder, accidents from kerosene pressure stove, lighting of crackers during “Diwali”, catching of fires in tents as pandal fires.
- Chemical burns-These are accidental burns in homes (such as from toilet cleaning agents), or as acid violence attacks (throwing of acid over somebody for seeking revenge and attempts to resolve disputes of love, land or business) and work place accidents.
- Electrical burns- Electrical burns are due to exposed “live” wires or short circuits. High tension wires close to homes, play areas and roads can lead to electrical burns.
Inhalational burns:
- Inhalational burns are the result of breathing in superheated gases, steam, hot liquids or noxious products of incomplete combustion.
- They cause thermal injury to the upper airway, irritation or chemical injury to the airways from soot, asphyxiation, and toxicity from carbon monoxide (CO) and other gases such as cyanide and accompany a skin burn in approximately 20% to 35% of cases.
- Inhalational burns are the most common cause of death among people suffering fire-related burn.
Risk factors:
Burns are more common in rural areas and urban poor of low income countries; some of the factors that are of prime concern include:
- use of cooking pots on ground level (floor cooking): toddlers and young children are at increased risk of scald burns as they can easily knock over the pots on the ground level;
- use of open wood fires;
- wearing of loose fitting cotton clothing (loose chunnis and pallus) can catch fire while cooking on an open fire (a risk factor for women in Asia); or due to faulty habits like use of clothing to hold cooking pot.
Other risk factors are:
- Exposure to fire during occupation;
- poverty, overcrowding(single room houses with kitchen adjacent to bed/play area for children)
- young girls performing household work as cooking and care of small children;
- smoking and alcohol abuse;
- inadequate safety measures for liquefied petroleum gas (LPG) and electricity;
- underlying medical conditions such as epilepsy, physical and cognitive disabilities.
Burns can occur in home and workplace. Children and women are usually burned in homes in their kitchens from hot liquids, flames, or from cook stove explosions. Men are mostly burned in the workplace due to fire, scalds, chemical and electrical burns.
Burns Diagnosis
A detailed history and physical examination are the initial steps in diagnosis.
a. History regarding cause of burns and age should be inquired as it helps in diagnosing extent and depth of burns, such as:
- Flame burns are usually full thickness burns, scald burns from hot water spilling may be superficial burns while scalds from ghee, oil are likely to be deep. Chemical and electrical burns are deep.
- Age of patients-At extremes of age (infants and older patents) burns are deep because of thinness of skin.
b. Examination: The severity of the burn is determined by burned surface area, depth of burn and other considerations. Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.
Whole body surface area is taken as 100%. Proportion of surface burn is represented as percentage(%). There are many ways to estimate the body surface area burned.
- The “Rule of 9’s” is commonly used to estimate the total body surface area (TBSA) burned in adults. In this, body is divided into 11 equal parts making this 99% and 1% is given to perineum. Therefore 9% each for the head and each upper limb; 18% each for each lower limb, front of trunk and back of trunk*.
- In newborns and children (younger than 10 years), because of the larger size of head and small body surface area of limbs, the Rule of Nine is not applicable. Lund and Browder chart can be used for the calculation of total body surface area of burns in children*.
- The “Rule of Palm” is one closed hand of an individual is equal to his 1% body surface area. (A hand consists of all the fingers and thumb brought together in extended position with palm).
Initially most of the burn patients are well oriented and may look like as if suffering from a simple injury but any burn above 5% should be taken seriously.
Burns can be classified as minor, moderate and critical burns according to severity:
Minor burns-
- Burns less than 15% in adults and 10% in children (excluding chemical, electrical burns and burns of face, hands and perineum).
- These burns can be treated on out-patient basis.
Moderate burns-
- Burns between 15-25% in adults and 10-15% in children.
- May require hospitalization.
Critical burns-
- Burns above 25% in adults, 15% in children and 5% in newborn and infants.
- Electrical burns
- Chemical burns
- Respiratory burns
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Burns associated with other injuries
- Orthopaedic injury
- Chest injury
- Abdominal injury
- Head injury
Burns Prevention
Specific recommendations/precautions to prevent burn injuries by individuals, communities -Primary prevention:
- Enclose fires and limit the height of open flames in domestic environments. Cooking on floor should be avoided.
- Restrain playing of toddlers in kitchen/cooking area.
- Watch the child constantly especially around gas burners, stoves, ovens, microwaves, heaters and other appliances.
- Turn pot handles toward the back or center of the stove to prevent tipping.
- Never cook while holding a child.
- Carefully use electrical appliances and switch off all electrical appliances when not in use.
- Avoid use of unauthorized gas cylinders & kerosene stove/chulha. Use safe stoves and lamps.
- Avoid loose clothing while cooking. Tie up loose saree end (pallu) or stole (chunni) properly.
- Never hold a cup of hot liquid near infant/toddlers.
- Check the temperature of water before bath.
- Beware of high tension wires passing over terrace or balcony and do not keep open electrical wires at home.
- In India, fireworks injuries commonly occur during Diwali (Festival of Lights).
Diwali safety:
- Supervise children while lighting fire crackers.
- Do not hold the cracker while bursting.
- Don’t point the burning fireworks towards you/others.
- Don’t fiddle with un-burnt crackers.
- Always light or burst crackers in open area /ground.
- Acid-throwing: Intensified legal reforms to the crime, restricted availability of acid and chemicals for general public and changing attitude of society so that person attacking in this way is no longer acceptable may be the effective steps in prevention. Handle chemicals (acids) carefully.
- Promote fire safety education and the use of smoke detectors/smoke alarms, fire sprinklers, and fire-escape systems in homes/buildings. Smoke alarms provide an early warning system; alerting people and allowing them time to escape before the fire spreads.
- Improve treatment of medical conditions such as epilepsy.
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During thunderstorms:
- Get inside a home, building (away from doors and windows, metal objects such as pipes, sinks, radiators, and plugged-in electrical appliances),
- When outside and unable to find shelter, maintain distance from tall trees.
- Lightning can travel through water, therefore avoid swimming, boating and bathing during a thunderstorm
Secondary Prevention: Both pre-hospital and hospital care play an important role in the management of burn patients by preventing deaths and disability.
- First aid: Education and sensitization of individuals/communities on the site management in the form of first aid can further help in early recovery of the burn patients.
- Better hospital care: These include better initial treatment to prevent shock and breathing problems, better infection control, increased use of skin grafts and assuring adequate nutrition. These measures can minimize the burden of death, disability and suffering from burns.
Tertiary prevention:
- Rehabilitation- Burn survivors are often left with disability and disfigurement that interferes with their future life. Rehabilitation measures such as physical therapy and addressing psychological issues can assure a better life in burn survivors.
National Programme for Prevention, Management and Rehabilitation of Burn Injuries (NPPMRBI)*:
Death and disability due to burn injury are preventable to a great extent provided timely and appropriate treatment is given by trained personnel. To strengthen the preventive, curative and rehabilitative services for burn victims, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India has initiated “National Programme for Prevention, Management and Rehabilitation of Burn Injuries (NPPMRBI)” during the 12th Five Year Plan.
- The programme is being implemented through state government Medical Colleges and District Hospitals with the objective to reduce the incidence, morbidity, mortality, and disability due to burn injuries.
- Awareness generation, providing adequate health facilities with proper infrastructure and trained manpower for management and rehabilitation of burn patients and research are the priority fields for the programme.