CHAPTER TWO

LITERATURE REVIEW
Burn is a catastrophe covering both the physical aspect of human body and the
emotions of an individual and associated community. Burn is an injury to the skin
or other organic tissue primarily caused by thermal or other acute trauma. Second-
degree burns are a form of burn that primarily result from heat, radioactivity,
electricity, friction, or contact with chemicals and harm both the epidermis and
dermis (W.H.O, 2018).
Burns can occur when the skin is exposed to heat sources, such as flames, flash
burns, hot objects, grease, scald, chemicals, and electricity (Tolles, 2018; Toussaint
& Singer, 2014). Burn injuries are highly variable, as is their severity. The patient's
comorbidities can influence the burn's clinical outcome. Additionally, morbidity and
mortality tend to increase as the surface area of the burn increases (Vivó, Galeiras
& del Caz, 2016). Therefore, it is vital to classify a burn accurately to determine the
outcome and guide management (Toussaint & Singer, 2014). The location,
temperature, and duration of exposure all factor into a burn injury's severity, and
there is a synergistic effect between the temperature and duration of exposure (Evers,
Bhavsar & Mailänder, 2015). Considering these critical factors is necessary to
determine the appropriate approach for treating a burn.
Burn injuries are frequently observed in emergency departments worldwide (Vivó
[Link], 2016). Medical professionals must understand how to treat burns, even if their
emergency department is not associated with a certified burn center. Despite recent
improvements to emergency management protocols, burns still pose significant risks
to morbidity and mortality. Intravenous fluid resuscitation may be necessary
depending on the severity and body surface affected. However, not all burns require
surgery and can be treated with local wound care. Accurately classifying burns is
crucial for optimal treatment and an accurate prognosis (Hautier, 2018; Nicolas &
Maréchal, 2018)
A second-degree burn, also known as a superficial partial-thickness burn, affects the
superficial layer of the dermis. A second-degree burn is a mild to moderate burn, and
it is the most common type. A burn is tissue damage caused by a heat, chemical or
light source. A second-degree burn damages the outer layer of your skin epidermis
and the second layer of your skin dermis. It is less severe than a third-degree burn.
You can treat most second-degree burns at home. Blisters are common and may still
be intact when first evaluated. Once the blister is unroofed, the underlying wound

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bed is homogeneously red or pink and will blanch with pressure. These burns are
painful. Healing typically occurs within 2 to 3 weeks with minimal scarring. A deep
partial-thickness burn involves the deeper reticular dermis. Similar to superficial
partial-thickness burns, these burns can also present with blisters intact. Once the
blisters are debrided, the underlying wound bed is mottled and will sluggishly blanch
with pressure. The patient with a partial thickness burn experiences minimal pain,
which may only be present with deep pressure. These burns can heal without surgery,
but it takes longer, and scarring is unavoidable (Tolles, 2018, Evers [Link], 2015).
Burns of the second degree can seriously harm a person's physical and mental health.
Following discharge, patients with second-degree burns experienced a wide range
of physical and psychological issues, including skin-related issues, pain, itching,
anguish, low self-esteem, anxiety, despair, and post-traumatic stress disorder
(PTSD). The altered physical condition due to Second-degree burn is a barrier in
way of interacting with other members of the society and causes feeling of
inferiority. This situation often leads to psychological problems and loss of social
network, such clients need social support (Liliane, Amara & Leila, 2016).
Second-degree burn Clients who experienced these issues required a variety of
physical, psychological, and social health care services as well as the ability to adapt
to a new situation, which included making modifications to one's lifestyle, returning
to the community, and practicing self-care at home. (Jagnoor, Lukaszyk, Fraser,
Chamania, Harvey, Potokar & Ivers, 2018). The first two years following an accident
are the most challenging for burn clients. Despite being released from the hospital,
clients still require long-term rehabilitation therapy and outpatient follow-up.
Making a follow-up plan, engaging in range-of-motion and strength training to
enhance physical function, learning how to perform ADLs, managing scars,
undergoing periodic assessments of functional status to modify treatment plans as
necessary, and, if necessary, contemplating reconstructive surgery are among the
health needs in this phase. (Serghiou, Ott, Cowan, Kemp- Offenberg, 2018).
Following discharge, community health nurses provide nursing care in an outpatient
burn clinic setting. Follow-up during this phase is crucial since transitions from the
hospital to the home can be challenging and complicated. Several years after the
burn, there may still be a need for support and direction. After the burn wound has
physically healed, nursing care must continue. The client with a second-degree burn
must also experience complete recovery in their psychosocial and spiritual domains.
The key to rehabilitation is assisting the client with a second-degree burn in coming
to terms with the "new me." The burn victim can be taught to accept themselves and

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create a course for their lives through family support, professional counselling,
and/or peer support, which can also aid in the process of reintegration. (Moss, 2014).
CAUSES OF BURN
Burns are caused by a variety of external sources classified as thermal (heat-related),
chemical, electrical, and radiation (Rosdahl, Kowalski, 2012). In the United States,
the most common causes of burns are: fire or flame (44%), scalds (33%), hot objects
(9%), electricity (4%), and chemicals (3%). Most (69%) burn injuries occur at home
or at work (9%),( American Burn Association, 2012) and most are accidental, with
2% due to assault by another, and 1–2% resulting from a suicide attempt (Peck,
(2011). These sources can cause inhalation injury to the airway and/or lungs,
occurring in about 6%. Burn injuries occur more commonly among the poor (Peck,
2011) Smoking and alcoholism are other risk factors. Fire-related burns are generally
more common in colder climates Specific risk factors in the developing world
include cooking with open fires or on the floor (Peck, 2011) as well as developmental
disabilities in children and chronic diseases in adults.
THERMAL BURN
A thermal burn is a type of burn resulting from making contact with heated objects,
such as boiling water, steam, hot cooking oil, fire, and hot objects. Scalds are the
most common type of thermal burn suffered by children, but for adult’s thermal
burns are most commonly caused by fire (Phillip & Dennis, 2013). Burns are
generally classified from first degree up to fourth degree, but the American Burn
Association (ABA) has categorized thermal burns as minor, moderate, and major,
based almost solely on the depth and size of the burn (Phillip & Dennis, 2013).
In the United States, fire and hot liquids are the most common causes of burns
(Herndon, 2012) Of house fires that result in death, smoking causes 25% and heating
devices cause 22% (Herndon, 2012). Almost half of injuries are due to efforts to
fight a fire (Herndon, 2012). Scalding is caused by hot liquids or gases and most
commonly occurs from exposure to hot drinks, high temperature tap water in baths
or showers, hot cooking oil, or steam (Eisen & Murphy, 2014). Scald injuries are
most common in children under the age of five and, in the United States and
Australia, this population makes up about two-thirds of all burns. Contact with hot
objects is the cause of about 20–30% of burns in children. Generally, scalds are first-
or second-degree burns, but third-degree burns may also result, especially with
prolonged contact (Herndon, 2012).

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CHEMICAL BURN
A chemical burn occurs when living tissue is exposed to a corrosive substance (such
as a strong acid, base or oxidizer) or a cytotoxic agent (such as mustard gas, lewisite
or arsine). Chemical burns follow standard burn classification and may cause
extensive tissue damage. The main types of irritants and/or corrosive products are:
acids, bases, oxidizers/reducing agents, solvents, and alkylants. Additionally,
chemical burns can be caused by biological toxins (such as anthrax toxin) and by
some types of cytotoxic chemical weapons, e.g., vesicants such as mustard gas and
Lewisite, or urticants such as phosgene oxime.
Chemical burns can be caused by over 25,000 substances (Tintinalli & Judith, 2015).
Most of which are either a strong base (55%) or a strong acid (26%) (Hardwicke,
Hunter, Staruch & Moiemen, 2012). Most chemical burn deaths are secondary to
ingestion (Tintinalli & Judith, 2015). Common agents include sulfuric acid as found
in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated
hydrocarbons as found in paint remover, among others (Tintinalli & Judith, 2015).
Hydrofluoric acid can cause particularly deep burns that may not become
symptomatic until sometime after exposure. Formic acid may cause the breakdown
of significant numbers of red blood cells.
ELECTRICAL BURN
An electrical burn is a burn that results from electricity passing through the body
causing rapid injury. Approximately 1000 deaths per year due to electrical injuries
are reported in the United States, with a mortality rate of 3-5% (Nasoori, 2017).
Electrical burns differ from thermal or chemical burns in that they cause much more
subdermal damage. They can exclusively cause surface damage, but more often
tissues deeper underneath the skin have been severely damaged. As a result,
electrical burns are difficult to accurately diagnose, and many people underestimate
the severity of their burn. In extreme cases, electricity can cause shock to the brain,
strain to the heart, and injury to other organs([Link], 2011).
For a burn to be classified as electrical, electricity must be the direct cause. For
example, burning a finger on a hot electric steam iron would be thermal, not
electrical. According to Joule's first law: electricity passing through resistance
creates heat, so there is no current entering the body in this type of burn. Likewise,
a fire that is ruled to be "electrical" in origin, does not necessarily mean that any
injuries or deaths are due to electrical burns. Unless someone was injured at the exact
moment that the fire began, it is unlikely that any electrical burns would occur.

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Electrical burns or injuries are classified as high voltage (greater than or equal to
1000 volts), low voltage (less than 1000 volts), or as flash burns secondary to an
electric arc (Tintinalli & Judith, 2015). The most common causes of electrical burns
in children are electrical cords (60%) followed by electrical outlets (14%) (Nasoori,
2017). Lightning may also result in electrical burns. Risk factors for being struck
include involvement in outdoor activities such as mountain climbing, golf and field
sports, and working outside. Mortality from a lightning strike is about 10% (Marx,
2016). While electrical injuries primarily result in burns, they may also cause
fractures or dislocations secondary to blunt force trauma or muscle contractions
(Marx, 2016). In high voltage injuries, most damage may occur internally and thus
the extent of the injury cannot be judged by examination of the skin alone. Contact
with either low voltage or high voltage may produce cardiac arrhythmias or cardiac
arrest.
RADIATION
A radiation burn is a damage to the skin or other biological tissue and organs as an
effect of radiation. The radiation types of greatest concern are thermal radiation,
radio frequency energy, ultraviolet light and ionizing radiation. The most common
type of radiation burn is a sunburn caused by UV radiation. High exposure to X-rays
during diagnostic medical imaging or radiotherapy can also result in radiation burns.
As the ionizing radiation interacts with cells within the body damaging them, the
body responds to this damage, typically resulting in erythema, that is, redness around
the damaged area.
Radiation burns may be caused by protracted exposure to ultraviolet light (such as
from the sun, tanning booths or arc welding) or from ionizing radiation (such as from
radiation therapy, X-rays or radioactive fallout) (Prahlow, 2013). Sun exposure is
the most common cause of radiation burns and the most common cause of superficial
burns overall. There is significant variation in how easily people sunburn based on
their skin type. Skin effects from ionizing radiation depend on the amount of
exposure to the area. Redness, if it occurs, may not appear until sometime after
exposure (Marx, 2016). Radiation burns are treated the same as other burns.
Microwave burns occur via thermal heating caused by the microwaves. While
exposures as short as two seconds may cause injury, overall, this is an uncommon
occurrence (Marx, 2016).
Because most burns are small and classified as minor burns, the history and physical
can proceed as usual. If the patient appears to have burns classified as severe, then

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the approach should be like that of a major trauma patient. Key factors in the history
include the type of burn, possible inhalation injury, and possible associated traumatic
injuries. If possible, ask prehospital emergency services providers if the patient had
prolonged smoke exposure (consider carbon monoxide poisoning, cyanide
poisoning, lung injury) or might have other injuries from explosions, falls or jumping
to safety. Examination of the burn can be done in the patient's secondary survey. The
patient's clothing should be removed, and the patient should be examined from head
to toe in a warm room.
The major factors to consider when evaluating the burned skin are the extent of the
burns (usually calculated by the percentage of total body surface area (% TBSA)
burned) and the estimated depth of the burns (superficial, partial thickness or full
thickness) (Grammatikopoulou, Theodoridis, Gkiouras, Stamouli, Mavrantoni,
Dardavessis, Bogdanos, 2019).
EXTENT OF BURN
Several methods are available to estimate the percentage of total body surface area
burned.
1. Rule of Nines - The head represents 9%, each arm is 9%, the anterior chest and
abdomen are 18%, the posterior chest and back are 18%, each leg is 18%, and the
perineum is 1%. For children, the head is 18%, and the legs are 13.5% each.
2. Lund and Browder Chart – This is a more accurate method, especially in children,
where each arm is 10%, anterior trunk and posterior trunk are each 13% and the
percentage calculated for the head and legs varies based on the patient’s age.
3. Palmar Surface - For small burns, the patient's palm surface (excluding the
fingers) represents approximately 0.5% of their body surface area, and the hand
surface (including the palm and fingers) represents about 1% of their body surface
area.
TREATMENT AND MANAGEMENT
The American Burn Association recommends burn center referrals for patients with:
1. partial thickness burns greater than 10% total body surface area.
2. Full thickness
3. Burns burns of the face, hands, feet, genitalia, or major joints
4. Chemical burns, electrical, or lighting strike injuries

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5. Significant inhalation injuries
6. Burns in patients with multiple medical disorders
7. Burns in patients with associated traumatic injuries
Patients being transferred to burn centers do not need extensive debridement or
topical antibiotics before transfer. Whether transferring or referring to a burn center,
you should contact them before beginning extensive local burn care treatments
(Regan & Hotwagner, 2023).
Minor burns which you plan to treat can be approached using the “C” of burn care:
Cooling - Small areas of burn can be cooled with tap water or saline solution to
prevent progression of burning and to reduce pain.
Cleaning - Mild soap and water or mild antibacterial wash. Debate continues over
the best treatment for blisters. However, large blisters are debrided while small
blisters and blisters involving the palms or soles are left intact.
Covering - Topical antibiotic ointments or cream with absorbent dressing or
specialized burn dressing materials are commonly used.
Comfort - Over-the-counter pain medications or prescription pain medications
when needed. Splints can also provide support and comfort for certain burned areas.
For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated
to maintain urine output > 0.5 mL/kg/hour. One commonly used fluid resuscitation
formula is the Parkland formula. The total amount of fluid to be given during the
initial 24 hours = 4 ml of LR × patient’s weight (kg) × % TBSA. Half of the
calculated amount is administered during the first eight hours beginning when the
patient was initially burned. For example, if a 70 kg patient has a 30% TBSA partial
thickness burn they will need 8400 mL Lactated Ringer solution in the first 24 hours
with 4200 mL of that total in the first 8 hours [(4 mL) × (70 kg) × (30% TBSA) =
8,400 mL LR]. Remember that the fluid resuscitation formula for burns is only an
estimate and the patient may need more or less fluid based on vital signs, urine
output, other injuries or other medical conditions.
In patients with moderate to severe flame burns and with suspicion for inhalation
injury, carboxyhemoglobin levels should be checked, and patients should be placed
on high flow oxygen until carbon monoxide poisoning is ruled out. If carbon
monoxide poisoning is confirmed, continue treatment with high-flow oxygen and
consider hyperbaric oxygen in select cases

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The management of burn patients is with an interprofessional team that consists of
a surgeon, intensivisit, burn specialist, dietitian, physical therapist, nurses, wound
care specialists, pulmonologist and plastic surgeon. Burn patients are best looked
after a burn team in a specialized center. The key is to prevent complications and
restore functionality. The outcomes of burn patients depend on the degree and extent
of the burn. Most second and third-degree burns require prolonged admission and
recovery is slow. Because cosmesis is significantly altered in burn patients a mental
health consult should be made prior to discharge (Mason, Nathens, Byrne, Ellis,
Fowler, Gonzalez, Karanicolas, Moineddin, Jeschke, 2017).

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