**3. Classifications of burns**

organic tissues primarily caused by heat or due to radiation, radioactivity, electricity, friction,

According to Juan P. Barret, trauma can be defined as bodily injury severe enough to pose a threat to life, limbs, tissues, and organs, but burn injury is different, because unlike other traumas, it can be quantified as to the exact percentage of body injured and can be viewed as a paradigm of injury from which many lessons can be learned about critical illness involving

According to the statistics of the World Health Organization, 180,000 deaths every year are caused by burns [2]. Majority of them occur in low- and middle-income countries. It is estimated that almost two thirds occur in the African and South-East Asia regions. The highest fire-related mortality rates are in Southeast Asia, 11.6 deaths per 100,000 population per year; in the Eastern Mediterranean, 6.4 deaths per 100,000 population per year; and in Africa, 6.1

Among pediatric population the rate of deaths from burns is over seven times higher in lowand middle-income countries than in high-income countries. Lowest mortality rates due to burns in high-income countries are the successful result of preventive interventions of many kinds, such as promotion of the use of smoke detectors, the lowering of temperatures of hot water heaters, the installation of sprinkler systems, the promotion of flame-retardant chil-

The epidemiology of burns differs in different age groups and depends on sex [3]. For example, in low- and middle-income countries, fire-related burns are the sixth leading cause of death among 5–14-year-old victims and the eighth leading cause death among 15–29-year-old

In low- and middle-income countries, women (especially young) are at higher risk of burns

In pediatric population, it is estimated that worldwide approximately 1% of all children sus-

The results of our studies conducted in Lower Silesia (the region of Poland) among children

The analysis of mechanism of trauma revealed that the most common type of injury in children treated in ambulatory conditions by general practitioners (GP) and requiring hospitalization due to burns in Lower Silesia was thermal burns [5, 6]. The second reason for hospitalization and ambulatory treatment were chemical burns [5]. In the studied population, there were no

Among the pediatric patients hospitalized due to thermal injury in Lower Silesia, 2010–2012, burns were usually located in the upper limbs [5]. Trunk and lower limbs were also frequently

dren's sleepwear, and the development of safer buildings and household fuels [3].

[3]. However in high-income countries, men are at higher risk of burns.

with burns indicate that boys are at higher risk of burn injury [5, 6].

or contact with chemicals.

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multiple organ systems [1].

victims [3].

affected [5].

tain a burn injury each year [4].

cases of burns caused by radiation [5, 6].

**2. Epidemiology of burns**

deaths per 100,000 population per year [3].

There are many ways in which burn injury can be classified.

Apart from the mechanism of injury, usually four criteria are taken into account: depth of injury, percent of body surface area involved, location of the burn, and association with other injuries [4].

#### **3.1. Etiologic factor of injury**

According to the etiological factor (factor that caused the burn injury), we can distinguish thermal, electrical, and chemical injury and burns caused by radiation.

The most common types of burns in children are thermal burns. Thermal injuries are caused by heat. They can be the result of hot liquids (scalds), hot solids (contact burns), and flames (flame burns). In pediatric population, especially in children under 2 years old, the most common type of burns is scalds.

#### **3.2. Location of injury**

Anatomic location is important in triage decision [4]. Burns can affect all parts of the body: head, neck, trunk, upper and lower extremities, perineum, and upper anterior abdominal wall (**Figures 1**–**3**).

International Classification of the Disease (ICD) is used by physicians, nurses, health-care providers, and researchers to classify the diseases and other health-care problems. It facilitated the comparison of date between different regions and is widely used for epidemiological purposes.

Burns involve also inhalation injuries. Inhalation injuries should be suspected in patients with

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The location is important in assessment of the risk of disability—the greatest is in the case of

The skin is composed of two layers: epidermis and dermis. The epidermis is composed of stratified squamous epithelium, which acts as a barrier to infectious agents and also prevents

As children's skin is thinner than adult's skin, exposure to the same agent will cause deeper burns in an infant compared to adults. For example, water at 60°C will cause a full-thickness

At the emergency department, it is difficult to describe the thickness of burn injury because

According to depth of the skin affected, burns can be divided into superficial, partial-thick-

In partial-thickness burns, the whole epidermis and part of the dermis are affected. Most of authors distinguish superficial partial-thickness burns and deep partial-thickness burns. In the superficial partial-thickness burns, the papillary layer of the dermis is affected, and the erythema of the skin and blistering are observed. In the deep partial-thickness burns, the reticular layer of the dermis is affected, and the skin looks paler and has a speckled appearance due to thrombosis of superficial vessels. The deep partial-thickness burns are less painful

In the full-thickness burns, the epidermis and dermis with epidermal appendages are affected [9]. This type of burns is usually the result of flame, prolonged contact with hot objects, and

In some old literatures, the classification involves first, second, third, and fourth degrees. The first degree corresponds with the superficial burns. The second degree A corresponds with the superficial partial-thickness burns; the second degree B corresponds with the deep partial-thickness burns. The third degree corresponds with the full-thickness burns. The fourth degree burns involve full depth of the skin and underlying fascia, muscles, or even bones [4].

The extension of burn injury is expressed as percentage of total body surface area. There are

facial burns, singed nasal hairs, and carbonaceous sputum [4].

patients with affected face, eyes, feet, perineum, and hands [4].

burn in less than 1 s in an infant and 20 s in an adult [10].

the appearance of burn wound evolves during first 24–48 h [9].

Usually in one pediatric patient, we observe burns of different depth.

Superficial burns involve only the epidermal layer; the skin is erythematosus.

**3.3. Depth of burns**

fluid loss from the body [9].

ness, and full-thickness burns [9].

than the superficial partial-thickness burns.

several methods used to count the surface of burn.

hot oil [9].

**3.4. Surface of burns**

**Figure 1.** The child with the thermal burn of the knee (partial thickness burn).

**Figure 2.** The child with the thermal burn of the lower extremity (partial thickness burn).

**Figure 3.** The child with the thermal burn (superficial) of the trunk caused by hot water (scald).

In the ICD-11 burns are divided into burns of external body surface, specified by site; burns of the eye or internal organs; and burns of multiple or unspecified body regions. In the ICD-10 the group of burns of external surface included burns and corrosions of all depth divided into burns and corrosions of head and neck (T20); burns and corrosions of trunk (T21); burns and corrosions of shoulder and upper limb, except the wrist and hand (T22); burns and corrosions of the wrist and hand (T23); burns and corrosions of the hip and lower limb, except the ankle and foot (T24); and burns and corrosions of the ankle and foot (T25) [8].

Burns involve also inhalation injuries. Inhalation injuries should be suspected in patients with facial burns, singed nasal hairs, and carbonaceous sputum [4].

The location is important in assessment of the risk of disability—the greatest is in the case of patients with affected face, eyes, feet, perineum, and hands [4].

#### **3.3. Depth of burns**

The skin is composed of two layers: epidermis and dermis. The epidermis is composed of stratified squamous epithelium, which acts as a barrier to infectious agents and also prevents fluid loss from the body [9].

As children's skin is thinner than adult's skin, exposure to the same agent will cause deeper burns in an infant compared to adults. For example, water at 60°C will cause a full-thickness burn in less than 1 s in an infant and 20 s in an adult [10].

At the emergency department, it is difficult to describe the thickness of burn injury because the appearance of burn wound evolves during first 24–48 h [9].

Usually in one pediatric patient, we observe burns of different depth.

According to depth of the skin affected, burns can be divided into superficial, partial-thickness, and full-thickness burns [9].

Superficial burns involve only the epidermal layer; the skin is erythematosus.

In partial-thickness burns, the whole epidermis and part of the dermis are affected. Most of authors distinguish superficial partial-thickness burns and deep partial-thickness burns. In the superficial partial-thickness burns, the papillary layer of the dermis is affected, and the erythema of the skin and blistering are observed. In the deep partial-thickness burns, the reticular layer of the dermis is affected, and the skin looks paler and has a speckled appearance due to thrombosis of superficial vessels. The deep partial-thickness burns are less painful than the superficial partial-thickness burns.

In the full-thickness burns, the epidermis and dermis with epidermal appendages are affected [9]. This type of burns is usually the result of flame, prolonged contact with hot objects, and hot oil [9].

In some old literatures, the classification involves first, second, third, and fourth degrees. The first degree corresponds with the superficial burns. The second degree A corresponds with the superficial partial-thickness burns; the second degree B corresponds with the deep partial-thickness burns. The third degree corresponds with the full-thickness burns. The fourth degree burns involve full depth of the skin and underlying fascia, muscles, or even bones [4].

#### **3.4. Surface of burns**

In the ICD-11 burns are divided into burns of external body surface, specified by site; burns of the eye or internal organs; and burns of multiple or unspecified body regions. In the ICD-10 the group of burns of external surface included burns and corrosions of all depth divided into burns and corrosions of head and neck (T20); burns and corrosions of trunk (T21); burns and corrosions of shoulder and upper limb, except the wrist and hand (T22); burns and corrosions of the wrist and hand (T23); burns and corrosions of the hip and lower limb, except the ankle

and foot (T24); and burns and corrosions of the ankle and foot (T25) [8].

**Figure 3.** The child with the thermal burn (superficial) of the trunk caused by hot water (scald).

**Figure 1.** The child with the thermal burn of the knee (partial thickness burn).

278 Essentials of Accident and Emergency Medicine

**Figure 2.** The child with the thermal burn of the lower extremity (partial thickness burn).

The extension of burn injury is expressed as percentage of total body surface area. There are several methods used to count the surface of burn.

In the teenagers and adults, the extent of the skin involved is estimated on the basis of "rule of nines." That means the surface of each upper extremity is 9% of total body surface area, each lower extremity is 18% of total body surface area, the anterior part of the trunk is 18% of the total body surface area, the posterior surface of the trunk is 18% of the total body surface area, the head is 9% of the total body surface area, and the perineum is 1% of the total body surface area [4]. There is a modified rule of nines for infants and children (**Figure 4**).

**3.5. Jackson's zones of injury**

**5. Causes of burns**

injury.

**4. Pathophysiological effects of burn injury**

According to Jackson it is possible to classify thermal burns into three zones of injury: the inner, the intermediate, and the outer zone. The inner zone is the zone of coagulative necrosis. The intermediate zone is the zone of stasis, while the outer zone is the zone of hyperemia [11].

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Pathophysiological effects of burn injury can be divided into local and systemic [11].

loss of the protective function of the gut, and pulmonary edema [11].

Most of burns in children are caused by the accident [12].

The local effects include release of inflammatory mediators from the capillary walls, white blood cells, and platelets. These inflammatory mediators result in vasodilatation and increased vessel permeability that leads to fluid loss from the circulation into the interstitial space [11]. Systemic effects occur in extended burns (usually in those that burned surface area exceeds 20% of total body surface area) and include hypovolemia, immunosuppression, catabolism,

A major burn injury leads to fluid and electrolyte imbalance with systemic intravascular losses of water, sodium, albumin, and red blood cells. If the intravascular volume is not rapidly restored, the shock develops [1]. Moreover, burns can lead to malnutrition and organ dysfunction due to metabolic disturbances (hypermetabolism and muscle catabolism) [1].

The burns according to the cause of the injury can be divided into accidental and nonaccidental.

There are several features that can make a health-care provider to suspect nonaccidental

Among them is delay in seeking medical help by parents. It is very important to write down all the details of mechanism of the injury provided by caregivers, because sometimes caregivers change the history of trauma with time. The non-accidental injury is suspected when the mechanism of injury given by parents is not coherent with the burn wound found in child and also when the history of trauma is not consistent with the developmental stage of the child. In

Characteristic for nonaccidental burns are burn wound caused by cigarettes. Also the socalled glove or sock burns are typical for nonaccidental injury. In many children with nonaccidental burns, additional sings of trauma can be found, for example, bruises, fractures, etc. According to Adronicus et al., there were no differences between the groups in age or mortality between children with accidental and nonaccidental burn injuries. The authors found that in the group of children with nonaccidental injuries, burns involving both hands or both legs

older children the abnormal behavior, such as avoiding eye contact, can be observed.

According to "rule of palm," the inner surface of the patient's palm is approximately 1% of total body surface area.

In younger children the Lund and Bowder charts are used to estimate the extension of burn wound [4].

According to extent of body surface involved, ICD-10 classified burns into burns involving less than 10% of body surface (T31.0), burns involving 10–19% of body surface (T31.1), burns involving 20–29% of body surface (T31.2), burns involving 30–39% of body surface (T31.3), burns involving 40–49% of body surface (T31.4), burns involving 50–59% of body surface (T31.5), burns involving 60–69% of body surface (T31.6), burns involving 70–79% of body surface (T31.7), burns involving 80–89% of body surface (T31.8), and burns involving 90% or more of body surface (T31.9) [8].

The extension of burn injury plays a crucial role in the process of decision-making about hospitalization of the patient. It is also important to count the amount of intravenous fluids that should be given to the patient.

**Figure 4.** Modified rule of nines in children in different age groups.

#### **3.5. Jackson's zones of injury**

In the teenagers and adults, the extent of the skin involved is estimated on the basis of "rule of nines." That means the surface of each upper extremity is 9% of total body surface area, each lower extremity is 18% of total body surface area, the anterior part of the trunk is 18% of the total body surface area, the posterior surface of the trunk is 18% of the total body surface area, the head is 9% of the total body surface area, and the perineum is 1% of the total body surface

According to "rule of palm," the inner surface of the patient's palm is approximately 1% of

In younger children the Lund and Bowder charts are used to estimate the extension of burn

According to extent of body surface involved, ICD-10 classified burns into burns involving less than 10% of body surface (T31.0), burns involving 10–19% of body surface (T31.1), burns involving 20–29% of body surface (T31.2), burns involving 30–39% of body surface (T31.3), burns involving 40–49% of body surface (T31.4), burns involving 50–59% of body surface (T31.5), burns involving 60–69% of body surface (T31.6), burns involving 70–79% of body surface (T31.7), burns involving 80–89% of body surface (T31.8), and burns involving 90% or

The extension of burn injury plays a crucial role in the process of decision-making about hospitalization of the patient. It is also important to count the amount of intravenous fluids that

area [4]. There is a modified rule of nines for infants and children (**Figure 4**).

total body surface area.

280 Essentials of Accident and Emergency Medicine

more of body surface (T31.9) [8].

should be given to the patient.

**Figure 4.** Modified rule of nines in children in different age groups.

wound [4].

According to Jackson it is possible to classify thermal burns into three zones of injury: the inner, the intermediate, and the outer zone. The inner zone is the zone of coagulative necrosis. The intermediate zone is the zone of stasis, while the outer zone is the zone of hyperemia [11].
