The Harsh Realities of Burns

Original Image by U.S. Army  via Flickr
Original Image by U.S. Army via Flickr

By: Nikki Nies

Accidents happen.  Unfortunately, many accidents can leave scars or marks.  While some people wear scars as a physical remembrance of the journey they have been on, some scars, such as burns are not always as appealing.  Burns can arise from dry heat (fire), wet heat (steam or hot liquids), radiation, friction, heated objects, electricity, the sun or interaction with chemicals.   Depending on the severity of the burn, location, depth and how much total body surface area (TBSA) will dictate the need of care and how much it will impact life going forward.

With 35% of burn victims children and listed as the 3rd leading cause of accidental death, burns are nothing to joke about.  In addition, if more than 15-20% of one’s body is burned, significant fluid loss can occur.  Those with more than 50% of their body burned have a higher mortality risk.  With direct contact to one’s skin, it can compromise one’s fluid and temperature regulation and can jeopardize the protective barrier against viruses and bacteria.

There are three layers of skin, the outer most layer is the epidermis.  Next is the dermis and the inner most layer is the hypodermis, also known as subcutanous tissues.  The epidermis is the only layer of skin that is able to regenerate itself.  If burns extend beyond the outer most layer, permanent damage can occur and prevent normal function.  The hypodermis contains nerves and blood vessels.  It is also the most important layer of tissue for temperature regulation.

The diagnosis of the degree of the burn is estimated by the percentage of the body burned to know total burn thickness as it impacts metabolic rate more than total body surface area (TBSA). 25-30% TBSA leads to systemic edema and catabolic response, 90% TBSA is fatal. 60% TBSA covered in elderly can be fatal.  The diagnosis of burns often follows the “rule of nines.”  It’s based on the concept that surface area of categorized body parts correspond to 9% of total body .

Rule of nines:

  • Head=9%
  • Chest (front)=9%
  • Abdromen (front)=9%
  • Upper, mid, low back and buttocks=18%
  • Each Arm=9%
  • Each palm=1%
  • Groin=1%
  • Each leg=18%; front=9%; back=9%

So if both legs, groin, front chest and abdomen were burned=55% of body.

The determination of total body surface area (TBSA) is done using charts, such as the Lund-Browder.

Degree of burn Indicator Significance
1st signified by redness of epidermis and by discolorization or erythema; superficial; skin may be tender to touch; skin integrity’s intact and body’s able to still regulate fluid and temperatures causes local inflammation of skin;  sunburns are categorized as 1st degree; injuries heal in 3-6 days
2nd (Partial thickness burn) redness and blistering; redness, inflammation, pain and blistering; fluid lost through damaged skin; will blanch under pressure impact epidermis and dermis; injuries heal in 1-3 weeks; can have long term skin changes
3rd (Full thickness burn) penetrate beyond the epidermis and dermis (affecting fat); skin and tissue destruction occurs ; involves all layers of skin, which kills that area of the skin; appear white and leathery due to nerve and blood vessel damage; often burns aren’t tender since cutaneous nerve endings have been destroyed healing occurs at wound edges; can have significant scarring unless skin graft is done

Seeking treatment for burns, no matter the size or occurence should be seen by a medical profession.   Burns can cause muscle catabolism, immune deficiency, peripheral lipolysis, reduced bone mineralization,  reduced linear growth, increased energy expenditure and increased metabolic rate and increased levels of catecholamines, prostaglandins, glucagon and cortisol.

Maintaining good nutrition status is a critical aspect of recovery from burns as the physiologic response to trauma decreases nutritional status regardless of pre-burn nutrition status.  The primary objective is to monitor and preserve skeletal mass.   Elevations in metabolic rate can range from 118-210% with those with at least 25% TBSA covered.  RMR is approximately 180% of basal rate during acute admission and calorie needs may exceed 5000 kcal/day.

The standard recommendation is to consume a diet of  20% protein, 50-60% carbohydrates and 20-30% fat, with 2-4% essential fatty acids and an increase in omega 3 fatty acids.  A high carb, low fat diet can decrease proteolysis and can see more improvement in lean body mass, reduce infectious morbidity and shorten hospitalization time compared to a high fat diet.  However, must monitor high carb diet as it can lead to hyperglycemia and can have detrimental effect on critically ill

Since every case is different and individualized, it’s important to be in contact with your physician and burn specialists if possible.  The recovery process can be grueling, but definitely possible.


Click to access Escharotomy_CPG_new_format.pdf

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