A severe burn injury requires immediate, specialized intervention because the skin, the body’s largest organ, provides a barrier against infection and regulates internal temperature and fluid balance. Extensive damage from thermal, chemical, or electrical sources triggers a profound systemic response affecting nearly every major organ system. The severity is determined by the burn’s depth, size relative to the body, and location. Successful management involves a coordinated, multidisciplinary approach starting at the injury scene and continuing through specialized rehabilitation.
Classifying Burn Injuries
Burns are categorized by the depth of tissue destruction, which dictates the severity and required treatment. First-degree burns (superficial) affect only the epidermis, causing redness and pain, and typically heal without scarring. Second-degree burns (partial-thickness) extend into the dermis, resulting in blisters, swelling, and significant pain, and the wound appears red and moist.
Third-degree burns are full-thickness injuries that destroy the entire epidermis and dermis, possibly extending into the subcutaneous tissue. These wounds may look white, charred, or leathery, and often have little sensation because nerve endings have been destroyed. Fourth-degree burns are the most severe, extending through the skin and fat into muscle, tendon, or bone. These deep injuries require specialized surgical intervention and often result in significant functional impairment.
Burn severity is also gauged by the Total Body Surface Area (TBSA) affected by second, third, and fourth-degree burns. Burns affecting more than 20% TBSA in adults, or 10% in children, are considered major injuries requiring specialized fluid resuscitation and burn center referral. TBSA is often estimated using the “Rule of Nines,” which divides the body into sections that are multiples of nine (e.g., the entire head and neck is 9%). This estimate helps determine the immediate need for fluid therapy to prevent shock.
Emergency First Aid and Stabilization
Immediate action focuses on stopping the burning process, stabilizing the patient, and calling emergency medical services. For thermal burns, extinguish the source using “stop, drop, and roll” or a blanket. The burned area should be cooled with cool running water for at least ten minutes to reduce pain and prevent deeper tissue damage. Submerging a patient with large burns should be avoided, as this can cause hypothermia.
For chemical burns, dry powdered chemicals must be brushed off before irrigation. The affected area requires copious flushing with running water for a minimum of 20 minutes to dilute and remove the caustic substance. For electrical burns, the power source must be turned off before touching the injured person. Electrical injuries are often deceptive, causing significant internal damage, including cardiac arrhythmias, even if the external burn appears small.
All clothing and jewelry on or near the burned areas should be removed immediately, unless adhered to the skin, because swelling occurs rapidly. After initial cooling, the patient should be covered with a clean, dry sheet or blanket to prevent body heat loss, which is a major risk with large surface area injuries.
Acute Hospital Treatment and Wound Management
Upon arrival at a burn center, the initial focus is on life-saving measures, primarily fluid resuscitation for patients with large TBSA burns. Severe burns cause a massive fluid shift from the bloodstream into surrounding tissues, leading to burn shock. Intravenous fluids, often administered using formulas like the Parkland formula, restore circulating blood volume and maintain tissue perfusion.
The next step is surgical management of the wound to prevent infection and promote healing. This involves excising the non-viable tissue, called the eschar. Early excision, often performed within the first 48 hours, is associated with a lower risk of infection and sepsis. The goal is to debride the wound down to healthy tissue suitable for receiving a skin graft.
Definitive wound closure uses skin grafting, the standard of care for full-thickness burns. Autografts, thin layers of the patient’s own healthy skin, provide permanent closure and are harvested from an unburned area. For extensive burns with limited healthy skin, temporary coverings are used, such as allografts (human donors) or xenografts (animal sources). These temporary grafts protect the wound, reduce fluid loss, and prepare the site for eventual permanent autografting.
Systemic Complications and Rehabilitation
A severe burn injury causes profound systemic disruption. Following the initial injury, patients enter a prolonged hyperdynamic and hypermetabolic “flow” phase that can last for months or years. During this state, the body’s energy expenditure and caloric demand increase significantly, leading to rapid muscle wasting and weight loss if not met with aggressive nutritional support.
The extensive damage creates a high risk for infection and sepsis, which is a leading cause of death in burn patients. The immune system becomes dysregulated, making the patient susceptible to pathogens. Careful wound management, early excision, and antibiotics are used to combat this risk.
Long-term recovery requires intensive rehabilitation beginning early in the hospital stay. Physical and occupational therapy prevent contractures, which are severe tightening of tissue that limits joint movement. Scar management is an ongoing process, frequently involving custom-fitted pressure garments worn for many months to flatten and soften developing scars. This multidisciplinary approach addresses physical, functional, and psychological challenges to help the patient regain independence and reintegrate into daily life.