By Aaron Collins

When we think of burns and their causes, we may imagine leaping flames and the terror of being engulfed by uncontrolled fire. But according to a 2008 report by the World Health Organization, every year, the majority of burn victims worldwide are injured by electricity, hot liquids, or chemicals rather than by flames. Nevertheless, 300,000 people worldwide will die from fire-related burns this year. Millions more will survive burns from all these causes, but many of their lives will be changed forever.

Statistics also show that poverty is one major predictor of the likelihood of a burn injury. The San Joaquin Valley and its position as one of the poorest regions in the U.S. makes this factor especially troubling. Victims of severe burns face both physical and emotional complications for the rest of their lives due to disability and disfigurement. The already-poor can expect to descend further into poverty.

Everyone should be diligent about burn prevention and also understand when expert medical treatment is called for, said Dr. James Smithson of Kaweah Delta Medical Center’s Emergency Department.

To distinguish burns that require professional care from those that may only need self-care, Smithson said, calls for understanding the meaning of burn classifications: Burns are classified by depth, size, and location as either first-, second-, third- or fourth-degree burns. Unlike criminal charges, in which “first-degree” denotes the highest severity, burns are classified the opposite way, with fourth-degree the most severe.

Burn location is of utmost importance, Smithson emphasized. “Burns that cross joints, particularly of the hands and […] extremities are more likely to cause long-term mobility issues because of scarring, and therefore deserve special consideration by the acute-care and long-term-care providers.”

First-degree burns are limited to the epidermis (top layer of the human skin structure) and characterized by redness and pain. “They generally heal within several days to a week,” Smithson said. “First-degree burns—which are red, painful, tender, and devoid of blisters—may generally be managed at home. Treatment includes topical and systemic analgesia, including immediate tap water submersion or cool compresses, topical aloe vera, ibuprofen, and acetaminophen.”

One of the most common misconceptions is that ice should be applied to a burn. “There is evidence that suggests that intermediately damaged skin can become permanently damaged if cooled too aggressively, such as occurs when a burn is submerged in ice water,” Smithson explained. “Tap water submersion or cool tap water compresses are the most appropriate choices.”

If you have trouble distinguishing burn severity, you are not alone. Medical professionals, too, find the process a challenge. Assessment of burn depth can be a pitfall even for health care providers, Smithson cautioned. “Clinical estimation of burn depth is often inaccurate, despite careful examination. Serial assessments are necessary to distinguish between deep and superficial burns as the injury is dynamic and often continues to evolve after initial presentation.” As a consequence, he said, close follow-up is a key component of burn care. “A patient with a poorly healing wound should be referred to a dedicated burn clinic,” he advised.

Second-degree burns are more severe and extend through the epidermis and into the dermis. “They may be classified as either superficial or deep depending on the depth of dermal injury. [So] appropriate classification is key,” said Smithson, who trained at UC San Francisco and UC San Diego, which both have Level I trauma centers as well as dedicated burn treatment centers.

“In superficial second-degree burns, the skin is red, blistered and may be moist. The wound blanches with pressure and is painful and tender,” Smithson said. “In deep second-degree burns, the skin may appear white with areas of redness and exhibits less blanching and moisture than superficial second-degree burns.

“In general, patients should see a physician if the burn sustained may be second degree or worse, particularly if there are multiple or large blisters, or involvement of skin of a cosmetically sensitive area, like the face, or overlying a joint,” Smithson advised.

Emergency room physicians provide initial care for burn patients. “Our initial focus is on securing vital functions for our patients so that specialty care can ensue. Patients, particularly those injured in closed-space burns, are prone to develop thermal and chemical airway and pulmonary injuries that may progress rapidly,” Smithson said, adding that such patients may need an artificial airway so that adequate ventilation and oxygenation can be guaranteed.

Severe burns are a major shock to the body and can play havoc with all the body’s functions, depleting fluids and even causing serious systemic crises such as kidney failure, Smithson said. Careful administration of IV fluids—neither too little nor too much—is crucial and must be individualized based on the extent of the patient’s burns and in the context of other medical issues they may have.

Treatment of burns with blisters can be additionally challenging and is best done by an emergency physician or general surgeon with burn training, Smithson said. “Blisters that are under 2 centimeters (1 inch) in diameter can be left intact, creating a sterile, moist environment for healing of the underlying burn.” But larger blisters or blisters that have broken should be removed and an antibiotic ointment applied, keeping the wound moist until healing has occurred, he noted.

Third-degree or full-thickness burns extend through the epidermis and the dermis and appear stiff, white or tan in color. Smithson said they are dry, do not blanch, and are not painful in their central regions.

Fourth-degree burns, the most grave, have permanently damaged tissue beyond the skin, resulting in significant scarring at best, or mortality at worst. “A serious burn is one of the most painful and disfiguring injuries a person can suffer. … Burn victims deal with stigma associated mainly with visible scarring and may be challenged by scarring that limits joint mobility and therefore independence,” Smithson said. While “fourth-degree” is not considered a technical term, it is frequently used for burns which reach muscle or bone.

Victims of severe burns need inpatient care from a burn center, Smithson said, noting that burn center staff have specialized resources, such as referrals to outside or in-house support groups and a multidisciplinary approach to patient care. There are several online resources, too, such as www.burnsurvivor.com, which have helpful, current and accurate information to support burn victims in their recovery, he said.

Severely burned victims in our region face a transfer to Fresno or Bakersfield hospitals, since Kaweah Delta is not a designated burn treatment center. “[But] now that Kaweah Delta Medical Center is a level 3 trauma center, it has a more direct relationship with local burn centers, which leads to more timely transfer and coordinated care,” Smithson said. “Kaweah Delta is staffed with emergency physicians and general surgeons with specific training in burn management [who] are well equipped to provide up-to-date emergency care and stabilization of patients with burns.”

Fortunately, recent medical advances have improved severe burn treatment approaches, Smithson said. Pressure dressings have been developed that significantly reduce scarring, particularly of the face and small joints of the hand, leading to improved cosmetic outcomes and long-term functionality. “Additionally, there are newer synthetic and biosynthetic dressings that create enhanced environments for skin regeneration in regions of deep second-degree burns,” Smithson said, noting that such new treatments require coordination by a burn clinic.

Smithson foresees “a new era is on the horizon in Tulare County with Kaweah Delta Medical Center and California Emergency Physicians teaming up to begin an emergency medicine residency in 2012. The medical center is continuing a course of growth, and a burn center [of our own] may be necessary to adequately serve the county in the future.”

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