Burn injuries are common in Oklahoma, with fires, explosions, smoke inhalation, defective product burns, and more. If you or a loved one has suffered a severe burn injury as a result of someone else’s negligence, contact an Oklahoma burn injury lawyer right once to discuss your legal options. Victims are entitled to recompense for both their physical injuries and the mental and emotional costs of recuperation.
Call 405.601.8899 if you have a burn injury in Oklahoma.
The Law Office of Dakota Low in Oklahoma is experienced in the enormous hardships experienced by those who have suffered burn injuries, and we are here to fight for harmed victims and their families. We provide a free initial consultation to address any questions or concerns you may have, and our attorneys work on a contingency fee basis, which means you will not be charged any fees until we win your case. In the meantime, we can help you obtain medical treatment and other life essentials you may require.
Quick Facts on Oklahoma Fires, Explosions, and Burn Injuries
Chemical burns, electrical burns, scaldings (from boiling liquid), and fires are all examples of burns. First-degree burns are the least devastating in terms of severity. Over-the-counter medicines and topical ointments can usually be used to treat them at home. Second- and third-degree burns, on the other hand, will necessitate hospitalization, prescription drugs, and possibly costly, extensive operations such as skin grafting.
The Oklahoma State Department of Health and the Oklahoma State Government both state that:
- For children under the age of five, scalds are the most common cause of severe burns.
- In 2004, 117 persons were hospitalized as a result of fire-related injuries.
- Those aged 65 and up had the highest rate of hospitalization.
- Males are more likely than females to be admitted to the hospital as a result of a burn injury.
- In Oklahoma, males are about twice as likely as females to die in a fire.
- Every year, around 100 people are injured by severe gas burns.
- Every year, about 70 Oklahoma people are killed in house fires.
- The most common sources of house fires are heaters, wood stoves, and fireplaces.
- Two out of every five victims with significant house fire injuries attempted to put out the fire.
Have you or a loved one recently been the victim of a fire, explosion, or burn? If that’s the case, it’s a good idea to talk to a reputable Oklahoma burn accident lawyer about your legal alternatives.
For more information about burn injuries and fire safety, visit the Oklahoma State Department of Health.
What Causes Burns?
Unfortunately, burns can occur at any time and in any place, although a large majority of serious burns occur at home. According to the American Burn Association, nearly 72 percent of all burns occur at home. Burns can also develop as a result of a car accident, at work, or in public.
If you recognize any of the circumstances below, contact an Oklahoma burn injury lawyer to discuss your legal options.
In Your Own Home
A lawsuit is unnecessary if a burn is regarded your responsibility, such as a culinary error or a lost cigarette. An attorney can hold someone responsible if a significant burn was caused by a defective product, landlord negligence, or other factors.
Involved in a Car Accident
Hot liquids such as gas or oil may flow during a serious car or truck accident, causing scorching. Vehicles can also catch fire, trapping victims inside or exposing them to the fire for an extended length of time.
At the Office
Accidental job injuries are common in Oklahoma’s energy, oil and gas, and medical industries. If you’ve been offered workers’ compensation, you won’t be able to file a personal injury claim, but you might be able to hold someone else responsible for their wrongdoing. Consult a skilled attorney about your choices.
How a Personal Injury Lawyer in Oklahoma Can Help
When it comes to proving fault, calculating damages, and obtaining adequate compensation for both the emotional and physical consequences of your injuries, an attorney is vital. Burn accident lawyers in Oklahoma can assist victims prevail against giant insurance companies who want to settle for as little as possible.
The Law Office of Dakota C. Low has over three decades of combined expertise representing victims and their families in Oklahoma. On behalf of victims, we battle aggressively against insurance companies and large corporations to ensure that they receive the compensation they need and deserve. We are proud of our client testimonials and previous case outcomes.
Get a Free Case Evaluation
Call The Law Office of Dakota C. Low at 405.601.8899 or use our contact form to schedule a free case review and first consultation if you have just suffered a serious burn injury in Oklahoma. We can get you in immediately to see the best burn medical specialists in Oklahoma and any other critical needs you may have.
Why is an Experienced Oklahoma Burn Injury Lawyer necessary?
For a Personal Injury Lawyer specializing in Burn injuries to be effective, considerable knowledge of burn treatments, triage and standards of care are necessary in addition to knowing and understanding the law. Be sure your Burn injury attorney knows the standard medical protocols. Dakota Low is an experienced Burn injury attorney who can ensure you receive proper care and the maximum compensation for your injury both now and throughout your recovery and potential life-time care.
In spite of major advances in therapeutic strategies for the management of patients with severe burns, including improved resuscitation, enhanced wound coverage, infection control, and management of inhalation injuries, the consequences of a severe burn are profound and result in complex metabolic changes that can adversely affect every organ system [1-3]. Management of a patient with a severe burn injury is a long-term process that addresses the local burn wound as well as the systemic, psychologic, and social consequences of the injury.
In situations where resources are limited (mass casualty, natural disaster), triage, stabilization, and transfer provide optimal outcomes. Outcomes for severely burned patients, particularly children or older individuals, who cannot be transferred for burn care are poor.
An overview of the initial care and subsequent management of patients with severe (major) burn injuries is presented here. The initial care and management of minor burns are discussed separately. (See “Treatment of minor thermal burns”.)
The management of associated traumatic injuries and other mechanisms of injury is reviewed separately. (See “Initial management of trauma in adults” and “Overview of inpatient management of the adult trauma patient”, section on ‘Consider other potential injuries’ and “Inhalation injury from heat, smoke, or chemical irritants” and “Topical chemical burns: Initial assessment and management” and “Environmental and weapon-related electrical injuries”.)
A severe burn is one that is complicated by major trauma or inhalation
Burn injury, a chemical burn, high-voltage electrical burn, and, in general for adults, any burn encompassing >20 percent of the total body surface area (TBSA), excluding superficial burns (epidermal; first-degree burns).
For older adults and young children, a burn encompassing less than 20 percent of the TBSA may be considered severe.
The prevalence of burns complicated by major trauma ranges from 0.4 to 5.8 percent. Approximately 1 to 5 percent of patients who sustain burn injuries incur penetrating and/or blunt trauma. Combined burn/trauma is often due to motor vehicle accidents with associated explosions, fires with structural collapse, falls while escaping a fire, electrical injuries and falls, scald burns during assaults, plane crashes, and explosions with airborne fragments and flames in civilian and combat settings. The most common injuries associated with burns and the frequency in which they occur include:
- Fractures: 45 to 64 percent
- Complex soft tissue injuries: 36 to 52 percent
- Traumatic brain injury: 17 to 26 percent
- Thoracic and abdominal injuries: 4 to 24 percent
Severe burns usually require initial care in a specialized intensive care unit of a burn center. Although burns involving the eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment should be cared for in a burn center, not all will require management in an intensive care unit. (See “Assessment and classification of burn injury” and ‘Criteria for intensive care’ below.)
Severe burns occur in approximately 5 to 20 percent of survivors of conventional conflicts and from civilian mass disasters or terrorist events. However, because resources are limited to care for large numbers of severely burned individuals, the majority of large TBSA burn patients die at the scene or within the first 24 hours following the burn. Among survivors, less than 20 percent TBSA is involved in 80 percent. In addition to the burn injury, patients may also suffer blunt or penetrating chest or abdominal injuries, neurologic injuries, orthopedic injuries, inhalation injures, blast injuries, and other possible injuries (eg, radiation contamination). (See ‘Combined burn/trauma’ below.)
The Emergency care of the burn patient and triage criteria for referral to a burn center are discussed in detail separately. (See “Emergency care of moderate and severe thermal burns in adults” and “Moderate and severe thermal burns in children: Emergency management” and “Overview of inpatient management of the adult trauma patient”, section on ‘Introduction’.)
Emergency care of the severely burned patient can be provided in an emergency department or in an intensive care unit (ICU), depending upon the protocol of the institution. In both scenarios, emergency care follows the principles of the Advanced Trauma Life Support guidelines for assessment and stabilization of airway, breathing, circulation, disability, exposure, and environment control.
Primary and secondary assessments for the severity (partial or full thickness) and extent (total body surface area [TBSA]) of the burn, and an evaluation for associated life-threatening injuries, are promptly performed. The ambient room temperature should be increased to prevent hypothermia and reduce the patient’s stress response.
Triage and transfer — If the patient does not present initially to a designated burn center, patients with any of the criteria given in the table should be transferred as soon as stabilized. If transportation is not feasible, or if no burn center is available, the patient should be admitted to an intensive care unit for interim management, until transfer can be arranged.
Mass casualty events — Approximately 25 to 30 percent of those injured in a casualty event (mass disaster, terrorist) will sustain a moderate-to-severe burn injury. Generally, a limited number of individuals are impacted in typical civilian accidents that result in burn injury (eg, house fires). By contrast, the magnitude and impact of burns associated with a mass disaster can be devastating, affecting many individuals simultaneously and often exceeding the capacity (beds, surgeons, nurses, operating rooms, equipment, supplies) of available local burn centers to provide optimal burn care.
With a disaster plan in place, a well-equipped burn center can typically handle a surge capacity that is up to 50 percent above the normal maximum capacity.
Guidelines for triage of burn patients in mass disasters recommend that adults and children with >20 percent TBSA burn should be transferred to a burn center [13,17,21]. The care of severely burned patients is generally best provided in dedicated burn centers that can provide surgical grafting support, ICU care, and rehabilitative care. In the United States, the American Burn Association (ABA) can assist with planning transfer to regional burn facilities.
Burns less than 20 percent TBSA can be managed at hospitals without a dedicated burn care center, including those who would otherwise have met the standard criteria for burn center referral (eg, specific anatomic sites, age, comorbid conditions).
In addition to percentage TBSA burned, in mass disasters, the presence of inhalation injury, other severe injuries, and extremes in age should be incorporated into triage and patient dispositions. (See ‘Palliative care’ below.)
With mass disasters, triage may require the use of a medical facility leapfrogging process. Burn victims may be first triaged to the closest hospital. After initial resuscitation, those meeting criteria should be transferred to a burn center. Transfer should occur between 24 and 72 hours after initial fluid resuscitation . It might also be necessary to redirect or redistribute patients if burn centers reach surge capacity.
Combined burn/trauma — For combined burn/trauma patients, an understanding of the independent temporal changes of each injury (eg, penetrating, blunt, burn) and how they interact with each other allows the clinician to devise the optimal management strategy. The highest priority (after airway, breathing, and intravenous access) in the setting of combined burn/trauma is the assessment and treatment of immediately life-threatening injuries, whether penetrating or blunt, then the management of the burn.
The key to the initial management of a combined burn/trauma patient is that the presence of burn wounds should not interfere with the basic resuscitation and stabilization.
As an example, the presence of burned skin should not preclude attempts at intravenous access, control of hemorrhaging sites, coverage of open fractures and wounds, and fixation of closed fractures. (See “Initial management of trauma in adults” and “Emergency care of moderate and severe thermal burns in adults” and “Moderate and severe thermal burns in children: Emergency management”.)
Criteria for intensive care — Burn patients who require mechanical ventilation (eg, inhalation injury, massive fluid resuscitation), require cardiac or other hemodynamic monitoring to guide fluid therapy or monitoring for other reasons, or have risk factors for multisystem organ failure should be managed in an intensive care setting. (See “Predictive scoring systems in the intensive care unit”.)
Palliative care — Although mortality rates related to burn injury have steadily declined, some patients with severe burns have such a poor chance for survival that they (or their health care proxy) may elect to withhold treatment. (See “Advance care planning and advance directives” and “Ethical issues in palliative care” and “Ethical considerations in effective pain management at the end of life”.)
Patients with very large burns and inhalation injury, particularly in the setting of other significant medical comorbidities, are at increased risk for death. A patient with a Baux score (age + TBSA, which correlates with mortality) or a revised Baux score (age + TBSA + 17 [presence of inhalation injury]) of more than 140 to 150 (little to no hope for survival) may elect to forego any specific burn treatment. Patients can also present with “Do not resuscitate/Do not intubate” or other advanced directives that are upheld by their surrogates that prohibit heroic efforts at resuscitation or other life-prolonging measures.
In these patients, pain and anxiety are controlled. Patients can receive such palliative care without being transferred to a burn center, but many centers prefer to send these patients under the premise that transfer to a specialized center may provide hope for any chance of survival.
In regions where dedicated burn centers are not available (or have been destroyed), the survival rate for ≥50 percent TBSA burns is low. The ABA categories and expected outcomes for burn patients involved in a mass casualty event based upon age and percentage TBSA burn are given in the table. Although difficult, placing a patient in the expectant category (ie, anticipated death) helps to save the greatest number of lives. However, doing so does not mean abandoning the patient. It is important to ensure that personnel are present to provide liberal use of medications to control pain and anxiety, as needed.
INTENSIVE CARE MANAGEMENT
Initial stabilization — Initial stabilization begun in the emergency department continues in the intensive care unit (ICU) and includes continuation of respiratory support, fluid resuscitation, cardiovascular stabilization, pain control, and local management of burn wounds. The initial approach to fluid resuscitation, fluid selection, and estimating initial fluid requirements in adults and children are discussed elsewhere. It is important to realize that the initial estimation of burn extent and depth is frequently inaccurate, particularly during triage associated with multiple injured patients. Once the patient has been transferred, the burn extent and depth should be reassessed and the fluid requirements recalculated and adjusted accordingly.
(See “Emergency care of moderate and severe thermal burns in adults”, section on ‘Fluid resuscitation’ and “Moderate and severe thermal burns in children: Emergency management”, section on ‘Fluid resuscitation’.)
Patients with severe burns are at risk for organ dysfunction, which may be related to under-resuscitation (eg, acute kidney injury), exacerbation of underlying medical comorbidities, or sepsis, which can occur early in the post-injury period related to dirty/contaminated burn wounds. Severely burned patients require a large amount of fluid during resuscitation, which may not be well tolerated, and which can contribute to the development of ileus, compartment syndromes (eg, abdominal compartment syndrome, extremity compartment syndrome), respiratory complications (pulmonary edema, adult respiratory distress syndrome), and generalized edema, which can complicate general patient care (eg, pressure-related wounds).
Patients at risk should be examined hourly with neurovascular checks to determine the need for escharotomy (if not already done) or compartment release.
If respiratory compromise occurs secondary to a chest wall eschar, longitudinal incisions are made in the midaxillary line and extended for the length of the eschar. If vascular compromise is identified in an extremity or hand, an escharotomy is performed using longitudinal incisions on the medial and lateral aspects of the extremity and digits. The escharotomy incisions on the extremities should be sited such that they do not interfere with potential incisions for orthopaedic repairs of fractures. A description of the escharotomy of the hand is discussed elsewhere and can be used as the model for performing this procedure along the chest wall and extremities.
In general, an escharotomy should be performed within six hours for extremities with full-thickness burns as these eschars will be excised in the coming days; thus, cosmetic considerations are not at issue. For other settings, an escharotomy should be performed upon recognition of potential for respiratory or vascular compromise.
Ongoing fluid needs depend upon the size of the burn, presence of inhalation injury, any comorbidities, and any signs of multiorgan dysfunction. The goal of ongoing fluid therapy is to maintain end-organ perfusion. In large TBSA burns, the effectiveness of perfusion can be monitored using urine output, central venous pressure, or cardiac output. For most patients, fluid resuscitation is adjusted to maintain urine output at 1.0 mL/kg/hour for children and 0.5 to 1 mL/kg/hour for adults; however, most adult burn units accept 30 to 50 mL/hour, regardless of the patient’s weight.
These targets are often doubled for patients with high voltage electrical injuries to facilitate clearance of myoglobin and decrease the risk of acute kidney injury. (See “Treatment of deep burns”, section on ‘Ongoing fluid therapy’.).
Subsequent management — The next set of priorities include pain control, thromboprophylaxis, early burn wound excision and closure with an autograft or temporary coverage with an allograft, nutritional support, control of hypermetabolism, and prevention of infection. Other preventive strategies are the same as with other trauma patients. (See “Overview of inpatient management of the adult trauma patient”, section on ‘Prophylaxis and preventive care’.)
Post stabilization management strategies for combined burn/trauma patients are based upon the severity and the type of associated injuries. Adjustment to standard burn management is dictated by severe injuries (eg, closed head injury, spinal injury, open fractures) that impact the timing of overall management. (See “Overview of inpatient management of the adult trauma patient”.)
Pain control — Superficial and partial-thickness burns can be extremely painful, and management of burn pain is a priority. The principles and treatment approaches for burn pain are discussed separately.
- (See “Management of burn wound pain and itching”.)
- (See “Paradigm-based treatment approaches for burn pain control”.)
Coagulopathy — It is important to recognize that severely burned patients with or without concomitant traumatic injury may have trauma-induced coagulopathy . Early recognition helps guide the approach to initial and ongoing resuscitation. The physiologic changes in coagulation in severely burned patients are characterized by changes in the innate coagulation cascade and dysfunctional fibrinolysis that are directly proportional to the severity of injury. There are currently no established treatment paradigms for burn-associated coagulopathy. Current recommendations focus on prevention, supportive care, and maintaining end-organ perfusion.
Thromboprophylaxis — Overall, the rates of venous thromboembolism (VTE) are low with prophylaxis. In a review of the Nationwide Inpatient Sample database that included nearly 40,000 patients, the overall incidence of deep vein thrombosis was 0.8 percent. The highest risk was for burns >20 percent TBSA, older patients, those with blood transfusion or mechanical ventilation, and in African Americans. For patients with severe burns, thromboprophylaxis should be initiated upon admission [53,54]. Associated traumatic injuries may alter the type and a timing of thromboprophylaxis.
In general, thromboprophylaxis in burn patients does not differ from that of other surgical patients. However, VTE prophylaxis can complicate burn wound excision, which is associated with hemorrhage, fluid shifts, coagulopathies, and blood transfusions. But, in general, burn wound management can be adapted to smaller but more frequent excisions and skin grafting to minimize blood loss and physiological derangements . Whether dosing in patients with severe burn injury that leads to hypermetabolism should be different remains controversial.In addition, whether fluid shifts during the resuscitation period affect the volume of distribution with subcutaneous administration of drugs is not clear.
Sequential compression devices can be used and can also decrease risk of deep vein thrombosis, but not more so compared with pharmacologic methods. The main benefit of mechanical prophylaxis compared with pharmacologic methods is a decrease in bleeding complications. Physiotherapy and early ambulation are also important for preventing thromboembolism but also help the burn patient maintain lean body mass.
Antimicrobial therapy — Burn patients are at risk for developing severe infections from common organisms as well as from organisms that are not usually virulent to those with an intact immune system. This is due in part to the immunologic dysfunction in severely burned patients. Burn wound sepsis can also lead to multiorgan dysfunction and death. Nosocomial infections (eg, central venous catheters, ventilator associated) and emerging multidrug-resistant strains of bacteria and fungi contribute to burn wound infections, sepsis, and associated death.
During mass casualty events, strict infection control and screening of wounds for resistant pathogens upon arrival to the new facility are important as outbreaks of multidrug-resistant bacteria in burn units have been described after patient transfers between hospitals [56,57]. (See “Burn wound infection and sepsis”, section on ‘Risk factors’.)
Even given the increased risk, the use of prophylactic antibiotics is controversial. Systemic antimicrobial therapy is only indicated for patients with proven burn wound infection or sepsis. (See “Burn wound infection and sepsis”.)
A systematic review found no benefit for prophylactic systemic antibiotics in reducing the incidence of burn wound infection . There is also no evidence that prophylactic antibiotics improves outcomes for burn patients with inhalational injury. One study found a benefit in patients with severe burn injury requiring mechanical ventilation, but these results have not yet been duplicated . (See “Inhalation injury from heat, smoke, or chemical irritants”.)
Nutritional support — A nasoenteric tube should be placed upon admission to initiate early enteral nutrition, usually within the first 24 hours . Early enteral nutrition has been shown to decrease bacterial translocation and risk of sepsis and improve morbidity and mortality after severe burn injury. In addition, a nasogastric tube may also be necessary for gastric decompression.
- (See “Overview of nutrition support in burn patients”.)
- (See “Clinical assessment and monitoring of nutrition support in adult surgical patients”.)
- (See “Nutritional demands and enteral formulas for adult surgical patients”.)
Every effort should be made to optimize nutrition delivery enterally to avoid the need for total parenteral nutrition, which is associated with increased mortality in burn patients . Patients who are tolerating oral diets that meet their full nutritional requirement can be weaned from continuous nutritional supplementation.
When feeding intolerance develops in a burn patient, it should be thoroughly investigated. The prevalence of delayed gastric emptying in critically ill burn patients can approach 77 percent due to hormonal and metabolic derangements [62-64]. At-risk patients who exhibit signs of feeding intolerance should be evaluated for burn wound sepsis. (See “Burn wound infection and sepsis”, section on ‘Clinical features’.)
Stress-induced ulcers from splanchnic hypoperfusion and mucosal ischemia during the resuscitation of severely burned patients have been effectively eliminated by the initiation of early enteral nutrition and gastrointestinal ulcer prophylaxis [65-67]. (See “Stress ulcers in the intensive care unit: Diagnosis, management, and prevention” and “Management of stress ulcers”.)
Attenuating hypermetabolism — The metabolic rate increases proportionally with burn size. The hypermetabolic response in burn patients is characterized by a hyperdynamic circulatory response with massive protein and lipid catabolism, total body protein loss, muscle wasting, peripheral insulin resistance, increased energy expenditure, increased body temperature, increased risk of infection, and stimulated synthesis of acute phase proteins located in the liver and intestinal mucosa. For adults and children with severe burns, oxandrolone, and possibly beta receptor blockade are indicated to attenuate hypermetabolism. Dosing and efficacy are discussed separately. (See “Hypermetabolic response to moderate-to-severe burn injury and management”.)
Burn Wound Management
Local treatment of burn wounds — The severely burned patient may have burns of varying depth, each having differing requirements. (See “Treatment of deep burns”, section on ‘Burn wound characterization’.)
Superficial burn wounds (superficial [epidermal], superficial partial thickness) are covered with dressing materials that aid with skin healing and reepithelialization. In general, superficial burns do not require antimicrobial therapy, but for extensive superficial burns, topical antimicrobial agents may help prevent wound colonization and maintain a moist wound healing environment. (See “Treatment of superficial burns requiring hospital admission”, section on ‘Local burn care’ and “Topical agents and dressings for local burn wound care”.)
Deep burn wounds (deep partial thickness, full thickness, deeper burns) ultimately require burn wound excision and burn wound closure. Prior to burn wound excision, the thick eschar prevents penetration of topical agents and must be removed before any topical agent can be effective. Thus, dry gauze is sufficient on unexcised eschar with plans for excision as soon as possible. Following eschar excision, if grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobial agents is used to provide a moist and minimally adherent provisional dressing. (See “Treatment of deep burns” and “Topical agents and dressings for local burn wound care”.)
Early burn excision and coverage — Burn wound debridement, excision, and coverage are performed in the operating room, generally between 24 and 72 hours after the injury. The length of time to accomplish full excision and burn coverage depends upon the extent of the burn injury. For large total body surface area (TBSA) burns, strategies to provide burn wound coverage include wide meshing, using the Meek technique, temporary coverage using xenografts or allografts, reharvesting donor sites, and using skin substitutes. (See “Treatment of deep burns”, section on ‘Early burn excision’ and “Treatment of deep burns”, section on ‘Burn wound closure’ and “Skin autografting”.)
During mass casualty events, early excision and grafting may need to be delayed in accordance with local resources. But in general, for patients with burns <20 percent TBSA who are triaged to hospitals without a dedicated burn care center, most patients have a very good outcomes. Consultation with burn experts for details of grafting, reconstruction, and rehabilitation may be needed.
Transition of Care
On average, patients remain in the intensive care unit (ICU) for one-half to one full day per percent total body surface area (TBSA) burned (eg, a patient with an 80 percent TBSA burn will remain in the ICU for 40 to 80 days) . Patients may be discharged from the ICU directly to a rehabilitation facility or to a hospital ward if no such facility exists when hemodynamic monitoring is no longer needed.
Criteria to discharge patients from the ICU directly to the rehabilitation facility include:
- Burn wounds that are closed, and without significant functional impairments from burn wound contractures
- The patient is receiving and tolerating full enteral nutritional requirements
- The patient is functionally independent from a rehabilitative standpoint
For patients who will remain in the hospital, at the time of transfer to the regular floor, burn wounds are mostly healed, and most patients are tolerating full enteral nutrition and have started rehabilitation. Unless major complications occur, patients typically receive inpatient care for one to four weeks after discharge from the ICU, depending upon their functional needs [70,71].
For patients with no functional disabilities from the burn injury or other traumatic injury, the patient can be discharged directly to home.
LONG-TERM CAREWith advancements in overall burn care, survival is no longer the exception but the expected outcome, shifting focus to improving other outcomes, reducing chronic pain, managing post-traumatic stress, and optimizing cosmetic appearance.
Long-term management of burn patients requires a team effort for months to years after the burn. Advantages of long-term care by the burn surgeon and burn specialist team include:
- Frequent evaluation and prompt surgical management of burn wound contractures not amenable or responsive to aggressive rehabilitation exercises.
- Timely management of late burn wound complications (eg, late contractures, graft loss).
- Optimization of nutritional support to avoid major loss of lean body mass as the hypermetabolic response persists.
- Psychosocial support for managing re-immersion into society and adjusting to scarring and disfigurement.
Delayed improvement in burn-specific health can be expected for most burn patients. In a prospective study that included 89 consecutive burn patients, preburn factors (eg, psychiatric disorders, major depression), length of hospital stay, hand injury, and post-traumatic stress disorder present at 12 months postburn were predictors of adverse long-term (two to seven years) burn-specific health in the affect and personal relations domain .
Psychological aspects — Survival from severe burns is no longer the exception but the rule. The price of survival is the risk of total disability, and the location of major injuries (eg, hands, face) determines one’s ability to adapt. With appropriate psychosocial support, patients are better able to adapt in society with physical disabilities [73-77].
Psychiatric/psychologic support of the burn patient should be an early and routine component of management. With improvements in mortality from severe burn injury, outcomes are focused on measures of function, adjustment, and community integration [73,78-80]. The Burn Specific Health Scale (BSHS) was designed to assess heat sensitivity, affect, hand function, treatment regimens, work, sexuality, interpersonal relationships, simple abilities, and body image in burn patients .
Severely burned patients can return to the community and adjust well; however, some burn patients do develop clinically significant psychological disturbances such as somatization and phobic anxiety.
Depression and post-traumatic stress disorder (PTSD) are the most common psychologic problems, occurring in 13 to 23 percent and 13 to 45 percent of patients, respectively . Risk factors related to depression include pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD include pre-burn depression, type and severity of baseline depressive symptoms, anxiety related to pain, and visibility of burn injury. Social problems include difficulties with sexual activity and social interactions, although quality of life appears to improve with time. Children with severe burns were found to have similar somatization problems as well as sleep disturbances but, in general, were reasonably adjusted [73,78,83].
Therapeutic interventions in long-term psychosocial rehabilitation following a major burn injury include optimizing social functioning and adjustment, therapies directed toward the specific conditions (eg, depression, PTSD, anxiety) encountered, and exercise to improve health-related quality of life [78,84,85].
(See “Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis” and “Psychosocial interventions for posttraumatic stress disorder in children and adolescents” and “Pharmacotherapy for posttraumatic stress disorder in adults”.)
Return to work — The ultimate goal of rehabilitation following a burn injury is reintegration into society, including gainful employment. In a retrospective review of 363 adults employed prior to the burn, 66 and 90 percent of patients returned to work at 6 and 24 months postburn, respectively. However, only 37 percent returned to the same job and employer without injury-related accommodations.
The percentage of TBSA burned was the most important predictor of time away from work . Other predictors of employment after a burn injury include burn site (eg, hands), length of hospitalization, psychiatric history, personality characteristics, and demographic factors, including age, marital status, and employment status at the time of injury [88-91].
Return to work can be delayed by the functional limitations of a burn. The management of the long-term functional limitations of burn scars and resultant contractures is reviewed separately and includes:
- (See “Overview of surgical procedures used in the management of burn injuries”.)
- (See “Principles of burn reconstruction: Face, scalp, and neck”.)
- (See “Principles of burn management: The breast”.)
- (See “Principles of burn reconstruction: Extremities and regional nodal basins”.)
- (See “Principles of burn reconstruction: Perineum and genitalia”.)
Other burn-related issues — Burn wounds are a chronic condition and require extended surveillance and follow-up beyond the acute hospitalization and acute inflammatory stage. For those who survive burn injury, there is the added burden of a permanent disability and economic hardship for the burn victim and their family and other caregivers. The depth of injury (partial thickness versus full thickness) and location determines specific long-term complications (eg, sensory loss due to nerve damage and full-thickness injury leading to impairment of sweat glands, contractures) [70,92,93].
In a retrospective survey of the mothers of 650 burned Ghanaian children, the risks of developing burn-related physical impairments were significantly increased when the injuries were associated with protracted healing, burns to the head/neck, more severe burns, and wound infection . The Global Childhood Unintentional Injury Surveillance pilot study noted that 17 percent of child survivors had greater than six weeks of temporary disability, and 8 percent had permanent disability .
The annual incidence of burns severe enough to restrict activity for one or more days in Ethiopia was 80 per 1000 children. The rate of permanent disability due to burns was 5.7 per 100,000. In one study, two-thirds of older adult individuals who were living independently before the burn injury required transition to a skilled nursing facility following hospitalization.
On the other hand, available epidemiologic data support that burn patients are not at a higher risk of developing skin cancers, particularly melanoma or squamous cell carcinomas, despite data from earlier case reports and small series. In a retrospective cohort study of 16,903 patients with a thermal or chemical burn that required hospitalization, only 139 burn patients developed skin cancers compared with an expected 189 cases in the general population (standardized incidence ratio 0.7, 95% CI 0.6-0.9). This was independent of severity of burn or duration of observation.
A second cohort study of 12,783 burn patients found no causal association of a burn injury and risk of developing skin cancer with 20 to 30 years of observation. However, female gender-specific skin cancer risk was identified (standardized incidence ratio 1.39, 95% CI 1.16-1.69).
Complications in burn-injured patients include systemic (multiorgan failure, individual organ complications) and burn-specific complications. These are reviewed separately. (See “Overview of complications of severe burn injury”.)
Overall mortality from a burn injury ranges from 3 to 55 percent, depending a variety of factors including region, age, and sex [105-107]. Those at the greatest risk for death are those at the extremes of age, greater extent of burn injury, burn injury in association with inhalation injury, and burn injury in those with serious comorbidities [108-111].
Studies have investigated the variables associated with increased mortality in burn patients. One-half of early deaths from burns (within the first 10 days) may be related to inadequate resuscitation [106,112-114]. All components of injury will contribute to the mortality rate; however, patients with combined burn/trauma have a higher mortality rate compared with burn-only and trauma-only patients [4,8]. In mass casualty events, mortality is higher than would otherwise be expected (figure 1). This is generally related to inadequate resources for burn care.
- A retrospective review compared outcomes of 5462 combined burn/trauma patients with 7324 burn-only patients and 411,173 trauma-only patients from the National Trauma Data Bank. The mortality rate for combined burn/trauma was 11 percent compared with 3 and 5 percent, for burn only and trauma only, respectively .
- In a retrospective review of 751 military and civilian patients, for those with moderate-to-severe burns (TBSA >20 percent), the consequences of the burn dominated all injuries after initial stabilization . Injury Severity Score (ISS) and nonburn Acute Injury Score (AIS) were not associated with an increase in mortality in the multivariate analysis. The TBSA for survivors was significantly lower compared with those who died (11 versus 52 percent).
Burn-related injury is the fourth leading cause of unintentional injury mortality among people aged 65 years or older. Comorbid illnesses obviously increase the risk of death in older adult patients. In addition, being alone at the time of injury increases the risk of injury but also increases the likelihood of mortality. In one retrospective review of 238 severely burned patients, the survival rate for patients with >95 percent total body surface area (TBSA) burns was approximately 50 percent for children aged 14 years and younger, 75 percent in adults 45 to 64 years, and 30 percent in older patients.
Mortality from thermal burns is related to the size of the burn. An observational study of 1223 children with burns found that all children with burns <30 percent of total body surface area (TBSA) survived, while 6 percent of children with burns ≥30 percent TBSA died. The mortality rate from deliberate self-burning, noted mainly in young women, ranges from 44 to 73 percent. The high mortality rate is related to the extensiveness of the burns.
The presence of inhalational injury is also associated with increased mortality. In an observational report describing children admitted to a burn center with ≥20 percent TBSA burns, there was a significant difference in mortality between those with and without inhalation injury (15 and 4 percent, respectively). For children with TBSA burns >80 percent, inhalation injury did not appear to significantly influence mortality. (See “Inhalation injury from heat, smoke, or chemical irritants”.)
Mortality around the world — An overall decline in mortality from burns due to fire and flames has been reported around the world. In the United States, the age-adjusted death rate from fire and burns decreased from 2.99 per 100,000 in 1981 to 1.2 per 100,000 in 2006. Between 1990 and 2010, the Global Burden of Disease Project noted a 6 percent decline worldwide in fire and burn deaths, from 5.3 to 4.9 per 100,000.
Between 1982 and 2002, fire and burn mortality in Australian men declined from 1.5 to 0.7 per 100,000. Similarly, the fire mortality rate in Brazilian women decreased from 1.1 to 0.5 per 100,000. Other countries observing a reduction in fire and burn mortality have included Canada, France, Mexico, Panama, Thailand, the United Kingdom, and Venezuela.
In the second half of the 20th century, mortality rates steadily decreased due to a number of therapeutic developments, including vigorous fluid resuscitation, early burn wound excision, advances in critical care and nutrition, topical antibiotics, and the evolution of specialized burn centers. Where appropriate burn care is not immediately available or if medical care is delayed (eg, mass casualty event), mortality is increased.
Related to age and sex — Mortality rates (per 100,000) from the Institute for Health Metrics and Evaluation, Global Health Data Exchange are as follows:
- Age 1 to 4: males 1.99 (1.39-2.4); females 2.39 (1.67-2.93)
- Age 10 to 14: males 0.32 (0.24-0.4); females 0.43 (0.32-0.54)
- Age 30 to 34: males 1.06 (0.86-1.25); females 1.22 (0.82-1.46)
- Age 60 to 64: males 2.6 (2.19-2.82); females 1.58 (1.25-1.76)
- Age ≥80: males 13.69 (11.99-14.88); females 12.89 (11.36-13.67)
Worldwide, childhood mortality from burns is higher for low-income countries compared with high-income countries. For unintentional fire and burn injuries in children, mortality was over 10 percent in low-income countries compared with 3 percent for high income countries. The 2004 fire mortality rate in female infants in Africa was 35 per 100,000, higher than in low- and middle-income populations from Europe (3.5 per 100,000), the Americas (2.2 per 100,000), or the Western Pacific (0.4 per 100,000).
Fire-related mortality in Southeastern Asia was nearly six times that in the Western Pacific low- and middle-income countries for males under the age of four years. Similarly, fire-related mortality rates in one- to four-year olds in Eastern Mediterranean low- and middle-income countries were nearly twice that of those from European low- and middle-income countries. The burn-related mortality rate was 0.6 per 100,000 in 173,000 children in Bangladesh.
Injuries resulting from exposure to fire are among the 10 leading causes of death for the age group 15 to 29 years but not for any other age group. Unintentional injury is the leading cause of death in US children aged one to nine years (10.4 per 100,000), and burns are the third leading cause of unintentional trauma death. Burns are the leading cause of injury-related death in Black American children between age one and nine years, with rates that are 2.7 times higher compared with other groups.
The higher mortality rates related to burn injuries for Black children remain higher throughout adolescence. Serious injury or death occurs frequently among children who are injured in residential fires. As an example, in an observational study of children in Texas, US who were injured in residential fires, 49 percent of injuries were fatal. Most deaths (60 percent) occurred in children under five years of age. Pediatric injuries and death were greater when the injury resulted from children playing with fire.
Mortality rates for fire-related injuries are twice as high in males compared with females in the 15- to 59-year age group in high-income countries whereas in this age group in low-income countries, female deaths occur at a rate 2.3 times that of males. The discrepancy is greatest in Southeastern Asia and the eastern Mediterranean region. Nine percent of all deaths among Egyptian women of reproductive age were caused by burns . In India, approximately 65 percent of burn deaths occur in females, most often caused by kitchen accidents, self-immolation, and domestic violence .
Society Guideline Links
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See “Society guideline links: Care of the patient with burn injury” and “Society guideline links: Health concerns following a disaster”.)
Summary and Recommendations
- Management of a patient with a severe burn injury is a long-term process that addresses the local burn wound care as well as the systemic, psychologic, and social consequences of the injury. (See ‘Introduction’ above.)
- A severe (major) burn is any burn injury that is complicated by major trauma or inhalation injury, chemical burn, high-voltage electrical burn, and, in general for adults, any burn encompassing over 20 percent of the total body surface area, excluding superficial burns such as sunburn. (See ‘Severe burn injury’ above.)
- If emergency care is not provided at a designated burn center, patients with the criteria listed in the table should be transferred to a burn center as soon as they are stabilized. (See ‘Triage and transfer’ above.)
- Intensive care unit management includes fluid resuscitation, cardiovascular stabilization including attenuation of the hyperdynamic response to burn injury, respiratory support, pain control, and local management of burn wounds initiated in the emergency department. The goal of the intensive care is to maintain end-organ perfusion and prevent shock. (See ‘Intensive care management’ above.)
- The local care of burn wound varies depending on burn depth. (See ‘Burn wound management’ above.)
- Superficial burn wounds (superficial [epidermal], superficial partial thickness) are covered with dressing materials that aid with skin healing and reepithelialization and generally do not require antimicrobial therapy. (See “Treatment of superficial burns requiring hospital admission”.)
- Deep burn wounds (deep partial thickness, full thickness, deeper burns) ultimately require burn wound excision and burn wound closure. Dry gauze is sufficient to cover unexcised eschar. Excision and grafting is generally performed between 6 and 24 hours after the injury. If grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobial agents is used to provide a moist and minimally adherent provisional dressing. (See “Treatment of deep burns”.)
- Ongoing management of the severely burned patient also includes optimization of nutritional support, management of long-term wound complications (eg, contractures), and psychosocial support to return to work and for re-immersion into society. (See ‘Long-term care’ above.)
Dakota Low is an Experienced Burn Injury Lawyer who understands and is experienced in the law and in medical treatment standards of care for burn injury victims. Contact Dakota Low today for a free case review and consultation at 405.601.8899 or use our contact form and begin receiving the standard of care you need and deserve.