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EPIDEMIOLOGY

More than 450,000 individuals in the United States receive medical treatment each year for burn injuries, with 486,000 receiving treatment in 2016 alone.1 Although 40,000 patients require hospitalization and >60% of those are treated at one of 128 specialized burn centers,1 the vast majority of burn patients are treated in the acute setting by emergency physicians and discharged with outpatient follow-up.2,3

Nearly 70% of burn victims are male,1 and risk is highest between the ages of 18 and 35 years. Seventy-seven percent of all injuries are accounted for by fire or scalding; 43% of scald injuries occur in children <5 years of age.4 Although overall survival exceeds 96%, fire, burn, and smoke inhalation still account for approximately 3400 deaths each year in the United States.1 Elderly patients understandably have a disproportionately higher death rate.4-6 The risk of death from a major burn increases with larger burn size, older age, the presence of inhalation injury, and female sex.6

The Centers for Disease Control and Prevention lists the following groups as being at increased risk of fire-related injuries and death: children ≤4 years of age, adults ≥65 years of age, African Americans and Native Americans, persons living in rural areas, persons living in manufactured homes or substandard housing, and persons living in poverty.7

Care of the acute burn–injured patient has improved significantly over the past several decades.8,9 The rate of hospital admissions has decreased owing to improvements in both the acute care provided in the ED and outpatient care at specialized burn centers. Indeed, over the past 50 years, dramatic improvements in survival after burn injury have been seen, in large part due to specialized burn care.10 Only approximately 4% of those treated in specialized burn treatment centers die from their injuries or associated complications.4,11 Additionally, survivors of high total body surface area (>20%) burns tend to have better 5-year survival than those with <20% total body surface area burns, because burn center survivors tend to be younger with fewer comorbidities.12

PATHOPHYSIOLOGY

Skin consists of two layers: the epidermis and the dermis (Figure 217-1). Skin thickness varies both by age and anatomic location: It is relatively thinner at extremes of age, whereas it is thicker on the palms, soles, and upper back. Thus, the depth and severity of thermal injury vary by both the age of the victim and the anatomic location exposed.

Skin functions as a semipermeable barrier to evaporative water loss, protects against environmental assault, and aids in the control of body temperature, sensation, and excretion. Partial-thickness thermal injury disrupts these barrier functions and contributes to free water deficits. This effect may be significant with moderate to large burns.

Thermal injury results in a spectrum of local and systemic ...

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