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        The incidence and severity of burn injuries have been declining, with both deaths and acute hospitalisation attributable to burns down about 50 per cent. Over three-fourths of burns involve less than 10 per cent of total body surface area. Aggressive, early excision (24-72 hours post-burn) of deeply bured tissues and skin grafting, and improved infection control have contributed to significantly lower mortality rates and shorter hospitalisations.

        Nonetheless, an estimated 1.25 million burn injuries and 51,000 acute hospitalisations of burn victims occur each year in the United States. Severe burns cause problems in the initial phase from hemodynamic compromise, related injuries such as smoke inhalation or fractures, and associated multi-organ failure and sepsis. Later, secondary scarring and constrictive wounds occur. Significant quality of life and social functionality can be expected even for severely burned patients. Burns are classified by extent, depth, patient age and associated illness or injury, Dr S Sathyanarayanan of Sri Chakra Hospital, Hindu Colony, Nanganallur, explained.

        Extent of burns: Detailed charts based on age are available when the patient reaches the burns unit. Therefore, it is important to view the entire patient after cleaning soot to make an accurate assessment, both initially and on subsequent examinations. Only second- and third-degree burns are included in calculating the total burn surface area (TBSA), since first-degree burns usually do not represent significant injury in terms of prognosis or fluid and electrolyte management. However, first- or second-degree burns may convert to deeper burns, especially if treatment is delayed or bacterial colonisation or superinfection occurs.

        Depth of burns: Judgement of depth of burn injury is difficult. The first-degree burn may be red or gray but will demonstrate excellent capillary refill. First-degree burns are not blistered initially. If the wound is blistered, this represents a partial-thickness injury to the dermis, or a second-degree burn. As the degree of burn is progressively deeper, there is a progressive loss of adnexal structures. Hairs can be easily extracted or are absent, sweat glands become less visible and the skin appears smoother.

        The distinction between second- and third-degree burns is unclear and in a sense artificial. Deep second-degree burns are generally treated as full-thickness (third-degree) burns and excised and grafted earlier because of the long time necessary for re-epithelialisation and the thin, poor quality of the resultant skin. More accurate depth measurement is possible with immuno-histochemical analysis.

        Survival after burn injury: The survival from major burn injury has dramatically increased in the last 20 years. Consistently, the three major risk factors for mortality were age greater than 60 years, burn area greater than 40 per cent of the total body surface area, and inhalation injury. The most accurate rule of thumb for predicting mortality after severe burn injury is still the Baux Score (age + per cent burn, eg 50 years + 20 per cent burn = 70 per cent mortality), though this is obviously quite variable depending on associated medical factors. Another study indicates that burn size, age and sex as well as duration of stay in the ICU and the presence of mechanical ventilation presage a poorer outcome. Likewise, a base deficit during resuscitation of greater than (-) mmol/L predicts a far higher incidence of multiple organ dysfunction and death.

        Associated injuries or illnesses: An injury commonly associated with burns is smoke inhalation. Suspicion of inhalation injury is aroused when the nasal hairs are singed, the mechanism of burn involves closed spaces, the sputm is carbonaccous, or the carboxy-hemoglobin level exceeds 5 per cent in non-smokers. This suspicion should lead the clinician to institute early intubation before air-way edema supervenes. The products of combustion, not heat, are responsible for lower air-way injury. Electrical injury that causes burns may also produce cardiac arrhythmias that require immediate attention. Pancreatitis occurs in severe burns. Prior alcohol exposure may axacerbate the pulmonary components of burn injury.

        Toxic Epidermal Necrolysis (TEN) occasionally occurs following sulfonamide or phenytoin administration. If TEN is severe, patients are best transferred to burns unit and treated as having severe burn injury. Corticosteroid therapy should be avoided.