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The American Burn Association estimates that 500,000 individuals are treated for burns in the U.S. annually. Of these, 40,000 require hospitalization.1 Thus, the majority of burn patients are treated and discharged from the ED to be followed as outpatients. More than 60% of those hospitalized are admitted to the 125 specialized burn treatment centers, and the others are cared for in community hospitals. Fire and burn deaths account for about 4000 deaths each year.1


The risk of burns is highest in the 18- to 35-year-old age group. There is a male-female ratio of 2:1 for both injury and death. The incidence of scalds from hot liquids is higher in children 1 to 5 years of age and in the elderly. The death rate in patients >65 years of age is much higher than that in the overall burn population.2,3


Significant strides have been made in the overall care of burn patients during the last two decades.4,5 These advances are reflected in a decreased mortality rate among patients with major thermal injury; only about 4% of those treated in specialized burn treatment centers die from their injuries or associated complications.6 The incidence of inpatient admissions has decreased over time owing to improvements in outpatient care both in the ED and in the burn unit. The risk of death from a major burn increases with larger burn size, older age, the presence of inhalation injury, and female sex.3


Skin consists of two layers: the epidermis and the dermis (Figure 210-1). Skin thickness is less in the very young and the elderly. It also varies significantly throughout the body. The skin is very thick on the palms of the hands and the soles of the feet. The skin on the upper part of the back is thicker than that on other parts of the body. Thus exposure to the same temperature for the same duration leads to different depths of injury on different parts of the body.

Figure 210-1.
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Layers of the skin. (Courtesy of Mary Myrand, Wayne State University School of Medicine, Bio-Medical Communications Department.)


Skin functions as a semipermeable barrier to evaporative water loss. Other functions of the skin include protection from the adversities of the environment, control of body temperature, sensation, and excretion. Partial-thickness thermal injury can result in disruption of the barrier function and contribute to free water deficits. The effect may be significant with moderate to large burns.


Thermal injury results in a spectrum of local and systemic homeostatic derangements that contribute to burn shock (Table 210-1). These include disruption of normal cell membrane function, hormonal alterations, changes in tissue acid-base balance, hemodynamic changes, and hematologic derangement.

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Table 210-1 Physiologic Effects of Thermal Injury

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