Principles and Practice of Burn Care

(Trang không có chữ)

Principles and Practice of
Burn Care
Editor-in-Chief
Sujata Sarabahi MS MCh DNB MNAMS
Assistant Professor and Specialist Plastic Surgeon
Department of Burns, Plastic,
Maxillofacial and Microvascular Surgery
Vardhman Mahavir Medical College and
Associated Safdarjung Hospital, New Delhi, India
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
St Louis (USA) • Panama City (Panama) • New Delhi • Ahmedabad • Bengaluru
Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur
Editors
VK Tiwari MS MCh
Professor and Senior Specialist Plastic Surgeon
Department of Burns,
Plastic, Maxillofacial and Microvascular Surgery,
Vardhman Mahavir Medical College and
Associated Safdarjung Hospital, New Delhi, India
Arun Goel MS MCh FICS
Senior Specialist Plastic Surgeon and Head of Unit
Department of Burns, Plastic,
Maxillofacial and Microvascular Surgery,
Lok Nayak Hospital and Associated Maulana Azad
Medical College, New Delhi, India
LC Gupta MD (Radiology) DMRE MD (PSM) FAMS DSc (Hon.)
Retd. Director Medical, Border Security Force, India
®

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Jitendar P Vij
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Principles and Practice of Burn Care
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
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To
My Parents who Made me
What I am Today
To
My Husband whose Constant Moral Support Gave me
The Base on Which I Worked
To
My Children, Rohan and Arushi whose Patience and Love Helped me
to Continue
To
My Father in Law who Inspired me
To Write this Book and his Constant Encouragement Helped me
Finish the Book
To
My Mother in Law whose Support Enabled me to Undertake this Venture
and last but not the least
To
My Sister for her Love and Encouragement

(Trang không có chữ)

Contributors
Amitabh Singh MS, DNB, MCh
Consultant Plastic Surgeon, Fortis Hospital
New Delhi, India
singh.amitabh@yahoo.com
Anil Chadha MS, MCh
Medical Director and Consultant Plastic Surgeon
Gujarat Medical Research Centre and Rajasthan Hospital
Ahmedabad, Gujarat
Formerly Professor and Head
Department of Burns and Plastic Surgery
BJ Medical College and Medical Superintendent
Civil Hospital, Ahmedabad, India
Arun Goel MS, MCh, FICS
Senior Specialist Plastic Surgeon and Head of Unit
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery, Lok Nayak Hospital and
Associated Maulana Azad Medical College
New Delhi, India
dragoel@hotmail.com
Arvind Vartak MBBS, MS, MCh
Honorary Plastic Surgeon and Head of Department of
Plastic Surgery, Ben Jerbai Wadia Hospital for Children
and Institute of Child Health, Parel, Mumbai
Masina Hospital, Byculla, SL Raheja Hospital
Mahim, Mumbai, Maharashtra, India
drvartak@gmail.com
Atul Kumar Shah MS, MCh, MPhil, LLB, PGDip
Medical Law and Ethics, Burns Specialist and
Medicolegal Consultant, Mahi Hospital Baroda
Gujarat, India
atulbda@rediffmail.com
B Karthikeya Prabhu MSc, PhD
Young Scientist, DST-SERC Fast Track Project
Biomaterials Division, Central Leather Research Institute
(CLRI), TICEL-BIOPARK, Taramani Main Road
Taramani, Chennai, Tamil Nadu, India
BC Shankar MS
Consultant Plastic Surgeon, Mumbai
Ex-Associate Director of Biomedical Group
Bhabha Atomic Research Centre (BARC), Mumbai
Maharashtra, India
Chandrakant MD
Formerly, Head, Department of Forensic Medicine
Safdarjung Hospital, New Delhi, India
Deepak Nanda MS, MCh
Specialist and Assistant Professor, Dept of Burns,
Plastic, Maxillofacial and Microvascular Surgery
Vardhman Mahavir Medical College and Associated
Safdarjung Hospital, New Delhi, India
drdeepaknanda@gmail.com
Deepthi Nair MD
Senior Specialist and Associate Professor of
Microbiology, Department of Microbiology, Safdarjung
Hospital and Vardhman Mahavir Medical College
New Delhi, India
Harish Chellani MD
Senior Pediatrician, Department of Pediatrics,
Safdarjung Hospital and Vardhman Mahavir
Medical College, New Delhi, India
Hemant Haldavnekar MBBS
Industrial Medicine Specialist, Bhabha Atomic Research
Centre (BARC), Mumbai, Maharashtra, India
Indu Chadha MD
Professor, Department of Anesthesiology
BJ Medical College and Civil Hospital
Ahmedabad, Gujarat, India
JC Suri MD, DTCD, DNB, FNCCP
Professor and Head of Respiratory Medicine
Vardhman Mahavir Medical College and
Safdarjung Hospital
New Delhi, India

viii
Principles and Practice of Burn Care
Karoon Agrawal MS, MCh
Professor and Head of Plastic Surgery, Jawahar Lal
Nehru Institute of Postgraduate Medical Education and
Research (JIPMER), Puducherry, India
karoonaparna@gmail.com
MK Sen DTCD, MD, FNCCP
Senior Chest Physician and Associate Professor
Safdarjung Hospital and Associated Vardhman Mahavir
Medical College and Safdarjung Hospital
New Delhi, India
Madhuri A Gore MS
Professor and Head of Surgery, Lokmanya Tilak
Medical College and General Hospital
Sion, Mumbai, Maharashtra, India
drmadhuri@hotmail.com
Mamta Sikroria MS, MCh
Senior Deputy Director and Head
Department of Burns and Plastic Surgery
JLN Hospital and Research Centre Bhilai
Chhatisgarh, India
mamtasikroria@yahoomail.com
Mary Babu
Ex-Head and Director Grade-Scientist ‘G’; Biomaterials
Division, Central Leather Research Institute (CLRI)
Chennai, Tamil Nadu, India
babumary2000@yahoo.com
N Shanmuganathan M Pharma, PhD
Assistant Professor, Department of Pharmaceutics
Sri Ramachandra College of Pharmacy
Sri Ramachandra University
Porur, Chennai, Tamil Nadu, India
PR Bongirwar MBBS
Industrial Medicine Specialist
Bhabha Atomic Research Centre (BARC)
Mumbai, Maharashtra, India
PK Bilwani MS, MCh
Director, Gujarat Burns Hospital and Research Centre
Hon. Professor of Plastic Surgery, NHL Muni Medical
College and KM School of Postgraduate Medicine
Ahmedabad, Hon Plastic Surgeon, LG Hospital
Ahmedabad, Gujarat, India
bilwanipk@satyam.net.in
PK Verma MD
Reader in Anesthesia and Senior Specialist,
Department of Anesthesiology and Intensive Care
Vardhman Mahavir Medical College and Safdarjung
Hospital, New Delhi, India
prateekverma88@hotmail.com
Pramod Kumar MS, MCh, DNB
Professor and Head, Department of Plastic Surgery
Kasturba Medical College, Manipal, Karnataka, India
pkumar86@hotmail.com
PS Bhandari MS, MCh
Senior Specialist Plastic Surgeon and Head of Unit
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery, Lok Nayak Hospital and
Associated Maulana Azad Medical College
New Delhi, India
drpsbhandari@rediffmail.com
Rajiv Kohli MD, FICP
Physician and Nephrologist, Head, Dialysis Unit
Lok Nayak Hospital and Associated Maulana Azad
Medical College, New Delhi, India
dr.rajivkohli@gmail.com
Rakesh Kain MS, MCh
Assistant Professor and Specialist Plastic Surgeon,
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery, Vardhman Mahavir Medical
College and Associated Safdarjung Hospital
New Delhi, India
rakeshkain@rediffmail.com
Ravi Chittoria MS, MCh, DNB, MNAMS
Head, Department of Plastic Surgery, Sri Venkateswara
Institute of Medical Sciences, Tirupati
Andhra Pradesh, India
drchittoria@yahoo.com
Ravindra Tah MS, MCh
Consultant Plastic Surgeon, Deepak Hospital and Apollo
Hospital, Ludhiana, Punjab, India
tahravindra@yahoo.com
RP Narayan MS, MCh, FICS
Professor and Head, Department of Burns, Plastic,
Maxillofacial and Microvascular Surgery, Vardhman
Mahavir Medical College and Associated Safdarjung
Hospital, New Delhi, India
drrpnarayan@gmail.com

Contributors
ix
S Raja Sabapathy MS, MCh, DNB (Plastic Surgery),
FRCS (Edin), MNAMS
Director, Ganga Hospital
Head, Department of Plastic Surgery, Hand and
Microsurgery and Burns, Ganga Hospital, Coimbatore
Tamil Nadu, India
rajahand@vsnl.com
Sameek Bhattacharya MS, DNB (Plastic Surgery),
FICS, MNAMS
Assistant Professor and Specialist Plastic Surgeon
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery, Vardhman Mahavir Medical
College and Associated Safdarjung Hospital
New Delhi, India
sameekb@gmail.com
Sarla Passi
Department in Physiotherapy
Postgraduate in Rehabilitation
Presently, Practising Physiotherapist, New Delhi
Ex-Incharge, Physiotherapy
Department of Burns and Plastic Surgery
Safdarjung Hospital, New Delhi, India
moneetapassi@hotmail.com
Savita Arora MS, MCh
Assistant Professor and Specialist Plastic Surgeon
Dept of Burns, Plastic, Maxillofacial and Microvascular
Surgery, Vardhman Mahavir Medical College and
Associated Safdarjung Hospital, New Delhi, India
groversavita@yahoo.com
Shailesh Ranade MS, MCh
Consultant Plastic Surgeon, Bhatia Hospital
Mumbai, Maharashtra, India
dr.shailesh@rediffmail.com
Shankar Sriniwasan MS, MCh
Plastic Surgeon, Wadia Hospital for Children, Parel
Hiranandani Hospital, Powai
Mumbai, Maharashtra, India
plastic_shankar@hotmail.com
SP Bajaj MS, MCh, FRCS
Formerly Professor and Head
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery Safdarjung Hospital
New Delhi
Consultant Plastic surgeon, Jaipur Golden Hospital
New Delhi, India
spbajaj@indiatimes.com
Sugandha Arya MD
Specialist Pediatrician, Safdarjung Hospital
New Delhi, India
Sugandha_arya@hotmail.com
Sujata Sarabahi MS, MCh, DNB (Plastic Surgery), MNAMS
Assistant Professor and Specialist Plastic Surgeon
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery, Vardhman Mahavir Medical
College and Associated Safdarjung Hospital
New Delhi, India
ssarabahi@yahoo.co.in
VK Tiwari MS, MCh
Professor and Senior Specialist Plastic Surgeon
Department of Burns, Plastic, Maxillofacial and
Microvascular Surgery Vardhman Mahavir Medical
College and Associated Safdarjung Hospital
New Delhi, India
vinaytiwari@hotmail.com

(Trang không có chữ)

It gives me a great pleasure to write a foreword for this book entitled Principles and Practice of Burn Care, which has
been ably compiled and edited by Dr Sujata Sarabahi, Dr VK Tiwari, Dr Arun Goel and Dr LC Gupta.
Sufferings of the World Wars have given some precious dividends of today. Efforts and contributions of Sir Harrold
Gillies in various fields of Plastic Surgery including his invaluable contributions in burns outshine till this day. The
unfortunate victims of burns are crippled, deformed, handicapped and disfigured and socially unacceptable. These poor
patients are shoved into dark and smelly corners of the surgical wards of hospitals and left to die or scar in their own
serum and sepsis. Being treated at general hospitals without skin grafting, most of them land up with horrible deformities
and scars.
The magnitude of problem in a developing country like ours is a colossal challenge. We still do not have a central burn
registry, which means that the magnitude of the problem is yet not fully understood, appreciated and defined. National
Academy of Burns—India (NABI) conducted a survey over several years and found that about 7 million (70 lakhs) people
get burnt annually, 7 lakhs need hospital admission, 2.5 lakhs get crippled with deformities and 1.4 lakhs die annually. The
facilities for treatment are from meager to non-existent in some parts of the country. The progress has been no happy
fluke, but a personal response to the challenge by a very few in the country. The research of some workers on the
physiology and pathology of this trauma has given us valuable new insights; others have had the vision to see how new
understandings could be translated into useful techniques, while yet others have responded to the clinical challenge by
commitment of their lives to the delivery of burn care and to burn prevention.
Historically speaking, the first dedicated burn unit was started in India under my guidance in the Department of Burns,
Plastic and Maxillofacial surgery at Safdarjung Hospital, New Delhi in 1963 and this department went on to become the
largest burn care unit in Asia. This unit has been an example of commitment and dedication to the cause of optimum burn
care in the country. Over the years, the details of treatment have been changing and facilities improved and advanced with
progress in the world by various subsequent heads of the department. It is a matter of great pride that this book also
comes from the same department where the story started in a barrack of a hospital designed for wartime casualties. The
journey for this department has been long and arduous and I am happy to say that it has enjoyed the status of excellence
all this while.
The editors are to be congratulated on recording in this volume entitled Principles and Practice of Burn Care, the
views of several authors covering the entire country. This book has been divided into 7 sections, depending on the various
situations in managing burns and has contributions from eminent specialists involved in burn care and research. Each
section has chapters relevant to clinical management of the burn patient. The book is comprehensive and yet makes for
easy reading. I am sure the students and doctors will find here the important practical information they need to give safe
and thorough care to their burn patients.
I also hope that this book will be used in other developing countries especially by those who work in peripheral district
hospitals and private medical practitioners with limited means. The basic essential to start a unit, is to have a committed
staff who are ready to be spent for the sake of those in their care. The book will provide them with knowledge they need.
I wish this book a great success.
JL Gupta
Consultant in Burns, Plastic and Maxillofacial Surgery,
Formerly, Head of Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung Hospital, New Delhi
Professor of Plastic Surgery, University of Delhi
Patron, National Academy of Burns – India
Foreword

(Trang không có chữ)

Preface
Burns is the most serious injury ever inflicted on mankind. This appears to be the price of civilization which man is paying
today. India is amongst the few countries of the world where the incidence of burns is showing a rising trend even though
it is on the decline in the Western world. Management of burns is difficult and time consuming. Apart from being a costly
treatment, it is also a heart-breaking experience for any specialist treating a burn victim and rehabilitating him back to the
society is equally difficult.
Over the centuries, we have discovered how to use new technological innovations and scientific advances to the
greater advantage of victims of burns, fire, bomb blast and other terrorist crimes. However, in view of the continuously
changing circumstances, it becomes imperative for burn surgeons, physicians and other para-medicals to constantly
learn to change and accept changes and keep themselves updated at all the times with the new skills and techniques in the
management of burn patients. We cannot afford to remain silent, inactive or resilient even in the treatment of minor
accidental burn cases which otherwise receive scant attention by the hospital staff possibly because they are not dangerous
to life or due to lack of interest on their part.
In the 21st century we are learning to evaluate new products and technologies more realistically. In short we are
re-discovering the wisdom of our ancestors and learning to value the efforts made by others so far in modifying and
improving our methods and skills in burn care. Regular studies and continuous research in various fields have proven to
be the right investment in improving every aspect of human life—so why not for burn injury?
Though a burn specialist treats burn patients, but the modern treatment of major burns depends upon multidisciplinary
team approach which includes anesthetist, medical specialist, pulmonologist, nutritionist, physiotherapist and occupational
therapist. Each of them helps in providing a holistic approach towards treating and rehabilitating a burn patient.
This book brings together the knowledge and clinical experience of many of the specialists from all over the country,
who have made outstanding contributions in the field of burn care. An attempt has been made to deliver comprehensive
information about the treatment of a burn victim in all its aspects from the experiences and expertise of these surgeons
and physicians serving in the battlefield of burns, i.e The Burn Units; thus gaining and giving opportunities to learn from
the best. This book emphasizes not only on the treatment and rehabilitation of burns but also the pathophysiology of burns
and its prevention. It was not an easy task and required constant follow up to get others associated in producing this
book.
I am thankful to all the contributors who are experts in their own fields for sharing their knowledge and experiences
which have been reflected in their contributions, which I am sure will be beneficial to all the postgraduate and practicing
burn surgeons who will be reading this book.
I have personally inserted photographs of many interesting cases in various chapters in addition to the photographs
provided by the contributors in order to make the topic more interesting and easy to comprehend.
A book of this magnitude cannot be brought out single handedly. Dr Arun Goel, Dr VK Tiwari and Dr LC Gupta have
been associated in editing this book and their help and support cannot be acknowledged in words. Without them, it would
not have been possible to bring out this book which is complete in every sense, whether it is in the text content, pictorial
depiction or practical case management protocol.
I am grateful to Dr SP Bajaj, who has been my guide and a father figure in burn management in India, for his valuable
suggestions and encouragement at every step.
I am also thankful to my residents specially Dr Jeethendran Iyer for providing help in procuring the case photographs
and Dr Geetika Khanna for providing the histological slides.

I must especially thank my publisher M/s Jaypee Brothers Medical Publishers (P) Ltd. especially Shri Jitendar P Vij
(Chairman and Managing Director), Mr Tarun Duneja (Director, Publishing) for having recognized the merits of the
presented material and to have come forward enthusiastically for publishing the book.
Lastly, I am thankful to my family for their moral support in helping me complete this book.
JAI HIND and Good Luck to my readers whoever and wherever they are.
Sujata Sarabahi
xiv
Principles and Practice of Burn Care

SECTION 1: General Considerations
1. History, Epidemiology and Prevention of Burns ................................................................................................. 3
Ravi Chittoria
2. Anatomy of the Skin ............................................................................................................................................ 18
Sujata Sarabahi
3. Burns: Etiology and Classification ..................................................................................................................... 25
Sameek Bhattacharya
4. Pathophysiology of Burn Shock .......................................................................................................................... 37
Arvind Vartak
5. Pathophysiology of Burn Wound ........................................................................................................................ 42
Arvind Vartak
6. Wound Healing in Burns ..................................................................................................................................... 51
Mary Babu, N Shanmuganathan, B Karthikeya Prabhu
7. Immunological Responses to Burn Injury ........................................................................................................ 69
Shankar Sriniwasan
8. The Immunobiology of Skin Transplant Rejection and Acceptance............................................................... 73
Rakesh Kain
9. Microbiology in Burns .......................................................................................................................................... 79
Deepthi Nair
SECTION 2: Early Care in Burns
10. Initial Evaluation and Resuscitation of Burn Patient .................................................................................... 101
Madhuri A Gore
11. Respiratory Tract Injury in Burns.................................................................................................................... 127
JC Suri, MK Sen
12. Fluid, Electrolyte and Acid-base Disturbances in Burns................................................................................ 137
Sujata Sarabahi
13. Acute Renal Failure in Burns and its Management...................................................................................... 142
Rajiv Kohli, Arun Goel
SECTION 3: Local Care of Burn Wound
14. Burn Wound Management ................................................................................................................................ 153
Sujata Sarabahi
15. Surgical Excision of Burn Wound and Skin Grafting .................................................................................... 196
Pramod Kumar
16. Anesthesia for the Thermally Injured ............................................................................................................. 208
PK Verma
17. Biological Dressings and Skin Substitutes in Burns ...................................................................................... 223
PK Bilwani, Deepak Nanda
18. Skin Banking ...................................................................................................................................................... 231
Sujata Sarabahi, Deepak Nanda
19. Keratinocyte Culture ......................................................................................................................................... 235
RP Narayan
Contents

xvi
Principles and Practice of Burn Care
20. Burn Wound Infection ....................................................................................................................................... 241
VK Tiwari, Sujata Sarabahi
SECTION 4: Burns of Special Types
21. Electrical Burns .................................................................................................................................................. 263
SP Bajaj
22. Industrial and Chemical Burns ........................................................................................................................ 290
Mamta Sikroria
23. Radiation Burns .................................................................................................................................................. 313
BC Shankar, PR Bongirwar, Hemant Haldavnekar
24. Friction Burns ..................................................................................................................................................... 326
Karoon Agrawal
25. Firework and Firecracker Injuries .................................................................................................................. 333
Arun Goel, Sameek Bhattacharya
SECTION 5: Burns of Special Sites
26. Facial Burns ........................................................................................................................................................ 345
PS Bhandari
27. Hand Burns.......................................................................................................................................................... 362
S Raja Sabapathy
28. Burns of Perineum and External Genitalia ..................................................................................................... 383
Deepak Nanda
29. Pediatric Burns ................................................................................................................................................... 390
Harish Chellani, Sugandha Arya
30. Burns during Pregnancy .................................................................................................................................... 405
Shailesh Ranade
SECTION 6: General Management and Rehabilitation
31. Multiple Organ Dysfunction Syndrome in Burns........................................................................................... 413
Anil Chadha , Indu Chadha, Amitabh Singh
32. Guidelines for Nutritional Management of the Burn Patient ....................................................................... 434
Savita Arora
33. Physiotherapy for Burn Patients ...................................................................................................................... 450
Sarla Passi
34. Post Burn Sequelae and their Management ................................................................................................... 468
Arun Goel
35. Medicolegal Aspects of Burn Injuries .............................................................................................................. 516
Chandrakant, Sujata Sarabahi
36. Legal Requirements in Managing Burn Patients ........................................................................................... 524
Atul Kumar Shah
37. Burn Disfigurement and Physical Impairment Calculations ........................................................................ 527
Atul Kumar Shah
SECTION 7: Organization of Burn Care
38. Organization of a Burn Unit.............................................................................................................................. 537
Madhuri A Gore
39. Burn Injury Management in Disasters: Indian Perspective ......................................................................... 546
Ravindra Tah
Appendices .................................................................................................................................................................... 569
Investigations ................................................................................................................................................................ 587
Index
.......................................................................................................................................................................... 601

Section General Considerations

History, Epidemiology and
Prevention of Burns
1
Ravi Chittoria
Chapter
Burn Injuries represent one of the most important public
health problems faced by both developing as well as
industrialized nations today. Burn Injuries may be intentional
or nonintentional but intent is sometimes difficult to
determine. Burns or thermal injuries occur when hot liquids
(scalds), hot solids (contact burns) or flames (flame burns)
destroy some or all of the different layers of cells which
form the human skin and even deeper tissues. For traditional
reasons, skin injuries due to ultraviolet radiations or
radioactivity, electricity and chemicals, as well as respiratory
insults resulting from smoke inhalation, are considered as
fire/burn injuries. Burns represent an extremely stressful
experience for both the burn victims as well as their families.
An extensive burn profoundly affects the patient’s physique,
psyche, financial situation and family. Patients suffering from
extensive burn injuries frequently die while others suffer
from painful and prolonged physical recovery. In different
communities and countries, the etiological factors
responsible for burn injuries vary considerably, hence a
careful analysis of the epidemiological factors in different
places is needed before the planning and implementation of
a sound prevention program. This chapter highlights the
history, epidemiology and prevention strategies for burns in
both the developed and developing countries especially
pertaining to Indian Scenario.1,2
HISTORY OF BURNS
“Those who fail to read history are destined to suffer the
repetition of its mistakes”.
“You have to learn what others have done because you
won’t live long enough to make all the mistakes yourself”.
INTRODUCTION
Burn trauma is as old as the discovery of fire in the history
of mankind. Medicine is built on the best of the past. Thus,
a study of ‘History of Burns’ contributes to a review of
accomplishments and errors, false theories and
misinformation and mistaken interpretations. The history
of burns, especially in India, is very fascinating. It teaches
us where we started from, where we stand today, in what
direction we are marching and guides us for the future.1,2
HISTORY OF BURNS IN THE ANCIENT AGES
World History
The philosopher Santayana said; “Those who cannot
remember the past are condemned to repeat it”. In an
address to the Royal College of Surgeons, Churchill
remarked; “The longer you look back, the further you can
look forward”. In considering the history of the treatment
of burn injuries, one might quote Adam MacDougall, who
in 1819 stated that “It would equally exceed the bounds of
convenience and utility to particularize all the remedies that
have been recommended in the treatment of accidents of
this kind”. Hippocrates (430 BC) used swine’s semen, resin,
bitumen and Oak bark solutions in the treatment of burns.
Chinese (600-500 BC) used extracts of tea leaves. Smith
papyrus (1500 BC Egyptians) used gum and goat’s milk
mixed with mother’s milk and strips soaked in oil. Celsius
(ancient Rome) advocated honey and bran. Glen (ancient
Rome) described vinegar or wine in the treatment of
burns1-3 (Table 1.1).

4
Principles and Practice of Burn Care
Indian History
Fire injuries in India have been common right from the
ancient times. Suicide by fire out of insult was one of the
common reasons. In Shiva Purana, it is mentioned that Lord
Shiva’s consort Sati had jumped into the sacred fire after
being insulted by her father Daksha. Another reason for
suicide by fire was ‘Sati Pratha’ a common tradition of
committing suicide by widows. It is well known that Plastic
Surgery originated in India in the Vedic Period about 3500
BC. Among the many distinguished names in Hindu medicine,
that of Sushruta, the ‘Father of Ancient Plastic Surgery’
stands out in prominence (Fig. 1.1). Sushruta was the son
of the sage Vishwamitra, contemporary of Rama of
Ramayana. He compiled the surgical knowledge of his time
in his classic ‘Sushruta Samhita’. It is believed that this
classic was compiled between 800 BC and 400 AD. Sushruta
was the first to classify burns into four degrees: Singeing,
Blister, Superficial and Deep Burns.1-3
HISTORY OF BURNS IN THE MIDDLE AGES
World History
The British at the Battle of Crecy in 1346 were the first to
use gunpowder and this development gave rise to many
medical problems including those associated with the
treatment of burns. The stimulus of the war experience
initiated new and experimental types of treatment. In 1596,
Clowes wrote a treatise on gun powder burns. He did not
differentiate the depth of burns but rather described multiple
types of treatment on different part of the body. He suggested
oily dressings containing many drugs, did not open the
blisters and was an advocate of bleeding. Ambroise Pare
(1517-1596) described about excision and ointments.
Fabricus Hildanus (1610), who wrote De Combustionibus,
was the first to classify burns into three categories and also
showed pictorially the early successful surgical release of
hand contractures. Pare clearly described the differences
between second and third degree burns that frequently
developed contractures. Richard Wiseman in 1676 wrote
several “chirurgical treatise” and discussed splinting to avoid
contractures. He advised refrigerants or calefactive
medicaments. Kentish (1797) described pressure dressings
as a relief for pain and in his essay on burns promised to
“rescue the healing art from empiricism and to reduce it to
established laws”. David Cleghorn (1792) used vinegar and
chalk poultice for burns treatment. The use of ice and ice
water for analgesia and the prevention of edema was
explained by H Earle (1799) in his essay “the means of
lessening the effects of fire on the human body”. Syme
(1827) used wool dressings. Lisfranc (1835) described
calcium chloride dressings. In 1823 the Edinburgh Medical
Journal published two papers on postmortem finding in two
burn deaths. One patient had a gastric ulcer and another
Table 1.1: Burn treatment history
Neanderthal man
Extracts of plants
Smith papyrus
Gum and goat’s milk mixed with
(1500 BC, Egyptians)
mother’s milk
Chinese (600-500 BC)
Extracts of tea leaves
Hippocrates (430 BC)
Swine’s semen, resin and bitumen
Oak bark solutions
Celsius (ancient Rome)
Honey and bran
Rhases (9th century)
Cold water
Pare (1517-1596)
Excision and ointments
David Cleghorn (1792)
Vinegar and chalk poultice
Edward Kentish (1797)
Pressure dressings
Syme (1827)
Wool dressings
Lisfranc (1835)
Calcium chloride dressings
Passavant (1858)
Saline baths
Joseph Lister (1875)
Boric acid and Carbolic acid
Tomasalis (1897)
Salt water injections
Wallace (1949)
Exposure treatment
Keswani MH
Boiled potato peel (BPP) bandage
(1984, India)
Fig. 1.1: Sushruta at work

History, Epidemiology and Prevention of Burns
5
gastric congestion. Multiple lectures at this time were
describing perforation of the stomach following burn deaths
and there was increased interest in studying both the
pathology and treatment of thermal injuries. Cotton dressing
over burns was first discussed in a Glasgow Medical Journal
in 1928. Readers were told how to apply dressing and were
cautioned against changing them more than once daily.
Dupuytren (1832), the brilliant French surgeon, made
multiple contributions to burn research, including the
documentation of the degree of injury to depth and the
description of the phases of the post-burns course—
irritation, inflammation, suppuration, and exhaustion. Sir
George Ballingall in 1833 gave one of the best description
of death from burn sepsis; “sinking in a hectic state,
exhausted by a profuse discharge of matter from an
extensive separating surface”. In a land mark decision in
1848, the managers of the Royal Infirmary in Edinburgh
designated one building for all burn cases and this became
known as the burns hospital. Passavant (1858) gave concept
of saline baths. In 1875 Joseph Lister recommended boric
acid and carbolic acid for burn wounds in order to kill
bacteria. In 1881 Tappeiner of Munich studied autopsies of
burn deaths and recognized the concentration of blood,
increased hemoglobin concentration and decreased blood
and water volume. The appreciation by Tappeiner of burn
pathology was a significant event. Thomasalis (1897)
described use of salt water injection.1-3
Indian History
The history of burns in India in medieval period is that of
decline in India and lull in European countries. The natural
feeling of fear for operations grew and love for medicines
increased. The governments prohibited and neglected the
practice of surgery. The famous Buddhist scripture
Mahavaggaa Jatak enjoined strict prohibition of surgery and
extended the terror of hell both for the surgeon and the
patient. ‘Manusmriti’ prescribed special rituals by way of
purifications of surgeons, who were looked down upon as
unclean. Later during the Rajput, Muslim and Maratha
periods, Ayurvedic (Hindu) and Unani (Arabic) systems of
medicine were practiced by Vaids and Hakims respectively.
The Vaids were purely physicians and the practice of surgery
was restricted only to incision of abscess, dressing of
wounds and treatment of bone and joint injuries by barbers
and bone-setters. Not much information is available in
literature related to burn injuries.1-3
HISTORY OF BURNS IN THE MODERN AGE
World History
In 1905, Sneve noted the importance of intravenous saline
for resuscitation and wrote an article in the Journal of the
American Medical Association advocating early skin grafting.
The understanding of burn pathology took a great leap
forward when Underhill (1930) studied a group of patients
burned in a theater fire in 1921. He analyzed the content of
blister fluid and determined that burn shock was due to
fluid loss and not toxins (a popular theory of that time).
The Coconut Grove Fire in Boston in 1942 resulted in
extensive studies by Cope and Moore on the diagnosis and
treatment of burn shock. Controversies over the best method
to treat the burn wound persist to the present day. Dressings
remained popular until Wallace in 1949 advocated exposure
treatment for burns of the face, buttock and perineum.
Formulas gradually evolved to calculate fluid losses. Evans
(1952) used burn skin surface area and weight as the
principal variable. The Brooke formula was a modification
of the Evans formula and utilized salt, colloid and water.
Moyer and Associates (1965) recommended only Ringer’s
lactate solution, yielding alert, oriented patients even when
the body surface area burn was large. The pattern of triage
of burn patients changed dramatically in the 1960’s. The
US Army Research Unit was initially guided by Pulaski and
Artz, who stressed patient care as well as clinical and
laboratory burn related research. Critically injured patients,
civilian and military, were referred to the center and the
concept of the multidisciplinary burn team evolved. In 1962
the Shriners fraternal organization in the United States began
development of three burn centers affiliated with universities
and dedicated specifically to the care of burned children.
These centers served as role models that have completely
altered burn care around the world. Their superb survival
statistics made others realize that patients with large burns
were not automatically doomed but had a chance of survival
if cared for in a specialized center. Laboratory and Clinical
Research in burn injury improved other areas of trauma
care as well. It became obvious that the burn patient with
multi-system involvement was the perfect trauma model.
The universality of the burn problems provided a reason
for better international cooperation and exchange of ideas.
In 1960, the first international congress on research in burns
was held in Washington, DC. At the second meeting in 1963,
The International Society for Burn Injuries (ISBI) was

6
Principles and Practice of Burn Care
founded and it has been conducting meetings every four
years. The American Burn Association was founded in 1968.
The society’s membership was unique in that it consisted
of all the members of the burn team, including non-
physicians (Dieticians, Physical and Occupational therapists,
Nurses and Psychologists).3
Indian History
Burns became alarmingly frequent in India in the modern
age of industrialization. To pour kerosene over the clothes
and then set them on fire is the most common form of
committing suicide or murder. There are also innumerable
instances of accidental burning caused by clothes catching
fire on low stoves or open gas rings; the loose flowing end
of ‘saris’ and ‘dupatta’ of Indian women increases this
danger enormously. Open fires in winter are an added hazard.
Acid burns of the face are frequently the result of blind
jealousy. Suicidal burns amongst Hindu women are usually
fatal because of its extent. Practice of tradition of ‘Sati
Pratha’ declined in this period. Most of the burn cases in
India are treated by General Surgeons and General
Practitioners in small cities and rural areas because Plastic
Surgeons are few and settled mostly in Metro cities. These
General Surgeons and General Practitioners have negligible
facilities and have no forum to exchange, enhance or update
their knowledge. The initial local treatment on admission to
hospitals varies according to the area involved in the burns—
face, front of chest and abdomen are routinely treated by
the exposure method. Burns of extremities and fingers alone
are dressed. The majority of hospitals do not have the
‘Stryker Frame’ and hence only circumferential body burns
are dressed. Resistant strains of organisms have increased
in recent years due to excessive use of antibiotics. Surgeons
are not in favor of keeping grafts exposed from the start.
Skin grafts are dressed with pressure pads for a week and
then kept exposed. To keep the donor area exposed was
attempted by many but were not satisfied by this method.
In fact, dressing of the donor area is retained for a fortnight
during which the part heals. Severe cases of contractures
of the flexor creases like the neck, axilla and elbow are
released and skin grafted. Free grafts are preferred to tube
pedicles as the relief is quick as well as complete.4
In India many Plastic Surgeons have contributed in the
development of Burns Unit and management in modern era.
Dr Noshir H Antia, the 3rd generation trained Plastic Surgeon
under Sir Harold Gillies was the first surgeon to start a unit
at Grant medical College and associated JJ Hospital, Mumbai
in 1959. In 1964, Tata Trusts provided a substantial grant
to carry out two projects–one on Leprosy and other on
Burns. In 1963, Safdarjung Hospital, Delhi started a
department of Burns, Plastic and maxillofacial surgery with
Dr JL Gupta as its head. Professor Antia felt that they should
have a forum and thus, a Burn Association of India (BAI)
was formed at JJ Group of hospitals, Bombay in 1972. Dr
MH Keswani was the Secretary. Later under leadership of
Dr Keswani the Burns Association of India (BAI) flourished
with contributions like Boiled Potato Peel (BPP) dressings,
prevention campaigns by way of radio and TV talks, small
documentary ads, ‘School Education Program’ in burns
etc. “Pour water on Burns” has received worldwide
popularity. ‘AGNIVARTA’ is a quarterly publication of ‘Burns
Association of India’ devoted to the problems concerning
Burns. Burn injury is a disease of the poor at least in our
country. Dr Keswani gave various modifications to reduce
the cost of burns treatment like common home made curd
(called yogurt in the US) as a de-sloughing agent, Butter
Milk Diet (BMD) as cheap high calorie high protein diet,
X-Plasty of Vartak as a simple operation of release of
contracture, Vartak’s wheel as mesh graft dermatome,
cellophane dressing for donor area, simple operation cum
bath trolley, etc. Dr Keswani has to his credit the setting up
of the first children’s burn unit in India and India’s first
skin bank at Bai Jerbai Wadia Hospital in Parel, Mumbai in
1975 and 1978 respectively.5-7
In 1990, Prof J L Gupta convened a meeting at Pragati
Maidan, New Delhi. A very active and detailed discussions
and consultations were held amongst Prof JL Gupta, Prof
Mathangi Ramakrishnan, Prof J K Sinha, Prof S P Bajaj,
Prof S K Bhatnagar, Prof R K Keswani, Prof Siti Roy
Choudhary, Prof PK Bilwani, Prof Madhuri Gore, Prof D L
N Prasad, Prof Swarna Arora and Prof Anil Chadha and
many others. This historic and significant meeting led to
the birth of National Academy of Burns - India (NABI).
NABI mainly aims at preparing and making available a
suitable appropriate and latest information relevant to all
those concerned with burn care. Recognizing the services
of Prof J L Gupta in the field of burns in the country, he
was unanimously named as the Patron of NABI. Prof S N
Sharma was the choice for the founder Presidentship. Dr S
P Bajaj became the founder Secretary. The academy brought
out an annual journal named ‘Indian Journal of Burns’ with
Dr Rajeev B Ahuja and Dr Arun Goel as editor and assistant
editor respectively. They worked for five years (1993-1997)
before passing on the task to others. The first volume was

History, Epidemiology and Prevention of Burns
7
brought out in 1993 and the journal is being regularly
published. While NABI is an association of burn care
professionals (doctors, nurses, therapists etc.), BAI even
included persons like businessmen, old recovered burn
victims, etc. who were ready to serve the cause of burns in
their own way.
Dr JL Gupta gave guidelines for planning a Burns Unit.8
Subsequently many Burn Units have been developed
successfully in various Institutions and Medical Colleges
like Burn Unit in the Department of Plastic Surgery at
Kasturba Medical College, Manipal, Karnataka, IPGME&R,
Kolkata etc. Of all the existing Burns Units in India, special
mention is made of Burns Unit of Safdarjung Hospital, New
Delhi which is the largest burn unit in the country and which
has been modernized and equipped with all modern Burn
care infrastructure facilities. ‘Early Tangential Excision and
skin grafting’, ‘Rescuer Burns’, ‘Policy of antibiotics in
Burns’ etc. has been popularized extensively by the Burns
Unit of Manipal, Karnataka.9,10
In India, Burn injuries due to fireworks on the occasion
of ‘Diwali’ are very common. Safety tips related to
Fireworks have been explained by Anjali Burma.11 The
Government health system is not able to keep pace with
population growth in recent years. Although major burn
accidents are decreasing in relation to the population growth,
the actual number of burn cases is on the increase. Gradually
more and more teaching hospitals started separate Burn
wards. Possibly about 60% of them are managed by the
General Surgery services and the rest by a Burn and Plastic
Surgeon. The requirement for more burn beds encouraged
many non-government groups into establishing burn
management centers. Many of these centers have well
equipped wards, trained support staff and enthusiastic Burn
Specialists. These specialists have been instrumental in
maintaining the prevention and rehabilitation programs
concerning burns.9,10
RECENT ADVANCES
What have been the outstanding features of burn injuries in
the last twenty five years? It is the better understanding of
burn pathophysiology that is the most remarkable feature
of last quarter of a century. The second important feature
is the realization that the care of Burns is a team effort, the
leader of the team being the one, who can lead the team
most inspiringly, a person with vision, with dedication and
with tenacity. It would not be fair to single out any one
individual for all the advances. Half a century ago, the
commonest cause of death following a burn greater than
20% was surgical shock, at least in India. With a better
understanding of post burn surgical shock it is possible to
treat this rationally and efficiently. The mortality from this
cause has reduced considerably. Generalized infection of
the tissues (septicemia) is the single most common cause
of death following burns, at present. Better drugs and their
wide-spread availability have helped us to control infection
to some extent. However, while these drugs are useful, they
have many undesirable side effects, some of them lethal.
Moreover, the cost of these drugs is prohibitive. They have
encouraged resistant strains to develop and they have put
the clock back in many instances. Post burn sequelae need
correction. These have been satisfactorily corrected by
reconstructive surgeons and in many instances by interested
general surgeons. Early post burn rehabilitation has been
encouraged, but much progress needs to be made in this
direction in this country. When the hands are burned, it is a
severe blow to the person’s economic viability. Better
methods of rehabilitation need to be developed. Unfortunately
over the last 25 years, not much progress has been made in
this area. It costs approximately US $1,000 per patient per
day to provide satisfactory care in the Western world. This
is clearly not possible in India and in many of the developing
countries. Prevention of burns is the only logical solution.
This is not easy and is time consuming. Easy or not, we
have no option(s). We must prevent burns. Fortunately the
Burns Association of India, which was formed in 1972, has
been doing precisely that. Burns Prevention has to be
propagated zealously by everyone who is able to do so,
especially Doctors, Nurses, Paramedical workers, Social
workers, teachers, surviving burns patients, and the
media — in fact it should be a national responsibility. India
is a country with tremendous problems-those of population
explosion, education, malnutrition, unemployment and many
more. Our hopes lie in a unified approach to work together
and solve some if not all of these problems.12
EPIDEMIOLOGY OF BURNS
“I keep six honest serving men; they taught me all I know.
Their names are ‘WHAT’, ‘WHY’, ‘WHEN’, ‘HOW’,
‘WHERE’, and ‘WHO’.”
INTRODUCTION
Epidemiology has been defined by John M. Last in 1988 as:
“The study of the distribution and determinants of health-

8
Principles and Practice of Burn Care
related states or events in specified populations and the
application of this study to the control of health problems”.
Epidemiology began with Adam and Eve, both trying to
investigate the qualities of the “forbidden fruit”. Epidemiology
is derived from the word epidemic (epi = among; demos =
people; logos = study), which is a very old word dating
back to the third Century BC. Burn injuries and their related
morbidity, disability and mortality represent a public health
problem of increasing importance in developing countries.
Developing countries have a high incidence of burn injuries,
creating a formidable public health problem. Epidemiological
studies of burn injuries are a prerequisite for effective burn
prevention programs because each population seems to have
its own epidemiological characteristics and knowledge of
the epidemiology of burns is needed to select target groups
for preventive actions.13
BURN REGISTRY
The American Burn Association (ABA) commissioned
Jeffrey T Suffle and Byron of the University of Utah Health
Center, Salt Lake City, Utah, USA, to develop a computer
program to assist burn units to collect data useful for patient
care and prevention. The ABA graciously permitted the
International Society for Burn Injuries (ISBI) to distribute a
version of this program, adapted for use internationally, to
ISBI members free of charge.14
USES OF BURN DATA
Burn data are useful to:
1. Define the burn problem.
2. Determine the most common ways that people are
burned.
3. Evaluate the effectiveness of medical care for burn
patients.
4. Identify which burn hazards should be targeted by burn
prevention programs.
5. Examine the economic impact of burn injuries and burn
treatment.14
SOURCES OF BURN DATA
The sources of burn data vary, depending upon the severity
of the burn injury:14
i. For burn deaths: Collect information from hospitals
and local, regional or national vital statistics registries.
Many people die immediately of fire and burn injuries
and do not receive medical care.
ii. For serious burns: Collect information from hospitals;
decide whether to collect data only on burn patients
admitted to the hospital, or on all patients seen at the
hospital. If there are several hospitals treating burn
patients from the defined population, collect data from
all these hospitals. Referral patterns may distort the
true profile of burns in that population.
iii. For less severe burns: Collect information from health
clinics, doctors’ offices, visiting nurses or any other
medical treatment service. A good sampling plan will
make this task easier.
iv. For burns of all levels of severity occurring in a
community: Collect information through a community
survey, asking residents in face-to-face or telephonic
interviews to recall circumstances of burn injuries
suffered by family members. Questions about burn
injuries could be added to a larger multipurpose
community survey.
v. For burns associated with building fires: Contact the
local fire service for information about fires in which
people were killed or injured. Remember, this is not a
good source for clothing ignition burns, scalds,
contact, electrical or chemical burns.
STANDARD CODING OF BURN INJURY DATA
Most countries use the World Health Organization’s
International Classification of Disease (ICD) Codes for
coding data on hospital discharge records, although there
are other coding schemes. For example, the Nordic countries
use a coding scheme called NOMESCO. The ICD system
contains two sets of codes for burn data. The first set
classifies what type of fire or burn injury was sustained:14
Code
Type of Burn
940-949
Burn injuries
986-987
Smoke inhalations
692.71
Sunburn
910-919
Superficial injuries (friction burns are among
these codes)
The second set of codes is the ICD E-codes (External
Cause of Injury), which classify the causes of burn. These
are four-digit codes, with the fourth digit often capturing
important burn information:14
Code
Cause of Burn
E890-899
Burns caused by fire and flames
E923
Accident caused by explosive material
(Includes fireworks and explosive gases; not
all injuries coded here are burns)

History, Epidemiology and Prevention of Burns
9
E924
Accident caused by hot substance or object,
caustic material and steam
E925
Accident caused by electric current (burns
or electrocution)
E926
Exposure to radiation
E958.1, .2
Suicide (by burns or scalds)
E965-968
Homicide and assault (965.6, 967, 968.0,
968.3 related to burns)
E988.1, .2
Undetermined if accidentally or purposely
inflicted
E990, 996
War
NATURE OF DATA NEEDED TO STUDY BURN
EPIDEMIOLOGY14
How Big is our Burn Problem?
Determine the number of people who have been burned.
Do not ignore burn deaths, especially those who die before
coming to the hospital. Counts of non-fatal burns are made
easier in areas where computerized hospital discharge
records are coded using the International Classification of
Disease Codes or another standard coding scheme. Count
the number of patients with a burn injury diagnosis, coded
using ‘type of burn’ codes.
How are our People Getting Burned?
Determine the number of people burned by specific causes
of burns, such as clothing ignition or scalds. Collect
information which will permit patients to be classified using
‘cause of burn’ codes. Accurate, useful coding depends
upon accurate, useful information in the medical record.
This includes details about the circumstances of the burning,
ignition sources and other product involvement, where the
event happened and the activities of the people involved and
demographic information about the patient. This often
requires an interview with the patient, a family member or
someone present at the burn episode. Make sure that this
information is written in the medical record, coded and,
whenever possible, entered into computerized hospital
discharge records.
How can we Prevent Burns?
Analyze data describing the common causes of burn injuries
in the population to identify high risk groups such as young
children and high-risk activities, such as meal preparation.
How can we Evaluate the Success of our
Prevention Programs?
The precise nature of the data required depends upon the
prevention program and the research design of the
evaluation.
Information about Larger Populations
It is important to know certain characteristics of the defined
population, whether this be a village, a region or a country.
Important characteristics are: the number of people in the
population and the age distribution of these people. If your
country collects and publishes census data, these provide
an excellent source of information to use to describe risk
factors for burns in your population.
Burn Rates
Burn epidemiology uses rates of burn injury or deaths. A
rate is calculated by dividing the number of burn injuries
sustained during a specified time period by the number of
people in a population during that same period. It is
expressed, for example, as ‘burns per 100,000 populations
per year’. One must use burn rates to compare the burn
problem in communities or countries with different sized
populations. A densely populated community may have
many more burns but a relatively lower burn rate than a
sparsely populated region. A lower burn rate signifies a lesser
burn problem. It is important to know the age distribution
of the defined population because burn risk is age-related. A
population with a lower median age will have higher rates
even if its adults have an equal or slightly lower risk than a
population with a higher median age.
Usefulness of Burn Data from a Single Hospital
If only one hospital treats patients with serious burns in a
defined population and if one is interested only in serious
burns, the vital statistics registry and this hospital are the
two appropriate data sources for fatal and serious burn
injuries, respectively, for that population. If the hospital is
one amongst many serving a single population, one cannot
draw any conclusions about the population’s burn problem
by studying only one hospital. However, even without
collaboration with other local hospitals, it can be valuable to
analyze burn data from a single hospital. Individual hospitals
can provide useful information about a specific circumstance

10
Principles and Practice of Burn Care
which causes burns and can provide ‘cases’ for a ‘case-
control’ study. One cannot, however, draw conclusions
about the population’s burn problem.
EPIDEMIOLOGY OF BURNS IN INDIA
National Burns Registry
One of the major activities of The National Academy of
Burns-India (NABI) is to maintain a National Burns Registry.
Various data is collected from centers engaged in
management of Burns. This is, however, a voluntary effort
and has so far not reached to all places. In a few years with
continued efforts and support from all areas, National Burns
Registry of NABI will be able to truly reflect the scene of
burns problem in India.15
Extent of Problem (Mortality and Morbidity)
Over 100,000 people are affected by burns in India annually
and 20,000 of them die according to rough estimates.16 In
1991, the reported deaths were 22,306. A survey of almost
3500 hospital admission over the past few years
supplemented by intermittent published reports over the past
30 years indicated a mortality rate of between 25% and
49% for adults and between 6% and 20% for children (0-
10 yrs old).17 Ten percent of all accidental deaths and seven
percent of all suicides in India are caused by fire. Although
incidence of burn trauma is on the decline in the developed
nations, it is still rising in India and is second largest killer
after road traffic accidents. Thousands of victims of burns
are being mutilated, disfigured and handicapped every year.18
The cost of burns is both visible and invisible. In India, the
cost of burns ranges from $25 to $300 a day. To this may
be added the loss of wages of the patient and of those who
have to be away from work to care for him or her during
hospitalization. The other visible cost is in the scarring and
deformity, of loss of hair and body- pigment and alterations
in skin texture. There is also a loss of physical skill which
leads to demotion at the place of work and makes one less
fit or unfit in domestic life. The invisible cost is in the pain
the patient undergoes, both physical and emotional, the
emotional trauma of itching, of scarring and intolerance to
heat. Neither the trauma of patient’s psyche nor the
imperceptible alterations of the patient’s personality can be
measured. And then, there is loss of time—of time lost from
studies, of vanished opportunities in social life, like marriage
or career promotion. And finally, one has to remember the
cost to the patient’s family–to the husband who loses a
beloved wife, to the child who becomes motherless, to a
young wife who becomes widowed and to the aged parents
who loose their support. In India, society is structured
differently and the cost borne by the patient’s family is truly
immense and immeasurable.19
Age and Sex Distribution
The age distribution revealed by various studies in India
shows that more than half the cases are aged between 21-
40 years. In children, the lack of coordination and
unawareness of dangerous substances play an important
role in the occurrence of burns. High incidence among
young adults may be explained by the fact that they are
generally active and exposed to hazardous situations both
at home and at work.20-22 Male predominance in the younger
age group (5-10 years) might be explained by the inquisitive
and exploring nature of boys of this age. As regards sex
distribution, the female preponderance in the age group
20-40 years concurs with reports from other developing
countries and might be explained by the involvement of
females in domestic activities and dowry deaths too.
However, figures from industrialized countries are clearly
lower than those reported from developing countries. This
may be due to the relatively lower percentage of occupational
and recreational burns or due to better home safety with
safer cooking and heating devices in industrialized
countries.23-25
Sociocultural Factors
Sociocultural factors are among the major causes of different
age and sex predisposition of developing countries like India
compared to other developed nations. The majority of the
patients belong to low socioeconomic status (69.6%), while
21.8% are from middle and only 8.6% are of high
socioeconomic status. 42.6% belong to an urban area while
the rest are from rural areas. Arrival time to hospital after
the incidence is variable, only few patients (9.7%) arrive
within six hours of the incidence. The majority (61.8%)
reached the hospital between 6 and 24 hours; those reaching
the hospital after 24 hours contribute about 28.5%.26-28
Etiology
An extensive study was done by the department of Burns,
Plastic and Maxillofacial Surgery, Safdarjang Hospital, New
Delhi.29 Analysis of the causes of 9927 burn cases is given
in Table 1.2.

History, Epidemiology and Prevention of Burns
11
It is seen that the vast majority in these are dry burns,
by direct contact with either flash or flame. The second
most common are scalds. This is because of conditions
which are peculiar to the villages in our country. Most of
the cooking is done at the floor level with open fire. Stoves,
coal and wood are commonly used. Often large families
live and cook in the same room. If there is a kitchen, it is
small, crowded and ill-designed. The storage shelves lie
above the chulla/angithi (a kind of open oven used in India)
or stove, so that while getting up to pick up an article from
the shelf, any loose garment can easily catch fire. The lamps
used for illumination are made of an ordinary glass bottle or
tin can, with cotton wick and kerosene oil. They are either
kept on the floor or on any shelf. They can be easily upset
and result in an oil fire. The majority of the population lives
in villages in thatched houses which easily catch fire.
Accidents at home form the major bulk and the common
causes are:
1. Loose clothing like ‘sari’ and ‘dupatta’, mostly made of
synthetic, inflammable material.
2. Spilling and spraying of kerosene oil from pressure stove
is more common than actual bursting of it. The jet of
oil under pressure catches fire immediately.
3. Hot food stuff and liquids carry a constant danger to
children and infants, particularly in over crowded rooms.
They often fall in the steaming food, cooking utensils
and hot water buckets and tubs.
4. It is common to heat water in a tin with its lid in position.
As the lid is handled, the steam under pressure inflicts
severe scalds of face, neck and upper chest wall.
After flame and scalds, electrical burn is the third most
common cause of burns in India. The electric appliances
used are substandard and are used without any regard to
safety measures. Electrical burns while flying kite is very
common in India especially in young children.
Circumstances of the Injury
There has been a change in the pattern of burn injuries as
far as circumstances of the burn injury are concerned.
Recent study shows that majority of burn injuries, i.e. more
than 85% occurs in homes. Kitchen-related activities are
most often responsible for burns in domestic setup. Flames
represent the most common agent of burn injuries (75.1%).
Among the flame burns, kerosene pressure stove is the most
common source. Chimney and Liquid petroleum gas (LPG)
burns rank the second most common source of flame
injuries. Most of the burn injuries are accidental (67.7%),
followed by homicidal (13.4%) and suicidal (18.9 %).30
Epidemiology of Pediatric Burns
Pediatric burns differ from adult burn injuries in many
aspects and need separate consideration. Only few pediatric
burn units exist in India. Most of the children with burns
are treated in a common burns unit. Epidemiological studies
on childhood burn injuries in India are very scant.
Information on the exact magnitude of burn injuries has not
been well documented. It is known, however, that burn
hazards are present in the daily life of children. Household
activities, including cooking are expected of girls early in
their lives. According to one of the epidemiological study of
pediatric burns, various risk factors attributed to burn injuries
in children are low socioeconomic conditions, poor living
conditions, illiteracy, overcrowding and floor level cooking,
on either kerosene pressure stove or an open fire. These
pressure stoves are sometimes of shoddy construction and
commonly malfunction leading to explosive disintegration.
The overcrowded conditions cause young children to play
in the vicinity of the cooking area leading to scalds from
spilled hot fluids or foods. Pre-existing diseases and
malnutrition afflict a considerable number of patients,
particularly children injured in slum areas, thereby ensuring
that patients have a reduced ability to compensate for the
physiological stress inherent in a severe burn. The ridiculous
first aid measures like application of ink, cow dung, hen’s
blood, haldi (turmeric), honey and other home made
remedies, surprisingly, are still frequently used. Delay in
transportation and initiation of treatment due to lack of
education, lack of transportation facilities and lack of
economic support are still prevalent.31 According to the
recent study of 500 pediatric burns, majority (24%) of burns
occur in children between one and two years age group.
Table 1.2: Showing incidence of different types of burns
Causes of Burns
%
Dry Burns
51.64
Scalds
33.35
Electric Burns
3.59
Chemical Burns
2.97
Petrol Burns
2.36
Coal Tar Burns
0.79
Industrial Burns
0.75
Miscellaneous
4.55

12
Principles and Practice of Burn Care
Male to female sex ratio was 1.38:1. Burn injury occurred
predominantly during winter. Most common type of burn
was scalds which occurred mainly in domestic
circumstances. Mortality rate was 10.4%. Mortality rate
was high in patients having more than 40% TBSA
involvement. Parental occupation, family size and the first
aid did not affect the mortality rate.32
PREVENTION OF BURNS IN INDIA
The only thing more expensive than education is ignorance
Prevention is better than cure
INTRODUCTION
Burn injuries are universal and incidence is on the increase
with the complexities of modern living and industrialization.
As most of the burns occur either at home or at the place of
work, it becomes important to know about Burn Prevention.
In order to bring down the incidence of burn, education
programs are oriented to bring the changes of culture pattern,
change in the way of life, change of rules and regulations at
work place, change in dangerous substandard gadgets and
change of habits. Prevention does not mean only to reduce
the incidence but also to reduce the depth and severity of
the burn.33
RISK FACTORS
Before preventive measures are discussed it is important to
know about the risk factors especially in Indian scenario.
Various risk factors are as follows:34
At Home
In India most of the burn injuries occur at home, especially
in the kitchen. Various risk factors are floor level cooking,
substandard kerosene pressure stove, loosely worn garments
(saris and dupatta), low level electric plug points, long over
hanging flex of kettle, overhanging table cloth over which
hot food or beverages are kept, carelessly kept match boxes
within reach of children, substandard pressure cookers,
etc.
At Work
Inadequate safety measures, overwork and fatigue are
common risk factors at work place.
At Play
During Diwali, Indians play with fire crackers and celebrate
the festival with lights. Inferior quality of crackers and
carelessness during their bursting are important risk factors.
RESEARCH DESIGNS FOR BURN PREVENTION
Given below are the broad outlines of four research designs
which may be helpful in planning and implementing burn
prevention programs and their evaluation.35,36
Nonexperimental Descriptive Study
Purpose
To determine dimensions of a serious burn problem in a
defined population.
Tasks
1. Define the population of interest, determine numbers
and age distribution, if possible.
2. Decide on a time period. Include at least one year, since
in most locations, burn injuries have seasonal variations.
3. Decide on the level of burn severity. Include all deaths
and people hospitalized for a burn injury and may be
those treated and released from hospital or clinic.
4. Identify all hospitals treating burn patients in the defined
population. Request permission to review medical records
or request hospital staff’s help to provide data.
5. Use a standardized burn form to collect all available
information. Record as much information as is available
on the circumstances surrounding the burn episode. The
ISBI Burn Registry computer software is a useful tool
for collecting and recording burn data.
6. Prepare report to include rates:
a. Death rates [(no. of deaths/no. in population) ×
1000,000], expressed as deaths per million persons
b. Injury rates [(no. of injuries/no. in population) ×
1000,000], expressed as injuries per million persons.
Calculate rates for the following categories:
i.
Age groups
ii.
Gender
iii.
Type of burn (flame, scald, other)
iv.
Severity (depth and extent of burn).
7. Identify the most common circumstances and/or
products causing injury (e.g., pressure stoves, clothing,
ignition).

History, Epidemiology and Prevention of Burns
13
8. Plan a prevention program to address these problems. A
review of literature may reveal which strategies have
been effective.
Preexperimental Design: One Group Pretest-
Posttest Design
Purpose
To document change associated with a prevention program.
Cautions
There is no control for natural time trends, societal forces
and factors other than the intervention which influence burn
rates.
Tasks
1. Conduct the descriptive study to determine the burn
problem in a defined population. Determine rates for
those types of burn injuries and those age groups
expected to be affected by the program.
2. Design or adapt a burn prevention program which
addresses a significant burn problem.
3. Repeat the descriptive study and compare burn-type and
age-specific rates before and after the intervention.
Note: If the prevention intervention has already been
instituted, as it often is with safety standards or regulations,
the descriptive studies of burns before and after implementation
are retrospective and may be conducted simultaneously.
Burns are relatively rare occurrence and are known to have
yearly fluctuations. For this reason, it is well to collect data
for several years before and after intervention.
Quasi-experimental Design: Non-equivalent
Control Group Design
Purpose
To measure the effectiveness of a burn prevention program.
Tasks
1. Conduct the descriptive study to determine the burn
problem in two communities. These communities should
be comparable in size, age distribution and
socioeconomic variables.
2. Select a burn prevention program, proven to be effective
in other locations, which addresses a burn problem
shared by both defined communities.
3. Randomly select one community as experimental and one
as control. Conduct the prevention program in the
experimental community.
4. Repeat the descriptive study in both populations and
compare burn-type and age-specific rates. A successful
program would be indicated by significantly lower burn
rates in the experimental community with rates essentially
unchanged in the control community.
Experimental Design: A Case-control Study
Purpose
To measure the effectiveness of a burn prevention program,
for example, whether a new inexpensive kerosene stove,
recently introduced into a community, has reduced the
likelihood that someone will be burned.
Tasks
1. Identify ‘cases’, that is, patients treated for burn injuries
caused by stoves.
2. Interview the patient or family member to determine the
type of stove used by the patient. Determine fuel source,
whether or not stove is the ‘new design’.
3. Select appropriate ‘control’ for each case. This is the
most difficult task of a case-control study, to find
persons comparable to the case in all things except the
type of stove used in the home. It is well to find multiple
controls for each case, drawn from different
categories. For instance, a hospital ‘control’ could be
a person admitted to the hospital the same day for an
illness rather than an injury, who is the same gender,
same socioeconomic status and in the same age group
as the burn patient. A neighborhood ‘control’ could be
a person living on the same road, within a certain
number of houses, who is the same gender, same
socioeconomic status and in the same age group as
the burn patient.
4. Interview each ‘control’ to determine the type of stove
used. Determine fuel source, whether or not stove is
the ‘new design’.
5. Analyze data using simple 2 × 2 table, categorizing
subjects along two axes: positive or negative for burn
injuries associated with stoves and positive or negative
for exposure to ‘new stove’. Success would be achieved
if those using the new stove were significantly less likely
to be in the burn category.

14
Principles and Practice of Burn Care
EVIDENCE THAT BURN PREVENTION
CAN SUCCEED
•
Throughout history, whole cities have burned down,
cities like Rome, London and Chicago, to name but a
few. Today, such massive fires are rare; when they do
occur, they are associated with war and natural disasters.
There are many reasons why whole cities do not burn
down: More fire-safe construction methods and
materials, fire-safety-related building codes and
standards, professional fire services and water delivery
systems.
•
Fewer children are being burned when their clothes catch
fire. There are many reasons: sleepwear flammability
standards, the introduction of new, less flammable fibers
and fabrics and more close-fitting designs for girls’
clothing. This pattern has not been seen in all countries,
particularly not in those countries like India where girls
and women commonly wear flowing dresses (saris)
made of cotton and rayon.
•
Fewer people in the USA are dying in residential fires,
due in part to the widespread adoption of smoke detectors
which warn residents of deadly smoke.
•
Electrical burns of the mouth were all but eliminated in
Denmark when a defective electrical cord for a popular
vacuum cleaner was recalled and replaced.37
COMMON ELEMENT IN SUCCESSFUL BURN
PREVENTION PROGRAMS
A consumer product or the environment is made safer for
everyone by using prevention programs. Although it might
seem easier to teach people to act safely in an unsafe
environment, it does not usually work that way. Put your
energy into making a safer environment. Burns can happen
to anyone, but some groups are at greater risk: the very
young or very old, the poor and people with disabilities or
who are impaired by drugs or alcohol. These groups are
the hardest to reach with educational messages or are less
able to adopt safe practices, even if they hear the educational
messages.37
BASIC PRINCIPLE UNDERLYING BURN
PREVENTION STRATEGIES
Keep people separated from excessive heat. This may appear
simplistic, but it is fundamental. A person cannot be burned
unless a person and a heat source come into contact.37
•
Separate with a barrier: For example, insulate the outer
surfaces of stoves and heaters to prevent contact burns;
install fences to keep trespassers away from electrical
power stations; use sun block creams, umbrellas and
roofs to protect people from sunburn.
•
Separate by location: For example, keep children out of
the kitchen or away from the cooking area.
•
Separate by time: For example, permit trucks carrying
volatile fuel to be driven through tunnels only during
hours of low traffic volume.
SEQUENCE OF TASKS FOR BURN
PREVENTION PROGRAMS
There are six major tasks within a burn prevention
program:37
1. Document the problem.
2. Set goals.
3. Consider possible strategies.
4. Design the intervention.
5. Implement program.
6. Evaluate program.
Above tasks can be exemplified by study program
conducted in India by Injury Prevention Workers to protect
the people of India from burns caused by fireworks; a
secondary success was increasing the use of cool water as
first aid for burns.
Document the Problem
Determine the size and nature of the burn problem in your
community. Make sure you get good information about what
causes these burns and what products and circumstances
are involved e.g., in India, researchers found out that the
‘cone fountain’ fireworks were involved in most of the
injuries sustained during Diwali, the festival of lights.38
Set Goals
Decide what you want to accomplish in your prevention
program. Have single and specific goals, not multiple and
broad ones, e.g. in India, researchers decided to prevent
injuries caused by ‘cone fountain’ fireworks.
Consider Possible Strategies
Use the ‘public health model’, following the example of
public health specialists who consider three factors (Agent,
Host and Environment) when trying to eradicate diseases.
Energy (be it thermal, electrical, chemical or ultraviolet

History, Epidemiology and Prevention of Burns
15
radiant energy) is the ‘agent’ for the burn injury. Host is
person at risk. Environment includes both social and physical
environment. Here is an example how planners in India have
addressed host, agent and environmental factors when
designing their programs:
Host (person at risk)
Teach proper use of fireworks
Agent (energy source)
Redesign ‘cone fountain’ fireworks or ban
them
Environment (social
Restrict sale of these fireworks to
and physical)
professionals and/or restrict locations where
they can be used
Design the Intervention
Decide how your goal will be accomplished. Be specific
about what is to be done, who is to do it, in what time
frame, with what resources, e.g. in India, researchers
decided to mount a media campaign during Diwali, to teach
people to handle ‘cone fountain’ fireworks safely and to
pour water on burn.
Implement Program
Gather the necessary resources to implement your program
and get to work. This means finding financial support if
necessary and hiring people or finding volunteers to perform
appointed tasks and to monitor progress. It means regular
review of progress and brainstorming on how to correct
elements of the program that are not working. It means
hard work. In India, researchers got financial support and
technical expertise from a local insurance company and
advertising firm which made television spots about safe
handling of ‘cone fountain’ fireworks and about cool water
as first aid for burns. Television spots, print advertisements
and brochures were prepared. The television ran the spots
just before and during Diwali.
Evaluate Program
Evaluation is the key to progress. This is true of surgical
procedures, infection control, skin replacements and
prevention practices. It indicates what is effective and what
is not, what should be duplicated, what should be redesigned
and what should be dropped. Evaluation is complex, but
easier when the goals of the program are very clear. The
bottom line is fewer burn injuries. Evaluators try to determine
if there are fewer burns after the program, linked to
measurable changes in behaviors, products or the
environment. In India, researchers found no significant
difference in the number of people injured by ‘cone fountain’
fireworks during Diwali after the media program. However,
they found significant increases in the number of patients
who used cool water for first aid for burns. Thus, this
program had mixed results.38
GENERAL GUIDELINES FOR POTENTIALLY
EFFECTIVE BURN PREVENTION ACTIVITIES
Burn prevention efforts must be tailored to the characteristics
of specific burn risks. It is not possible to prevent all burns
simultaneously. Burn prevention specialists must be patient
and systematic, addressing one type of burn at a time. The
best strategy to prevent scald burns will not reduce the
number of flame or chemical burns.
Kerosene Lamps and Stoves
In homes throughout the lower income nations, the most
common flame burn risk is associated with kerosene lamps
and stoves. These two appliances are in constant use for
cooking and lighting. Burns occur when these appliances
malfunction and kerosene sprays out while people attempt
to clean and fix them. One study from India reported that a
kerosene stove was involved in 80 percent of the flame
burn injuries treated at a burn unit. Customary cooking at
floor level was cited as an additional risk factor. Flame burns
would be reduced dramatically worldwide if people used
efficient, safe, inexpensive kerosene lamps and stoves placed
above floor level. Keep children out of kitchen. Avoid storing
cooking material across the stove. Avoid bending over the
flame to put out fire. Avoid keeping stove near gas cylinder.39
Flammable Fabrics
In many higher income countries, clothing ignition burns
have become quite rare and those which do occur are often
linked with flammable liquids. Reasons for this reduction
include: flammability standards for children’s nightwear, a
trend toward closer-fitting garments for women and girls
and the redesign of ignition sources, such as space heaters.
However, clothing ignition is a major problem in countries
where women’s traditional dress is loosely draped (saris)
and made of cotton or rayon. The beauty of these garments
and pride in the traditional dress has made it unlikely that
reductions seen elsewhere will occur. These garments
combined with floor-level cooking, place women at very
high risk. Research is needed in the development of
inexpensive flame-resistant materials that can be used in
the manufacture of saris and other traditional women’s

16
Principles and Practice of Burn Care
clothing. While cooking, the women should be encouraged
to wear only those designs of traditional dress which fit
closer to the body and are thus, less likely to catch fire at the
stove. Avoid using ‘sari’ or ‘dupatta’ to handle hot vessels.39
Cigarette
Lighted tobacco products, primarily cigarettes, are the major
cause of fire deaths in higher income countries, for example,
approximately 50%in Sweden,40 33% in Canada and 25%
in USA.41 In Japan, smoking materials cause 14% of fire-
deaths, second only to incendiary suicide (23 %).42 In the
USA, the Center for Fire Research at the National Institute
for Standards and Technology has developed a test method
to measure compliance with a performance standard to
reduce cigarette ignition propensity. Once this standard is
adopted, death and injury from cigarette-ignited fires should
drop dramatically around the world. It is necessary that all
cigarettes manufactured, imported or exported, and/or sold
within a country meet the performance standard for reduced
cigarette ignition propensity. Home owners must install
smoke detectors in all owner-occupied and rented homes.
Educate people not to smoke in bed or under influence of
alcohol and drugs. Extinguish all cigarettes before throwing.
Redesign cigarette to make them fire safe. Ban use of
cigarette at places like petrol pump.
Hot Liquids
Do not keep hot liquids/foods near the edge of table. Keep
them out of the reach of children. The temperature of the
hot water heater should be set at 124° F. Check temperature
of water before bathing children. Never leave a child
unattended in the bathroom. Avoid leaving unattended hot
liquids. Do not use loose pressure cooker rubber (casket).
Do not carry hot water on a slippery floor. Avoid carrying
hot liquids when children are around. Do not pour water in
an empty hot car radiator, wait to cool or keep the face
away from the radiator while pouring water.42
Liquid Petroleum Gas (LPG) Leak
Windows and door should be kept open. Do not light a
match or switch on the electric light. Call Gas Company or
Fire Department.42
Fire Works/Fire Crackers
Fire crackers should be ignited from a distance and those
which fail to burst should not be inspected from close
distance because it can burst at any time. Do not wear
easily flammable fabrics while playing with fire crackers.
Do not leave children to play with firecrackers unsupervised.
Redesign fire crackers with safety measures. Ban dangerous
fire crackers. Use fire works in the open ground only.42
Crowded Places (Theater)
Heat and smoke detectors should be installed. A well designed
fire escape plan should be available. Fire brigade and police
telephone numbers should be kept near phone. Fire
extinguishers, water and sand should be available readily.42
Electric Burn
Educate children not to touch wires and electrical appliances.
Do not handle electric appliances with wet hands and bare
feet. Unplug electric appliances when not in use. Use
standard company electric appliances. Plug point should be
placed at higher level out of the reach of children and it
should be covered with a cap. There should be no dangling
cords. All flawed cords should be replaced with redesigned
cords. Keep electric appliances away from the water. Hot
iron should not be left unattended within reach of children.
Avoid open plug point. Avoid open bathrooms if immersion
rod is used to heat water. The rescuer must be careful so
that he does not become a part of the electrical circuit in
attempting to free a person still in contact with a live wire.
Use dry wood and push the patient away from current
source.
When flying a kite, it is important to remember the 3
C’s of kite safety: Caution, Courtesy and Common Sense.
By keeping these three items in mind at all times, you will
make your recreational time more enjoyable, and safer43.
Here are some extra tips for making your kite outing a
safe one:
•
Choose a flying site at least 3 miles (5 km) away from
airfields; also stay away from roads and railway lines.
•
Never fly your kite near electrical pylons, overhead
power cables or overhead lines of any kind.
•
If your kite becomes entangled, do not attempt to free it
yourself. Seek help from your local authorities.
•
Do not fly your kite in electrical storms. The kite will
act as a lightning conductor, causing injury and even
death.
•
Be aware of casual observers. They could be unaware
of the potential dangers involved in kite flying.
•
Flying kites on larger lines can cause line burns on your
hands, so be sure to wear gloves.
•
Always be aware of who or what is behind you as well
as in front of you.

History, Epidemiology and Prevention of Burns
17
•
Know your skill level, limitations and strength. Do not
fly anything too large for the conditions or try any
complicated moves in crowded areas.44
SUMMARY
Burn injuries in a developing nation like India are still a major
problem. Poverty, illiteracy, lack of funds and lack of burn
education, etc. are the major hurdles in solving the problem
of burns in India. The only answer is Burn Prevention. It is
not quick, cheap or easy. If it were, the burn problem would
have been eliminated long ago. Be prepared to make long-
term plans to gather public support for safer product designs
and for codes and regulations which are often necessary
for effective burn prevention. Be prepared to rethink strategies
halfway through a project. Be prepared for a struggle. But
know that burns are preventable.
A final word: ‘Prevention takes time, energy and money
but ultimately, it is the solution to the world’s burn problem’.
‘Vision is nothing but a dream that’s backed by the drive to
achieve it’.
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37. McLoughlin E. A simple guide to burn prevention. Burns:Vol. 21,
No. 3, 1995: 226-229.
38. Mohan D, Varghese M Fireworks cast a shadow on India’s festival of
lights World Health Forum 1990; 11:323-6
39. Sawhney CP. Flame burns involving kerosene pressure stoves in
India. Burns 1989; 15: 362-4.
40. Hall JR. Fire in the USA and Sweden: International Fire Comparison
Report No. 7. Quincy, MA: National Fire Protection Association,
August, 1997.
41. Hall JR. Fire in the USA and Canada: International Fire Comparison
Report No. I. Quincy, MA; National Fire Protec­tion Association,
October 1992.
42. Keswani MH. The prevention of burning injury. Burns 1986; 12:533-
539.
43. Tiwari V K, Sharma D. Kite flying: a unique but dangerous mode of
electrical injury in children. Burns 1999; 25: 537-9.
44. Kumar P. Clinical Forensic evidence in burns: Rescuer Burns. Burns
2007; 33:1071.

18
Principles and Practice of Burn Care
Anatomy of the Skin
2
Sujata Sarabahi
Chapter
INTRODUCTION
Skin is the largest organ, covering a surface area of 1.5 to
2.0 m2 in an adult. In burns, although there is a direct damage
by the causative agent to this outer protective layer of the
body, almost all the other organ systems are indirectly
involved, in addition. Before considering the pathophysiology
of burn wound, it is imperative to understand the anatomy
and physiology of normal skin as both are disrupted
following burns.
The skin consists of a thin outer layer which is cellular
and derived from the ectoderm – the epidermis and an inner
thicker fibrous layer which originates from the mesoderm
–the dermis (Figs 2.1 and 2.2). The two layers are separated
by a basement membrane or basal lamina. Nerve endings
are present throughout both the layers. The connective tissue
of the dermis provides a firm structural base for the skin.
Underneath the skin lie the subcutaneous tissues, muscle
and bone. The thickness of skin is variable in different
anatomical areas of the body, in different sexes and at
different ages in the same individual. This produces differing
depths of burn injury in different parts of the body and at
different ages from a given temperature and time of
exposure. In general, the skin of infants, children and elderly
is thinner as compared to that of adults. Thus, the burns
may be deeper in children and elderly with the same agent
causing a comparatively superficial injury in adults. Males
have thicker skin as compared to females.
The skin of the scalp, palm and soles is thickest (2 mm
thick) compared to the rest of the body, whereas it is thinnest
on the eyelids (0.5 mm thick) and external genitalia. This is
because of the difference in degree of keratinization of the
epidermis. The degree of keratinization of skin is largely
under genetic control. However, intermittent mechanical
pressure or abrasion stimulates adventitious production
of keratinized cells which enhances stress resisting
properties of skin. The interface between epidermis and
dermis is marked by peg and socket or ridge and groove
interdigitations which along with specialized anchoring
structures linking epidermis to dermis prevent the epithelium
from being stripped off the surface of dermis by shearing
forces.
ANATOMY OF EPIDERMIS
Normal epidermis is a terminally differentiated, stratified
squamous epithelium divided into five distinct layers each
of which represents different stages in the development of
the fully mature cells of the outermost layer—the Stratum
Corneum (as we go from the innermost layer to the
outermost layer). The thickness of stratum corneum varies
in different parts of the body and it is subjected to constant
shedding. It consists of several rows of cornified, non-
nucleated dead cells containing keratin. This layer forms a
barrier on the surface of the skin, protecting the underlying
living cells from damage by trauma and desiccation.
The Stratum lucidum lies immediately below stratum
corneum and is found only in the skin of soles of feet and
palm of hand as a thin eosinophilic band. The Stratum
granulosum is the next layer of flattened nucleated cells
containing a precursor of keratin called keratohyaline
granules. The fourth layer is the Stratum spinosum which
is prickle cell layer containing several layers of polyhedric
and cylindrical cells.

Anatomy of the Skin
19
so that there is shedding of outer layers of epidermis as
deeper layers move outwards. The time taken for the deepest
layer of stratum corneum to reach the outermost layer and
desquamate is approximately 14 days. Thus, the normal
epidermis completely replaces itself in 45-75 days.
Within the germinative layer of epidermis, there are three
other cell types, viz., the melanocytes, the Langerhans cells
and the Merkel’s cells.
Melanocytes are dendritic cells which produce pigment
granules called melanosomes which contain melanin pigment.
Majority of these melanocytes are located at the dermo-
epidermal junction beneath the basal cells and some lie in
the dermis. Embryonically, melanocytes are derived from
the neural crest and they migrate to the epidermis. The
dendritic processes of the melanocytes contain the
melanosomes and once their tips are sheared off, they are
phagocytosed by the keratinocytes. Thus, the pigment is
transferred from the melanocytes to the keratinocytes.
The rate of melanin production, transfer to keratinocytes
and degradation of melanosomes determine the degree of
skin pigmentation. The ratio of melanocytes to epidermal
cells is 1 in 5 on face and 1 in 20 in the buttocks. The
average ratio of melanocyte to keratinocyte on the body
varies from 1:4 to 1:10.The relative number of melanocytes
is approximately equal for men and women and for all races.
The difference in color between races is not due to difference
in number of melanocytes but due to activity, rate and
production of melanin. For example, individuals with darker
skin have very large melanosomes which are fully melanized
as compared to individuals with fairer skin who have smaller
and less melanized melanosomes. This is to be kept in mind
when choosing a donor area for procuring the skin graft.
There will be a definite difference in color when skin from
an area of higher melanosomes content is grafted on to
areas that have a smaller number of melanosomes.
The melanin protects epidermis from harmful effects
of ultraviolet rays of Sun by forming a protective layer
around the nucleus of the keratinocyte so that these rays do
not damage the DNA in the nucleus. A higher amount of
melanin, thus, protects the skin from Sun burn which is a
first degree epidermal burn of skin on increased exposure
to sunlight.
Langerhans cells are also dendritic cells found in the
epidermis but devoid of melanin. They contain rod like
Langerhans granules, some of which are in continuity with
the external membrane of the cell. Their function is still
unclear. Recent research has shown that these cells are a
type of phagocytic cells and they provide a ‘trap’ for various
Fig. 2.1: Diagrammatic representation of anatomy of skin
Fig. 2.2: Normal skin on histopathological examination
(Photo courtesy: Dr Geetika Khanna)
The deepest layer is the Stratum Basale or the germinal
layer of the epidermis. This consists of a single layer of
pigment granules containing cuboidal or columnar shaped
cells called keratinocytes which are in a state of high mitotic
activity. These epidermal stem cells in the basal layer divide
to form transient amplifying cells which then migrate
suprabasally, stop dividing and undergo terminal
differentiation. This process of maturation and migration
from basal layer to outermost layer takes about 26-42 days.
The keratinocytes are attached to each other by desmosomes
which can be broken and reformed allowing the mature
keratinocytes to migrate upwards. The desmosomes of the
stratum corneum are also degraded before desquamation

20
Principles and Practice of Burn Care
contact antigens and present them to T–cells for destruction.
Thus, they protect the internal structures from the potentially
infectious agents in the external environment.
Merkel cells are found in the basal part of epidermis of
hairy skin. They are in close contact with the tactile sensory
nerve endings terminating in the basal part of the epidermis.
Thus, they play an important role in the sensory processes.
The basement membrane at the dermo-epidermal junction
is a highly organized structure of protein that anchors the
epidermis to the dermis. It consists of grooves on the
epidermal side called epidermal ridges which fit into
projections from the dermis called dermal papillae. A number
of microfilaments insert into this basement membrane and
get aggregated in the adjacent papillary dermis resulting in
structures called ‘rete pegs’ or ‘rete ridges’ which are seen
as invaginations into the papillary dermis to increase the
surface area. These resist the shearing forces between
epidermis and dermis. Any gap due to shearing between
epidermis and dermis can produce a blister as is seen
following superficial dermal burns.
ANATOMY OF EPIDERMAL APPENDAGES
The functions of human skin are further affected by certain
cutaneous appendages which are of ectodermal origin. These
are the hair follicles, sebaceous glands, apocrine glands and
sweat glands.
Hair Follicle
Hair are found on nearly all parts of the human body except
palm of hands and sole of feet, glans penis, inner surface of
prepuce and clitoris, labia majora and minora. The hair has
a root which is the part inside the skin and a shaft which is
projecting outside the skin. The root of the hair has a
proximal enlargement, the hair bulb, which is set in an
invagination of the epidermis and superficial portion of the
dermis called the hair follicle. The hair follicle commences
on the skin surface with a funnel shaped opening and then
passes obliquely downwards to become dilated at its end
which corresponds to the hair bulb. The ducts of one or
more sebaceous glands open into the follicle near the skin
surface. In the hair bulb there is a small conical vascular
prominence or papilla which is continuous with the dermal
layer of the follicle and is supplied with myelinated and
nonmyelinated nerve endings. The nutrition to the hair is
derived from the capillaries in this papilla.
The hair follicle has two coats—an outer coat which is
mainly fibrous tissue and is continuous with the dermis and
an inner coat or root sheath which is closely adherent to the
root of the hair and is basically a continuation of the epidermal
cell layer. Since the hair follicle is primarily composed of
epidermal tissue, it has a significant role in re-epithelialization
of burn wounds.
The hair bulb is moulded over the papilla and consists
of polyhedral cells which are undifferentiated and rapidly
dividing. The products of these rapidly dividing cells are
the inner root sheath and hair which move outwards towards
surface of the skin.
The hair shaft is a dead cornified structure which extends
from the follicle above the skin surface. The shaft consists
from within outwards, the medulla, the cortex and the cuticle.
The color of the hair depends on the amount of melanin and
its distribution in the cortex. Blond hair has few melanosomes
while gray hair does not have melanosomes due to a relative
absence of melanocytes.
The terminal hair follicle has three phases in its growth
cycle, the active phase or anagen, the involuting phase or
catagen and the resting phase or telogen. The hair follicles
produce hair independent of each other.
In burns, unless the wound is very deep or full thickness,
the epidermal tissue lining the hair follicles is still available
in the depths of the dermis in the wound site to generate
new epithelium. The hair also traps air and provide insulation,
though this is true only for the scalp.
Sebaceous Glands
These are small sacculated glands arising from an epithelial
bud from outer hair root sheath. They are found in most
parts of the skin, more abundant in the scalp and face while
being absent in the palms of hand and sole of feet. Each
gland has a single duct which emerges from a cluster of
oval or piriform alveoli. Each alveolus has a basement
membrane enclosing a number of epithelial cells. The
marginal cells are small and polyhedral and in continuation
with the cells lining the ducts. The remainder of the alveolus
is filled with larger cells containing fat. In the center, the
cells are broken up leaving a cavity filled with a mass of
fatty matter called sebum cutaneum. Since the sebaceous
glands produce their secretions by complete fatty
degeneration of their central cells they are classified as
holocrine glands. Commonly, their ducts open into the hair
follicles. Occasionally they open on to the general surface.
Sebum acts as a natural lubricant for the hair and skin and
thus protects them from desiccation. It has bactericidal action
as well. Their secretory activity is under hormonal control,
especially androgens. Following a burn injury, if the

Anatomy of the Skin
21
sebaceous glands are damaged or the raw area is split skin
grafted the new skin may not be able to secrete enough
sebum to lubricate the skin. Hence, a frequent application
of moisturizing creams/bland oil is required to prevent the
dried skin from cracking and subsequent infection.
Sweat Glands
Sweat glands are present in the skin of almost every part of
the body and are classified into two types: eccrine and
apocrine.
The eccrine glands are more numerous. They consist
of a single tube which is coiled into a spherical or oval ball
called body in its deep part which is situated in the deeper
layers of the dermis or in subcutaneous tissues. The duct
traverses the dermis and epidermis and opens on to the
surface of skin by an aperture. The size and number of
glands vary in different parts of the body. They are large in
axilla and groin where the amount of perspiration is more.
They are also numerous in palm and sole. The tube consists
of two layers –an outer layer of fine areolar tissue which is
continuous with superficial layer of dermis and inner
epithelial layer consisting of cubical or polyhedral cells.
Between the basal aspects of these cells and basement
membrane, there is an incomplete layer of myoepithelial
cells which help in the expression of secretions from the
gland by virtue of their contractile property. The ducts are
composed of a basement membrane lined by two to three
layers of polyhedral cells. These eccrine sweat glands are
merocrine in nature, i.e. they produce their thin watery
secretions without epithelial cell disintegration.
Apocrine sweat glands are present in the axilla, eyelids,
nipple, areola and circumareolar region of the breast and in
the external genitalia. They are in close association with
hair follicles and produce thick secretions. They contain a
coiled secretory gland in the lower dermis and a straight
excretory duct. Their secretions are sterile and odorless
within the duct but once excreted onto the surface of skin,
bacteria degrade them resulting in body odor.
The primary stimulus for the production of sweat is
heat. The thermoregulatory center in hypothalamus is
responsible for sweat production in an effort to maintain
body temperature as sweating helps in dissipating heat. A
patient who has sustained deep dermal or full thickness
burns looses majority or all of his eccrine sweat glands and
if significant body surface area is involved in these burns,
the patient’s rate of sweating becomes inefficient. Thus,
these patients may not be able to regulate their body
temperature by sweating in hot and humid surroundings
leading to a rise in their core body temperature.
ANATOMY OF DERMIS
Dermis is also called Corium. It is a tough, flexible and
highly elastic structure. It is very thick in palm of hand (1.6
mm) and sole of feet and very thin in eyelids (0.4 mm),
scrotum and penis. It consists of mainly connective tissue
with varying number of elastic and collagen fibers, numerous
blood vessels, lymphatic vessels and nerves. The fibroblasts
are the ‘master cells’ of the dermis which produce the
collagen fibers, elastic fibers and ground substance. Collagen
forms approximately 77% of dry weight of dermis and
provides tensile strength to it. Eighty five percent of the
collagen is Type I and 15% is Type II collagen. Elastic
fibers are interwoven within the network of collagen fibers.
The connective tissue in dermis is arranged in two layers,
superficial papillary dermis and deeper reticular dermis.
Papillary dermis consists of numerous papillae which
are highly sensitive vascular conical projections which
project perpendicularly into corresponding pits on
undersurface of the epidermis. Each papilla consists of small
closely interlacing bundles of fine fibrillar tissue with a few
elastic fibers and within this there is a capillary loop. In
some papillae, especially on the palms and fingers, there are
tactile corpuscles. The papillary dermis primarily consists
of small loosely distributed elastic and collagen fibrils with
a greater proportion of interfibrillar gel and connective tissue
that encloses the microcirculation and lymphatic network
below the papillary projections.
Reticular dermis is the thicker part of dermis and is
more acellular and avascular compared to papillary dermis.
It consists of strong interlacing bands of white fibrous tissue
and some yellow elastic fibers. The collagen bundles are
arranged mainly parallel to the skin surface and some are
perpendicularly arranged forming a lattice work. This
arrangement of collagen fibers in reticular dermis provides
skin with extensibility in different directions. The directions
taken by the parallel bundles of collagen fibers form the
cleavage lines of the skin. Surgical incisions given along the
direction of cleavage lines heal with minimal scar tissue
whereas incisions perpendicular to these lines cause
retraction of the severed fibers, leading to a broad scar.
With increasing age, the yellow elastic fibers atrophy and
skin loses its elasticity and becomes wrinkled.
Following burns if only the epidermis is involved, they
heal without any scarring of skin. However as the deeper

22
Principles and Practice of Burn Care
layers of skin are involved, depending on depth of dermis
involved, the skin always heals with scarring. Again,
depending on amount of collagen production and the
arrangement of collagen fibers there can either be
hypertrophic scarring or keloid formation (Figs 2.3A to C).
Details of the pathophysiology of post burn scar formation
has been described in detail in the Chapter On Wound Healing
in Burns.
Deep to the reticular layer is the subcutaneous areolar
tissue which contains fat. In many regions, the skin is
separated from the deep fascia or other structures by loose
areolar tissue and in these sites the skin is freely movable
over the deeper structures. Elsewhere, however, the skin
may be firmly anchored to structures like the periosteum
over subcutaneous parts of bones or to deep fascia in regions
related to movements of underlying joints where it leads to
permanent creases in the skin known as flexure lines, e.g.
palm of hand and flexure surface of digits.
BLOOD SUPPLY OF SKIN
The blood supply and drainage of skin lies along well
determined pathways which depend upon the metabolic
requirement of various cellular components. The most active
areas of the skin are the epidermis and its appendages and
the dermal papillae which contain active fibroblasts and
sensory endings of cutaneous nerves. The reticular layer is
highly fibrous and contains few active cells; therefore, its
metabolic requirement is low. There are two vascular
plexuses –one at the dermal-subcutaneous junction called
rete cutaneum and one in the papillary dermis called rete
subpapillare or superficial plexus. These are connected by
vertical vascular channels. In the papillary plexus there is a
network of arterioles, capillaries and venules which provide
a large amount of blood supply to this layer. Capillaries extend
from this layer towards the base of epidermis within the
dermal papillae and loop back to flat venous plexus which
lies immediately beneath the rete subpapillare which drains
into venous plexus at dermis-subcutaneous junction via
another intermediate plexus in the middle of reticular dermis.
Various capillaries in dermis around glands and hair follicle
also drain into these three venous plexuses at different levels
in the skin.
Apart from providing nutrition to the skin, the cutaneous
vasculature has an important function of thermoregulation.
Another important role of microcirculation is in the
inflammatory process seen in the skin following any kind
of trauma which helps in healing process. Following burns
involving only superficial layers of skin, the microvascular
Figs 2.3A to C: (A) Mature scar with atrophy of overlying epidermis
and bundles of fibrocollagen in the dermis. (B) Histopathology of
Hypertrophic scar (H & E, 100 X) showing increased keratin, epidermal
hyperplasia with marked increase in collagen in the upper dermis.
(C) Higher magnification of a Hypertrophic scar (H & E, 200 X) showing
marked epidermal hyperplasia with collagenization of the upper
dermis (Photo courtesy: Dr Geetika Khanna)
A
B
C

Anatomy of the Skin
23
circulation in the deeper layer is intact. Therefore, the deeper
vascular bed of the skin has the potential to heal rapidly as
it promotes the re-epithelialization process.
LYMPHATIC DRAINAGE OF SKIN
The lymphatic drainage of skin is via numerous blindly ending
lymphatic vessels which terminate in the dermis near the
base of epidermis and drain first into a dermal network in
papillary layer and then into another network in the middle
of reticular layer and finally into a network at the junction
of dermis and subcutaneous tissues. Deeper to this, there
are wide channels with valves which drain into the main
lymphatics of the area.
INNERVATION OF SKIN
Skin is richly supplied by myelinated and nonmyelinated
sensory fibers of craniospinal nerves and via nonmyelinated
autonomic fibers which supply blood vessels, sweat glands
and hair follicles. The nerves penetrate superficial fascia
and ramify through reticular and papillary layer of dermis
forming nerve plexuses around hair follicles in both the
reticular dermis and the papillary dermis. Most of the nerve
fibers end in the dermis and some penetrate into basement
membrane.
The skin contains sensory organs for all the principle
sensations like touch, pain, temperature, pressure, itch and
tickle. There are mainly six types of sensory receptors in
the skin:
1. Free terminals or free nerve endings form majority of
the sensory receptors found in epidermis and dermis.
They are related to sensations of itch and pain and fine
discrimination for sensory stimuli in digits. As the name
suggests, they contain one or more axons enclosed in
an extension of Schwann cell which is then covered
with a basal lamina.
2. Merkel cells are special cells found in the epidermal ridges
having attachments next to keratinocytes. They act as
mechanoreceptors for sensation of touch.
3. Meissner’s corpuscles are found mainly in the papillary
dermis of palm and sole, responsible for sensation of
touch and relative pressure associated with touch.
4. Pacinian corpuscles are present in the deep layers of
dermis in palm and palmar subcutaneous tissue and near
periosteum of proximal phalanges. They are responsible
for sensation of vibration and signal for local changes
of blood flow.
5. Pilo-ruffini corpuscles are sensory receptors which
encircle the hair follicles and therefore, they respond to
changes in pressure on skin sensed by movements of
hair follicles. They are also responsible for sensation of
warmth.
6. Krause’s end bulb’s are widely distributed in superficial
layers of dermis and are end organs for cold sensation.
Patient sustaining burns may lose some or all of these
sensory receptors depending on depth of burns. As a
result, they may lose some of the sensations in the
affected areas.
FUNCTIONS OF SKIN
•
The most important function of skin is its ability to act
as a physical barrier preventing bacteria and other
organisms from entering it. It also serves as a water
barrier and thus maintains fluid balance in the body.
Following burns, the integrity of skin is disrupted allowing
loss of fluids from the body and entry of organisms into
the body. Thus, hypovolemia and infection are the two
major complications to be tackled by a burn surgeon.
•
Skin also regulates heat exchange and helps body
temperature homeostasis. When the cutaneous vessels
dilate the blood flow to skin is increased, as also the
amount of heat transmitted to the body surface. When
cutaneous vessels constrict, blood flow to the skin is
decreased with consequential decrease in heat loss from
body. In this way, the body temperature is maintained.
•
Similarly, perspiration from the skin surface also controls
the body temperature. The rate of evaporative water
loss from the burned skin surface is directly proportional
to the extent and depth of burns. This evaporative water
loss enhances the heat loss from the body as well.
Approximately 580 Kcal are required for evaporation of
one liter of water from the body surface. The excessive
heat loss from the body surface of a burn victim causes
a severe metabolic drain as well because this is
accompanied by hypermetabolism. This evaporative
water loss can be estimated by the following formula:
•
Evaporative water loss (ml) = (25 + %TBSA burn) ×
BSA m2
TBSA —Total Body Surface Area
BSA—Body Surface Area
•
The stratum corneum of the skin has the ability for
selective permeability allowing absorption of some
substances and acting as a barrier to others, while hair
follicles and eccrine glands only allow percutaneous
absorption. A concentration gradient is required to allow
the percutaneous absorption of substances across
stratum corneum. This is also affected by the relative
hydration of stratum corneum. Lipid and lipid soluble

24
Principles and Practice of Burn Care
substances pass through the skin easily compared to
hydrophilic organic compounds. A gaseous compound
like carbon monoxide can also get absorbed by the skin
when present in high concentrations.
•
Through its various sensory receptors, the skin
transmits sensory feedback from the environment.
•
Last but not the least, the skin has a sophisticated immune
system which plays an important role in host defenses.
Whenever skin is exposed to a new antigen, activated
antigen expressing Langerhans cells migrate from the
skin to lymph nodes, where they activate naïve T-cells
which then become memory T-cells and express new
surface markers that allow them to accumulate
preferentially in the skin in response to cutaneous injury.
SUMMARY
Knowledge of detailed anatomy and physiology of skin is
a must for the better understanding of the mechanisms of
alterations produced in burns, the management of burn
patient as a whole and the causation and minimization of
scars.
BIBLIOGRAPHY
1. Archer CB. Functions of the skin. In Burns T, Breathnach S, Cox
N, Griffiths C (Eds) Rook’s Textbook of Dermatology, Blackwell
Vol. 1, 7th edition,2004 (Chapter 4), 4.1-4.12.
2. Chu DH, Haake AR, Holbrook K, Loomis CA. The structure and
development of skin. In Freedberg IM, Eisen AZ et al. (Eds)
Fitzpatrick’s Dermatology in General Medicine, McGraw Hill ,New
York. 6th edition, 2003 (Chapter 6), 58-88.
3. James WD, Berger TG, Elston DM Skin. Basic structure and
function. Andrew’s Diseases of the Skin Clinical Dermatology, 10th
edition Saunders Elsevier’s, Canada.2006;1-14
4. McGrath JA, Eady RAJ, Pope FM. Anatomy and organization of
human skin. In Burns T, Breathnach S, Cox N, Griffiths C (Eds)
Rook’s Textbook of Dermatology, Blackwell Vol. 1, 7th edition,
2004 (Chapter 3), 3:1-3.84.
5. Murphy GF. Histology of the skin. In Elder DL et al (Eds). Lever’s
Histopathology of the Skin, Lippincott William and Wilkins,
Philadelphia. 9th edition, 2005 (Chapter 3), 9-58.

Burns: Etiology and Classification
25
Burns: Etiology and Classification
3
Sameek Bhattacharya
Chapter
INTRODUCTION
Since the discovery of fire, man has been on a relentless
quest for energy. This pursuit is driven by the expansion
and progress of human civilization. The benefits of fire
reaped by man have paralleled the fatalities and disabilities
caused by it. The magnitude of this devastating injury has
increased with the ability to harness higher energy source,
use of fire in most activities of life and its application as a
destructive modality. Hence, the epidemiological profile of
burn injury has changed with time and advancement of the
society. The incidence of burn injury directly reflects the
imbalance between the use of fire and the level of fire safety
consciousness of a society. Therefore, any preventive
strategy must be preceded by adequate and reliable data
collection about the cause and circumstances of injury.
Burns are classified on the basis of etiology, depth and
percentage of body surface area involved.
CLASSIFICATION ACCORDING TO ETIOLOGY
Burn injury is a syndrome of local and systemic manifestations
of exposure to very high temperature, electrical energy,
chemical and radiation.
Thermal Burns
The commonest cause of burns is thermal, caused by flame,
blast, contact with hot objects and hot liquids. Thermal
damage to skin is primarily a function of energy transfer
from heat source to the body. The heat transmission depends
on the temperature of the source, conductivity of the tissues,
insulation such as hair and keratin layer and the clothing.
The thermal threshold of human skin is about 70°C.
Flame Burns
Flame burns account for over 80% of the total burn cases
in India and other developing countries1 (Fig. 3.1). This is
at variance with the western data where scalds are the
predominant cause. More than 85% of the flame burns in
our country are attributed to accidents of which mishaps in
the kitchen account for over 60%.1 In contrast, space heating
and house fires are the predominant causes in the west.2
The high incidence of cooking accidents is ascribed to unsafe
heating appliances, floor level cooking and wearing of loose
fitting clothes. The major killer among these is the kerosene
pressure stoves, which work on aerosolized kerosene oil
(Fig. 3.2A). In the event of carbon-choked burner holes,
vigorous pumping of the stove suddenly opens up the holes
expressing out a large volume of kerosene aerosol which
Fig. 3.1: Flame burns leading to extensive injury

26
Principles and Practice of Burn Care
ignites into fireball (Fig. 3.2B). This event is frequently
labeled as “stove burst”. A better version of the kerosene
stove is ‘wick’stove which works by capillary action (Fig.
3.2C). Another frequent mishap in kitchen is LPG (Liquid
Petroleum Gas) leak. The leak can be from a cracked tubing,
faulty regulator or from an un-ignited burner. The LPG gas,
being heavier than air, does not diffuse out of the ventilators
and instead gets settled over the floor. In the event of an
ignition, be it lighting of the burner or even switching on of
the electric light or exhaust fan, the expressed gas bursts
into flames. Although LPG stoves are labeled as safer
appliances than kerosene pump stoves, LPG mishaps
generally involve a larger number of casualties compared to
the latter where only the operator gets burnt (Fig. 3.3). In
addition to the inherent unsafe nature of these devices, lack
of basic safety consciousness is also to be blamed in these
accidents. A frequent practice among the underprivileged
class is floor level cooking. The loose fitting clothes of the
housewife catch fire when she stands up near the stove to
pick up some thing from the overhead kitchen shelves.
Another frequent cause of domestic fire accidents is home-
made kerosene oil lamps to lighten the house in absence of
electricity. These are kept on overhead locations, get tripped
by domestic pets, igniting the spilled kerosene oil on
unsuspecting victims below.
Homicidal burns account for about 10% of all flame
burns.1 The common mode of this aggression is to douse
the victim with kerosene and then set on fire. This frequently
results in extensive and deep burns as the victim is generally
incapacitated or restrained. Suicidal burns, around 5% of
all flame burns, frequently involve kerosene doused over
the body by the individual herself/himself in a fit of anger
and then set on fire.1
Fig. 3.3: LPG stove
Flame burns on the whole are more frequent in the age
group of 16 to 55 years. Also, there is a definite female
predominance among flame burns which is more so in the
productive age group of 16 to 35 years. This is obvious as
traditionally females are engaged in the unsafe kitchens.
Homicidal and suicidal burns are also more frequent among
females.
Scald Burns
Scalds or burns due to hot liquids account for more than
50% of all burn admission in the developed world 2(Fig.
3.4). In contrast scalds constitute only 15% of all burn
admissions in India.1 In both scenario scalds are more
frequent in children. In the developed world, the incidence
of flame burns is far less compared to the developing
countries because of better safety features in the kitchens.
Figs 3.2A to C: (A) Kerosene pump stove. (B) Kerosene pump stove in action –it is a pressure stove in which continuous pumping aerosolizes
the kerosene. If the burner holes are choked and suddenly open up by vigorous pumping of the stove, there is a release of large volume of
kerosene aerosol which ignites into a fireball when the stove burner is lit.This is wrongly labeled as ‘Stove burst’. (C) Kerosene ‘wick’ stove—
Safer than pump stove
A
B
C

Burns: Etiology and Classification
27
In contrast, incidence of scalds remains high in the west as
children are less protected with working parents in nuclear
families. In developing countries, on the other hand, children
are relatively better off with non-working mothers and in
joint families. The incidence of scalds peaks around the age
group of 3 to 5 years. This is the time when the child is
highly mobile, inquisitive, lacks awareness regarding hazards
and devoid of experiences to cope up with them. Most of
the accidents take place when the child is unattended or
parents are momentarily distracted or engaged with hot liquid
with the child in their arms. The extent of scald burns depends
on the temperature, volume and density of the liquid, age of
the child and the absorbing ability of the garment. A small
amount of boiling water causes a higher % age TBSA burn
in a small child compared to an adult. Also hot water absorbed
by the clothes worn spreads and involves a larger area and
causes deeper burns as the exposure time is longer. The
sticky sugar syrup, oil or ‘ghee’ and thick gravy cause deeper
burns as they can be extremely hot and stick to the skin.
Due to their thin skin, children suffer full thickness scald
burns more frequently than adults. Commonest
circumstances of scalds in developed world are during bath
followed by kettle. On the contrary, Indian children get
scalded while the mother is handling hot food or water with
child in her lap or around her. Children also get burnt when
they “reach and pull” containers of hot liquid kept on tables.
They either pull table cloth or the container itself. If the
container falls over the child, face and upper trunk gets
burnt. If the liquid splashes on the floor the legs get burnt.
The sitting child gets perineal and thigh burns if it falls on
his/her lap. A toddler sometimes tumbles into a large liquid
container suffering 100% burn injuries. Overall, the boys
get scald injuries more frequently as compared to female
children. Although most scalds are accidental, a small definite
percentage has been attributed to child abuse in the west.
Such cases are a rarity in India. Thermal burns in adults are
also mostly accidental. The accidents occur, while preparing
tea or gravy or boiling milk and from spillage from hot
water bottle. Steam burns are caused by faulty pressure
cookers and on forcibly opening car radiators. Scalds and
steam burns are also seen in boiler rooms of factories, ships
and steam locomotives. Steam having a high latent heat
causes severe burns and can cause upper airway edema on
inhalation.
Thermal Contact Burn
Thermal contact burns are caused by touching hot objects.
Unlike flame and scald burns the injury is always localized
to the area of contact. Depending on the temperature and
duration of contact the burns can be very deep. In domestic
settings, contact thermal burn is caused by touching hot
utensils, room heating coils, light bulbs, bike silencers, etc.
Contact burns are frequently seen in epileptics who fall on
stoves or hot objects during an attack. Due to post-ictal
unconsciousness, the prolonged contact may lead to very
deep burns up to bone. Contact burn injuries are also seen
in insensate hands and feet. Contact thermal burns in
factories are caused by hot machine parts, molten metals
and coal tar. These burns are also seen in case of torture
and commonly used modalities are hot metals, cigarette
butts, etc.
Blast Injury
Other than warfare, blast burns happen in abundance during
Diwali and other festive occasions. The ill defined legalities
regarding sale and use of firecrackers and lack of safety
consciousness among people, explain the high incidence of
such injuries. Most of the victims are males and are in the
age group of 10 to 25 years. The victims are mostly
foolhardy “bravehearts” or unsupervised children. Although
the firework operator is more frequently injured, about 15%
of the victims are bystanders. Most incriminating
firecrackers are ‘bomb’, ‘anar’, and igniting of collected
firework powder accounting for more than 60% of cases.3
The injuries are sustained whenever the explosion is either
delayed or earlier than expected. Hands and the face are
mostly affected. A ‘bomb’ or an ’anar’ exploding in the
hand causes extensive damage and disruption and even loss
Fig. 3.4: Scalds over face of an infant due to accidental
spilling of hot tea

28
Principles and Practice of Burn Care
of digits. An explosion on the face of an inquisitive child
stooping over a lighted cracker not only involves the face
but also damages the eyes. The ocular injury can range
from reactive conjunctivitis, corneal abrasion and
perforations. Misdirected rockets accounting over 10% of
cases always affect unsuspecting bystanders who get burnt
when their clothes catch fire. Firecrackers like ‘phooljhari’
and ‘zameen chakri’ account for minority of injuries which
are purely thermal burns3 (Fig. 3.5).
In addition to the scattered cases, mass burn casualties
due to fire in firecracker factories, storage depots and
markets are also reported during Diwali. Adjoining residential
buildings and parked motor vehicles may also come in range
of these fires.
Fig. 3.5: Firecracker injury causing thermal burns of face
Electrical Burn
Electrical burn account for only 5% of the burn cases but
are generally extremely devastating.4 Majority of the cases
are males and are in the age group of 10 to 30 years. Electrical
injury is broadly divided into low and high tension injury,
the demarcating voltage being 1000 volts.4 The injury is
also classified as flash or contact burn depending on the
mode of injury (Figs 3.6A and B). Flash burn mimics thermal
burn and contact burn is manifested by deeper tissue
destruction. The low tension injury is generally seen in
domestic settings and is characterized by flash burn on the
surface with varying degrees of deeper tissue destruction
depending on the site and duration of contact. Such mishaps
happen with unprofessional handling and repairing of meter
boxes, switchboards and domestic electrical appliances.
Although most victims are young males, children get electric
Fig. 3.6A: Electrical contact burn to hand and wrist
Fig. 3.6B: Electrical contact burn due to contact with high tension
wire on back of trunk
burn when they try to mouth or handle a live wire or poke
finger in a plug socket (Fig. 3.7).
High tension burns are commonly seen in linemen
working on high tension wires and in factory settings. Such
injuries are also seen in cases of attempted illegal tapping of
electricity from high tension wires. These cases are on the
rise due to mushrooming of unauthorized dwellings near
high tension cables (Fig. 3.8). Construction workers in these
areas are also frequent victims. High tension injury has also
been reported from fallen live cables lying in agricultures
fields and from passengers travelling on roof top of
electrified trains. Young children are known to get injured
while flying kites with the thread getting entangled in high
tension cables, especially in rainy season 5(Fig. 3.9).
Chemical Burn
Chemical burn is non-immunological destruction of the skin
due to acute exposure to hazardous chemicals. Unlike other
forms of burn, there is extensive and deeper damage owing

Burns: Etiology and Classification
29
to prolonged exposure and continuous reaction of the
chemical with tissues. More than 25,000 chemicals are
known to cause chemical burns and they are broadly
classified according to their chemical nature (Table 3.1).6
Chemical burns are reported in industrial accidents, civilian
mishaps and chemical warfare. The chemicals involved in
civilian injuries are acids (40%), inorganic products (30%),
alkalis (20%) and organic products (10%).1 During warfare,
the commonest chemical implicated is phosphorus followed
poisonous gases like phosgene and Dimethyl sulfoxide
(DMSO). Hence, the incidence and pattern of chemical burn
varies with countries, societies and situation. Overall
incidence of chemical burn is about 2-4% of all burn
admissions during peace time. In the industrialized western
world majority are reported as accidents from factories
handling hazardous chemicals and the victims being male
adults of working age. On the contrary, in developing
countries like India most of the chemical burns are of non-
industrial nature. Most of the domestic accidents are due to
mishandling of household acid cleaners which are frequently
stored in discarded mineral water bottles and victims are
both adults and children. In addition to homes children also
get chemical injury while working in school laboratories.
Homicidal vitriolage account for a major share of chemical
burns in India, while such cases are rare in the west. The
majority of victims of this depraved aggression are women
who reject the advances or proposals of local goons. The
accidental as well as homicidal chemical injuries commonly
involve face, upper trunk and upper extremities. Loss of
vision due to ocular damage is also frequently reported
(Fig. 3.10). The agents responsible for chemical injury are
listed according to their mechanism of action in Table 3.2.1,6
Fig. 3.7: A child with loss of tissues of face due to electrical contact
burn by chewing of electrical wire in mouth
Fig. 3.9: Kite entangled in electric wires – common cause of
electrical injury in children during kite flying
Fig. 3.8: Unauthorized residential areas near electrical pole with
wires running close to the balcony of the houses
Table 3.1: Different types of chemical which can cause burns
Chemical Nature
Agent
Acids
Hydrochloric acid

Nitric acid

Hydrofluoric acid

Chromic acid

Sulfuric acid
Alkalis
Sodium hydroxide

Potassium hydroxide

Calcium oxide

Metallic Sodium

Metallic potassium

Sodium hypochlorite
Inorganic
Phosphorus

Cyanide
Organic
Phenol

Lysol

Cresol

30
Principles and Practice of Burn Care
Radiation Burn
Incidence of radiation injury during peace time is far lower
than other types of burn. These mishaps are reported from
the thermonuclear explosions, nuclear reactor accidents,
radiography industries and X-ray departments. Burn injury
from non-ionizing radiations like radio and micro waves are
rare and minimal as they have minimal tissue penetration.
Minor burns are reported with prolonged exposure to
microwaves. On the contrary ionizing radiation like gamma
rays, X-rays and high energy particles like protons penetrates
deeply into tissues causing serious burn injuries. There has
been around 50 radiation accidents reported till date other
than Three Mile Island and Chernobyl nuclear reactor
mishaps and Hiroshima Nagasaki bombings.1,7
Laser Burns
Burns caused by lasers are basically thermal burns where
laser energy is used for other purposes like hair removal or
resurfacing of vascular or pigmented lesions and heat released
is dissipated into the normal skin leading to skin burns. The
damage to the skin will depend upon the energy released by
the laser. Therefore, these can be superficial burns which
are more common or deep dermal, when the energy used is
very high ,which take a long time to heal. Fires also have
been reported with use of lasers whenever there are
flammable substances present in the operating field like
oxygen used during anesthesia, dry gauze, alcohol, perfume,
Table 3.2: Mechanism of action of various chemical agents
Mechanism of Action
Agents
Use
Effect


Oxidation
Chromic acid
Bleach, Chlorinator
Corrosive type damage

Sodium hypochlorite
Disinfectant
Does not penetrate deep

Potassium
permanganate

Dehydration
Sulfuric acid
Toilet cleaner
Coagulative necrosis by cellular

Hydrochloric acid
Toilet cleaner
desiccation and exothermic reaction

Oxalic acid
Rust remover
Dry eschar prevents deep penetration
Denaturation
Hydrofluoric acid
Rust remover
Denature and forms salt with

Tannic acid
Metal cleaner
vital cell proteins
Corrosion
Sodium, potassium and
Drain, Oven cleaner
Liquefactive necrosis and saponification

ammonium hydroxide
Paint remover
by combining with protein and lipids

Phenol
Disinfectant
Soft burn and deep penetration
Vesicant
Gasoline
Fuel
De-fattening properties produce tissue
amines and local tissue anoxia

Chloro di-ethyl sulfide
Chemical warfare
Local irritation, blister and corrosive

(Mustard gas)
damage on prolonged exposure

Methyl bromide
Insecticide
Self Ignition
White -phosphorus
Military ammunition
Thermal burn, particles get embedded

Yellow phosphorus
Fire works
in skin with blast and cause pain and


Flares
prolonged damage
Fig. 3.10: Chemical burns of face involving eye
nail polish, etc. Hence fire extinguishers should always be
available near by (Fig. 3.11).
Friction Burns
Burns due to friction are one of the commonest non thermal
burns. In majority of the cases they are associated with
mechanical injury, which may be more severe than the burns.
Usually, friction causes partial thickness burn in a small

Burns: Etiology and Classification
31
body surface area which is ignored. Whenever there is
friction between two objects, like between a body part and
a machine or tyre or road, the relatively delicate object, i.e
the skin bears the brunt of the mechanical trauma in the
form of abrasion, laceration or avulsion. Hence, most often
the burn takes a back seat and the mechanical injury becomes
the priority (Fig. 3.12).
CLASSIFICATION ACCORDING TO BURN DEPTH
ESTIMATING BURN DEPTH
In addition to etiological categorization, a burn injury is also
classified on the basis of depth. Whereas, etiological
classification dwells on the epidemiology, classification based
on burn depth is purely prognostic. Burn depth determination
and its exact categorization are fundamental in electing a
conservative or surgical modality of management. Although
the prognostic importance of burn depth was postulated by
Jean de Vigo in 1483, Peter Lowe in 1597 was first to
classify burns into “superficial, average and great”. Fabricus
in 1610 classified burns into three degrees and was first to
recognize erythema, vesication and eschar formation. Later
Heister in 1743 and Richter in 1799 recognized four degrees
of burn but were highly subjective as pain in addition to
erythema eschar formation and vesication. The classical
classification of burn depth was propounded by Dupuytren
in 1832, which is as follows:
First Degree: Erythema without vesication
Second Degree: Vesication, loss of epithelium and
inflammation
Third Degree: Destruction of papillary dermis
Fourth Degree: Destruction of whole dermis
Fifth Degree: Eschar formation of all superficial parts and
muscle
Sixth Degree: Carbonization of whole limb
Dupuytren never described the morphology of third and
fourth degree burns. After years of controversy, a general
consensus dawned with the classification of Boyer and
Ginnard in 1855, who categorized burns in three degrees
based on erythema, vesication and eschar formation.
Ironically it was almost identical to the postulation of
Fabricus of 1610. This classification is still followed with
slight modifications. Snonnenburg and Tschmarke in 1915
added fourth degree as carbonization which was added to
the above classification. In 1944, Converse and Robb-Smith
classified burns anatomically and described as Superficial
(Partial Skin Loss), Deep (Total Skin Loss) and Mixed. This
system was further refined by Jackson in 1953. He
subdivided Partial Skin Loss into Superficial Skin Loss (Sup.
SL) and Deep Skin Loss (Deep SL). He suggested that
former heals from hair follicle remnants and latter heals
from sweat gland and deep hair follicle remnants.
Burns in this context is basically involvement of epidermis
and some amount of dermis and purely epidermal burn which
is mostly seen in sun burn (Fig. 3.13) is not dealt in this
context. The general consensus on classification of burn
depth is on the basis of dermal thickness involvement which
ranges from partial thickness to full thickness. Burns
involving superficial papillary dermis is termed as superficial
Fig. 3.11: Laser burns in axilla –Laser used for hair removal
Fig. 3.12: Friction burns of face in a young boy

32
Principles and Practice of Burn Care
partial thickness burn and those extending into the deeper
reticular dermis are called deep partial thickness burn. To
categorize a burn as partial thickness some amount of dermis
must be spared with its viable epidermal elements in hair
follicle and glands, facilitating healing by epithelialization.
On the contrary, a burn involving the whole of dermis is
termed as full thickness burn which needs skin grafting as
spontaneous epithelialization is not possible due to the lack
of epidermal adnexal elements. A parallel terminology also
used in this context is degree of burn. Epidermal burns are
termed as first degree burn and as mentioned earlier are not
considered in this context. Partial thickness burn is
synonymous with second degree burn and is further sub-
classified into second degree superficial dermal and second
degree deep dermal based on the same criteria of involvement
of dermal thickness mentioned above.
Full thickness burns are third degree burns. The modality
of categorizing on the basis of depth is purely clinical and
subjective based on the clinical picture of the wound and
symptoms. In superficial partial thickness or second degree
burns, vesication is primary feature (Figs 3.14 to 3.15B).
This is due to subepidermal fluid collection and when
deroofed, it exposes a glistening pink and wet dermis. Such
bullae are not seen in deep partial thickness burn as the
burnt epidermis and the reticular dermis sticks to the wound
and give a waxy white appearance (Figs 3.16A and B). In
full thickness burns, the whole devitalized skin is adherent
as a parchment like eschar on the wound (Figs 3.17 and
3.18) with thrombosed vessels shining through the dead
skin (Fig. 3.19). The depth of burn can also be judged by
Fig. 3.13: Epidermal burn or sunburn
Fig. 3.14: Superficial partial thickness or superficial dermal burns
showing blisters
Fig. 3.15A: Superficial dermal burns over chest and abdomen after
debridement of blisters with moist red look
Fig. 3.15B: Superficial dermal burns involving arm after removal of
loose dead skin. The areas blanch on pressure with brisk capillary
refill

Burns: Etiology and Classification
33
the involvement of hair follicles. In deeper burns there is
easy pluckability of hair signifying their devitalization.
Similarly, pain in the burn wound is inversely proportional
to the amount of dermal involvement as nerve endings are
destroyed in deeper burns. The pink appearance which
blanches on pressure in a superficial burn indicates the rich
capillary arborization in the superficial dermis and hence
deep partial thickness burns are relatively pale or waxy white
and do not blanch on pressure. The blanching test should
always be done as a deeper burn can also be fallaciously
erythematous due to fixation of erythrocytes leaked out of
the destroyed capillaries. Such a picture is frequently seen
in children who have thin skin. A subdermal burn damages
muscle, bone, and interstitial tissue as is usually seen in
electrical contact burns (Fig. 3.20). They are termed fourth
degree burns.
A workable classification with interchangeable terms is
given in Table 3.3. While using this system, it is prudent to
note that burn wound is in a perpetual state of change
depending upon tissue perfusion and infection. A wound
categorized as superficial dermal on admission, may covert
into deep dermal burn because of inadequate fluid
resuscitation and wound infection. Hence, repeated and
regular assessment is always rewarding diagnostically. The
term ‘eschar’ needs to be defined, which is synonymous
with third degree burn. But the waxy white layer seen in
second degree deep dermal or deep partial thickness burn
should also be regarded as “soft eschar”. This layer is
formed by dead papillary and reticular dermis and needs to
be excised in tangential excision.
Fig. 3.16A: Deep dermal or deep partial thickness burns involving
forearm with waxy white look
Fig. 3.16B: Deep dermal burns of chest and abdomen with mixed red
and white wet look with areas that blanch on pressure but capillary
refill is sluggish or absent
Fig. 3.17: Deep burns over chest and arms
Fig. 3.18: Deep burns over arm and thighs

34
Principles and Practice of Burn Care
Table 3.3: Clinical classification of burns
Burns
Involvement
Features
Depth
First degree (Sun Burn)
Epidermis
Erythema only.
Partial thickness
Heals in < 5 days
Second degree
Epidermis and
Extremely painful
Partial thickness
- Superficial dermal or
papillary dermis
Blister formation.
Superficial partial thickness
Wet, glistening pink
Heals in 10-15 days.
- Deep dermal or deep
Epidermis, papillary
Less painful, waxy
Partial thickness
partial thickness
dermis and part of
white appearance.
reticular dermis
Heals in 3-5 weeks.
Third degree
Entire thickness of skin
Painless Inelastic, translucent,
Full thickness
parchmentlike eschar with
visible thrombosed veins
Require skin grafting.
Fourth degree
Skin, subcutaneous tissue,
Thick eschar to gangrene
Full thickness
muscle, carbonization of limb
or gangrene
Fig. 3.19: Deep or full thickness burns over shoulder with dry
translucent eschar with thrombosed vessels
Fig. 3.20: Deep electrical contact burn involving skin, subcutaneous
tissue, muscle and bone
It is obvious that this clinical classification system of
burns, based on visual examination, is fraught with
subjectivity and high experience requirement. There is an
ongoing quest for an objective system to obviate these
shortcomings. Numerous attempts using thermographic,
infrared and ultraviolet imaging, radioisotope scanning,
Doppler laser flux measurement and visual digital imaging
have been reported.8-13 Unfortunately, none have risen out
of research journals into user friendly modality due to
economic reasons.
ESTIMATION OF BURN SIZE
The amount of body surface area involved in burns,
expressed as a percentage of the total body surface area
(%TBSA), is the key to the estimation of fluid requirement
to treat shock and is also an important prognostic factor.
The extent of burn is estimated by Wallace’s Rule of Nine.
According to this system head and neck account for 9%,
each upper limb and each lower limb constitute 9% and 18%
respectively. The anterior and posterior trunk constitutes 18%
each and external genitalia account for 1%. The estimation
is different in children owing to the larger proportion of the
head. Hence in a child, head and neck account for 18% and
the lower limb constitute 13.5% each. Proportion of upper
limb and trunk remains same as adult. A more accurate
estimation system is the Lund and Browder Chart which
can be used for all age groups and also compensates for
variable body size and shape (Table 3.4). Estimation of extent
of scattered and irregular areas in all age groups is done by
Rule of Palm or Hand. The palm of an individual with fingers
and thumb adducted account for 1%.

Burns: Etiology and Classification
35
CLASSIFICATION ACCORDING TO SEVERITY
OF BURNS (TABLE 3.5)
The severity categorization of burn is done by taking into
consideration extent and depth. This classification is useful
for establishing admission criteria and is indispensable in
triaging in event of a fire disaster. The categorization is as
follows:
Critical Burn
a. Partial thickness burn >25%TBSA in adult, >15%TBSA
in children and > 5%TBSA in infants.
b. Full thickness burn >10%TBSA in adults and > 3%TBSA
in children and infants.
c. Burns of hand, face and perineum
d. Burns with associated head injury, thoracic or abdominal
trauma, old age and preexisting systemic illness.
e. Burns with associated inhalation injury
f. Electrical burn.
Moderate Burns
a. Partial thickness burn 15-25%TBSA in adults and
10-15%TBSA in children and infants.
b. Full thickness burn 3-10%TBSA in adults and
1-3%TBSA in children and infants.
Minor Burns
a. Partial thickness burn< 15%TBSA burn in adults and <
10%TBSA in children and infants.
b. Full thickness burn <3%TBSA in adults and up to
1%TBSA in children and infants.
Grading of Burns
A further refinement to this system was propounded by
Kumar (1993) by including the percentage of deep burn as
an additional criterion (Table 3.6).14 He included deep partial
Table 3.4: Lund and Browder’s chart for estimating area of burns
Area
Birth to1
1 to 4
5 to 9
10 to 14
15 years
Adult
2nd°
3rd°
TBSA
year
years
years
years
Head
19
17
13
11
9
7
Neck
2
2
2
2
2
2
Anterior trunk
13
13
13
13
13
13
Posterior trunk
13
13
13
13
13
13
Right buttock
2.5
2.5
2.5
2.5
2.5
2.5
Left buttock
2.5
2.5
2.5
2.5
2.5
2.5
Genitalia
1
1
1
1
1
1
Right upper arm
4
4
4
4
4
4
Left upper arm
4
4
4
4
4
4
Right lower arm
3
3
3
3
3
3
Left lower arm
3
3
3
3
3
3
Right hand
2.5
2.5
2.5
2.5
2.5
2.5
Left hand
2.5
2.5
2.5
2.5
2.5
2.5
Right thigh
5.5
6.5
8
8.5
9
9.5
Left thigh
5.5
6.5
8
8.5
9
9.5
Right leg
5
5
5.5
6
6.5
7
Left leg
5
5
5.5
6
6.5
7
Right foot
3.5
3.5
3.5
3.5
3.5
3.5
Left foot
3.5
3.5
3.5
3.5
3.5
3.5
Total:
100
100
100
100
100
100
Table 3.5: Classification of burns as per their severity
Grade
Criteria
Critical burns
Partial thickness burns > 25% TBSA (total body
surface area)

Full thickness burns >10%

Burns of special sites like hands, face and
perineum.

Burns with associated injury or any pre-existing
illness and old age.

Electrical burns.

Burns complicated by respiratory tract
involvement.
Moderate burns
Partial thickness burns 15-25% TBSA

Full thickness burns 1-3% TBSA
Minor burns
Partial thickness burns <10-15% TBSA.