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A burn is a type of injury to flesh or skin caused by heat, electricity, chemicals, friction, or radiation.^[1] Burns that affect only the superficial skin are known as superficial or first-degree burns. When damage penetrates into some of the underlying layers, it is a partial-thickness or second-degree burn. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. A fourth-degree burn additionally involves injury to deeper tissues, such as muscle or bone.

The treatment required depends on the severity of the burn. Superficial burns may be managed with little more than simple pain killers, while major burns may require prolonged treatment in specialized burn centers. Cooling with tap water may help relieve pain and decrease damage; however, prolonged exposure may result in low body temperature. Partial-thickness burns may require cleaning with soap and water, followed by dressings. Blisters should be left unbroken to reduce the likelihood of infection. Full-thickness burns usually require surgical treatments, such as skin grafting. Extensive burns often require large amounts of intravenous fluids because the subsequent inflammatory response will result in significant capillary fluid leakage and edema. The most common complications of burns are related to infection.

While large burns can be fatal, modern treatments developed since 1960 have significantly improved the outcomes, especially in children and young adults.^[2] Globally, about 11 million people seek medical treatment, and 300,000 die from burns.^[3] In the United States, approximately 4% of those admitted to a burn center die from their injuries.^[4] The long-term outcome is primarily related to the size of burn and the age of the person affected.

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns have pain lasting two or three days followed by peeling of the skin over the next few days.^[5]^[6] Individuals suffering from more severe burns may indicate discomfort or complain of feeling pressure rather than pain. Full-thickness burns may be entirely insensitive to light touch or puncture.^[6] While superficial burns are typically red in color, severe burns may be pink, white or black.^[6] Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred, but these findings are not definitive.^[7] More worrisome signs include: shortness of breath, hoarseness, stridor or wheezing.^[7] Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all children.^[8] Numbness or tingling may persist for a prolong period of time after an electrical injury.^[9] Burns may also produce emotional and psychological distress.^[3]

Type^[10]	Layers involved	Appearance	Texture	Sensation	Healing Time	Prognosis
Superficial (First degree)	Epidermis^[5]	Red without blisters^[10]	Dry	Painful^[10]	7 days^[10]	Heal well;^[10] Repeated sunburns increase the risk of skin cancer later in life^[11]
Superficial partial thickness (Second degree)	Extends into superficial (papillary) dermis^[10]	Redness with clear blister. Blanches with pressure.^[10]	Moist^[10]	Very painful^[10]	less than 2–3 weeks^[10]^[6]	Local infection/cellulitis but no scarring typically^[6]
Deep partial thickness (Second degree)	Extends into deep (reticular) dermis^[10]	Yellow or white. Less blanching. May be blistering.^[10]	Fairly dry^[6]	Pressure and discomfort^[6]	3–8 weeks^[10]	Scarring, contractures (may require excision and skin grafting)^[6]
Full thickness (Third degree)	Extends through entire dermis^[10]	Stiff and white/brown^[10] No blanching^[6]	Leathery^[10]	Painless^[10]	Prolonged (months) and incomplete^[10]	Scarring, contractures, amputation (early excision recommended)^[6]
Fourth degree	Extends through entire skin, and into underlying fat, muscle and bone^[10]	Black; charred with eschar	Dry	Painless	Requires excision^[10]	Amputation, significant functional impairment, and in some cases death.^[10]

Cause

Burns are caused by a variety of external sources classified as thermal, chemical, electrical, and radiation.^[12] In the United States, the most common causes of burns are: fire/flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%).^[13] Most (69%) burn injuries occur at home or at work (9%),^[4] and most are accidental, with 2% due to assault by another, and 1-2% resulting from a suicide attempt.^[3] These sources can cause inhalation injury to the airway and/or lungs, occurring in about 6%.^[14]

Burn injuries occur more commonly in the poor. Smoking is a risk factor, although alcohol use is not. Fire related burns are generally more common in colder climates.^[3] Specific risk factors in the developing world include cooking with open fires or on the floor^[1] as well as developmental disabilities in children and chronic diseases in adults.^[15]

Thermal

In the United States, fire and hot liquids are the most common causes of burns.^[14] Of house fires that result in death, smoking cause of 25%, and heating devices cause of 22%.^[1] Almost half of injuries are due to efforts to fight a fire.^[1] Scalding is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature tap water in baths or showers, hot cooking oil or steam.^[16] Scald injuries are most common in children under the age of five^[10] and, in the United States and Australia, this population makes up about two-thirds of all burns.^[14] Contact with hot objects is the cause of about 20-30% of burns in children.^[14] Generally, scalds are first or second degree burns, but third degree burns can result, especially with prolonged contact.^[17] Fireworks are a common cause of burns during holiday seasons in many countries.^[18] This is a particular risk for adolescent males.^[19]

Chemical

Chemicals cause from 2 to 11% of all burns and contribute to as many as 30% of burn-related deaths.^[20] Chemical burns can be caused by over 25,000 substances,^[10] most of which are either a strong base (55%) or a strong acid (26%).^[20] Most chemical burn deaths are secondary to ingestion.^[10] Common agents include: sulfuric acid as found in toilet cleaners, sodium hypochlorite as found in bleach, and halogenated hydrocarbons as found in paint remover, among others.^[10] Hydrofluoric acid can cause particularly deep burns which may not become symptomatic until some time after exposure.^[21] Formic acid may cause the breakdown of significant numbers of red blood cells.^[7]

Electrical

Electrical burns or injuries are classified as high voltage (greater than or equal to 1000 volts), low voltage (less than 1000 volts), or as flash burns secondary to an electric arc.^[10] The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).^[14] Lightning may also result in electrical burns.^[22] Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.^[9] Mortality from a lightning strike is about 10%.^[9]

While electrical injuries primarily result in burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions.^[9] In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone.^[9] Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest.^[9]

Radiation

Radiation burns may be caused by protracted exposure to ultraviolet light (such as from the sun, tanning booths or arc welding) or from ionizing radiation (such as from radiation therapy, X-rays or radioactive fallout).^[23] Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.^[24] There is significant variation in how easily people sunburn based on their skin type.^[25] Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3 Gy, redness seen after 10 Gy, wet skin peeling after 20 Gy, and necrosis after 30 Gy.^[26] Redness, if it occurs, may not appear until some time after exposure.^[26] Radiation burns are treated the same as other burns.^[26] Microwave burns occur via thermal heating caused by the microwaves.^[27] While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.^[27]

Intentional

In those hospitalized from scalds or fire burns, 3–10% are from assault.^[28] Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes.^[28] An immersion injury or immersion scald may indicate child abuse.^[17] It is created when an extremity or the lower body (buttock or perineum) is held under the surface of hot water.^[17] It typically produces a sharp upper border and is often symmetrical.^[17] Other high-risk signs of potential abuse include: circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse.^[29]

Bride burning, a form of domestic violence, occurs in some cultures such as India where a woman is burned due to what the husband or his family consider to be an inadequate dowry.^[30]^[31] In Pakistan, acid burns represent 13% of intentional burns, and are frequently related to domestic violence.^[29] Self-immolation (setting oneself on fire as a form of protest) is also relatively common among Indian women.^[3]

Pathophysiology

At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down.^[32] This results in cell and tissue damage.^[10] Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin.^[10] They include disruption of the skin's sensation, ability to prevention water loss through evaporation, and ability to control body temperature.^[10] Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.^[10]

In large burns (over 30% of the total body surface area), there is a significant inflammatory response.^[33] This results in increased leakage of fluid from the capillaries^[7] and subsequent tissue edema.^[10] This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated.^[10] Poor blood flow to organs such as the kidneys and gastrointestinal tract may result in renal failure and stomach ulcers.^[34]

Increased levels of catecholamines and cortisol may result in a hypermetabolic state which may last for years.^[33] This is associated with increased cardiac output, metabolism, a fast heart rate, and poor immune function.^[33]

Diagnosis

Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.^[10] It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary.^[7] In those who have a headache or are dizzy and have a fire-related burn, carbon monoxide poisoning should be considered.^[35] Cyanide poisoning should also be considered.^[7]

Size

The size of a burn is measured as a percentage of total body surface area (TBSA) affected by partial thickness or full thickness burns.^[10] First-degree burns that are only red in color and are not blistering are not included in this estimation.^[10] Most burns (70%) involve less than 10% of the TBSA.^[14]

There are a number of methods to determine the TBSA including: the "rule of nines", Lund and Browder charts, and estimations based on a person's palm size.^[5] The rule of nines is easy to remember but only accurate in people over 16 years of age.^[5] More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children.^[5] The size of a person's hand print (including the palm and fingers) is approximately 1% of their TBSA.^[5]

Severity

American Burn Association severity classification^[35]
Minor	Moderate	Major
Adult <10% TBSA	Adult 10-20% TBSA	Adult >20% TBSA
Young or old < 5% TBSA	Young or old 5-10% TBSA	Young or old >10% TBSA
<2% full thickness burn	2-5% full thickness burn	>5% full thickness burn
	High voltage injury	High voltage burn
	Possible inhalation injury	Known inhalation injury
	Circumferential burn	Significant burn to face, joints, hands or feet
	Other health problems	Associated injuries

In order to determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate and minor. This is assessed based on a number of factors, including total body surface area affected, the involvement of specific anatomical zones, the age of the person, and associated injuries.^[35] Minor burns can typically be managed at home, moderate burns are often managed in hospital, and major burns are managed by a burn center.^[35]

Prevention

Historically, about half of all burns were deemed to be preventable.^[1] Burn prevention programs have significantly decreased rates of serious burns.^[32] Preventative measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing.^[1] Experts recommend setting water heaters below 48.8 °C (119.8 °F).^[14] Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves.^[32] While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit^[36] with recommendations including the limitation of the sale of fireworks to children.^[14]

Management

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.^[5] If inhalation injury is suspected, early intubation maybe required.^[7] This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospital.^[7] As burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years.^[37] In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.^[3] With major burns, early feeding is important.^[33] Hyperbaric oxygenation may be useful in addition to traditional treatments.^[38]

Intravenous fluids

In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given.^[5] In children with more than 10-20% TBSA burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow.^[5]^[39]^[40] This should be begun pre-hospital if possible in those with burns greater than 25% TBSA.^[39] The Parkland formula can help determine the volume of intravenous fluids required over the first 24 hours. The formula is based on the affected individual's TBSA and weight. Half of the fluid is to be administered over the first 8 hours, and the remainder given over the following 16 hours. The time frame is calculated from the time at which the burn occurred, and not from the time at which fluid resuscitation was begun. Children require additional maintenance fluid that includes glucose.^[7] Additionally, those with inhalation injuries require more fluid.^[41] While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental.^[42] The formulas are only a guide, with infusions ideally tailored to a urinary output of >30 mL/h in adults or >1mL/kg in children and mean arterial pressure greater than 60 mmHg.^[7]

While lactated Ringer's solution is often used, there is no evidence that it is superior to normal saline.^[5] Crystalloid fluids appear just as good as colloid fluids, and as colloids are more expensive they are not recommended.^[43] Blood transfusions are rarely required.^[10] They are typically only recommended when the hemoglobin levels falls below 60-80 g/L (6-8 g/dL)^[44] due to the associated risk of complications.^[7] Intravenous catheters may be placed through burned skin if needed or intraosseous infusions may be used.^[7]

Wound care

Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as overcooling can result in hypothermia.^[10]^[5] It should be performed with cool water 10–25 °C (50.0–77.0 °F) and not ice water as the latter can cause further injury.^[5]^[32] Chemical burns may require extensive irrigation.^[10] Cleaning with soap and water, removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second degree burns should be re-evaluated after two days.^[32]

In the management of first and second degree burns, little quality evidence exists to determine which type of dressing should be used.^[45]^[46] It is reasonable to manage first degree burns without dressings.^[32] While topical antibiotics are often recommended, there is little evidence to support their use.^[47] Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time.^[46] There is insufficient evidence to support the use of silver containing dressings^[48] or negative-pressure wound therapy.^[49]

Medications

Burns can be very painful and a number of different options maybe used for pain management. These include simple analgesics (such as ibuprofen and acetaminophen) and opioids such as morphine. Benzodiazepines may be used in addition to analgesics to help with anxiety.^[32] During the healing process, antihistamines, massage, or transcutaneous nerve stimulation may be used to aid with itching.^[8] Antihistamines, however, are only effective in 20% of people for this purpose.^[50] There is tentative evidence supporting the use of gabapentin^[8] and its use may be reasonable in those who do not improve with antihistamines.^[51]

Intravenous antibiotics are recommended before surgery for those with extensive burns (>60% TBSA).^[52] As of 2008^[update], guidelines do not recommend their general use due to concerns regarding antibiotic resistance^[47] and an increased the risk of fungal infections.^[7] Tentative evidence, however, shows that they may improve survival in those with large and severe burns.^[47] Erythropoietin has not been found to be effective to prevent or treat anemia in people with burns.^[7] In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically.^[21]

Surgery

Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible.^[53] Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy.^[54] This is done to treat or prevent problems with distal circulation, or ventilation.^[54] It is uncertain if it is useful for neck or digit burns.^[54] Fasciotomies may be required for electrical burns.^[54]

Alternative medicine

Honey has been used since ancient times to aid wound healing and may be beneficial in first and second degree burns.^[55] There is little evidence that vitamin E helps with keloids or scarring.^[56] In low income countries, burns are treated up to one-third of the time with traditional medicine, which may include applications of eggs, mud, leaves or cow dung.^[15] Surgical management is limited in some cases due to insufficient financial resources and availability.^[15] There are a number of other methods that may be used in addition to medications to reduce procedural pain and axiety including: virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.^[51]

Prognosis

Prognosis in the USA^[57]
TBSA	Mortality
<10%	0.6%
10-20%	2.9%
20-30%	8.6%
30-40%	16%
40-50%	25%
50-60%	37%
60-70%	43%
70-80%	57%
80-90%	73%
>90%	85%
Inhalation	23%

The prognosis is worse in those with larger burns, those who are older and those who are females.^[10] The presence of a smoke inhalation injury, other significant injuries such as long bone fractures, and serious co-morbidities (e.g. heart disease, diabetes, psychiatric illness, and suicidal intent) also influence prognosis.^[10] In one large United States series of people admitted to burn centres on average 4% of people died^[14] with a mortality of less than 1% in those with burn areas less than 10% TBSA and 85% in those with more than 90% TBSA burns.^[57] In Afghanistan, people with more than 60% TBSA burns rarely survive.^[14] The Baux score has historically been used to determine prognosis of major burns; however, with improved care, it is no longer very accurate.^[7] The score is determined by adding the size of the burn (% TBSA) to the age of the person which used to more or less equal the risk of death.^[7]

Complications

A number of complications may occur, with infections being the most common.^[14] In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure.^[14] Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.^[58] Pneumonia occurs particularly commonly in those with inhalational injuries.^[7]

Anemia secondary to full thickness burns of greater than 10% TBSA is common.^[5] Electrical burns may lead to compartment syndrome or rhabdomyolysis due to muscle breakdown.^[7] Blood clotting in the veins of the legs is estimated to occur in 6 to 25% of people.^[7] The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.^[33] Keloids may form subsequent to a burn, particularly in those who are young and dark skinned.^[56] Following a burn, children may have significant psychological trauma and experience post-traumatic stress disorder.^[59] Scarring may also result in a disturbance in body image.^[59] In the developing world, significant burns may result in social isolation, extreme poverty and in children abandonment.^[3]

Epidemiology

As of 2004, 11 million burns required medical care worldwide and resulted in 300,000 deaths.^[3] This makes it the 4th leading cause of injuries after motor vehicle collisions, falls, and violence.^[3] About 90% of burns occur in the developing world.^[3] This has been attributed partly to overcrowding and an unsafe cooking situation.^[3] Overall, nearly 60% of fatal burns occur in Southeast Asia with a rate of 11.6 per 100,000.^[14]

In the developed world, adult males have twice the mortality as females from burns. This is probably due to their higher risk occupations and greater risk-taking activities. In many countries in the developing world, however, females have twice the risk of males. This is often related to accidents in the kitchen or domestic violence.^[3] In children, deaths from burns occurs at more than ten times the rate in the developing than the developed world.^[3] Overall in children it is one of the top fifteen leading causes of death.^[1] From the 1980s to 2004 many countries have seen both a decrease in the rates of fatal burns, and in burns generally.^[3]

Developed countries

An estimated 500,000 burn injuries receive medical treatment yearly in the United States.^[32] They resulted in about 3,300 deaths in 2008.^[1] Most burns (70%) and deaths from burns occur in males.^[4]^[10] The highest incidence of fire burns occurs in those 18–35 years old, while the highest incidence of scalds occurs in children less than five years old and adults over 65.^[10] Electrical burns result in about 1,000 deaths per year.^[61] Lighting results in the death of about 60 people a year.^[9] In Europe, intentional burns occur most commonly in middle aged men.^[28]

Developing countries

In India, about 700,000 to 800,000 people a year sustain significant burns, though very few are looked after in specialist burn units.^[62] The highest rates occur in women 16–35 years of age.^[62] Part of this high rate is related to unsafe kitchens and loose-fitting clothing typical to India.^[62] It is estimated that one-third of all burns in India are due to clothing catching fire from open flames.^[63] Intentional burns are also a common cause and occur at high rates in young women secondary to domestic violence and self-harm.^[28]^[3]

History

Cave paintings from more than 3,500 years ago document burns and their management.^[2] The 1500 BCE Egyptian Smith papyrus describes treatments using honey and the salve of resin.^[2] Many other treatments have been used over the ages including: tea leaves by the Chinese documented to 600 BCE, pig fat and vinegar by Hippocrates documented to 400 BCE, and wine and myrrh by Celsus documented to 100 CE.^[2] The first description of different degrees of burns was by the French barber-surgeon Ambroise Paré in the 1500s.^[64] These degrees were expanded into six different severities by Guillaume Dupuytren in 1832.^[65]^[2]

The first hospital to treat burns opened in 1843 in London, England and the development of modern burn care began in the late 1800s and early 1900s.^[2]^[64] The importance of infection control was realized in the 1910s with sodium hypochlorite used to clean the wounds.^[2] The importance of early excision and skin grafting was acknowledged in the 1940s and around the same time, fluid resuscitation and formulas to guide it were developed.^[2] The significance of the hypermetabolic state that follows large burns was realized in the 1970s.^[2]

References

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^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ Herndon D (ed.). "Chapter 1: A Brief History of Acute Burn Care Management". Total burn care (4th ed.). Edinburgh: Saunders. p. 1. ISBN 978-1-4377-2786-9.
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^ ^a ^b ^c "Burn Incidence and Treatment in the United States: 2012 Fact Sheet". American Burn Association. 2012. Retrieved 20 April 2013.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m Granger, Joyce (2009). "An Evidence-Based Approach to Pediatric Burns". Pediatric Emergency Medicine Practice. 6 (1). {{cite journal}}: Unknown parameter |month= ignored (help)
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Herndon D (ed.). "Chapter 10: Evaluation of the burn wound: management decisions". Total burn care (4th ed.). Edinburgh: Saunders. p. 127. ISBN 978-1-4377-2786-9.
^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q ^r ^s Brunicardi, Charles (2010). "Chapter 8: Burns". Schwartz's principles of surgery (9th ed.). New York: McGraw-Hill, Medical Pub. Division. ISBN 978-0-07-154769-7.
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^ ^a ^b ^c ^d ^e ^f ^g Marx, John (2010). "Chapter 140: Electrical and Lightning Injuries". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 0-323-05472-2.
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^ National Burn Repository Pg. i
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^ ^a ^b ^c Forjuoh, SN (2006 Aug). "Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention". Burns : journal of the International Society for Burn Injuries. 32 (5): 529–37. PMID 16777340. {{cite journal}}: Check date values in: |date= (help)
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^ ^a ^b Makarovsky, I (2008 May). "Hydrogen fluoride--the protoplasmic poison". The Israel Medical Association journal : IMAJ. 10 (5): 381–5. PMID 18605366. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
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^ Balk, SJ (2011 Mar). "Ultraviolet radiation: a hazard to children and adolescents". Pediatrics. 127 (3): e791-817. PMID 21357345. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b ^c Marx, John (2010). "Chapter 144: Radiation Injuries". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 0-323-05472-2.
^ ^a ^b Krieger, John (2001). Clinical environmental health and toxic exposures (2nd ed.). Philadelphia, Pa. [u.a.]: Lippincott Williams & Wilkins. p. 205. ISBN 978-0-683-08027-8.
^ ^a ^b ^c ^d Peck, MD (2012 Aug). "Epidemiology of burns throughout the World. Part II: intentional burns in adults". Burns : journal of the International Society for Burn Injuries. 38 (5): 630–7. PMID 22325849. {{cite journal}}: Check date values in: |date= (help)
^ ^a ^b Herndon D (ed.). "Chapter 61: Intential burn injuries". Total burn care (4th ed.). Edinburgh: Saunders. p. 689-698. ISBN 978-1-4377-2786-9.
^ Jutla, RK (2004 Mar-Apr). "Love burns: An essay about bride burning in India". The Journal of burn care & rehabilitation. 25 (2): 165–70. PMID 15091143. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Peden, Margie (2008). World report on child injury prevention. Geneva, Switzerland: World Health Organization. p. 82. ISBN 978-92-4-156357-4.
^ ^a ^b ^c ^d ^e ^f ^g ^h Marx, John (2010). "Chapter 60: Thermal Burns". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 978-0-323-05472-0.
^ ^a ^b ^c ^d ^e Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN (2012). "Burns: an update on current pharmacotherapy". Expert Opin Pharmacother. 13 (17): 2485–94. doi:10.1517/14656566.2012.738195. PMC 3576016. PMID 23121414. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
^ Hannon, Ruth (2010). Porth pathophysiology : concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1516. ISBN 978-1-60547-781-7.
^ ^a ^b ^c ^d Garmel, edited by S.V. Mahadevan, Gus M. (2012). An introduction to clinical emergency medicine (2nd ed.). Cambridge: Cambridge University Press. pp. 216–219. ISBN 978-0-521-74776-9. {{cite book}}: |first= has generic name (help)CS1 maint: multiple names: authors list (link)
^ Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 46. ISBN 978-3-7091-0348-7.
^ Klingensmith M, ed. (2007). The Washington manual of surgery (5th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. p. 422. ISBN 978-0-7817-7447-5.
^ Cianci, P (2013 Jan-Feb). "Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns". Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc. 40 (1): 89–108. PMID 23397872. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b Enoch, S (2009 Apr 8). "Emergency and early management of burns and scalds". BMJ (Clinical research ed.). 338: b1037. PMID 19357185. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Hettiaratchy, S (2004 Jul 10). "Initial management of a major burn: II--assessment and resuscitation". BMJ (Clinical research ed.). 329 (7457): 101–3. PMID 15242917. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 77. ISBN 978-3-7091-0348-7.
^ Endorf, FW (2011 Dec). "Burn management". Current opinion in critical care. 17 (6): 601–5. PMID 21986459. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Perel, P (2012 Jun 13). Perel, Pablo (ed.). "Colloids versus crystalloids for fluid resuscitation in critically ill patients". Cochrane database of systematic reviews (Online). 6: CD000567. doi:10.1002/14651858.CD000567.pub5. PMID 22696320. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Curinga, G (2011 Aug). "Red blood cell transfusion following burn". Burns : journal of the International Society for Burn Injuries. 37 (5): 742–52. PMID 21367529. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Wasiak, J (2013 Mar 28). "Dressings for superficial and partial thickness burns". Cochrane database of systematic reviews (Online). 3: CD002106. PMID 23543513. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b Wasiak J, Cleland H, Campbell F (2008). Wasiak, Jason (ed.). "Dressings for superficial and partial thickness burns". Cochrane Database Syst Rev (4): CD002106. doi:10.1002/14651858.CD002106.pub3. PMID 18843629.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b ^c Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M (2010). "Prophylactic antibiotics for burns patients: systematic review and meta-analysis". BMJ. 340: c241. doi:10.1136/bmj.c241. PMC 2822136. PMID 20156911.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Storm-Versloot, MN (2010 Mar 17). Storm-Versloot, Marja N (ed.). "Topical silver for preventing wound infection". Cochrane database of systematic reviews (Online) (3): CD006478. doi:10.1002/14651858.CD006478.pub2. PMID 20238345. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Dumville, JC (2012 Dec 12). "Negative pressure wound therapy for partial-thickness burns". Cochrane database of systematic reviews (Online). 12: CD006215. PMID 23235626. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Zachariah, JR (2012 Aug). "Post burn pruritus--a review of current treatment options". Burns : journal of the International Society for Burn Injuries. 38 (5): 621–9. PMID 22244605. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b Herndon D (ed.). "Chapter 64: Management of pain and other discomforts in burned patients". Total burn care (4th ed.). Edinburgh: Saunders. p. 726. ISBN 978-1-4377-2786-9.
^ Herndon D (ed.). "Chapter 31: Etiology and prevention of multisystem organ failure". Total burn care (4th ed.). Edinburgh: Saunders. p. 664. ISBN 978-1-4377-2786-9.
^ Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 266. ISBN 978-3-7091-0348-7.
^ ^a ^b ^c ^d Orgill, DP (2009 Sep-Oct). "Escharotomy and decompressive therapies in burns". Journal of burn care & research : official publication of the American Burn Association. 30 (5): 759–68. PMID 19692906. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Jull AB, Rodgers A, Walker N (2008). Jull, Andrew B (ed.). "Honey as a topical treatment for wounds". Cochrane Database Syst Rev (4): CD005083. doi:10.1002/14651858.CD005083.pub2. PMID 18843679.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b Juckett, G (2009 Aug 1). "Management of keloids and hypertrophic scars". American family physician. 80 (3): 253–60. PMID 19621835. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b National Burn Repository, Pg. 10
^ Young, Christopher King, Fred M. Henretig, ed. (2008). Textbook of pediatric emergency procedures (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1077. ISBN 978-0-7817-5386-9.{{cite book}}: CS1 maint: multiple names: editors list (link)
^ ^a ^b Roberts, edited by Michael C. (2009). Handbook of pediatric psychology (4th ed.). New York: Guilford. p. 421. ISBN 978-1-60918-175-8. {{cite book}}: |first= has generic name (help)
^ "WHO Disease and injury country estimates". World Health Organization. 2009. Retrieved Nov. 11, 2009. {{cite web}}: Check date values in: |accessdate= (help)
^ Edlich, RF (2005). "Modern concepts of treatment and prevention of electrical burns". Journal of long-term effects of medical implants. 15 (5): 511–32. PMID 16218900. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ ^a ^b ^c Ahuja, RB (2004 Aug 21). "Burns in the developing world and burn disasters". BMJ (Clinical research ed.). 329 (7463): 447–9. PMID 15321905. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
^ Gupta (2003). Textbook of Surgery. Jaypee Brothers Publishers. p. 42. ISBN 978-81-7179-965-7.
^ ^a ^b Song, David. Plastic surgery (3rd ed. ed.). Edinburgh: Saunders. p. 393.e1. ISBN 9781455710553. {{cite book}}: |edition= has extra text (help)
^ Wylock, Paul (2010). The life and times of Guillaume Dupuytren, 1777-1835. Brussels: Brussels University Press. p. 60. ISBN 9789054875727.

Notes

National Burn Repository (PDF). American Burn Association. 2012.

External links

Template:Dmoz

Template:Link FA

[TBCChp4-1] ^ ^a ^b ^c ^d ^e ^f ^g ^h Herndon D (ed.). "Chapter 4: Prevention of Burn Injuries". Total burn care (4th ed.). Edinburgh: Saunders. p. 46. ISBN 978-1-4377-2786-9.

[TBCChp1-2] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ Herndon D (ed.). "Chapter 1: A Brief History of Acute Burn Care Management". Total burn care (4th ed.). Edinburgh: Saunders. p. 1. ISBN 978-1-4377-2786-9.

[Epi2011-3] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o Peck, MD (2011 Nov). "Epidemiology of burns throughout the world. Part I: Distribution and risk factors". Burns : journal of the International Society for Burn Injuries. 37 (7): 1087–100. doi:10.1016/j.burns.2011.06.005. PMID 21802856. {{cite journal}}: Check date values in: |date= (help)

[ABA2012-4] "Burn Incidence and Treatment in the United States: 2012 Fact Sheet". American Burn Association. 2012. Retrieved 20 April 2013.

[EMP2009-5] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m Granger, Joyce (2009). "An Evidence-Based Approach to Pediatric Burns". Pediatric Emergency Medicine Practice. 6 (1). {{cite journal}}: Unknown parameter |month= ignored (help)

[TBCChp10-6] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Herndon D (ed.). "Chapter 10: Evaluation of the burn wound: management decisions". Total burn care (4th ed.). Edinburgh: Saunders. p. 127. ISBN 978-1-4377-2786-9.

[Schw2010-7] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q ^r ^s Brunicardi, Charles (2010). "Chapter 8: Burns". Schwartz's principles of surgery (9th ed.). New York: McGraw-Hill, Medical Pub. Division. ISBN 978-0-07-154769-7.

[Itchy2009-8] Goutos, I (2009 Mar-Apr). "Pruritus in burns: review article". Journal of burn care & research : official publication of the American Burn Association. 30 (2): 221–8. PMID 19165110. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[RosenChp140-9] ^ ^a ^b ^c ^d ^e ^f ^g Marx, John (2010). "Chapter 140: Electrical and Lightning Injuries". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 0-323-05472-2.

[Tint2010-10] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o ^p ^q ^r ^s ^t ^u ^v ^w ^x ^y ^z ^aa ^ab ^ac ^ad ^ae ^af ^ag ^ah ^ai ^aj ^ak ^al ^am ^an ^ao ^ap Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 0-07-148480-9.

[11] Buttaro, Terry (2012). Primary Care: A Collaborative Practice. Elsevier Health Sciences. p. 236. ISBN 978-0-323-07585-5.

[12] Kowalski, Caroline Bunker Rosdahl, Mary T. (2008). Textbook of basic nursing (9th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 1109. ISBN 978-0-7817-6521-3.{{cite book}}: CS1 maint: multiple names: authors list (link)

[ABA2012pgi-13] National Burn Repository Pg. i

[TBCChp3-14] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m Herndon D (ed.). "Chapter 3: Epidemiological, Demographic, and Outcome Characteristics of Burn Injury". Total burn care (4th ed.). Edinburgh: Saunders. p. 23. ISBN 978-1-4377-2786-9.

[LMIC2006-15] Forjuoh, SN (2006 Aug). "Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention". Burns : journal of the International Society for Burn Injuries. 32 (5): 529–37. PMID 16777340. {{cite journal}}: Check date values in: |date= (help)

[16] Training in paediatrics : the essential curriculum. Oxford: Oxford University Press. 2009. p. 36. ISBN 978-0-19-922773-0. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |editors= ignored (|editor= suggested) (help)

[Mag2008-17] Maguire, S (2008 Dec). "A systematic review of the features that indicate intentional scalds in children". Burns : journal of the International Society for Burn Injuries. 34 (8): 1072–81. PMID 18538478. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[18] Peden, Margie (2008). World report on child injury prevention. Geneva, Switzerland: World Health Organization. p. 86. ISBN 978-92-4-156357-4.

[19] World Health Organization. "World report on child injury prevention" (PDF).

[Hard2012-20] Hardwicke, J (2012 May). "Chemical burns--an historical comparison and review of the literature". Burns : journal of the International Society for Burn Injuries. 38 (3): 383–7. PMID 22037150. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[HF2008-21] Makarovsky, I (2008 May). "Hydrogen fluoride--the protoplasmic poison". The Israel Medical Association journal : IMAJ. 10 (5): 381–5. PMID 18605366. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[22] Edlich, RF (2005). "Modern concepts of treatment and prevention of lightning injuries". Journal of long-term effects of medical implants. 15 (2): 185–96. PMID 15777170. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

[23] Prahlow, Joseph (2010). Forensic pathology for police, death investigators, and forensic scientists. Totowa, N.J.: Humana. p. 485. ISBN 978-1-59745-404-9.

[24] Kearns RD, Cairns CB, Holmes JH, Rich PB, Cairns BA (2013). "Thermal burn care: a review of best practices. What should prehospital providers do for these patients?". EMS World. 42 (1): 43–51. PMID 23393776. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[25] Balk, SJ (2011 Mar). "Ultraviolet radiation: a hazard to children and adolescents". Pediatrics. 127 (3): e791-817. PMID 21357345. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[RosenChp144-26] Marx, John (2010). "Chapter 144: Radiation Injuries". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 0-323-05472-2.

[Micro2001-27] Krieger, John (2001). Clinical environmental health and toxic exposures (2nd ed.). Philadelphia, Pa. [u.a.]: Lippincott Williams & Wilkins. p. 205. ISBN 978-0-683-08027-8.

[Peck2012-28] Peck, MD (2012 Aug). "Epidemiology of burns throughout the World. Part II: intentional burns in adults". Burns : journal of the International Society for Burn Injuries. 38 (5): 630–7. PMID 22325849. {{cite journal}}: Check date values in: |date= (help)

[TBCChp61-29] Herndon D (ed.). "Chapter 61: Intential burn injuries". Total burn care (4th ed.). Edinburgh: Saunders. p. 689-698. ISBN 978-1-4377-2786-9.

[30] Jutla, RK (2004 Mar-Apr). "Love burns: An essay about bride burning in India". The Journal of burn care & rehabilitation. 25 (2): 165–70. PMID 15091143. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[31] Peden, Margie (2008). World report on child injury prevention. Geneva, Switzerland: World Health Organization. p. 82. ISBN 978-92-4-156357-4.

[Rosen2009-32] ^ ^a ^b ^c ^d ^e ^f ^g ^h Marx, John (2010). "Chapter 60: Thermal Burns". Rosen's emergency medicine : concepts and clinical practice (7th ed.). Philadelphia: Mosby/Elsevier. ISBN 978-0-323-05472-0.

[Roj2012-33] Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN (2012). "Burns: an update on current pharmacotherapy". Expert Opin Pharmacother. 13 (17): 2485–94. doi:10.1517/14656566.2012.738195. PMC 3576016. PMID 23121414. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

[34] Hannon, Ruth (2010). Porth pathophysiology : concepts of altered health states (1st Canadian ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1516. ISBN 978-1-60547-781-7.

[CEM2012-35] Garmel, edited by S.V. Mahadevan, Gus M. (2012). An introduction to clinical emergency medicine (2nd ed.). Cambridge: Cambridge University Press. pp. 216–219. ISBN 978-0-521-74776-9. {{cite book}}: |first= has generic name (help)CS1 maint: multiple names: authors list (link)

[36] Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 46. ISBN 978-3-7091-0348-7.

[37] Klingensmith M, ed. (2007). The Washington manual of surgery (5th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. p. 422. ISBN 978-0-7817-7447-5.

[38] Cianci, P (2013 Jan-Feb). "Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns". Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc. 40 (1): 89–108. PMID 23397872. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[Enoch2009-39] Enoch, S (2009 Apr 8). "Emergency and early management of burns and scalds". BMJ (Clinical research ed.). 338: b1037. PMID 19357185. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[40] Hettiaratchy, S (2004 Jul 10). "Initial management of a major burn: II--assessment and resuscitation". BMJ (Clinical research ed.). 329 (7457): 101–3. PMID 15242917. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[41] Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 77. ISBN 978-3-7091-0348-7.

[42] Endorf, FW (2011 Dec). "Burn management". Current opinion in critical care. 17 (6): 601–5. PMID 21986459. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[43] Perel, P (2012 Jun 13). Perel, Pablo (ed.). "Colloids versus crystalloids for fluid resuscitation in critically ill patients". Cochrane database of systematic reviews (Online). 6: CD000567. doi:10.1002/14651858.CD000567.pub5. PMID 22696320. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[44] Curinga, G (2011 Aug). "Red blood cell transfusion following burn". Burns : journal of the International Society for Burn Injuries. 37 (5): 742–52. PMID 21367529. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[45] Wasiak, J (2013 Mar 28). "Dressings for superficial and partial thickness burns". Cochrane database of systematic reviews (Online). 3: CD002106. PMID 23543513. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[Was2008-46] Wasiak J, Cleland H, Campbell F (2008). Wasiak, Jason (ed.). "Dressings for superficial and partial thickness burns". Cochrane Database Syst Rev (4): CD002106. doi:10.1002/14651858.CD002106.pub3. PMID 18843629.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[Anti2010-47] Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M (2010). "Prophylactic antibiotics for burns patients: systematic review and meta-analysis". BMJ. 340: c241. doi:10.1136/bmj.c241. PMC 2822136. PMID 20156911.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[48] Storm-Versloot, MN (2010 Mar 17). Storm-Versloot, Marja N (ed.). "Topical silver for preventing wound infection". Cochrane database of systematic reviews (Online) (3): CD006478. doi:10.1002/14651858.CD006478.pub2. PMID 20238345. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[49] Dumville, JC (2012 Dec 12). "Negative pressure wound therapy for partial-thickness burns". Cochrane database of systematic reviews (Online). 12: CD006215. PMID 23235626. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[50] Zachariah, JR (2012 Aug). "Post burn pruritus--a review of current treatment options". Burns : journal of the International Society for Burn Injuries. 38 (5): 621–9. PMID 22244605. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[TBCChp64-51] Herndon D (ed.). "Chapter 64: Management of pain and other discomforts in burned patients". Total burn care (4th ed.). Edinburgh: Saunders. p. 726. ISBN 978-1-4377-2786-9.

[TBCChp31-52] Herndon D (ed.). "Chapter 31: Etiology and prevention of multisystem organ failure". Total burn care (4th ed.). Edinburgh: Saunders. p. 664. ISBN 978-1-4377-2786-9.

[53] Jeschke, Marc (2012). Handbook of Burns Volume 1: Acute Burn Care. Springer. p. 266. ISBN 978-3-7091-0348-7.

[Surgery2009-54] Orgill, DP (2009 Sep-Oct). "Escharotomy and decompressive therapies in burns". Journal of burn care & research : official publication of the American Burn Association. 30 (5): 759–68. PMID 19692906. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[55] Jull AB, Rodgers A, Walker N (2008). Jull, Andrew B (ed.). "Honey as a topical treatment for wounds". Cochrane Database Syst Rev (4): CD005083. doi:10.1002/14651858.CD005083.pub2. PMID 18843679.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[Juck2009-56] Juckett, G (2009 Aug 1). "Management of keloids and hypertrophic scars". American family physician. 80 (3): 253–60. PMID 19621835. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[ABA2012pg10-57] National Burn Repository, Pg. 10

[58] Young, Christopher King, Fred M. Henretig, ed. (2008). Textbook of pediatric emergency procedures (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1077. ISBN 978-0-7817-5386-9.{{cite book}}: CS1 maint: multiple names: editors list (link)

[Psyc2009-59] Roberts, edited by Michael C. (2009). Handbook of pediatric psychology (4th ed.). New York: Guilford. p. 421. ISBN 978-1-60918-175-8. {{cite book}}: |first= has generic name (help)

[60] "WHO Disease and injury country estimates". World Health Organization. 2009. Retrieved Nov. 11, 2009. {{cite web}}: Check date values in: |accessdate= (help)

[Ed2005-61] Edlich, RF (2005). "Modern concepts of treatment and prevention of electrical burns". Journal of long-term effects of medical implants. 15 (5): 511–32. PMID 16218900. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

[Ahu2004-62] Ahuja, RB (2004 Aug 21). "Burns in the developing world and burn disasters". BMJ (Clinical research ed.). 329 (7463): 447–9. PMID 15321905. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[63] Gupta (2003). Textbook of Surgery. Jaypee Brothers Publishers. p. 42. ISBN 978-81-7179-965-7.

[David2012-64] Song, David. Plastic surgery (3rd ed. ed.). Edinburgh: Saunders. p. 393.e1. ISBN 9781455710553. {{cite book}}: |edition= has extra text (help)

[65] Wylock, Paul (2010). The life and times of Guillaume Dupuytren, 1777-1835. Brussels: Brussels University Press. p. 60. ISBN 9789054875727.

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 <!--Management  -->
-The treatment required depends on the severity of the burn. Superficial burns may be managed with little more than simple pain killers, while major burns may require prolonged treatment in specialized [[burn center]]s. Cooling with tap water may help relieve pain and decrease damage; however, prolonged exposure may result in [[hypothermia|low body temperature]]. Partial-thickness burns may require cleaning with soap and water, followed by dressings. Blisters should be left unbroken, to reduce the likelihood of infection. Full-thickness burns usually require surgical treatments, such as [[skin graft]]ing, and extensive burns often require large amounts of [[intravenous fluids]]. The most common complications of burns are related to [[infection]].
+The treatment required depends on the severity of the burn. Superficial burns may be managed with little more than simple pain killers, while major burns may require prolonged treatment in specialized [[burn center]]s. Cooling with tap water may help relieve pain and decrease damage; however, prolonged exposure may result in [[hypothermia|low body temperature]]. Partial-thickness burns may require cleaning with soap and water, followed by dressings. Blisters should be left unbroken to reduce the likelihood of infection. Full-thickness burns usually require surgical treatments, such as [[skin graft]]ing.  Extensive burns often require large amounts of [[intravenous fluids]] because the subsequent inflammatory response will result in significant [[capillary]] fluid leakage and [[edema]]. The most common complications of burns are related to [[infection]].
 <!-- Epidemiology -->
-While large burns can be fatal, modern treatments developed in the last 50 years have significantly improved the outcomes, especially in children and young adults.<ref name=TBCChp1/> Globally about 11&nbsp;million people seek medical treatment and 300,000 people die from burns.<ref name=Epi2011/> In the United States, of those admitted to a [[burn center]], approximately 4% die from their injuries.<ref name=ABA2012/> The long term outcome is primarily related to the size of burn and the age of the person effected.
+While large burns can be fatal, modern treatments developed since 1960 have significantly improved the outcomes, especially in children and young adults.<ref name=TBCChp1/> Globally, about 11&nbsp;million people seek medical treatment, and 300,000 die from burns.<ref name=Epi2011/> In the United States, approximately 4% of those admitted to a [[burn center]] die from their injuries.<ref name=ABA2012/> The long-term outcome is primarily related to the size of burn and the age of the person affected.
 {{TOC limit|3}}
 ==Signs and symptoms==
-The characteristics of a burn depend upon its depth. Superficial burns are painful and typically last two or three days followed by peeling of the skin over the next few days.<ref name=EMP2009/><ref name=TBCChp10/> Individuals suffering from more severe burns may indicate discomfort or complain of feeling pressure rather than pain, and full-thickness burns may be entirely insensitive to light touch or puncture.<ref name=TBCChp10/> While superficial burns are typically red in color, severe burns may be pink, white or black.<ref name=TBCChp10/> Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred but these findings are not definitive.<ref name=Schw2010/> More worrisome signs include: [[shortness of breath]], hoarseness, [[stridor]] or [[wheezing]].<ref name=Schw2010/> [[Pruritus|Itchiness]] is common during the healing process, being present in as much as 90% of adults and nearly all children.<ref name=Itchy2009>{{cite journal|last=Goutos|first=I|coauthors=Dziewulski, P; Richardson, PM|title=Pruritus in burns: review article.|journal=Journal of burn care & research : official publication of the American Burn Association|date=2009 Mar-Apr|volume=30|issue=2|pages=221–8|pmid=19165110}}</ref> Numbness or tingling may persist for a prolong period of time after an electrical injury.<ref name=RosenChp140/> Burns may also produce emotional and psychological distress.<ref name=Epi2011/>
+The characteristics of a burn depend upon its depth. Superficial burns have pain lasting two or three days followed by peeling of the skin over the next few days.<ref name=EMP2009/><ref name=TBCChp10/> Individuals suffering from more severe burns may indicate discomfort or complain of feeling pressure rather than pain.  Full-thickness burns may be entirely insensitive to light touch or puncture.<ref name=TBCChp10/> While superficial burns are typically red in color, severe burns may be pink, white or black.<ref name=TBCChp10/> Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred, but these findings are not definitive.<ref name=Schw2010/> More worrisome signs include: [[shortness of breath]], hoarseness, [[stridor]] or [[wheezing]].<ref name=Schw2010/> [[Pruritus|Itchiness]] is common during the healing process, occurring in up to 90% of adults and nearly all children.<ref name=Itchy2009>{{cite journal|last=Goutos|first=I|coauthors=Dziewulski, P; Richardson, PM|title=Pruritus in burns: review article.|journal=Journal of burn care & research : official publication of the American Burn Association|date=2009 Mar-Apr|volume=30|issue=2|pages=221–8|pmid=19165110}}</ref> Numbness or tingling may persist for a prolong period of time after an electrical injury.<ref name=RosenChp140/> Burns may also produce emotional and psychological distress.<ref name=Epi2011/>
 {| class="wikitable"
 |-
-! Type<ref name=Tint2010/> !! Layers involved !! Appearance !! Texture !! Sensation !! Healing Time !! Complications !! Example
+! Type<ref name=Tint2010/> !! Layers involved !! Appearance !! Texture !! Sensation !! Healing Time !! Prognosis !! Example
 |-
-| Superficial (First degree)|| [[Epidermis (skin)|Epidermis]]<ref name=EMP2009/> ||[[Erythema|Red]] without blisters<ref name=Tint2010/>|| Dry || [[Pain]]ful<ref name=Tint2010/>|| 7&nbsp;days<ref name=Tint2010/> || Heal well.<ref name=Tint2010/> Repeated [[sunburn]]s increase the risk of [[skin cancer]] later in life<ref>{{cite book|last=Buttaro|first=Terry|title=Primary Care: A Collaborative Practice|year=2012|publisher=Elsevier Health Sciences|isbn=978-0-323-07585-5|page=236|url=http://books.google.ca/books?id=YBcHR-wQOWQC&pg=PA236}}</ref> || [[Image:Sunburn.jpg|70px|A sunburn is a typical first degree burn.]]
+| Superficial (First degree)|| [[Epidermis (skin)|Epidermis]]<ref name=EMP2009/> ||[[Erythema|Red]] without blisters<ref name=Tint2010/>|| Dry || [[Pain]]ful<ref name=Tint2010/>|| 7&nbsp;days<ref name=Tint2010/> || Heal well;<ref name=Tint2010/> Repeated [[sunburn]]s increase the risk of [[skin cancer]] later in life<ref>{{cite book|last=Buttaro|first=Terry|title=Primary Care: A Collaborative Practice|year=2012|publisher=Elsevier Health Sciences|isbn=978-0-323-07585-5|page=236|url=http://books.google.ca/books?id=YBcHR-wQOWQC&pg=PA236}}</ref> || [[Image:Sunburn.jpg|70px|A sunburn is a typical first degree burn.]]
 |-
 | Superficial partial thickness (Second degree) || Extends into superficial (papillary) [[dermis]]<ref name=Tint2010/> || Redness with clear [[blister]].<!-- <ref name=Tint2010/> --> Blanches with pressure.<ref name=Tint2010/> || Moist<ref name=Tint2010/> || Very painful<ref name=Tint2010/> || less than 2–3 weeks<ref name=Tint2010/><ref name=TBCChp10/> || Local infection/[[cellulitis]] but no scarring typically<ref name=TBCChp10>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=127|edition=4th|chapter=Chapter 10: Evaluation of the burn wound: management decisions}}</ref>||
@@ Line 45: / Line 45: @@
 ==Cause==
-Burns are caused by a variety of external sources classified into thermal, chemical, electrical, and radiation.<ref>{{cite book|last=Kowalski|first=Caroline Bunker Rosdahl, Mary T.|title=Textbook of basic nursing|year=2008|publisher=Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-6521-3|page=1109|url=http://books.google.ca/books?id=odY9mXicPlYC&pg=PA1109|edition=9th}}</ref> In the United States the most common cause of burns are fire/flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%)<ref name=ABA2012pgi>National Burn Repository Pg. i</ref> Most (69%) of burn injuries occur at home or at work (9%).<ref name=ABA2012>{{cite web|title=Burn Incidence and Treatment in the United States: 2012 Fact Sheet|url=http://www.ameriburn.org/resources_factsheet.php|work=American Burn Association|accessdate=20 April 2013|year=2012}}</ref> and most are accidental, with 2% due to assault by another and 1-2% representing a [[suicide]] attempt.<ref name=Epi2011/> These sources can cause inhalational injury to the airway and/or lungs which occur in about 6%.<ref name=TBCChp3/>
+Burns are caused by a variety of external sources classified as thermal, chemical, electrical, and radiation.<ref>{{cite book|last=Kowalski|first=Caroline Bunker Rosdahl, Mary T.|title=Textbook of basic nursing|year=2008|publisher=Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-6521-3|page=1109|url=http://books.google.ca/books?id=odY9mXicPlYC&pg=PA1109|edition=9th}}</ref> In the United States, the most common causes of burns are: fire/flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%).<ref name=ABA2012pgi>National Burn Repository Pg. i</ref> Most (69%) burn injuries occur at home or at work (9%),<ref name=ABA2012>{{cite web|title=Burn Incidence and Treatment in the United States: 2012 Fact Sheet|url=http://www.ameriburn.org/resources_factsheet.php|work=American Burn Association|accessdate=20 April 2013|year=2012}}</ref> and most are accidental, with 2% due to assault by another, and 1-2% resulting from a [[suicide]] attempt.<ref name=Epi2011/> These sources can cause inhalation injury to the airway and/or lungs, occurring in about 6%.<ref name=TBCChp3/>
-Burn injuries occur more commonly in the poor.<!-- <ref name=Epi2011/> --> Smoking is another risk factor while alcohol use is not.<!-- <ref name=Epi2011/> --> Fire related burns are generally more common in colder climates.<ref name=Epi2011/> Specific risk factors in the developing world include cooking with open fires or on the floor<ref name=TBCChp4/> as well as [[developmental disabilities]] in children and chronic diseases in adults.<ref name=LMIC2006/>
+Burn injuries occur more commonly in the poor.<!-- <ref name=Epi2011/> --> Smoking is a risk factor, although alcohol use is not.<!-- <ref name=Epi2011/> --> Fire related burns are generally more common in colder climates.<ref name=Epi2011/> Specific risk factors in the developing world include cooking with open fires or on the floor<ref name=TBCChp4/> as well as [[developmental disabilities]] in children and chronic diseases in adults.<ref name=LMIC2006/>
 ===Thermal===
-In the United States fire and hot liquids are the most common cause of burns.<ref name=TBCChp3/> Of house fires that result in death, smoking was the cause of 25%, and heating devices were the cause of 22%.<ref name=TBCChp4/> Almost half of injuries are due to efforts to fight a fire.<ref name=TBCChp4/> [[Scalding]] is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature [[tap water]] in baths or showers, hot cooking oil or steam.<ref>{{cite book|editors=Murphy, Catherine; Gardiner, Mark; Sarah Eisen |title=Training in paediatrics : the essential curriculum|year=2009|publisher=Oxford University Press|location=Oxford|isbn=978-0-19-922773-0|page=36|url=http://books.google.ca/books?id=FLBMvTff9sMC&pg=PA36|coauthors=Eisen, Sarah; Murphy, Catherine}}</ref> Scald injuries are most common in children under the age of five<ref name=Tint2010/> and, in the United States and Australia, this population makes up about two-thirds of all burns.<ref name=TBCChp3/> Contact with hot objects is the cause of about 20-30% of burns in children.<ref name=TBCChp3/> Generally, scalds are first or second degree burns, but third degree burns can result, especially with prolonged contact.<ref name=Mag2008/> [[Fireworks]] are a common cause of burns during holiday seasons in many countries.<ref>{{cite book|last=Peden|first=Margie|title=World report on child injury prevention|year=2008|publisher=World Health Organization|location=Geneva, Switzerland|isbn=978-92-4-156357-4|page=86|url=http://books.google.ca/books?id=UeXwoNh8sbwC&pg=PA86}}</ref> This is a particular risk for adolescent males.<ref>{{cite web|title=World report on child injury prevention|url=http://www.who.int/violence_injury_prevention/child/injury/world_report/Burns_english.pdf|author=World Health Organization}}</ref>
+In the United States, fire and hot liquids are the most common causes of burns.<ref name=TBCChp3/> Of house fires that result in death, smoking cause of 25%, and heating devices cause of 22%.<ref name=TBCChp4/> Almost half of injuries are due to efforts to fight a fire.<ref name=TBCChp4/> [[Scalding]] is caused by hot liquids or gases and most commonly occurs from exposure to hot drinks, high temperature [[tap water]] in baths or showers, hot cooking oil or steam.<ref>{{cite book|editors=Murphy, Catherine; Gardiner, Mark; Sarah Eisen |title=Training in paediatrics : the essential curriculum|year=2009|publisher=Oxford University Press|location=Oxford|isbn=978-0-19-922773-0|page=36|url=http://books.google.ca/books?id=FLBMvTff9sMC&pg=PA36|coauthors=Eisen, Sarah; Murphy, Catherine}}</ref> Scald injuries are most common in children under the age of five<ref name=Tint2010/> and, in the United States and Australia, this population makes up about two-thirds of all burns.<ref name=TBCChp3/> Contact with hot objects is the cause of about 20-30% of burns in children.<ref name=TBCChp3/> Generally, scalds are first or second degree burns, but third degree burns can result, especially with prolonged contact.<ref name=Mag2008/> [[Fireworks]] are a common cause of burns during holiday seasons in many countries.<ref>{{cite book|last=Peden|first=Margie|title=World report on child injury prevention|year=2008|publisher=World Health Organization|location=Geneva, Switzerland|isbn=978-92-4-156357-4|page=86|url=http://books.google.ca/books?id=UeXwoNh8sbwC&pg=PA86}}</ref> This is a particular risk for adolescent males.<ref>{{cite web|title=World report on child injury prevention|url=http://www.who.int/violence_injury_prevention/child/injury/world_report/Burns_english.pdf|author=World Health Organization}}</ref>
 ===Chemical===
 {{Main|Chemical burn}}
-Chemicals cause from 2 to 11% of all burns and contribute to as many as 30% of burn-related deaths.<ref name=Hard2012>{{cite journal|last=Hardwicke|first=J|coauthors=Hunter, T; Staruch, R; Moiemen, N|title=Chemical burns--an historical comparison and review of the literature.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 May|volume=38|issue=3|pages=383–7|pmid=22037150}}</ref> Chemical burns can be caused by over twenty-five thousand substances,<ref name=Tint2010/> most of which are either a strong [[base (chemistry)|base]] (55%) or a strong [[acid]] (26%).<ref name=Hard2012/> Most chemical-burn deaths are  secondary to [[ingestion]].<ref name=Tint2010/> Common agents include: [[sulfuric acid]] as found in toilet cleaners, [[sodium hypochlorite]] as found in bleach, and [[halogenated hydrocarbons]] as found in paint remover, among others.<ref name=Tint2010/> [[Hydrofluoric acid]] can cause particularly deep burns which sometimes do not become symptomatic until some time after exposure.<ref name=HF2008>{{cite journal|last=Makarovsky|first=I|coauthors=Markel, G; Dushnitsky, T; Eisenkraft, A|title=Hydrogen fluoride--the protoplasmic poison.|journal=The Israel Medical Association journal : IMAJ|date=2008 May|volume=10|issue=5|pages=381–5|pmid=18605366}}</ref> [[Formic acid]] may cause the breakdown of significant numbers of [[red blood cell]]s.<ref name=Schw2010/>
+Chemicals cause from 2 to 11% of all burns and contribute to as many as 30% of burn-related deaths.<ref name=Hard2012>{{cite journal|last=Hardwicke|first=J|coauthors=Hunter, T; Staruch, R; Moiemen, N|title=Chemical burns--an historical comparison and review of the literature.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 May|volume=38|issue=3|pages=383–7|pmid=22037150}}</ref> Chemical burns can be caused by over 25,000 substances,<ref name=Tint2010/> most of which are either a strong [[base (chemistry)|base]] (55%) or a strong [[acid]] (26%).<ref name=Hard2012/> Most chemical burn deaths are  secondary to [[ingestion]].<ref name=Tint2010/> Common agents include: [[sulfuric acid]] as found in toilet cleaners, [[sodium hypochlorite]] as found in bleach, and [[halogenated hydrocarbons]] as found in paint remover, among others.<ref name=Tint2010/> [[Hydrofluoric acid]] can cause particularly deep burns which may not become symptomatic until some time after exposure.<ref name=HF2008>{{cite journal|last=Makarovsky|first=I|coauthors=Markel, G; Dushnitsky, T; Eisenkraft, A|title=Hydrogen fluoride--the protoplasmic poison.|journal=The Israel Medical Association journal : IMAJ|date=2008 May|volume=10|issue=5|pages=381–5|pmid=18605366}}</ref> [[Formic acid]] may cause the breakdown of significant numbers of [[red blood cell]]s.<ref name=Schw2010/>
 ===Electrical===
 {{main|Electrical burn}}
-Electrical burns or injuries are classified as high voltage (greater than or equal to 1000&nbsp;[[volts]]), low voltage (less than 1000&nbsp;[[volts]]), or as [[flash burn]]s secondary to an [[electric arc]].<ref name=Tint2010/> The most common cause of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).<ref name=TBCChp3/> [[Lightning]] may also result in electrical burns.<ref>{{cite journal|last=Edlich|first=RF|coauthors=Farinholt, HM; Winters, KL; Britt, LD; Long WB, 3rd|title=Modern concepts of treatment and prevention of lightning injuries.|journal=Journal of long-term effects of medical implants|year=2005|volume=15|issue=2|pages=185–96|pmid=15777170}}</ref> Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports as well as working outside.<ref name=RosenChp140/> Mortality from a lightning strike is about 10%.<ref name=RosenChp140/>
+Electrical burns or injuries are classified as high voltage (greater than or equal to 1000&nbsp;[[volts]]), low voltage (less than 1000&nbsp;[[volts]]), or as [[flash burn]]s secondary to an [[electric arc]].<ref name=Tint2010/> The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).<ref name=TBCChp3/> [[Lightning]] may also result in electrical burns.<ref>{{cite journal|last=Edlich|first=RF|coauthors=Farinholt, HM; Winters, KL; Britt, LD; Long WB, 3rd|title=Modern concepts of treatment and prevention of lightning injuries.|journal=Journal of long-term effects of medical implants|year=2005|volume=15|issue=2|pages=185–96|pmid=15777170}}</ref> Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.<ref name=RosenChp140/> Mortality from a lightning strike is about 10%.<ref name=RosenChp140/>
-While electrical injuries primarily result in burns they may also cause [[fractures]] or [[dislocations]] secondary to [[blunt force trauma]] or [[muscle contraction]]s.<ref name=RosenChp140/> In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone.<ref name=RosenChp140/> Contact with either low voltage or high voltage may produce [[cardiac arrhythmias]] or [[cardiac arrest]].<ref name=RosenChp140/>
+While electrical injuries primarily result in burns, they may also cause [[fractures]] or [[dislocations]] secondary to [[blunt force trauma]] or [[muscle contraction]]s.<ref name=RosenChp140/> In high voltage injuries, most damage may occur internally and thus the extent of the injury cannot be judged by examination of the skin alone.<ref name=RosenChp140/> Contact with either low voltage or high voltage may produce [[cardiac arrhythmias]] or [[cardiac arrest]].<ref name=RosenChp140/>
 ===Radiation===
 {{Main|Radiation burn}}
-[[Radiation burns]] may be caused by protracted exposure to [[ultraviolet light]] (such as from the sun, [[tanning booths]] or [[arc welding]]) or from [[ionizing radiation]] (such as from [[radiation therapy]], [[X-rays]] or [[radioactive fallout]]).<ref>{{cite book|last=Prahlow|first=Joseph|title=Forensic pathology for police, death investigators, and forensic scientists|year=2010|publisher=Humana|location=Totowa, N.J.|isbn=978-1-59745-404-9|page=485|url=http://books.google.ca/books?id=rF1WTiX0nHEC&pg=PA485}}</ref> Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.<ref>{{cite journal|author=Kearns RD, Cairns CB, Holmes JH, Rich PB, Cairns BA |title=Thermal burn care: a review of best practices. What should prehospital providers do for these patients? |journal=EMS World |volume=42 |issue=1 |pages=43–51 |year=2013|month=January|pmid=23393776 |doi= |url=}}</ref> There is significant variation in how easily people [[sunburn]] based on their [[skin type]].<ref>{{cite journal|last=Balk|first=SJ|coauthors=Council on Environmental, Health; Section on, Dermatology|title=Ultraviolet radiation: a hazard to children and adolescents.|journal=Pediatrics|date=2011 Mar|volume=127|issue=3|pages=e791-817|pmid=21357345}}</ref> Skin effects from ionizing radiation depend on the amount of exposure to the area with hair loss seen after 3&nbsp;[[Gray (unit)|Gy]], redness seen after 10&nbsp;Gy, wet skin peeling after 20&nbsp;Gy, and necrosis after 30&nbsp;Gy.<ref name=RosenChp144>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=0-323-05472-2|edition=7th|chapter=Chapter 144:  Radiation Injuries}}</ref> Redness, if it occurs, may not appear until some time after exposure.<ref name=RosenChp144/> Radiation burns are treated the same as other burns.<ref name=RosenChp144/> [[Microwave burn]]s occur via thermal heating caused by the [[microwaves]].<ref name=Micro2001/> While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.<ref name=Micro2001>{{cite book|last=Krieger|first=John|title=Clinical environmental health and toxic exposures|year=2001|publisher=Lippincott Williams & Wilkins|location=Philadelphia, Pa. [u.a.]|isbn=978-0-683-08027-8|page=205|url=http://books.google.ca/books?id=PyUSgdZUGr4C&pg=PA205|edition=2nd}}</ref>
+[[Radiation burns]] may be caused by protracted exposure to [[ultraviolet light]] (such as from the sun, [[tanning booths]] or [[arc welding]]) or from [[ionizing radiation]] (such as from [[radiation therapy]], [[X-rays]] or [[radioactive fallout]]).<ref>{{cite book|last=Prahlow|first=Joseph|title=Forensic pathology for police, death investigators, and forensic scientists|year=2010|publisher=Humana|location=Totowa, N.J.|isbn=978-1-59745-404-9|page=485|url=http://books.google.ca/books?id=rF1WTiX0nHEC&pg=PA485}}</ref> Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.<ref>{{cite journal|author=Kearns RD, Cairns CB, Holmes JH, Rich PB, Cairns BA |title=Thermal burn care: a review of best practices. What should prehospital providers do for these patients? |journal=EMS World |volume=42 |issue=1 |pages=43–51 |year=2013|month=January|pmid=23393776 |doi= |url=}}</ref> There is significant variation in how easily people [[sunburn]] based on their [[skin type]].<ref>{{cite journal|last=Balk|first=SJ|coauthors=Council on Environmental, Health; Section on, Dermatology|title=Ultraviolet radiation: a hazard to children and adolescents.|journal=Pediatrics|date=2011 Mar|volume=127|issue=3|pages=e791-817|pmid=21357345}}</ref> Skin effects from ionizing radiation depend on the amount of exposure to the area, with hair loss seen after 3&nbsp;[[Gray (unit)|Gy]], redness seen after 10&nbsp;Gy, wet skin peeling after 20&nbsp;Gy, and necrosis after 30&nbsp;Gy.<ref name=RosenChp144>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=0-323-05472-2|edition=7th|chapter=Chapter 144:  Radiation Injuries}}</ref> Redness, if it occurs, may not appear until some time after exposure.<ref name=RosenChp144/> Radiation burns are treated the same as other burns.<ref name=RosenChp144/> [[Microwave burn]]s occur via thermal heating caused by the [[microwaves]].<ref name=Micro2001/> While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.<ref name=Micro2001>{{cite book|last=Krieger|first=John|title=Clinical environmental health and toxic exposures|year=2001|publisher=Lippincott Williams & Wilkins|location=Philadelphia, Pa. [u.a.]|isbn=978-0-683-08027-8|page=205|url=http://books.google.ca/books?id=PyUSgdZUGr4C&pg=PA205|edition=2nd}}</ref>
 ===Intentional===
-In those hospitalized from scalds or fire burns, 3-10% are from assault.<ref name=Peck2012/> Reasons include: [[child abuse]], personal disputes, spousal abuse, elder abuse, and business disputes.<ref name=Peck2012/> An immersion injury or immersion scald may indicate child abuse.<ref name=Mag2008>{{cite journal|last=Maguire|first=S|coauthors=Moynihan, S; Mann, M; Potokar, T; Kemp, AM|title=A systematic review of the features that indicate intentional scalds in children.|journal=Burns : journal of the International Society for Burn Injuries|date=2008 Dec|volume=34|issue=8|pages=1072–81|pmid=18538478}}</ref> It is created when an extremity or the lower body (buttock or [[perineum]]) is held under the surface of hot water.<ref name=Mag2008/> It typically produces a sharp upper border and is often symmetrical.<ref name=Mag2008/> Other high risk sign of potential abuse include: circumferential burns, the absence of splash marks, entire burn of same depth, and association with other signs of neglect or abuse.<ref name=TBCChp61/>
+In those hospitalized from scalds or fire burns, 3{{endash}}10% are from assault.<ref name=Peck2012/> Reasons include: [[child abuse]], personal disputes, spousal abuse, elder abuse, and business disputes.<ref name=Peck2012/> An immersion injury or immersion scald may indicate child abuse.<ref name=Mag2008>{{cite journal|last=Maguire|first=S|coauthors=Moynihan, S; Mann, M; Potokar, T; Kemp, AM|title=A systematic review of the features that indicate intentional scalds in children.|journal=Burns : journal of the International Society for Burn Injuries|date=2008 Dec|volume=34|issue=8|pages=1072–81|pmid=18538478}}</ref> It is created when an extremity or the lower body (buttock or [[perineum]]) is held under the surface of hot water.<ref name=Mag2008/> It typically produces a sharp upper border and is often symmetrical.<ref name=Mag2008/> Other high-risk signs of potential abuse include: circumferential burns, the absence of splash marks, a burn of uniform depth, and association with other signs of neglect or abuse.<ref name=TBCChp61/>
-[[Bride burning]], a form of [[domestic violence]], occurs in some cultures such as India where a woman is burned due to what the husband or his family considers to be an inadequate [[dowry]].<ref>{{cite journal|last=Jutla|first=RK|coauthors=Heimbach, D|title=Love burns: An essay about bride burning in India.|journal=The Journal of burn care & rehabilitation|date=2004 Mar-Apr|volume=25|issue=2|pages=165–70|pmid=15091143}}</ref><ref>{{cite book|last=Peden|first=Margie|title=World report on child injury prevention|year=2008|publisher=World Health Organization|location=Geneva, Switzerland|isbn=978-92-4-156357-4|page=82|url=http://books.google.ca/books?id=UeXwoNh8sbwC&pg=PA82}}</ref> In Pakistan [[acid throwing|acid burns]] represent 13% of intentional burns and are frequently related to domestic violence.<ref name=TBCChp61>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=689-698|edition=4th|chapter=Chapter 61: Intential burn injuries}}</ref> [[Self-immolation]] (setting oneself on fire as a form of protest) is also relatively common among Indian women.<ref name=Epi2011/>
+[[Bride burning]], a form of [[domestic violence]], occurs in some cultures such as India where a woman is burned due to what the husband or his family consider to be an inadequate [[dowry]].<ref>{{cite journal|last=Jutla|first=RK|coauthors=Heimbach, D|title=Love burns: An essay about bride burning in India.|journal=The Journal of burn care & rehabilitation|date=2004 Mar-Apr|volume=25|issue=2|pages=165–70|pmid=15091143}}</ref><ref>{{cite book|last=Peden|first=Margie|title=World report on child injury prevention|year=2008|publisher=World Health Organization|location=Geneva, Switzerland|isbn=978-92-4-156357-4|page=82|url=http://books.google.ca/books?id=UeXwoNh8sbwC&pg=PA82}}</ref> In Pakistan, [[acid throwing|acid burns]] represent 13% of intentional burns, and are frequently related to domestic violence.<ref name=TBCChp61>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=689-698|edition=4th|chapter=Chapter 61: Intential burn injuries}}</ref> [[Self-immolation]] (setting oneself on fire as a form of protest) is also relatively common among Indian women.<ref name=Epi2011/>
 == Pathophysiology ==
 [[File:Burn Degree Diagram.svg|thumb|Three degrees of burns]]
-At temperatures greater than {{convert|44|C|F}}, proteins begin losing their three-dimensional shape and start breaking down.<ref name=Rosen2009>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=978-0-323-05472-0|edition=7th |chapter=Chapter 60:  Thermal Burns}}</ref> This results in cell and tissue damage.<ref name=Tint2010/>
+At temperatures greater than {{convert|44|C|F}}, proteins begin losing their three-dimensional shape and start breaking down.<ref name=Rosen2009>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=978-0-323-05472-0|edition=7th |chapter=Chapter 60:  Thermal Burns}}</ref> This results in cell and tissue damage.<ref name=Tint2010/> Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin.<ref name=Tint2010/> They include disruption of the skin's sensation, ability to prevention water loss through evaporation, and ability to control body temperature.<ref name=Tint2010/> Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.<ref name=Tint2010/>
-Many of the direct health effects of a burn are secondary to disruption in the normal functioning of the skin.<ref name=Tint2010/> The includes disruption of the skin's ability to: prevention water loss through evaporation, maintain temperature control, and sensation.<ref name=Tint2010/> Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.<ref name=Tint2010/>
-In large burns (>30% TBSA) there is a significant inflammatory response.<ref name=Roj2012>{{cite journal |author=Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN |title=Burns: an update on current pharmacotherapy |journal=Expert Opin Pharmacother |volume=13 |issue=17 |pages=2485–94 |year=2012 |month=December |pmid=23121414 |pmc=3576016 |doi=10.1517/14656566.2012.738195 |url=}}</ref> This results in increased leakage of fluid from [[capillaries]]<ref name=Schw2010/> and subsequent tissue [[edema]].<ref name=Tint2010/> There is significant [[plasma]] loss with the blood becomes concentrated and less in volume.<ref name=Tint2010/> Poor blood flow to [[organs]] such as the kidneys and [[gastrointestinal tract]] may result in [[renal failure]] and [[gastric ulcers|stomach ulcers]].<ref>{{cite book|last=Hannon|first=Ruth|title=Porth pathophysiology : concepts of altered health states|year=2010|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia, PA|isbn=978-1-60547-781-7|page=1516|url=http://books.google.ca/books?id=2-MFXOEG0lcC&pg=PA1516|edition=1st Canadian}}</ref>
+In large burns (over 30% of the total body surface area), there is a significant inflammatory response.<ref name=Roj2012>{{cite journal |author=Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN |title=Burns: an update on current pharmacotherapy |journal=Expert Opin Pharmacother |volume=13 |issue=17 |pages=2485–94 |year=2012 |month=December |pmid=23121414 |pmc=3576016 |doi=10.1517/14656566.2012.738195 |url=}}</ref> This results in increased leakage of fluid from the [[capillaries]]<ref name=Schw2010/> and subsequent tissue [[edema]].<ref name=Tint2010/> This causes overall blood volume loss, with the remaining blood suffering significant [[Blood plasma|plasma]] loss, making the blood more concentrated.<ref name=Tint2010/> Poor blood flow to [[organs]] such as the kidneys and [[gastrointestinal tract]] may result in [[renal failure]] and [[gastric ulcers|stomach ulcers]].<ref>{{cite book|last=Hannon|first=Ruth|title=Porth pathophysiology : concepts of altered health states|year=2010|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia, PA|isbn=978-1-60547-781-7|page=1516|url=http://books.google.ca/books?id=2-MFXOEG0lcC&pg=PA1516|edition=1st Canadian}}</ref>
 Increased levels of [[catecholamines]] and [[cortisol]] may result in a [[hypermetabolism|hypermetabolic state]] which may last for years.<ref name=Roj2012/> This is associated with increased [[cardiac output]], [[metabolism]], [[tachycardia|a fast heart rate]], and poor [[immune suppression|immune function]].<ref name=Roj2012/>
 ==Diagnosis==
-Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.<ref name=Tint2010/> It may be difficult to accurately determine the depth of a burn on a single examination and repeated examination over a few days may be necessary.<ref name=Schw2010/> In those who have a [[headache]] or are dizzy and have a fire related burn [[carbon monoxide poisoning]] should be considered.<ref name=CEM2012/> [[Cyanide poisoning]] should also be considered.<ref name=Schw2010>{{cite book|last=Brunicardi|first=Charles|title=Schwartz's principles of surgery|year=2010|publisher=McGraw-Hill, Medical Pub. Division|location=New York|isbn=978-0-07-154769-7|edition=9th|chapter=Chapter 8:  Burns}}</ref>
+Burns can be classified by depth, mechanism of injury, extent, and associated injuries. The most commonly used classification is based on the depth of injury. The depth of a burn is usually determined via examination, although a biopsy may also be used.<ref name=Tint2010/> It may be difficult to accurately determine the depth of a burn on a single examination and repeated examinations over a few days may be necessary.<ref name=Schw2010/> In those who have a [[headache]] or are dizzy and have a fire-related burn, [[carbon monoxide poisoning]] should be considered.<ref name=CEM2012/> [[Cyanide poisoning]] should also be considered.<ref name=Schw2010>{{cite book|last=Brunicardi|first=Charles|title=Schwartz's principles of surgery|year=2010|publisher=McGraw-Hill, Medical Pub. Division|location=New York|isbn=978-0-07-154769-7|edition=9th|chapter=Chapter 8:  Burns}}</ref>
 ===Size===
-The size of a burn is measured as a percentage of [[total body surface area]] (TBSA) affected by partial thickness or full thickness burns.<ref name=Tint2010/> First degree burns (red only, no blisters) are not included in this estimation.<ref name=Tint2010/> Most burns (70%) involve less than 10% of the TBSA.<ref name=TBCChp3/>
+The size of a burn is measured as a percentage of [[total body surface area]] (TBSA) affected by partial thickness or full thickness burns.<ref name=Tint2010/> First-degree burns that are only red in color and are not blistering are not included in this estimation.<ref name=Tint2010/> Most burns (70%) involve less than 10% of the TBSA.<ref name=TBCChp3/>
-There are a number of methods to determine the TBSA including: the rule of nines, Lund and Browder charts, and estimations based on a person's palm size.<ref name=EMP2009/> The rule of nines is easy to remember but only accurate in people over 16&nbsp;years of age.<ref name=EMP2009/> More accurate estimation can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children.<ref name=EMP2009/>
+There are a number of methods to determine the TBSA including: the "rule of nines", Lund and Browder charts, and estimations based on a person's palm size.<ref name=EMP2009/> The rule of nines is easy to remember but only accurate in people over 16&nbsp;years of age.<ref name=EMP2009/> More accurate estimates can be made using Lund and Browder charts, which take into account the different proportions of body parts in adults and children.<ref name=EMP2009/>
-The size of a person's hand print (palm and fingers) is approximately 1% of their TBSA.<ref name=EMP2009/>
+The size of a person's hand print (including the palm and fingers) is approximately 1% of their TBSA.<ref name=EMP2009/>
 ===Severity===
@@ Line 109: / Line 108: @@
 | || Other health problems || Associated injuries
 |}
-In order to determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate and minor. This is assessed based on a number of factors, including total body surface area burnt, the involvement of specific anatomical zones, age of the person and associated injuries.<ref name=CEM2012/> Minor burns can typically be managed at home, moderate burns are often managed in hospital and major burns are managed by a burn center.<ref name=CEM2012>{{cite book|last=Garmel|first=edited by S.V. Mahadevan, Gus M.|title=An introduction to clinical emergency medicine|year=2012|publisher=Cambridge University Press|location=Cambridge|isbn=978-0-521-74776-9|pages=216–219|url=http://books.google.ca/books?id=pyAlcOfBhjIC&pg=PA216|edition=2nd}}</ref>
+In order to determine the need for referral to a specialized burn unit, the American Burn Association devised a classification system. Under this system, burns can be classified as major, moderate and minor. This is assessed based on a number of factors, including total body surface area affected, the involvement of specific anatomical zones, the age of the person, and associated injuries.<ref name=CEM2012/> Minor burns can typically be managed at home, moderate burns are often managed in hospital, and major burns are managed by a burn center.<ref name=CEM2012>{{cite book|last=Garmel|first=edited by S.V. Mahadevan, Gus M.|title=An introduction to clinical emergency medicine|year=2012|publisher=Cambridge University Press|location=Cambridge|isbn=978-0-521-74776-9|pages=216–219|url=http://books.google.ca/books?id=pyAlcOfBhjIC&pg=PA216|edition=2nd}}</ref>
 ==Prevention==
-Historically about half of burns were deemed to be preventable.<ref name=TBCChp4>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=46|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&pg=PA47-IA4|edition=4th|chapter=Chapter 4: Prevention of Burn Injuries}}</ref> Burn prevention programs have significantly decreased rates of serious burns.<ref name=Rosen2009/> Preventative measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire resistant clothing.<ref name=TBCChp4/> Water heaters should be set below {{convert|48.8|C|F|1}}.<ref name=TBCChp3>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=23|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&pg=PA15|edition=4th|chapter=Chapter 3: Epidemiological, Demographic, and Outcome Characteristics of Burn Injury}}</ref> Other measures to prevent scalds include using a thermometer to measure bath water temperatures and splash guards on stoves.<ref name=Rosen2009/> While the effect of the regulation of fireworks is unclear there is tentative evidence of benefit<ref>{{cite book|last=Jeschke|first=Marc|title=Handbook of Burns Volume 1: Acute Burn Care|year=2012|publisher=Springer|isbn=978-3-7091-0348-7|page=46|url=http://books.google.ca/books?id=olshnFqCI0kC&pg=PA46}}</ref> with recommendation including the limitation of their sale to children.<ref name=TBCChp3/>
+Historically, about half of all burns were deemed to be preventable.<ref name=TBCChp4>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=46|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&pg=PA47-IA4|edition=4th|chapter=Chapter 4: Prevention of Burn Injuries}}</ref> Burn prevention programs have significantly decreased rates of serious burns.<ref name=Rosen2009/> Preventative measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing.<ref name=TBCChp4/> Experts recommend setting water heaters below {{convert|48.8|C|F|1}}.<ref name=TBCChp3>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=23|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&pg=PA15|edition=4th|chapter=Chapter 3: Epidemiological, Demographic, and Outcome Characteristics of Burn Injury}}</ref> Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves.<ref name=Rosen2009/> While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit<ref>{{cite book|last=Jeschke|first=Marc|title=Handbook of Burns Volume 1: Acute Burn Care|year=2012|publisher=Springer|isbn=978-3-7091-0348-7|page=46|url=http://books.google.ca/books?id=olshnFqCI0kC&pg=PA46}}</ref> with recommendations including the limitation of the sale of fireworks to children.<ref name=TBCChp3/>
 ==Management==
-Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.<ref name=EMP2009/> If inhalation injury is suspected, early [[intubation]] maybe required.<ref name=Schw2010/> This is followed by care of the burn wound itself. People with extensive burns can be wrapped in clean sheets until brought to hospital.<ref name=Schw2010/> As burn wounds are prone to infection a tetanus booster shot should be given if an individual has not been immunized within the last five years.<ref>{{cite book|editor=Klingensmith M|title=The Washington manual of surgery|year=2007|publisher=Lippincott Williams & Wilkins|location=Philadelphia, Pa.|isbn=978-0-7817-7447-5|page=422|url=http://books.google.ca/books?id=XTYAxJntdvAC&pg=PA422|edition=5th}}</ref> In the United States 95% of burns that present to the emergency department are treated and discharged with 5% requiring admission to hospital.<ref name=Epi2011/> With major burns early feeding is important.<ref name=Roj2012/> [[Hyperbaric oxygenation]] may be useful in addition to traditional treatments.<ref>{{cite journal|last=Cianci|first=P|coauthors=Slade JB, Jr; Sato, RM; Faulkner, J|title=Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns.|journal=Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc|date=2013 Jan-Feb|volume=40|issue=1|pages=89–108|pmid=23397872}}</ref>
+Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.<ref name=EMP2009/> If inhalation injury is suspected, early [[intubation]] maybe required.<ref name=Schw2010/> This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospital.<ref name=Schw2010/> As burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years.<ref>{{cite book|editor=Klingensmith M|title=The Washington manual of surgery|year=2007|publisher=Lippincott Williams & Wilkins|location=Philadelphia, Pa.|isbn=978-0-7817-7447-5|page=422|url=http://books.google.ca/books?id=XTYAxJntdvAC&pg=PA422|edition=5th}}</ref> In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.<ref name=Epi2011/> With major burns, early feeding is important.<ref name=Roj2012/> [[Hyperbaric oxygenation]] may be useful in addition to traditional treatments.<ref>{{cite journal|last=Cianci|first=P|coauthors=Slade JB, Jr; Sato, RM; Faulkner, J|title=Adjunctive hyperbaric oxygen therapy in the treatment of thermal burns.|journal=Undersea & hyperbaric medicine : journal of the Undersea and Hyperbaric Medical Society, Inc|date=2013 Jan-Feb|volume=40|issue=1|pages=89–108|pmid=23397872}}</ref>
 ===Intravenous fluids===
-In those with poor [[tissue perfusion]], boluses of [[fluid replacement|isotonic crystalloid solution]] should be given.<ref name=EMP2009/> In children with more than 10-20% total body surface area burns, and adults with more than 15% total body surface area burns, formal fluid resuscitation and monitoring should follow.<ref name=EMP2009/><ref name=Enoch2009>{{cite journal|last=Enoch|first=S|coauthors=Roshan, A; Shah, M|title=Emergency and early management of burns and scalds.|journal=BMJ (Clinical research ed.)|date=2009 Apr 8|volume=338|pages=b1037|pmid=19357185}}</ref><ref>{{cite journal|last=Hettiaratchy|first=S|coauthors=Papini, R|title=Initial management of a major burn: II--assessment and resuscitation.|journal=BMJ (Clinical research ed.)|date=2004 Jul 10|volume=329|issue=7457|pages=101-3|pmid=15242917}}</ref> This should be begun pre-hospital if possible in those with burns greater than 25%&nbsp;TBSA.<ref name=Enoch2009/> The [[Parkland formula]] can help determine intravenous fluids over the first 24&nbsp;hours.<!-- <ref name=Schw2010/> --> The formula is 4&nbsp;mL x (percentage of total body surface area sustaining non-superficial burns) x (person's weight in kgs), with half of this volume administered over the first 8&nbsp;hours, and the remainder given over the following 16&nbsp;hours.<!-- <ref name=Schw2010/> --> The time frame is calculated from the time at which the burn occurred, and not from the time at which fluid resuscitation was begun.<!-- <ref name=Schw2010/> --> Children require additional maintenance fluid that includes [[glucose]].<ref name=Schw2010/> Additionally those with inhalation injuries require more fluid.<ref>{{cite book|last=Jeschke|first=Marc|title=Handbook of Burns Volume 1: Acute Burn Care|year=2012|publisher=Springer|isbn=978-3-7091-0348-7|page=77|url=http://books.google.ca/books?id=olshnFqCI0kC&pg=PA77}}</ref> While inadequate fluid resuscitation may cause problems over-resuscitation can also be detrimental.<ref>{{cite journal|last=Endorf|first=FW|coauthors=Ahrenholz, D|title=Burn management.|journal=Current opinion in critical care|date=2011 Dec|volume=17|issue=6|pages=601–5|pmid=21986459}}</ref> The formulas are only a guide, with infusions ideally tailored to a [[urinary output]] of >30&nbsp;mL/h in adults or >1mL/kg in children and [[mean arterial pressure]] greater than 60&nbsp;mmHg.<ref name=Schw2010/>
+In those with poor [[tissue perfusion]], boluses of [[fluid replacement|isotonic crystalloid solution]] should be given.<ref name=EMP2009/> In children with more than 10-20%&nbsp;TBSA burns, and adults with more than 15%&nbsp;TBSA burns, formal fluid resuscitation and monitoring should follow.<ref name=EMP2009/><ref name=Enoch2009>{{cite journal|last=Enoch|first=S|coauthors=Roshan, A; Shah, M|title=Emergency and early management of burns and scalds.|journal=BMJ (Clinical research ed.)|date=2009 Apr 8|volume=338|pages=b1037|pmid=19357185}}</ref><ref>{{cite journal|last=Hettiaratchy|first=S|coauthors=Papini, R|title=Initial management of a major burn: II--assessment and resuscitation.|journal=BMJ (Clinical research ed.)|date=2004 Jul 10|volume=329|issue=7457|pages=101-3|pmid=15242917}}</ref> This should be begun pre-hospital if possible in those with burns greater than 25%&nbsp;TBSA.<ref name=Enoch2009/> The [[Parkland formula]] can help determine the volume of intravenous fluids required over the first 24&nbsp;hours.<!-- <ref name=Schw2010/> -->  The formula is based on the affected individual's TBSA and weight.  Half of the fluid is to be administered over the first 8&nbsp;hours, and the remainder given over the following 16&nbsp;hours.<!-- <ref name=Schw2010/> --> The time frame is calculated from the time at which the burn occurred, and not from the time at which fluid resuscitation was begun.<!-- <ref name=Schw2010/> --> Children require additional maintenance fluid that includes [[glucose]].<ref name=Schw2010/> Additionally, those with inhalation injuries require more fluid.<ref>{{cite book|last=Jeschke|first=Marc|title=Handbook of Burns Volume 1: Acute Burn Care|year=2012|publisher=Springer|isbn=978-3-7091-0348-7|page=77|url=http://books.google.ca/books?id=olshnFqCI0kC&pg=PA77}}</ref> While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental.<ref>{{cite journal|last=Endorf|first=FW|coauthors=Ahrenholz, D|title=Burn management.|journal=Current opinion in critical care|date=2011 Dec|volume=17|issue=6|pages=601–5|pmid=21986459}}</ref> The formulas are only a guide, with infusions ideally tailored to a [[urinary output]] of >30&nbsp;mL/h in adults or >1mL/kg in children and [[mean arterial pressure]] greater than 60&nbsp;mmHg.<ref name=Schw2010/>
 While [[lactated Ringer's solution]] is often used, there is no evidence that it is superior to [[normal saline]].<ref name=EMP2009/> [[Crystalloid fluids]] appear just as good as [[colloid fluids]], and as colloids are more expensive they are not recommended.<ref>{{cite journal|last=Perel|first=P|coauthors=Roberts, I|title=Colloids versus crystalloids for fluid resuscitation in critically ill patients|journal=Cochrane database of systematic reviews (Online)|date=2012 Jun 13|volume=6|pages=CD000567|pmid=22696320|doi=10.1002/14651858.CD000567.pub5|editor1-last=Perel|editor1-first=Pablo}}</ref> [[Blood transfusions]] are rarely required.<ref name=Tint2010/> They are typically only recommended when the [[hemoglobin]] levels falls below 60-80&nbsp;g/L (6-8&nbsp;g/dL)<ref>{{cite journal|last=Curinga|first=G|coauthors=Jain, A; Feldman, M; Prosciak, M; Phillips, B; Milner, S|title=Red blood cell transfusion following burn.|journal=Burns : journal of the International Society for Burn Injuries|date=2011 Aug|volume=37|issue=5|pages=742–52|pmid=21367529}}</ref> due to the associated risk of complications.<ref name=Schw2010/> Intravenous catheters may be placed through burned skin if needed or [[intraosseous infusion]]s may be used.<ref name=Schw2010/>
 === Wound care ===
-Early cooling, within 30 minutes of the burn, reduces burn depth and pain, but care must be taken as cooling can result in hypothermia.<ref name=Tint2010>{{cite book |author=Tintinalli, Judith E. |title=Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)) |publisher=McGraw-Hill Companies |location=New York |year=2010 |pages=1374–1386|isbn=0-07-148480-9 |oclc= |doi= |accessdate=}}</ref><ref name=EMP2009/> This should be done with cool water {{convert|10|–|25|C|F|1}} and not ice water as the latter can cause further injury.<ref name=EMP2009/><ref name=Rosen2009/> Chemical burns may require extensive irrigation.<ref name=Tint2010/> Cleaning with soap and water, [[debridement|removal of death tissue]], and dressings are important aspects of wound care.<!-- <ref name=Rosen2009/> --> If intact blisters are present it is not clear what should be done with them.<!-- <ref name=Rosen2009/> --> Some tentative evidence supports leaving them intact.<!-- <ref name=Rosen2009/> --> Second degree burns should be re-evaluated after two days.<ref name=Rosen2009/>
+Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as overcooling can result in hypothermia.<ref name=Tint2010>{{cite book |author=Tintinalli, Judith E. |title=Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)) |publisher=McGraw-Hill Companies |location=New York |year=2010 |pages=1374–1386|isbn=0-07-148480-9 |oclc= |doi= |accessdate=}}</ref><ref name=EMP2009/> It should be performed with cool water {{convert|10|–|25|C|F|1}} and not ice water as the latter can cause further injury.<ref name=EMP2009/><ref name=Rosen2009/> Chemical burns may require extensive irrigation.<ref name=Tint2010/> Cleaning with soap and water, [[debridement|removal of dead tissue]], and application of dressings are important aspects of wound care.<!-- <ref name=Rosen2009/> --> If intact blisters are present, it is not clear what should be done with them.<!-- <ref name=Rosen2009/> --> Some tentative evidence supports leaving them intact.<!-- <ref name=Rosen2009/> --> Second degree burns should be re-evaluated after two days.<ref name=Rosen2009/>
-In the management of first and second degree burns little quality evidence exists to determine which type of dressing should be used.<ref>{{cite journal|last=Wasiak|first=J|coauthors=Cleland, H; Campbell, F; Spinks, A|title=Dressings for superficial and partial thickness burns.|journal=Cochrane database of systematic reviews (Online)|date=2013 Mar 28|volume=3|pages=CD002106|pmid=23543513}}</ref><ref name=Was2008>{{cite journal |author=Wasiak J, Cleland H, Campbell F |title=Dressings for superficial and partial thickness burns |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD002106 |year=2008 |pmid=18843629 |doi=10.1002/14651858.CD002106.pub3 |url= |editor1-last=Wasiak |editor1-first=Jason}}</ref> It is reasonable to manage first degree burns without dressings.<ref name=Rosen2009/> While topical antibiotics are often recommended there is little evidence for their use.<ref name=Anti2010/> [[Silver sulfadiazine]] (a type of antibitic) is not recommended as it potentially prolongs healing time.<ref name=Was2008/> There is insufficient evidence to support the use of [[silver]] containing dressings<ref>{{cite journal|last=Storm-Versloot|first=MN|coauthors=Vos, CG; Ubbink, DT; Vermeulen, H|title=Topical silver for preventing wound infection|journal=Cochrane database of systematic reviews (Online)|date=2010 Mar 17|issue=3|pages=CD006478|pmid=20238345|doi=10.1002/14651858.CD006478.pub2|editor1-last=Storm-Versloot|editor1-first=Marja N}}</ref> or [[negative-pressure wound therapy]].<ref>{{cite journal|last=Dumville|first=JC|coauthors=Munson, C|title=Negative pressure wound therapy for partial-thickness burns.|journal=Cochrane database of systematic reviews (Online)|date=2012 Dec 12|volume=12|pages=CD006215|pmid=23235626}}</ref>
+In the management of first and second degree burns, little quality evidence exists to determine which type of dressing should be used.<ref>{{cite journal|last=Wasiak|first=J|coauthors=Cleland, H; Campbell, F; Spinks, A|title=Dressings for superficial and partial thickness burns.|journal=Cochrane database of systematic reviews (Online)|date=2013 Mar 28|volume=3|pages=CD002106|pmid=23543513}}</ref><ref name=Was2008>{{cite journal |author=Wasiak J, Cleland H, Campbell F |title=Dressings for superficial and partial thickness burns |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD002106 |year=2008 |pmid=18843629 |doi=10.1002/14651858.CD002106.pub3 |url= |editor1-last=Wasiak |editor1-first=Jason}}</ref> It is reasonable to manage first degree burns without dressings.<ref name=Rosen2009/> While topical antibiotics are often recommended, there is little evidence to support their use.<ref name=Anti2010/> [[Silver sulfadiazine]] (a type of antibiotic) is not recommended as it potentially prolongs healing time.<ref name=Was2008/> There is insufficient evidence to support the use of [[silver]] containing dressings<ref>{{cite journal|last=Storm-Versloot|first=MN|coauthors=Vos, CG; Ubbink, DT; Vermeulen, H|title=Topical silver for preventing wound infection|journal=Cochrane database of systematic reviews (Online)|date=2010 Mar 17|issue=3|pages=CD006478|pmid=20238345|doi=10.1002/14651858.CD006478.pub2|editor1-last=Storm-Versloot|editor1-first=Marja N}}</ref> or [[negative-pressure wound therapy]].<ref>{{cite journal|last=Dumville|first=JC|coauthors=Munson, C|title=Negative pressure wound therapy for partial-thickness burns.|journal=Cochrane database of systematic reviews (Online)|date=2012 Dec 12|volume=12|pages=CD006215|pmid=23235626}}</ref>
 ===Medications===
-Burns can be very painful and a number of different options maybe used for [[pain management]].<!-- <ref name=Rosen2009/> -->  These include simple analgesics (such as [[ibuprofen]] and [[acetaminophen]]) and [[opioids]] such as morphine.<!-- <ref name=Rosen2009/> --> [[Benzodiazepines]] may be used in addition to analgesics to help with anxiety.<ref name=Rosen2009/> During the healing process [[antihistamines]], [[massage]], or [[transcutaneous nerve stimulation]] may be used to aid with itching.<ref name=Itchy2009/> Antihistamines however are only effective in 20% of people for this indication.<ref>{{cite journal|last=Zachariah|first=JR|coauthors=Rao, AL; Prabha, R; Gupta, AK; Paul, MK; Lamba, S|title=Post burn pruritus--a review of current treatment options.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 Aug|volume=38|issue=5|pages=621–9|pmid=22244605}}</ref> There is tentative evidence supporting the use of [[gabapentin]]<ref name=Itchy2009/> and its use may be reasonable in those who do not improve with antihistamines.<ref name=TBCChp64>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=726|edition=4th|chapter=Chapter 64: Management of pain and other discomforts in burned patients}}</ref>
+Burns can be very painful and a number of different options maybe used for [[pain management]].<!-- <ref name=Rosen2009/> -->  These include simple analgesics (such as [[ibuprofen]] and [[acetaminophen]]) and [[opioids]] such as morphine.<!-- <ref name=Rosen2009/> --> [[Benzodiazepines]] may be used in addition to analgesics to help with anxiety.<ref name=Rosen2009/> During the healing process, [[antihistamines]], [[massage]], or [[transcutaneous nerve stimulation]] may be used to aid with itching.<ref name=Itchy2009/> Antihistamines, however, are only effective in 20% of people for this purpose.<ref>{{cite journal|last=Zachariah|first=JR|coauthors=Rao, AL; Prabha, R; Gupta, AK; Paul, MK; Lamba, S|title=Post burn pruritus--a review of current treatment options.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 Aug|volume=38|issue=5|pages=621–9|pmid=22244605}}</ref> There is tentative evidence supporting the use of [[gabapentin]]<ref name=Itchy2009/> and its use may be reasonable in those who do not improve with antihistamines.<ref name=TBCChp64>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=726|edition=4th|chapter=Chapter 64: Management of pain and other discomforts in burned patients}}</ref>
-Intravenous [[antibiotic]]s before surgery in those with extensive burns (>60%) are recommended.<ref name=TBCChp31>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=664|edition=4th|chapter=Chapter 31: Etiology and prevention of multisystem organ failure}}</ref> Current guidelines as of 2008 do not recommend their general use due to concerns regarding [[antibiotic resistance]]<ref name=Anti2010>{{cite journal |author=Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M |title=Prophylactic antibiotics for burns patients: systematic review and meta-analysis |journal=BMJ|volume=340 |issue= |pages=c241 |year=2010 |pmid=20156911 |pmc=2822136 |doi= 10.1136/bmj.c241|url=}}</ref> and an increased the risk of [[Mycosis|fungal infections]].<ref name=Schw2010/> Tentative evidence however shows that they may improve survival in those with large and severe burns.<ref name=Anti2010/> [[Erythropoietin]] has not been found to be effective to prevent or treat anemia in people with burns.<ref name=Schw2010/> In burns caused by hydrofluoric acid [[calcium gluconate]] is a specific [[antidote]] and may be used intravenously and/or topically.<ref name=HF2008/>
+Intravenous [[antibiotic]]s are recommended before surgery for those with extensive burns (>60% TBSA).<ref name=TBCChp31>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=664|edition=4th|chapter=Chapter 31: Etiology and prevention of multisystem organ failure}}</ref>  {{As of|2008}}, guidelines do not recommend their general use due to concerns regarding [[antibiotic resistance]]<ref name=Anti2010>{{cite journal |author=Avni T, Levcovich A, Ad-El DD, Leibovici L, Paul M |title=Prophylactic antibiotics for burns patients: systematic review and meta-analysis |journal=BMJ|volume=340 |issue= |pages=c241 |year=2010 |pmid=20156911 |pmc=2822136 |doi= 10.1136/bmj.c241|url=}}</ref> and an increased the risk of [[Mycosis|fungal infections]].<ref name=Schw2010/> Tentative evidence, however, shows that they may improve survival in those with large and severe burns.<ref name=Anti2010/> [[Erythropoietin]] has not been found to be effective to prevent or treat anemia in people with burns.<ref name=Schw2010/> In burns caused by hydrofluoric acid, [[calcium gluconate]] is a specific [[antidote]] and may be used intravenously and/or topically.<ref name=HF2008/>
 ===Surgery===
@@ Line 136: / Line 135: @@
 ===Alternative medicine===
-Honey has been used since ancient times to aid wound healing and may be beneficial in first and second degree burns.<ref>{{cite journal |author=Jull AB, Rodgers A, Walker N |title=Honey as a topical treatment for wounds |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005083 |year=2008 |pmid=18843679 |doi=10.1002/14651858.CD005083.pub2 |url= |editor1-first=Andrew B |editor1-last=Jull}}</ref> There is little evidence that [[vitamin E]] helps with keloids or scarring.<ref name=Juck2009/> In low income countries burns are treated up to a third of the time with [[traditional medicine]] which may include applications of eggs, mud, leaves or cow dung.<ref name=LMIC2006>{{cite journal|last=Forjuoh|first=SN|title=Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention.|journal=Burns : journal of the International Society for Burn Injuries|date=2006 Aug|volume=32|issue=5|pages=529–37|pmid=16777340}}</ref> Surgical management is limited in some cases due to insufficient financial resources and availability.<ref name=LMIC2006/> There are a number of other methods that may be used in addition to medications to reduce procedural pain and axiety including: [[virtual reality therapy]], [[hypnosis]], and behavioral approaches such as distraction techniques.<ref name=TBCChp64/>
+Honey has been used since ancient times to aid wound healing and may be beneficial in first and second degree burns.<ref>{{cite journal |author=Jull AB, Rodgers A, Walker N |title=Honey as a topical treatment for wounds |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD005083 |year=2008 |pmid=18843679 |doi=10.1002/14651858.CD005083.pub2 |url= |editor1-first=Andrew B |editor1-last=Jull}}</ref> There is little evidence that [[vitamin E]] helps with keloids or scarring.<ref name=Juck2009/> In low income countries, burns are treated up to one-third of the time with [[traditional medicine]], which may include applications of eggs, mud, leaves or cow dung.<ref name=LMIC2006>{{cite journal|last=Forjuoh|first=SN|title=Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention.|journal=Burns : journal of the International Society for Burn Injuries|date=2006 Aug|volume=32|issue=5|pages=529–37|pmid=16777340}}</ref> Surgical management is limited in some cases due to insufficient financial resources and availability.<ref name=LMIC2006/> There are a number of other methods that may be used in addition to medications to reduce procedural pain and axiety including: [[virtual reality therapy]], [[hypnosis]], and behavioral approaches such as distraction techniques.<ref name=TBCChp64/>
 ==Prognosis==
@@ Line 166: / Line 165: @@
 |Inhalation||23%
 |}
-The prognosis is worse in those with larger burns, those who are older and those who are females.<ref name=Tint2010/> The presence of a smoke inhalation injury, other significant injuries such as long bone fractures, and serious co-morbidities (heart disease, diabetes, psychiatric illness, suicidal intent etc.) also influences prognosis.<ref name=Tint2010/> In one large United States series of people admitted to burn centres on average 4% of people died<ref name=TBCChp3/> with a mortality of less than 1% in those with burn areas less than 10% TBSA and 85% in those with more than 90% TBSA burns.<ref name=ABA2012pg10/> In Afghanistan people with more than 60% TBSA burns rarely survive.<ref name=TBCChp3/> The [[Baux score]] has historically been used to determine prognosis of major burns however with improved care it is no longer very accurate.<ref name=Schw2010/> The score is determined by adding the size of the burn (%&nbsp;TBSA) to the age of the person which used to more or less equal the risk of death.<ref name=Schw2010/>
+The prognosis is worse in those with larger burns, those who are older and those who are females.<ref name=Tint2010/> The presence of a smoke inhalation injury, other significant injuries such as long bone fractures, and serious co-morbidities (e.g. heart disease, diabetes, psychiatric illness, and suicidal intent) also influence prognosis.<ref name=Tint2010/> In one large United States series of people admitted to burn centres on average 4% of people died<ref name=TBCChp3/> with a mortality of less than 1% in those with burn areas less than 10% TBSA and 85% in those with more than 90% TBSA burns.<ref name=ABA2012pg10/> In Afghanistan, people with more than 60% TBSA burns rarely survive.<ref name=TBCChp3/> The [[Baux score]] has historically been used to determine prognosis of major burns; however, with improved care, it is no longer very accurate.<ref name=Schw2010/> The score is determined by adding the size of the burn (%&nbsp;TBSA) to the age of the person which used to more or less equal the risk of death.<ref name=Schw2010/>
 === Complications ===
-A number of complications may occur with [[infection]]s being the most common.<ref name=TBCChp3/> In order of frequency potential complications include: [[pneumonia]], [[cellulitis]], [[urinary tract infections]] and respiratory failure.<ref name=TBCChp3/> Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.<ref>{{cite book|editor=Young, Christopher King, Fred M. Henretig|title=Textbook of pediatric emergency procedures|year=2008|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-5386-9|page=1077|url=http://books.google.ca/books?id=Xi0rlODiFY0C&pg=PA1077|edition=2nd}}</ref> Pneumonia occurs particularly commonly in those with inhalational injuries.<ref name=Schw2010/>
+A number of complications may occur, with [[infection]]s being the most common.<ref name=TBCChp3/> In order of frequency, potential complications include: [[pneumonia]], [[cellulitis]], [[urinary tract infections]] and respiratory failure.<ref name=TBCChp3/> Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.<ref>{{cite book|editor=Young, Christopher King, Fred M. Henretig|title=Textbook of pediatric emergency procedures|year=2008|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-5386-9|page=1077|url=http://books.google.ca/books?id=Xi0rlODiFY0C&pg=PA1077|edition=2nd}}</ref> Pneumonia occurs particularly commonly in those with inhalational injuries.<ref name=Schw2010/>
-Anemia secondary to full thickness burns of greater than 10% of the body is common.<ref name=EMP2009>{{cite journal|last=Granger|first=Joyce|title=An Evidence-Based Approach to Pediatric Burns|journal=Pediatric Emergency Medicine Practice|year=2009|month=Jan|volume=6|issue=1|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=186}}</ref> Electrical burns may lead to [[compartment syndrome]] or [[rhabdomyolysis]] due to muscle breakdown.<ref name=Schw2010/> [[Deep vein thrombosis|Blood clot in the veins of the legs]] is estimated to occur in 6 to 25% of people.<ref name=Schw2010/> The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.<ref name=Roj2012/> [[Keloids]] may form subsequent to a burn particularly in those who are young and dark skinned.<ref name=Juck2009>{{cite journal|last=Juckett|first=G|coauthors=Hartman-Adams, H|title=Management of keloids and hypertrophic scars.|journal=American family physician|date=2009 Aug 1|volume=80|issue=3|pages=253–60|pmid=19621835}}</ref> Following a burn children may have significant psychological trauma and experience [[post-traumatic stress disorder]].<ref name=Psyc2009/> Scarring may also result in a disturbance in body image.<ref name=Psyc2009>{{cite book|last=Roberts|first=edited by Michael C.|title=Handbook of pediatric psychology.|year=2009|publisher=Guilford|location=New York|isbn=978-1-60918-175-8|page=421|url=http://books.google.ca/books?id=niMTm_3_KBoC&pg=PA421|edition=4th}}</ref> In the developing world significant burns may result in social isolation, [[extreme poverty]] and in children [[abandonment]].<ref name=Epi2011/>
+Anemia secondary to full thickness burns of greater than 10% TBSA is common.<ref name=EMP2009>{{cite journal|last=Granger|first=Joyce|title=An Evidence-Based Approach to Pediatric Burns|journal=Pediatric Emergency Medicine Practice|year=2009|month=Jan|volume=6|issue=1|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=186}}</ref> Electrical burns may lead to [[compartment syndrome]] or [[rhabdomyolysis]] due to muscle breakdown.<ref name=Schw2010/> [[Deep vein thrombosis|Blood clotting in the veins of the legs]] is estimated to occur in 6 to 25% of people.<ref name=Schw2010/> The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.<ref name=Roj2012/> [[Keloids]] may form subsequent to a burn, particularly in those who are young and dark skinned.<ref name=Juck2009>{{cite journal|last=Juckett|first=G|coauthors=Hartman-Adams, H|title=Management of keloids and hypertrophic scars.|journal=American family physician|date=2009 Aug 1|volume=80|issue=3|pages=253–60|pmid=19621835}}</ref> Following a burn, children may have significant psychological trauma and experience [[post-traumatic stress disorder]].<ref name=Psyc2009/> Scarring may also result in a disturbance in body image.<ref name=Psyc2009>{{cite book|last=Roberts|first=edited by Michael C.|title=Handbook of pediatric psychology.|year=2009|publisher=Guilford|location=New York|isbn=978-1-60918-175-8|page=421|url=http://books.google.ca/books?id=niMTm_3_KBoC&pg=PA421|edition=4th}}</ref> In the developing world, significant burns may result in social isolation, [[extreme poverty]] and in children [[abandonment]].<ref name=Epi2011/>
 ==Epidemiology==
@@ Line 191: / Line 190: @@
 {{legend|#cb0000|>&nbsp;600}}
 {{Multicol-end}}]]
-As of 2004, 11&nbsp;million burns required medical care worldwide and resulted in 300,000 deaths.<ref name=Epi2011>{{cite journal|last=Peck|first=MD|title=Epidemiology of burns throughout the world. Part I: Distribution and risk factors|journal=Burns : journal of the International Society for Burn Injuries|date=2011 Nov|volume=37|issue=7|pages=1087–100|pmid=21802856|doi=10.1016/j.burns.2011.06.005}}</ref> This makes it the 4th leading cause of injuries after [[motor vehicle collision]]s, falls, and [[violence]].<ref name=Epi2011/> About 90% of burns occur in the [[developing world]].<ref name=Epi2011/> This has been attributed partly to overcrowding and an unsafe cooking situation.<ref name=Epi2011/> Overall nearly 60% of fatal burns occur in [[WHO regions|Southeast Asia]] with a rate of 11.6 per 100,000.<ref name=TBCChp3/>
+As of 2004, 11&nbsp;million burns required medical care worldwide and resulted in 300,000 deaths.<ref name=Epi2011>{{cite journal|last=Peck|first=MD|title=Epidemiology of burns throughout the world. Part I: Distribution and risk factors|journal=Burns : journal of the International Society for Burn Injuries|date=2011 Nov|volume=37|issue=7|pages=1087–100|pmid=21802856|doi=10.1016/j.burns.2011.06.005}}</ref> This makes it the 4th leading cause of injuries after [[motor vehicle collision]]s, falls, and [[violence]].<ref name=Epi2011/> About 90% of burns occur in the [[developing world]].<ref name=Epi2011/> This has been attributed partly to overcrowding and an unsafe cooking situation.<ref name=Epi2011/> Overall, nearly 60% of fatal burns occur in [[WHO regions|Southeast Asia]] with a rate of 11.6 per 100,000.<ref name=TBCChp3/>
-In the developed world adult males have twice the mortality as females from burns.<!-- <ref name=Epi2011/> --> This is probably due to higher risk occupations and greater risk taking activities.<!-- <ref name=Epi2011/> --> In many countries in the developing world, however, females have twice the risk of males. This is often related to accidents in the kitchen or domestic violence.<ref name=Epi2011/> In children deaths from burns occurs at more than ten times the rate in the developing than the developed world.<ref name=Epi2011/> Overall in children it is one of the top fifteen leading causes of death.<ref name=TBCChp4/> From the 1980s to 2004 many countries have seen both a decrease in the rates of fatal burns and burns generally.<ref name=Epi2011/>
+In the developed world, adult males have twice the mortality as females from burns.<!-- <ref name=Epi2011/> --> This is probably due to their higher risk occupations and greater risk-taking activities.<!-- <ref name=Epi2011/> --> In many countries in the developing world, however, females have twice the risk of males. This is often related to accidents in the kitchen or domestic violence.<ref name=Epi2011/> In children, deaths from burns occurs at more than ten times the rate in the developing than the developed world.<ref name=Epi2011/> Overall in children it is one of the top fifteen leading causes of death.<ref name=TBCChp4/> From the 1980s to 2004 many countries have seen both a decrease in the rates of fatal burns, and in burns generally.<ref name=Epi2011/>
 ===Developed countries===
-An estimated 500,000 burn injuries receive medical treatment yearly in the United States.<ref name=Rosen2009/> They resulted in about 3,300 deaths in 2008.<ref name=TBCChp4/> Most burns (70%) and deaths from burns occur in males.<ref name=ABA2012/><ref name=Tint2010/> The highest incidence of fire burns occurs in those 18-35&nbsp;year old, while the highest incidence of scalds occurs in children less than five years old and adults over 65.<ref name=Tint2010/> Electrical burns result in about one thousand deaths a year.<ref name=Ed2005>{{cite journal|last=Edlich|first=RF|coauthors=Farinholt, HM; Winters, KL; Britt, LD; Long WB, 3rd|title=Modern concepts of treatment and prevention of electrical burns.|journal=Journal of long-term effects of medical implants|year=2005|volume=15|issue=5|pages=511–32|pmid=16218900}}</ref> Lighting results in the death of about 60 people a year.<ref name=RosenChp140>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=0-323-05472-2|edition=7th|chapter=Chapter 140: Electrical and Lightning Injuries}}</ref> In Europe intentional burn occur most commonly in middle aged men.<ref name=Peck2012/>
+An estimated 500,000 burn injuries receive medical treatment yearly in the United States.<ref name=Rosen2009/> They resulted in about 3,300 deaths in 2008.<ref name=TBCChp4/> Most burns (70%) and deaths from burns occur in males.<ref name=ABA2012/><ref name=Tint2010/> The highest incidence of fire burns occurs in those 18{{endash}}35&nbsp;years old, while the highest incidence of scalds occurs in children less than five years old and adults over 65.<ref name=Tint2010/> Electrical burns result in about 1,000 deaths per year.<ref name=Ed2005>{{cite journal|last=Edlich|first=RF|coauthors=Farinholt, HM; Winters, KL; Britt, LD; Long WB, 3rd|title=Modern concepts of treatment and prevention of electrical burns.|journal=Journal of long-term effects of medical implants|year=2005|volume=15|issue=5|pages=511–32|pmid=16218900}}</ref> Lighting results in the death of about 60 people a year.<ref name=RosenChp140>{{cite book|last=Marx|first=John|title=Rosen's emergency medicine : concepts and clinical practice|year=2010|publisher=Mosby/Elsevier|location=Philadelphia|isbn=0-323-05472-2|edition=7th|chapter=Chapter 140: Electrical and Lightning Injuries}}</ref> In Europe, intentional burns occur most commonly in middle aged men.<ref name=Peck2012/>
 ===Developing countries===
-In India about 700,000 to 800,000 people a year sustain significant burns, though very few are looked after in specialist burn units.<ref name=Ahu2004>{{cite journal|last=Ahuja|first=RB|coauthors=Bhattacharya, S|title=Burns in the developing world and burn disasters.|journal=BMJ (Clinical research ed.)|date=2004 Aug 21|volume=329|issue=7463|pages=447–9|pmid=15321905}}</ref> The highest rates occur in women 16–35&nbsp;years of age.<ref name=Ahu2004/> Part of this high rate is related to unsafe kitchens and loose fitting clothing typical to India.<ref name=Ahu2004/> It is estimated that a third of all burns in India are due to clothing catching fire from open flames.<ref>{{cite book|last=Gupta|title=Textbook of Surgery|year=2003|publisher=Jaypee Brothers Publishers|isbn=978-81-7179-965-7|page=42|url=http://books.google.ca/books?id=eXZznFybjEwC&pg=PR42}}</ref> Intentional burns are also a common cause and occur at high rates in young women secondary to domestic violence and self-harm.<ref name=Peck2012>{{cite journal|last=Peck|first=MD|title=Epidemiology of burns throughout the World. Part II: intentional burns in adults.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 Aug|volume=38|issue=5|pages=630–7|pmid=22325849}}</ref><ref name=Epi2011/>
+In India, about 700,000 to 800,000 people a year sustain significant burns, though very few are looked after in specialist burn units.<ref name=Ahu2004>{{cite journal|last=Ahuja|first=RB|coauthors=Bhattacharya, S|title=Burns in the developing world and burn disasters.|journal=BMJ (Clinical research ed.)|date=2004 Aug 21|volume=329|issue=7463|pages=447–9|pmid=15321905}}</ref> The highest rates occur in women 16–35&nbsp;years of age.<ref name=Ahu2004/> Part of this high rate is related to unsafe kitchens and loose-fitting clothing typical to India.<ref name=Ahu2004/> It is estimated that one-third of all burns in India are due to clothing catching fire from open flames.<ref>{{cite book|last=Gupta|title=Textbook of Surgery|year=2003|publisher=Jaypee Brothers Publishers|isbn=978-81-7179-965-7|page=42|url=http://books.google.ca/books?id=eXZznFybjEwC&pg=PR42}}</ref> Intentional burns are also a common cause and occur at high rates in young women secondary to domestic violence and self-harm.<ref name=Peck2012>{{cite journal|last=Peck|first=MD|title=Epidemiology of burns throughout the World. Part II: intentional burns in adults.|journal=Burns : journal of the International Society for Burn Injuries|date=2012 Aug|volume=38|issue=5|pages=630–7|pmid=22325849}}</ref><ref name=Epi2011/>
 ==History==
 [[Image:Guillaume Dupuytren.jpg|right|Guillaume Dupuytren (1777-1835) who developed the degree classification of burns|thumb]]
-Cave painting from more than 3500&nbsp;years ago document burns and their management.<ref name=TBCChp1>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=1|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&printsec=frontcover|edition=4th|chapter=Chapter 1: A Brief History of Acute Burn Care Management}}</ref> The 1500&nbsp;BCE Egyptian [[Smith papyrus]] describes treatments using honey and the salve of resin.<ref name=TBCChp1/> Many other treatments have been used over the ages including: tea leaves by the Chinese in 600 BCE, pig fat and vinegar by [[Hippocrates]] 400&nbsp;BCE, and wine and [[myrrh]] by [[Celsus]] 100&nbsp;AD.<ref name=TBCChp1/> The first description of different degrees of burns was by the French barber-surgeon [[Ambroise Paré]] in the 1500s.<ref name=David2012>{{cite book|last=Song|first=David|title=Plastic surgery.|publisher=Saunders|location=Edinburgh|isbn=9781455710553|page=393.e1|url=http://books.google.ca/books?id=qMDwwF8vsSEC&pg=PA393-IA3|edition=3rd ed.}}</ref> These degrees were expanded into six different severities by [[Guillaume Dupuytren]] in 1832.<ref>{{cite book|last=Wylock|first=Paul|title=The life and times of Guillaume Dupuytren, 1777-1835|year=2010|publisher=Brussels University Press|location=Brussels|isbn=9789054875727|page=60|url=http://books.google.ca/books?id=OWrznUOS1agC&pg=PA60}}</ref><ref name=TBCChp1/>
+Cave paintings from more than 3,500&nbsp;years ago document burns and their management.<ref name=TBCChp1>{{cite book|editor=Herndon D|title=Total burn care|publisher=Saunders|location=Edinburgh|isbn=978-1-4377-2786-9|page=1|url=http://books.google.ca/books?id=nrG7ZY4QwQAC&printsec=frontcover|edition=4th|chapter=Chapter 1: A Brief History of Acute Burn Care Management}}</ref> The 1500&nbsp;BCE Egyptian [[Smith papyrus]] describes treatments using honey and the salve of resin.<ref name=TBCChp1/> Many other treatments have been used over the ages including: tea leaves by the Chinese documented to 600 BCE, pig fat and vinegar by [[Hippocrates]] documented to 400&nbsp;BCE, and wine and [[myrrh]] by [[Celsus]] documented to 100&nbsp;CE.<ref name=TBCChp1/> The first description of different degrees of burns was by the French barber-surgeon [[Ambroise Paré]] in the 1500s.<ref name=David2012>{{cite book|last=Song|first=David|title=Plastic surgery.|publisher=Saunders|location=Edinburgh|isbn=9781455710553|page=393.e1|url=http://books.google.ca/books?id=qMDwwF8vsSEC&pg=PA393-IA3|edition=3rd ed.}}</ref> These degrees were expanded into six different severities by [[Guillaume Dupuytren]] in 1832.<ref>{{cite book|last=Wylock|first=Paul|title=The life and times of Guillaume Dupuytren, 1777-1835|year=2010|publisher=Brussels University Press|location=Brussels|isbn=9789054875727|page=60|url=http://books.google.ca/books?id=OWrznUOS1agC&pg=PA60}}</ref><ref name=TBCChp1/>
-The first hospital to treat burns opened in 1843 in London, England and the development of modern burn care began in the late 1800s and early 1900s.<ref name=TBCChp1/><ref name=David2012/> The importance of infection control was realized in the 1910s with [[sodium hypochlorite]] used to clean the wounds.<ref name=TBCChp1/> The importance of early excision and skin grafting was acknowleged in the 1940s and around the same  fluid resuscitation and formulas to guide it were developed.<ref name=TBCChp1/> The significance of the hypermetabolic state that follows large burns was realized in the 1970s.<ref name=TBCChp1/>
+The first hospital to treat burns opened in 1843 in London, England and the development of modern burn care began in the late 1800s and early 1900s.<ref name=TBCChp1/><ref name=David2012/> The importance of infection control was realized in the 1910s with [[sodium hypochlorite]] used to clean the wounds.<ref name=TBCChp1/> The importance of early excision and skin grafting was acknowledged in the 1940s and around the same time, fluid resuscitation and formulas to guide it were developed.<ref name=TBCChp1/> The significance of the hypermetabolic state that follows large burns was realized in the 1970s.<ref name=TBCChp1/>
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v t e General wounds and injuries
Abrasions	Abrasion Avulsion
Blisters	Blood blister Coma blister Delayed blister Edema blister Fracture blister Friction blister Sucking blister
Bruises	Hematoma/Ecchymosis Battle's sign Raccoon eyes Black eye Subungual hematoma Cullen's sign Grey Turner's sign Retroperitoneal hemorrhage
Biting	Animal Insect Spider Snake
Other:	Ballistic trauma Stab wound Splinter Blunt trauma/superficial/closed Penetrating trauma/open Aerosol burn Burn/Corrosion/Chemical burn Frostbite Occupational injuries Traumatic amputation
By region	Hand injury Head injury Chest trauma Abdominal trauma