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Burn
Injury to flesh or skin, often caused by excessive heat

A burn is an injury to skin or other tissues caused by heat, cold, electricity, chemicals, friction, or ionizing radiation such as sunburn. Burns range from superficial first-degree burns, which cause redness and pain, to severe fourth-degree burns that damage deeper tissues like muscle and bone. Treatment varies from simple pain medication to specialized care in burn centers, including skin grafting. Prevention is possible, though millions suffer burns annually, especially in the developing world, where unsafe cooking methods or workplace hazards are common causes. Complications like infection are frequent, and proper care including tetanus vaccination is important for recovery.

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History

Cave paintings from more than 3,500 years ago document burns and their management.41 The earliest Egyptian records on treating burns describes dressings prepared with milk from mothers of baby boys,42 and the 1500 BCE Edwin Smith Papyrus describes treatments using honey and the salve of resin.43 Many other treatments have been used over the ages, including the use of 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 the 1st century CE.44 French barber-surgeon Ambroise Paré was the first to describe different degrees of burns in the 1500s.45 Guillaume Dupuytren expanded these degrees into six different severities in 1832.4647

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.4849 During World War I, Henry D. Dakin and Alexis Carrel developed standards for the cleaning and disinfecting of burns and wounds using sodium hypochlorite solutions, which significantly reduced mortality.50 In the 1940s, the importance of early excision and skin grafting was acknowledged, and around the same time, fluid resuscitation and formulas to guide it were developed.51 In the 1970s, researchers demonstrated the significance of the hypermetabolic state that follows large burns.52

The "Evans formula", described in 1952, was the first burn resuscitation formula based on body weight and surface area (BSA) damaged. The first 24 hours of treatment entails 1ml/kg/% BSA of crystalloids plus 1 ml/kg/% BSA colloids plus 2000ml glucose in water, and in the next 24 hours, crystalloids at 0.5 ml/kg/% BSA, colloids at 0.5 ml/kg/% BSA, and the same amount of glucose in water.5354

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two or three days, followed by peeling of the skin over the next few days.5556 Individuals with 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.57 While superficial burns are typically red in color, severe burns may be pink, white or black.58 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.59 More worrisome signs include: shortness of breath, hoarseness, and stridor or wheezing.60 Itchiness is common during the healing process, occurring in up to 90% of adults and nearly all children.61 Numbness or tingling may persist for a prolonged period of time after an electrical injury.62 Burns may also produce emotional and psychological distress.63

Type64Layers involvedAppearanceTextureSensationHealing timePrognosis and complicationsExample
Superficial (first-degree)Epidermis65Red without blisters66DryPainful675–10 days6869Heals well.70
Superficial partial thickness (second-degree)Extends into superficial (papillary) dermis71Redness with clear blister.72 Blanches with pressure.73Moist74Very painful752–3 weeks7677Local infection (cellulitis) but no scarring typically78
Deep partial thickness (second-degree)Extends into deep (reticular) dermis79Yellow or white. Less blanching. May be blistering.80Fairly dry81Pressure and discomfort823–8 weeks83Scarring, contractures (may require excision and skin grafting)84
Full thickness (third-degree)Extends through entire dermis85Stiff and white/brown.86 No blanching.87Leathery88Painless89Prolonged (months) and unfinished/incomplete90Scarring, contractures, amputation (early excision recommended)91
Fourth-degreeExtends through entire skin, and into underlying fat, muscle and bone92Black; charred with escharDryPainlessDoes not heal; Requires excision93Amputation, significant functional impairment and, in some cases, death.94

Cause

Burns are caused by a variety of external sources classified as thermal (heat-related), chemical, electrical, and radiation.95 In the United States, the most common causes of burns are: fire or flame (44%), scalds (33%), hot objects (9%), electricity (4%), and chemicals (3%).96 Most (69%) burn injuries occur at home or at work (9%),97 and most are accidental, with 2% due to assault by another, and 1–2% resulting from a suicide attempt.98 These sources can cause inhalation injury to the airway and/or lungs, occurring in about 6%.99

Burn injuries occur more commonly among the poor.100 Smoking and alcoholism are other risk factors.101 Fire-related burns are generally more common in colder climates.102 Specific risk factors in the developing world include cooking with open fires or on the floor103 as well as developmental disabilities in children and chronic diseases in adults.104

Thermal

Main article: Thermal burn

In the United States, fire and hot liquids are the most common causes of burns.105 Of house fires that result in death, smoking causes 25% and heating devices cause 22%.106 Almost half of injuries are due to efforts to fight a fire.107 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.108 Scald injuries are most common in children under the age of five109 and, in the United States and Australia, this population makes up about two-thirds of all burns.110 Contact with hot objects is the cause of about 20–30% of burns in children.111 Generally, scalds are first- or second-degree burns, but third-degree burns may also result, especially with prolonged contact.112 Fireworks are a common cause of burns during holiday seasons in many countries.113 This is a particular risk for adolescent males.114 In the United States, for non-fatal burn injuries to children, white males under the age of 6 comprise most cases.115  Thermal burns from grabbing/touching and spilling/splashing were the most common type of burn and mechanism, while the bodily areas most impacted were hands and fingers followed by head/neck.116

Chemical

Main article: Chemical burn

Chemical burns can be caused by over 25,000 substances,117 most of which are either a strong base (55%) or a strong acid (26%).118 Most chemical burn deaths are secondary to ingestion.119 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.120 Hydrofluoric acid can cause particularly deep burns that may not become symptomatic until some time after exposure.121 Formic acid may cause the breakdown of significant numbers of red blood cells.122

Electrical

Main article: Electrical burn

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.123 The most common causes of electrical burns in children are electrical cords (60%) followed by electrical outlets (14%).124125 Lightning may also result in electrical burns.126 Risk factors for being struck include involvement in outdoor activities such as mountain climbing, golf and field sports, and working outside.127 Mortality from a lightning strike is about 10%.128

While electrical injuries primarily result in burns, they may also cause fractures or dislocations secondary to blunt force trauma or muscle contractions.129 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.130 Contact with either low voltage or high voltage may produce cardiac arrhythmias or cardiac arrest.131

Radiation

Main article: 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).132 Sun exposure is the most common cause of radiation burns and the most common cause of superficial burns overall.133 There is significant variation in how easily people sunburn based on their skin type.134 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.135 Redness, if it occurs, may not appear until some time after exposure.136 Radiation burns are treated the same as other burns.137 Microwave burns occur via thermal heating caused by the microwaves.138 While exposures as short as two seconds may cause injury, overall this is an uncommon occurrence.139

Non-accidental

In those hospitalized from scalds or fire burns, 3–10% are from assault.140 Reasons include: child abuse, personal disputes, spousal abuse, elder abuse, and business disputes.141 An immersion injury or immersion scald may indicate child abuse.142 It is created when an extremity, or sometimes the buttocks are held under the surface of hot water.143 It typically produces a sharp upper border and is often symmetrical,144 known as "sock burns", "glove burns", or "zebra stripes" - where folds have prevented certain areas from burning.145 Deliberate cigarette burns most often found on the face, or the back of the hands and feet.146 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.147

Bride burning, a form of domestic violence, occurs in some cultures, such as India where women have been burned in revenge for what the husband or his family consider an inadequate dowry.148149 In Pakistan, acid burns represent 13% of intentional burns, and are frequently related to domestic violence.150 Self-immolation (setting oneself on fire) is also used as a form of protest in various parts of the world.151

Pathophysiology

At temperatures greater than 44 °C (111 °F), proteins begin losing their three-dimensional shape and start breaking down.152 This results in cell and tissue damage.153 Many of the direct health effects of a burn are caused by failure of the skin to perform its normal functions, which include: protection from bacteria, skin sensation, body temperature regulation, and prevention of evaporation of the body's water. Disruption of these functions can lead to infection, loss of skin sensation, hypothermia, and hypovolemic shock via dehydration (i.e. water in the body evaporated away).154 Disruption of cell membranes causes cells to lose potassium to the spaces outside the cell and to take up water and sodium.155

In large burns (over 30% of the total body surface area), there is a significant inflammatory response.156 This results in increased leakage of fluid from the capillaries,157 and subsequent tissue edema.158 This causes overall blood volume loss, with the remaining blood suffering significant plasma loss, making the blood more concentrated.159 Poor blood flow to organs like the kidneys and gastrointestinal tract may result in kidney failure and stomach ulcers.160

Increased levels of catecholamines and cortisol can cause a hypermetabolic state that can last for years.161 This is associated with increased cardiac output, metabolism, a fast heart rate, and poor immune function.162

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.163 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.164 In those who have a headache or are dizzy and have a fire-related burn, carbon monoxide poisoning should be considered.165 Cyanide poisoning should also be considered.166

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.167 First-degree burns that are only red in color and are not blistering are not included in this estimation.168 Most burns (70%) involve less than 10% of the TBSA.169

There are a number of methods to determine the TBSA, including the Wallace rule of nines, Lund and Browder chart, and estimations based on a person's palm size.170 The rule of nines is easy to remember but only accurate in people over 16 years of age.171 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.172 The size of a person's handprint (including the palm and fingers) is approximately 1% of their TBSA.173

Severity

American Burn Association severity classification174
MinorModerateMajor
Adult <10% TBSAAdult 10–20% TBSAAdult >20% TBSA
Young or old < 5% TBSAYoung or old 5–10% TBSAYoung or old >10% TBSA
<2% full thickness burn2–5% full thickness burn>5% full thickness burn
High voltage injuryHigh voltage burn
Possible inhalation injuryKnown inhalation injury
Circumferential burnSignificant burn to face, joints, hands, or feet
Other health problemsAssociated injuries

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.175 Minor burns can typically be managed at home, moderate burns are often managed in a hospital, and major burns are managed by a burn center.176 Severe burn injury represents one of the most devastating forms of trauma.177 Despite improvements in burn care, patients can be left to suffer for as many as three years post-injury.178

Prevention

Historically, about half of all burns were deemed preventable.179 Burn prevention programs have significantly decreased rates of serious burns.180 Preventive measures include: limiting hot water temperatures, smoke alarms, sprinkler systems, proper construction of buildings, and fire-resistant clothing.181 Experts recommend setting water heaters below 48.8 °C (119.8 °F).182 Other measures to prevent scalds include using a thermometer to measure bath water temperatures, and splash guards on stoves.183 While the effect of the regulation of fireworks is unclear, there is tentative evidence of benefit184 with recommendations including the limitation of the sale of fireworks to children.185

Management

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.186 If inhalation injury is suspected, early intubation may be required.187 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.188 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.189 In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.190 With major burns, early feeding is important.191 Protein intake should also be increased, and trace elements and vitamins are often required.192 Hyperbaric oxygenation may be useful in addition to traditional treatments.193

Intravenous fluids

In those with poor tissue perfusion, boluses of isotonic crystalloid solution should be given.194 In children with more than 10–20% TBSA (Total Body Surface Area) burns, and adults with more than 15% TBSA burns, formal fluid resuscitation and monitoring should follow.195196197 This should be begun pre-hospital if possible in those with burns greater than 25% TBSA.198 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 administered over the first 8 hours, and the remainder over the following 16 hours. The time is calculated from when the burn occurred, and not from the time that fluid resuscitation began. Children require additional maintenance fluid that includes glucose.199 Additionally, those with inhalation injuries require more fluid.200 While inadequate fluid resuscitation may cause problems, over-resuscitation can also be detrimental.201 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.202

While lactated Ringer's solution is often used, there is no evidence that it is superior to normal saline.203 Crystalloid fluids appear just as good as colloid fluids, and as colloids are more expensive they are not recommended.204205 Blood transfusions are rarely required.206 They are typically only recommended when the hemoglobin level falls below 60-80 g/L (6-8 g/dL)207 due to the associated risk of complications.208 Intravenous catheters may be placed through burned skin if needed or intraosseous infusions may be used.209

Wound care

Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia.210211 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.212213 Chemical burns may require extensive irrigation.214 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.215

In the management of first and second-degree burns, little quality evidence exists to determine which dressing type to use.216 It is reasonable to manage first-degree burns without dressings.217 While topical antibiotics are often recommended, there is little evidence to support their use.218219 Silver sulfadiazine (a type of antibiotic) is not recommended as it potentially prolongs healing time.220221 There is insufficient evidence to support the use of dressings containing silver222 or negative-pressure wound therapy.223 Silver sulfadiazine does not appear to differ from silver containing foam dressings with respect to healing.224

Medications

Burns can be very painful and a number of different options may be 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.225 During the healing process, antihistamines, massage, or transcutaneous nerve stimulation may be used to aid with itching.226 Antihistamines, however, are only effective for this purpose in 20% of people.227 There is tentative evidence supporting the use of gabapentin228 and its use may be reasonable in those who do not improve with antihistamines.229230 Intravenous lidocaine requires more study before it can be recommended for pain.231

Intravenous antibiotics are recommended before surgery for those with extensive burns (>60% TBSA).232 As of 2008[update], guidelines do not recommend their general use due to concerns regarding antibiotic resistance233 and the increased risk of fungal infections.234 Tentative evidence, however, shows that they may improve survival rates in those with large and severe burns.235 Erythropoietin has not been found effective to prevent or treat anemia in burn cases.236 In burns caused by hydrofluoric acid, calcium gluconate is a specific antidote and may be used intravenously and/or topically.237 Recombinant human growth hormone (rhGH) in those with burns that involve more than 40% of their body appears to speed healing without affecting the risk of death.238 The use of steroids is of unclear evidence.239

Allogeneic cultured keratinocytes and dermal fibroblasts in murine collagen (Stratagraft) was approved for medical use in the United States in June 2021.240

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.241 Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as an escharotomy.242 This is done to treat or prevent problems with distal circulation, or ventilation.243 It is uncertain if it is useful for neck or digit burns.244 Fasciotomies may be required for electrical burns.245

Skin grafts can involve temporary skin substitutes, derived from animal (human donor or pig) skin or synthesized. They are used to cover the wound as a dressing, preventing infection and fluid loss, but will eventually need to be removed. Alternatively, human skin can be treated to be left on permanently without rejection.246

There is no evidence that the use of copper sulphate to visualise phosphorus particles for removal can help with wound healing due to phosphorus burns. Meanwhile, absorption of copper sulphate into the blood circulation can be harmful.247

Alternative medicine

Honey has been used since ancient times to aid wound healing and may be beneficial in first- and second-degree burns.248 There is moderate evidence that honey helps heal partial thickness burns.249250 The evidence for aloe vera is of poor quality.251 While it might be beneficial in reducing pain,252 and a review from 2007 found tentative evidence of improved healing times,253 a subsequent review from 2012 did not find improved healing over silver sulfadiazine.254 There were only three randomized controlled trials for the use of plants for burns, two for aloe vera and one for oatmeal.255

There is little evidence that vitamin E helps with keloids or scarring.256 Butter is not recommended.257 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.258 Surgical management is limited in some cases due to insufficient financial resources and availability.259 There are a number of other methods that may be used in addition to medications to reduce procedural pain and anxiety including: virtual reality therapy, hypnosis, and behavioral approaches such as distraction techniques.260

Patient support

Burn patients require support and care – both physiological and psychological. Respiratory failure, sepsis, and multi-organ system failure are common in hospitalized burn patients. To prevent hypothermia and maintain normal body temperature, burn patients with over 20% of burn injuries should be kept in an environment with the temperature at or above 30 degree Celsius.261[better source needed]

Metabolism in burn patients proceeds at a higher than normal speed due to the whole-body process and rapid fatty acid substrate cycles, which can be countered with an adequate supply of energy, nutrients, and antioxidants. Enteral feeding a day after resuscitation is required to reduce risk of infection, recovery time, non-infectious complications, hospital stay, long-term damage, and mortality. Controlling blood glucose levels can have an impact on liver function and survival.

Risk of thromboembolism is high and acute respiratory distress syndrome (ARDS) that does not resolve with maximal ventilator use is also a common complication. Scars are long-term after-effects of a burn injury. Psychological support is required to cope with the aftermath of a fire accident, while to prevent scars and long-term damage to the skin and other body structures consulting with burn specialists, preventing infections, consuming nutritious foods, early and aggressive rehabilitation, and using compressive clothing are recommended.

Prognosis

Prognosis in the US262
TBSAMortality
0–9%0.6%
10–19%2.9%
20–29%8.6%
30–39%16%
40–49%25%
50–59%37%
60–69%43%
70–79%57%
80–89%73%
90–100%85%
Inhalation23%

The prognosis is worse in those with larger burns, those who are older, and females.263 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.264 On average, of those admitted to burn centers in the United States, 4% die,265 with the outcome for individuals dependent on the extent of the burn injury. For example, admittees with burn areas less than 10% TBSA had a mortality rate of less than 1%, while admittees with over 90% TBSA had a mortality rate of 85%.266 In Afghanistan, people with more than 60% TBSA burns rarely survive.267 The Baux score has historically been used to determine prognosis of major burns. However, with improved care, it is no longer very accurate.268 The score is determined by adding the size of the burn (% TBSA) to the age of the person and taking that to be more or less equal to the risk of death.269 Burns in 2013 resulted in 1.2 million years lived with disability and 12.3 million disability adjusted life years.270

Complications

A number of complications may occur, with infections being the most common.271 In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure.272 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.273 Pneumonia occurs particularly commonly in those with inhalation injuries.274

Anemia secondary to full thickness burns of greater than 10% TBSA is common.275 Electrical burns may lead to compartment syndrome or rhabdomyolysis due to muscle breakdown.276 Blood clotting in the veins of the legs is estimated to occur in 6 to 25% of people.277 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.278 Keloids may form subsequent to a burn, particularly in those who are young and dark skinned.279 Following a burn, children may have significant psychological trauma and experience post-traumatic stress disorder.280 Scarring may also result in a disturbance in body image.281 To treat hypertrophic scars (raised, tense, stiff and itchy scars) and limit their effect on physical function and everyday activities, silicone sheeting and compression garments are recommended.282283284 In the developing world, significant burns may result in social isolation, extreme poverty and child abandonment.285

Epidemiology

In 2015 fire and heat resulted in 67 million injuries.286 This resulted in about 2.9 million hospitalizations and 238,000 dying.287 This is down from 300,000 deaths in 1990.288 This makes it the fourth leading cause of injuries after motor vehicle collisions, falls, and violence.289 About 90% of burns occur in the developing world.290 This has been attributed partly to overcrowding and an unsafe cooking situation.291 Overall, nearly 60% of fatal burns occur in Southeast Asia with a rate of 11.6 per 100,000.292 The number of fatal burns has changed from 280,000 in 1990 to 176,000 in 2015.293294

In the developed world, adult males have twice the mortality as females from burns. This is most 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.295 In children, deaths from burns occur at more than ten times the rate in the developing than the developed world.296 Overall, in children it is one of the top fifteen leading causes of death.297 From the 1980s to 2004, many countries have seen both a decrease in the rates of fatal burns and in burns generally.298

Developed countries

An estimated 500,000 burn injuries receive medical treatment yearly in the United States.299 They resulted in about 3,300 deaths in 2008.300 Most burns (70%) and deaths from burns occur in males.301302 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 65.303 Electrical burns result in about 1,000 deaths per year.304 Lightning results in the death of about 60 people a year.305 In Europe, intentional burns occur most commonly in middle aged men.306

Developing countries

In India, about 700,000 to 800,000 people per year sustain significant burns, though very few are looked after in specialist burn units.307 The highest rates occur in women 16–35 years of age.308 Part of this high rate is related to unsafe kitchens and loose-fitting clothing typical to India.309 It is estimated that one-third of all burns in India are due to clothing catching fire from open flames.310 Intentional burns are also a common cause and occur at high rates in young women, secondary to domestic violence and self-harm.311312

See also

General and cited references

Wikipedia's health care articles can be viewed offline with the Medical Wikipedia app. Wikimedia Commons has media related to burns.

References

  1. Herndon D, ed. (2012). "Chapter 4: Prevention of Burn Injuries". Total burn care (4th ed.). Edinburgh: Saunders. p. 46. ISBN 978-1-4377-2786-9. 978-1-4377-2786-9 ↩

  2. Moore K (2014). Clinically Oriented Anatomy (7th ed.). Lippincott Williams & Wilkins. p. 45. ISBN 9781451119459. 9781451119459 ↩

  3. "Burns Fact sheet N°365". WHO. April 2014. Archived from the original on 10 November 2015. Retrieved 3 March 2016. https://web.archive.org/web/20151110140702/http://www.who.int/mediacentre/factsheets/fs365/en/ ↩

  4. "Burns". World Health Organization. September 2016. Archived from the original on 21 July 2017. Retrieved 1 August 2017. https://www.who.int/mediacentre/factsheets/fs365/en/ ↩

  5. "Burns". World Health Organization. September 2016. Archived from the original on 21 July 2017. Retrieved 1 August 2017. https://www.who.int/mediacentre/factsheets/fs365/en/ ↩

  6. "Burns". World Health Organization. September 2016. Archived from the original on 21 July 2017. Retrieved 1 August 2017. https://www.who.int/mediacentre/factsheets/fs365/en/ ↩

  7. "Burns". World Health Organization. September 2016. Archived from the original on 21 July 2017. Retrieved 1 August 2017. https://www.who.int/mediacentre/factsheets/fs365/en/ ↩

  8. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  9. Granger J (January 2009). "An Evidence-Based Approach to Pediatric Burns". Pediatric Emergency Medicine Practice. 6 (1). Archived from the original on 17 October 2013. http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=186 ↩

  10. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  11. Granger J (January 2009). "An Evidence-Based Approach to Pediatric Burns". Pediatric Emergency Medicine Practice. 6 (1). Archived from the original on 17 October 2013. http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=186 ↩

  12. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  13. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  14. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  15. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  16. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  17. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  18. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

  19. Tintinalli, Judith E. (2010). Emergency Medicine: A Comprehensive Study Guide (Emergency Medicine (Tintinalli)). New York: McGraw-Hill Companies. pp. 1374–1386. ISBN 978-0-07-148480-0. 978-0-07-148480-0 ↩

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