Facial Burns

What is Facial Burns?

In 2017, around half a million people with burn injuries were treated in U.S. emergency departments, based on data from the National Hospital Ambulatory Medical Care Survey. Approximately 7% of these patients needed to be admitted to the hospital for advanced treatment, and the survival rate was very high at 96.7%. However, despite the relatively low death rate, burn injuries still rank as one of the top causes of accidental death or injury in the U.S.

Beyond causing death, burns can also lead to long-term health problems, especially facial burns. Treating patients with facial burns can be quite challenging for doctors. The face is not just a functional part of our body, helping us eat, breathe and perceive the world around us; it’s also a complex and significant component of our identity. Facial burns can cause scarring and changes to the face that go beyond surface damage. They can impact a person’s sense of self and their ability to interact with others, significantly lowering their quality of life. This kind of injury can have many long-term physical, emotional, and social side effects. Care for patients with facial burns often requires a team of healthcare professionals and the treatment can take months or even years.

The good news is that death rates from burns have been steadily dropping in developed countries over the past few decades. This is largely attributed to many factors, including improvements in treatment methods, safer working conditions, and better-designed products. The ideal management and reconstruction of burns can lead to improved physical appearance and function, which can improve a patient’s quality of life. With ongoing technological advances, we can expect further improvements in the condition of patients and a decrease in death rates. It takes a team of healthcare professionals with different specialties to provide comprehensive care for burn injuries, especially facial ones.

The journey to recovery from a facial burn is long, often involving multiple healthcare providers over time. The initial treatment decisions can impact later treatment options. This means that everyone involved in treating facial burns needs to understand the entire care process so they can make the best decisions for immediate treatment.

What Causes Facial Burns?

Burns on the face can be caused by heat (thermal), electrical shock, chemicals, or radiation. Heat-related burns are the most common and their severity can depend on how hot something was and how long the skin was exposed to it. For instance, burns caused by hot liquids (scalds) typically don’t penetrate deeply because the liquid tends to splash and roll off, but if the skin is in direct contact with a heat source for a long period, it can result in full-thickness injury, which is a deep-seated type of burn.

Electrical burns represent a small fraction of admitted burn cases but need to be treated with particular care. These can happen from contact with electrical wiring or in rare cases, from lightning strikes. It’s important to note that electrical burns can also occur in children if they bite into electrical cords. Sometimes, electrical burns may appear mild on the skin, but they can cause severe internal injuries, including broken bones, dislocated joints, heart rhythm irregularities, or rhabdomyolysis (a breaking down of damaged muscle). Rarely, lightning strikes may cause hidden injuries to the head and neck.

Chemical burns are responsible for roughly 3% of burn-related hospital visits and can result from exposure to various household or industrial chemicals. These injuries can happen from skin contact, ingestion, or inhaling these chemicals. The quicker the chemicals are removed from contact, the better the chance of recovery. The eyes are particularly sensitive to chemical burns and should be given immediate attention in the case of a chemical incident.

Radiation burns are often the result of sun exposure but can also be caused by medical radiation procedures. The nose and ear tips are especially prone to sunburn but are often overlooked when applying sunscreen. Though most sunburns are superficial and don’t require medical assistance, the sun can also cause corneal burns in your eyes, particularly if you’re not wearing suitable eye protection while welding or are exposed to intense sunlight in snowy or high-altitude settings.

While most burn injuries are accidental, abuse, self-harm, or assault should also be considered possible causes. Almost 2% of burns result from assault or abuse, and 1% from self-harm. It’s crucial to remain vigilant for signs of abuse or neglect, especially in vulnerable groups like children and teenagers, and to consider non-accidental trauma in cases of facial burns.

Risk Factors and Frequency for Facial Burns

Face burns are a big issue, making up about two-thirds of all burn incidents. Factors like age, location, economic status, gender and even the season can affect the possibility of a burn. Depending on the circumstances, some areas or people might have a higher risk of severe injury or death from such injuries. Sometimes, burn injuries are caused by domestic violence or are not accidental, so it’s important for healthcare practitioners to notice these signs. Public health officials should also know about these patterns so they can make better decisions about prevention.

• In the U.S., adults (excluding older adults) are the group that is most impacted by burns.
• Burns in women often happen while preparing meals, while men get them often at work.
• About a third of all burn injuries are estimated to be workplace-related.
• Most of these workplace burns happen to young men working in construction, food service or manufacturing.
• In poor countries, domestic burns often occur because of open flames used for cooking, causing higher risk for women and children.
• In developed countries, incidents of getting scalded in the kitchen or by hot water in the bathroom are frequent. This is especially common for children under five.
• Older adults generally tend to suffer more from hot water scalds rather than burns from flames.
• As children grow and start playing unsupervised, flame-related injuries become more common, particularly in single-parent households.

Fireworks are a big cause of burn injuries, especially affecting the face and eyes. This type of injury has declined over time, but still remains a big issue. Boys tend to have three times the chance of getting injured compared to girls, with about 10% ending up disfigured or disabled. Another unique issue is children getting electric burns in their mouth, with most cases happening because of contact with electric outlets, wires or extension cords. Most of these patients are boys under the age of 5.

Child abuse can also involve burn injuries, making up about a tenth of child abuse cases. These victims are usually kids below ten years of age. The most common type of burn in these cases is from scalding, which can leave obvious patterns like circular burns on the buttocks, untouched areas on the foot soles and ‘water lines’ on the skin. Burns from hot items like cigarettes or kitchen utensils can also leave a clear pattern. If a kid has inconsistent stories or signs of old burns healing, they might be victims of abuse. The face is especially vulnerable in such cases.

Socioeconomic factors can also influence the risk of a burn. This can happen in both poor and developed countries. For example, in less developed countries, factors like open flames in the kitchen, not wearing shoes, inadequate water supply and large families leading to less supervision can increase the risk. In the U.S., things like having a single parent, poor fire protection in homes and crowded living conditions can put kids at greater risk.

Overall, the rate and severity of burn injuries around the world seem to be reducing. At the same time, the chances of survival and hospital stay duration seem to have improved. However, burns still remain a major cause of injury, especially among vulnerable populations. Healthcare practitioners should be aware of social and economic factors that can affect treatment outcomes for burn victims. For example, considering whether the patient can afford medications, has means of transportation, can follow up treatment and has necessary support at home is crucial when deciding treatment plans.

Signs and Symptoms of Facial Burns

The first step in the evaluation of a patient with facial burns starts with understanding their medical history and carrying out a physical examination. If the patient is unconscious, information can be gathered from witnesses or emergency medical staff. The cause of the injury can often hint at hidden injuries or complications such as inhalation injuries or the threat of airway obstruction. Immediately at the site of injury, safety measures such as shutting off electrical hazards and decontaminating the patient must be taken. The severity of the airway and tissue damage will depend on how long the patient was exposed to the cause of the burns, whether it was an enclosed or open space, and the clothing they were wearing. Ideally, clothing should be removed without further harming the patient.

In a hospital setting, medical professions follow the Advanced Trauma Life Support (ATLS) guidelines to evaluate and treat the patient. The ATLS approach allows the medical team to find and address life-threatening conditions methodically. The first thing they look at is the airway. Mucosal inflammation (swelling of the moist tissues lining certain organs and body cavities) can occur rapidly causing unexpected issues. They usually intubate (insert a tube into) patients who can’t maintain adequate oxygen levels, breathe properly, or protect their own airways. Because burns cause rapid swelling, intubation is commonly done early, before the swelling begins. The criteria to decide on early intubation include:

• Signs of airway obstruction: hoarseness, noisy inhaling, overuse of muscles involved in breathing, collar bone retraction
• Extent of the burn (more than 40 to 50% of the total body surface area affected)
• Extensive and deep facial burns
• Burns inside the mouth
• Significant or potential for significant swelling
• Difficulty swallowing
• Signs of respiratory compromise: inability to clear secretions, fatigue from breathing, poor oxygenation or ventilation
• Decreased consciousness where the patient can’t protect their airway
• Expected transfer of a large burn patient with an airway issue without qualified personnel to perform intubation on the way

Some research suggests that intubation may not be necessary in certain cases and may even lead to unnecessary complications. These studies suggest a more direct examination of the airway and continuous monitoring when certain criteria are met. They even developed a set of these criteria, known as the Denver criteria, which list symptoms that may lead to considering intubation and symptoms that may warrant close observation instead:

• Full-thickness facial burns
• Stridor (noisy inhaling)
• Respiratory distress
• Swelling on viewing the larynx (voice box) with a fiberoptic scope
• Upper airway trauma
• Change in mental status
• Low oxygen/high carbon dioxide in the blood
• Hemodynamic instability (abnormal blood pressure, heart rate, or organ blood flow)
• Suspected smoke inhalation
• Singed facial hair

A physical exam should focus on sensitive facial areas. The cornea must be assessed and any contact lenses removed. If there’s injury to the eye or eyelid, an eye specialist should be involved. The ears should be checked, in particular, the eardrum, especially in cases of explosion injuries. Medical professionals also estimate the total body surface area (TBSA) affected by the burn to guide initial fluid replacement. Different methods are used to calculate TBSA. If the burn area is small, the size of the patient’s hand represents about 1% of TBSA. Some use a chart for more accurate measurements, and some use new technology. Only partial and full-thickness burns are considered for fluid resuscitation.

Burns are also classified according to the depth of the skin damage. Superficial burns affect only the outermost skin layer and appear red. They are sensitive to touch. Partial-thickness burns involve both the outer and lower skin layers. They appear red, blistered, and are painful. Full-thickness burns extend beyond all skin layers into the underlying tissue. They appear crusty and are not painful because the nerve endings have been damaged.

Testing for Facial Burns

When diagnosing a burn or other trauma, routine tests such as laboratory work or x-rays are not always necessary. Instead, these tests are conducted as per the patient’s health condition. People who have suffered major burns, been involved in accidents, or inhaled harmful substances may require additional tests to check for hidden injuries. Similarly, if someone has been injured in a building fire, an industrial accident, or suffered an electrical injury, they might need special medical attention and tests. Once the initial examination is done, doctors may recommend more scans to detect hidden injuries.

In some cases, harmful gases like carbon monoxide and cyanide can be inhaled, which can affect the body badly. To check for these, doctors can use a CO-pulse oximeter, which measures oxygen levels in your blood. If this device is not available, a blood test may be conducted. Cyanide poisoning is a bit more difficult to detect, often recognized by changes in the patient’s behavior and insufficient response to fluid intake. If these symptoms are seen along with a high concentration of carboxyhemoglobin (a harmful substance produced when carbon monoxide enters your bloodstream), treatment for cyanide poisoning may be necessary. A safe treatment option for this is a drug called hydroxocobalamin.

Electrical burns are a special case as the outside injury might not look severe, but there can be significant hidden injuries like fractures, muscle damage, heart irregularities, and increased pressure within muscles (called compartment syndrome). Doctors will usually assess the entry and exit points of the electric current, conduct a heart test (ECG), and observe the patient’s heart rhythm. Lab tests may also be necessary to search for muscle damage (rhabdomyolysis).

Additionally, x-rays may be used to check for hidden fractures. For example, electrical burns on the face can cause serious skin tightening and damage to the tissue underneath. This is especially a concern for young children who might bite into an electrical cord. Also, the path of the electric current through the body can be unpredictable and may not be a straight line. This depends on the body’s resistance to the electrical current, making a thorough examination necessary.

Lightning strikes are rare but can present a variety of symptoms which can appear later. Injuries can occur both from the electrical current and from the trauma associated with the strike itself. Therefore an intense examination of the head, neck, eardrums, and corneas (transparent front part of the eye) is essential in such patients.

Treatment Options for Facial Burns

When a person gets severe burns on their face from a fire or chemical exposure, there are a set of medical principles and guidelines used by doctors and healthcare providers for proper care and treatment. The immediate priority is the patient’s safety. This involves stopping the burning process, safely exposing the burn to assess it, and quickly transporting the patient to a suitable medical center.

In the hospital, patient care still follows these established guidelines. Certain chemicals or burns need to be managed in specific ways. For instance, solid chemicals on the skin should be brushed off, but chemical eye exposure should be rinsed with saline solution, a saltwater mixture. It’s important to remember that burn patients can lose body heat quickly and should be kept warm to avoid a dangerous drop in body temperature.

People with severe face burns or those with burns around or inside the airway could experience difficulties with breathing. Giving them additional oxygen can help manage any potential carbon monoxide or cyanide poisoning which can occur due to the burning process. The burned skin and tissue can start swelling in response to the burn, which may cause extra stress on the surrounding area and extend the injury. Healthcare providers take steps to manage this swelling through using medical interventions like a breathing tube early on.

Quite often, the lungs are not directly damaged by heat from a burn, as the warmth doesn’t easily spread through the moist air in our windpipe and lungs. However, chemical substances can still cause injuries in the lung tissue. This can lead to complications, like fluid buildup and bronchospasm (tightening of the airways), that can restrict normal breathing. There are numerous medical treatments available, like aerosol medicines to relax and open the airways, and supportive therapies like mechanical ventilation. Nonetheless, the best treatment approach would be evaluated on a case-by-case basis.

Fires can produce harmful gases like carbon monoxide and cyanide, which can cause harm to various organs in the body by disrupting normal energy production. However, providing 100% oxygen can help to rapidly reduce carbon monoxide concentrations in the blood. Cyanide also gets into the body quickly and binds to important proteins, preventing them from functioning properly. If a patient has signs of possible cyanide exposure, a specific antidote called hydroxocobalamin may be given.

People with significant burns may need substantial fluids to maintain proper blood pressure and prevent shock. It’s crucial to keep a careful balance between giving too little or too much fluid. Doctors often use a urine output goal of 0.5 mL/kg/hour in adults or 1 mL/kg/hour in children as a guide for this balance.

Managing the pain from burns can be a challenging task due to the unique individual perception and complexity of pain. The initial pain from the burn can later transition to a different type called neuropathic pain as the burns start healing. Strategies for managing pain usually involve using multiple types of pain medications, with adjustments made depending on the patient’s pain levels and the effect of the drugs. Anxiety is also common after a burn injury, so medications to manage this are often a key part of keeping the patient comfortable.

Dealing with burns on the face involves several steps. The initial management includes cleaning the burn gently to prevent further damage. Burn dressings should help to keep the wound moist without leaving it too wet. It’s important that the dressing is changed frequently with suitable antibacterial creams applied. Certain types of burns may need specific treatments. For instance, eye injuries can lead to serious problems like vision loss. Having an eye doctor involved in the treatment plan early on is crucial to managing these burns. For burns affecting structures like the eyebrows, eyelashes, lips, and ears, reconstruction procedures may be needed.

It’s important to note that there are unique challenges when handling certain types of burns. For instance, burns from chemicals like hydrofluoric acid can interfere with the body’s chemical balance and cause additional harm, requiring special treatment. In case of electrical injuries, a specialist may be needed because the direct impact of the electricity can affect critical body functions and systems, leading to various complications.

Overall, proper care of facial burns requires careful observation, suitable medical and surgical interventions, tailored pain management, and, in some cases, psychological support.

What else can Facial Burns be?

For most burns, it’s usually clear what the problem is based on the patient’s story and what the doctor sees during the examination. But sometimes, if a patient can’t provide a clear story or if some time has passed since the burn happened, it can be harder to tell. There are other conditions that can look like a burn and require similar treatment. Let’s go through a list of some of them:

• Stevens-Johnson syndrome: This is a sudden skin reaction that we don’t fully understand. It causes different colored circles on the skin, which may be triggered by viruses like herpes, Epstein-Barr or HIV, or medications.
• Lyell syndrome (toxic epidermal necrolysis): This condition also causes skin symptoms and can make you feel unwell like a burn might. It leads to irregular dark skin patches, and has been linked to several common medications.
• Erythema multiforme: This causes matching skin lesions on different parts of the body. There’s no blistering and the inner lining parts of the body are not affected. Usually, it happens after an upper respiratory infection.
• Necrotizing fasciitis: Causes rapid death of the connective tissue and muscle under the skin, leading to skin loss. It is rapidly progressive and associated with severe health issues caused by various bacteria.
• Scalded skin syndrome: Mainly seen in infants and caused by a toxin that splits skin layers.
• Pemphigoid: An autoimmune disease that leads to blistering of the skin and mucous membranes.
• Subacute cutaneous lupus: Presents with scaly red lesions, typically seen on the face and scalp as well as the mucosa, and it affects women more than men.

The treatment needed by these patients will often be similar to that required by burn patients, they may need things like creams applied to the skin, careful monitoring of medications, or an emergency procedure to release pressure from a severe skin wound. Specialized burn care units provide the appropriate environment for treating these conditions. Studies have shown that patients do better when treatment is given by healthcare providers trained in these principles.

What to expect with Facial Burns

Patients who experience facial burns can be left with substantial scars and long-term effects. These effects can be both cosmetic, affecting their appearance, and functional, impacting their ability to perform certain tasks. The priority in the initial handling of facial burns is to restore function. As the healing process proceeds, improving the patient’s appearance also becomes important, seeing as our faces play a crucial role in how we communicate. This might mean several procedures or even a facial transplant in severe cases.

Each patient’s treatment for reconstruction will be tailored to their individual injuries because the range of the burn might curtail the application of local flaps and donated skin or tissue. The ideal scenario is to use tissue similar to the one lost in the burn for coverage, but skin or cartilage from remote donor sites can also be used, with functional areas being given priority.

Immediate attention is needed for burns on the eyelids. Burns of the eyelids, which can occur in as many as 20% of facial flame injuries, can lead to eye damage and even blindness. In the worst-case scenario, eyelid deformities can cause exposure keratopathy – dry eyes due to excessive exposure to air – and corneal ulceration. These complications can be avoided but need urgent eye specialist consultation and ongoing eye lubrication. The patient needs to consistently lubricate the eye, and arrangements must be made for potential early surgery. The understanding is that the surgical intervention might need to be performed multiple times. Studies have revealed that early, aggressive surgical intervention can improve vision and overall results. Patients with severe burns to the eyelids have options for reconstruction, and skin grafting can save their vision.

Burn contractures, or the tightening of skin as a result of burns, in the mouth can cause significant functional impairment. But surgical intervention with splinting and skin grafting can result in a successful outcome. Conservative, nonsurgical treatment might not be as successful. Though nonsurgical treatment can lead to positive outcomes, the rehabilitation period is long, and a loss of function is unavoidable.

A nose contracture is a common complication of facial burns, especially in children due to facial growth. Staged surgery to release scar contracture and reconstruct the nose might be needed. Reconstructing a nose can be difficult and entail multiple surgeries and long-term rehabilitation. The nose being the center of the face, getting a good cosmetic result is imperative.

A burn to the ear is common with facial burns. However, careful management can treat the majority of ear burns. A study revealing one case out of 89 patients required a skin graft, which resulted in an excellent graft take, supports this.

It’s important to align hairlines like eyebrows and scalp cosmetically. Hair transplantation can treat significant hair loss.

The psychological effect of a major burn can be substantial, with up to 30% of patients experiencing symptoms of posttraumatic stress disorder (PTSD). It is often challenging to predict who will develop these symptoms, and all patients with significant burn injury should be screened, especially those with facial burns. Chronic pain and neuropathy are another consequence of burns, and as many as 10% of burn survivors may experience them.

Risk factors for death from a burn injury could include age above 60 years, burn area above 40%, and inhalation injury. This information can help the healthcare team with management and family members with the decision-making process.

Possible Complications When Diagnosed with Facial Burns

There are several potential problems that could arise during medical care, including misdiagnosis, late treatment, inadequate initial care, and improper surgical execution. All of these could result in poor outcomes for the patient. Though healthcare systems are improving, there are still difficulties to face. Specifically, severe burns can cause an individual’s immune system to weaken and overheat the body’s metabolism. This makes the patient vulnerable to blood infections or failure of multiple organs. Through careful management, these complications can be lessened, but sometimes injuries are too serious to avoid severe complications.

Eye problems can result from multiple complications due to facial burns, but are usually caused by keratopathy, a state where a patient’s cornea degenerates due to extensive exposure. This can come from retracting eyelashes from symptoms like ectropion or lagophthalmos that leave the cornea open, causing the development of corneal ulcers. To avoid this situation, a consultation with an eye doctor and lubrication of the cornea is recommended early on. Chemical burns on the face can result in high pressure in the eyes and are easily overlooked. This requires careful watching because the increased eye pressure could happen immediately or up to a month after the injury.

Closing of the mouth is a common issue after facial burns, which can affect both functionality and personal appearance and requires physical therapy that could last from months to years. The progress of oral burn recovery is usually monitored by measuring the opening of the mouth both vertically and horizontally. Microstomia is a common issue following facial burns affecting the lips or throat. To avoid the mouth closing up during the healing process, medical splints are applied.

Fixing a nose after a burn injury can be quite difficult, with a common issue being the narrowing of nostrils. To prevent this, surgeons usually open up the nostrils, reconstruct the nose and use graded nasal stents, which are devices used to ensure that the nostrils stay open. This treatment has been known to maintain long-term nasal patency, or the act of keeping nostrils open.

Burns on the ears from facial burns are fairly common although less so than other parts of the face. The reconstruction process is typically difficult, given the unique shape of the ear. However, it’s possible to avoid issues related to the inflammation and dying off of cartilage with careful wound management. Another tip would be to avoid heavy dressings on the ears as they could lead to cauliflower ear deformities.

It’s important to remember that facial burns can also bring about psychological and social problems. These adverse effects can be lessened by surgical reconstruction and effective pain management, though the recovery process may take years. The mental health of burn patients should be taken into account early on in their treatment. Furthermore, issues like acute stress reactions, anxiety, post-traumatic stress disorder, depression, behavioural disorders and others should be considered as they could make recovery more difficult. Early intervention from the entire healthcare team can help lower the psychological and social impact.

Preventing Facial Burns

There has been a decrease in the number of burn injuries, especially in wealthier countries. This trend can be attributed to a variety of factors such as implementations of new laws, better product safety, and increased public awareness. However, less developed regions are still facing higher rates of burn injuries, largely due to lack of infrastructure that supports prevention measures.

Burn prevention is more than just educating the public. It has also entailed enhancing the safety and regulation in products, housing, and utilities, which are crucial to reducing the rate and severity of burn-related injuries.

In the 1970s, products like seatbelts and smoke detectors were not as widely used. However, changes in laws in 1975 along with a drop in costs and aggressive marketing led to these lifesaving devices becoming more commonplace. This has significantly reduced the number of burns and deaths caused by structural fires. Similarly, laws around household appliances have resulted in safer stoves, lamps, and furnaces. In addition, since the 1960s, laws have required the use of flame-resistant materials in mattresses, carpets, and furniture. Regulations have also contributed to safer electrical wiring, plumbing, and water heaters and have limited the availability of fireworks.

Other safety measures in workplaces, such as industry changes focussed on cutting costs from lost time off due to occupational burns, have helped in their prevention. These changes have reduced such burns greatly, particularly in sectors like food service, manufacturing, and construction. In fact, injuries from flames and hot liquids have dropped by over 40% in just the last 20 years. Even in healthcare environments, efforts have been made to reduce ‘iatrogenic burns’ or burns caused unintentionally by medical treatment, such as those caused by overheated dental instruments or chemical burns related to certain procedures. Despite this, due to the combination of flammable substances and equipment used in the operating room, it’s possible that these incidents are more prevalent than is often reported.

When it comes to individual healthcare workers like doctors, evaluating and treating a patient provides an opportunity to educate them about burn safety. For example, after treating a minor injury, a discussion about childproofing the home for burn safety could prevent more serious incidents in the future. Small attentiveness to these details could potentially avert a major domestic accident.