Neurologic aspects of burn injuries

Ravindra Kumar Garg DM FRCP

General Neurology

Updated 01.08.2024
Released 10.19.2014
Expires For CME 01.08.2027

Neurologic aspects of burn injuries

Author: Ravindra Kumar Garg DM FRCP

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Editor: Peter J Koehler MD PhD

Neurologic aspects of burn injuries

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Introduction

Overview

According to World Health Organization estimates, 180,000 deaths occur annually due to burn injury (47). Burns are often devastating injuries that affect almost every system of the body. Multiorgan failure and sepsis are important causes of death. Immediate management of burn injury requires airway maintenance, 100% oxygen administration, fluid resuscitation, monitoring and maintenance of circulation, nutrition, and measures for pain relief. Various neurologic and musculoskeletal complications may appear a few weeks to years after injury. The risk of stroke is higher in patients with burn injury than in the general population. Burn and pathologic scars can cause intense pain, even without evidence of underlying nerve damage. Psychiatric complications are common among survivors. Neurologic complications are frequently undiagnosed. Posterior ischemic optic neuropathy following burns is an infrequent but devastating complication of major burns. A high index of suspicion is warranted if a burn patient complains of vision loss. Some patients develop critical care polyneuropathy. The factors associated with critical care polyneuropathy in burns were prolonged ventilation, large burns, and sepsis. In the presence of preexisting diabetic neuropathy, the management of lower-extremity burn injuries becomes difficult, and many such patients may require limb amputation. Several burn patients suffer long-term cognitive dysfunctions, like memory defects, that affect quality of life. Studies suggest CNS reorganization, inflammation, and pain are critical in burn survivors, and noninvasive brain stimulation methods could significantly improve quality of life. Correct management requires a skilled multidisciplinary approach that addresses all the problems facing a burn patient. In this article, the author discusses the neurologic aspects of burn injuries.

Key points

	• A burn is a devastating form of injury caused by thermal, chemical, electrical, or radiation energy.
	• Burns affect almost every system of the body and result in several early and long-term complications.
	• Burns are associated with pruritus, encephalopathy, neuropathy, and other neuromuscular complications.
	• Psychiatric complications are common among survivors.
	• Survival of burn patients has improved considerably over the past several decades.
	• Multiorgan failure and sepsis are important causes of death.
	• Patients with epilepsy have a higher incidence and severity of burn injury.

Historical note and terminology

A burn is an injury caused by thermal, chemical, electrical, or radiation energy. Burn injury has been known since the discovery of fire from prehistoric times. Written descriptions of burns date back to Hippocrates (460-377 BC). Egyptian healers made remedies for burns from plants, animal products, and minerals, along with divine methods. The Edwin Smith papyrus (1500 BC) used honey and grease for the treatment of burns; Charak and Sushruta (Ayurveda) used honey in burn dressings. Wilhelm Fabry (1560-1634; also known as Hildanus) was the first surgeon who, in 1607, wrote a specific treatise dealing with burn injury titled “De combustionibus.” He described the widely used system for classifying burns injuries (33; 15). Ambroise Paré (1510-1590), the famous French barber-surgeon, contributed immensely to the surgical care of burns (41). French surgeon Guillaume Dupuytren described wound debridement. The three zones of a burn were described by Jackson (20).

The availability of sulfa drugs and antibiotics, such as sulfonamide in 1932 and penicillin in 1941, during World War II brought revolutionary changes to burn management. The need for urgent burn resuscitation was felt after major burn disasters of modern times (eg, the Rialto Theatre House Fire in New Haven, Connecticut in 1921 and the Coconut Grove Nightclub Fire in Boston, Massachusetts in 1942). Evans and co-workers devised the fluid resuscitation methods in 1952 (13).

Clinical manifestations

Presentation and course

Burns injury leads to swelling, blister formation, scarring of varying severity, and in extensive burn injury, even shock and death. Burn to the skin disrupts its normal function and may produce infection, pain, dehydration, and hypothermia, so it is crucial from a management point of view to evaluate the burn’s extent, depth, and circumferential components. Management decisions depend on this information.

The skin consists of epidermis, dermis, and subcutaneous fat. First-degree burns are superficial and affect only the epidermis or outer layer of skin. First-degree burns are characterized by pain, redness, and mild swelling with no blister formation. Skin may be tender to the touch. Second-degree burns are deeper and in addition to the signs of inflammation, there is also blister formation. Third-degree burns affect all layers of the skin and damage the epidermis, dermis, and subcutaneous tissue. The cutaneous nerves and blood vessels are also destroyed. In third-degree burns, the skin is often white and dry. Fourth-degree burns also destroy the underlying bones, muscles, tendons, and ligaments.

Grade-2 burn injury

This 4-year-boy was burned while playing near fire. Burns were superficial. (Contributed by Ravindra K Garg.)
Grade-3 burn injury

Extensive third-degree burn injury. (Contributed by Ravindra K Garg.)
Grade-3 healed burn

This 30-year-old female had extensive burns of variable degrees. Now burn wounds are in the healing stage. (Contributed by Ravindra K Garg.)
Extensive burn injury

A 22-year-old female with burns covering more than 90% body area from a cooking accident. (Contributed by Ravindra K Garg.)

The classification system categorizes burns into either superficial, partial-thickness, or full-thickness groups. This classification is important to determine the need for surgery. Patients with full-thickness burns require surgery if the burn area is larger than 2 cm. Older patients with thin epidermis and dermis often require surgery. The extent of the burn means the total body surface area affected by the burn injury. The most popular method to estimate total burn area in older children and adults is the “rule of nines.” According to this rule, a value of 9% body surface area is assigned to the head and neck region, 9% to each arm (including the hand), 18% to each leg (including the foot), and 18% to each side of the trunk (back, chest and abdomen). The Lund and Browder method is employed for children younger than 10 years of age. According to this method, the size of a child’s palm is roughly 1% of the total body surface area (16; 17; 08).

A variety of CNS and peripheral nervous system manifestations has been described. Burn encephalopathy or burn-induced delirium, often hypoxic and metabolic, has extensively been described in the acute phase of burn injury. A retrospective clinicopathologic study of 139 patients who died following severe burns reported that 53% of the patients had CNS complications. Cerebral infarcts and hemorrhages, metabolic encephalopathies, central pontine myelinolysis, and cerebral trauma were major central nervous system complications in these patients. Eighteen percent of the patients had pathologic evidence of cerebral infarcts. In almost half of the patients, the infarcts were caused by septic arterial occlusions or other complications of the burn, like disseminated intravascular coagulation and septic shock. In only one third of the cases, infarcts were due to atherosclerosis, atrial fibrillation, or other causes prevalent in the general population. Intracranial hemorrhages were only one fifth as frequent as infarcts and were due to disseminated intravascular coagulation and thrombocytopenia caused by bacteremia.

Sixteen percent of the patients had a CNS infection. Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa caused almost 80% of CNS infections. S. aureus and candida caused cerebral microabscesses and septic infarcts. Pseudomonas aeruginosa caused meningitis and infarcts due to meningitis. The major risk factors for CNS infection were an extensive burn, Staphylococcus aureus endocarditis, and a burn wound infection due to candida or Pseudomonas aeruginosa. Patients with burns of less than 30% of the surface area of their body, those without a systemic infection, and those in the first week after their burn were at low risk (46).

Burn injury-induced CNS complications have also been described in children. Among 287 children with burns, 13 (5%) showed evidence of encephalopathy. The major clinical manifestations were an altered sensorium and seizures. In the majority, symptoms began later than 48 hours after the burn and were accompanied by multiple metabolic abnormalities. Eleven children improved to normal. CNS dysfunction was possibly a result of complex metabolic, hematological, and hemodynamic abnormalities rather than a single metabolic abnormality (32). Hypoxia was the principal determinant in children with burn encephalopathy. Other factors that were responsible for CNS alterations were hypovolemia, sepsis, hyponatremia, and cortical vein thrombosis (03). Systemic inflammatory response syndrome following burn injury may affect dysfunction of microcirculation of body resulting in CNS dysfunction (26). A retrospective study observed that patients with multiple sclerosis and concurrent burn injuries need longer hospital stays and burn triage and treatment (28).

The risk of ischemic stroke is significantly higher in hospitalized patients with burn injury in comparison to the general population. In one case-control study, 1763 burn injury patients were matched with 176,300 unexposed patients. The adjusted hazard ratio of ischemic stroke was significantly increased in burn injury patients versus controls (19).

A case series noted a correlation between severe burns and the occurrence of ischemic optic neuropathy. Medina and coworkers described three patients with severe burns who developed visual loss because of bilateral ischemic optic neuropathy during their hospital stay (31). These patients needed more than 25 L of crystalloid fluid within 24 hours, had multiple bouts of sepsis, and required extended pressor support. The authors postulated that ischemic optic neuropathy possibly developed because of shock, sepsis, and the need for large-volume fluid resuscitation. Hughes and colleagues reported another patient with posterior ischemic optic neuropathy following burns (18). They suggested that a high index of suspicion should be kept if a burn patient develops vision loss.

Neuromuscular manifestations are important complications in acute stages as well as later in life as major disabling sequelae. In acute stages, neurologic findings are often missed. Mononeuropathies, mononeuritis multiplex, and polyneuropathies have all been described in burn-injured patients (39). Patients with severe burn injuries are likely to develop rhabdomyolysis and subsequent acute kidney injury (24).

A retrospective study was performed to evaluate neuropathies in patients with burns. Nineteen of a total of 800 patients had signs and symptoms of neuropathy, confirmed on neurophysiological testing. Most patients with neuropathies were severely burned, with 11 patients (69%) having a total burn surface area of greater than 20%. Twenty-eight percent were full-thickness burns. Mononeuritis multiplex was the most common finding in these patients, occurring in 11 (69%). Three patients (19%) had an isolated mononeuropathy, one (6%) had a radiculopathy, and one had a generalized axonal polyneuropathy. The length of hospitalization and severity of the burns were the only factors correlated with the number of affected nerves (27).

In a cohort of 572 patients with major burn injuries, 64 (11%) of patients had clinical evidence of mononeuropathy, peripheral neuropathy, or both. Electrical cause, history of alcohol abuse, and number of days in intensive care were significantly associated with mononeuropathy. The number of days in intensive care and patient age were significantly associated with peripheral neuropathy (25). A system review noted that of the 1533 burn patients, 98 cases (6.39%) later presented with peripheral neuropathy. Thermal and electrical burns were the most common etiologies (42).

Tight dressings can cause compression to superficial nerves, and improper and prolonged positioning can cause excessive stretch of nerves. Thus, proper positioning of patients and careful monitoring of wound care can mitigate neuromuscular complications. Poor positioning at the neck and shoulder leads to excessive stretch of the brachial plexus and places the plexus at risk for injury. Also, several bed and intraoperative positions commonly used in the treatment of burn injuries put the patient at risk of developing mononeuropathies or plexopathies. In the upper extremity, the ulnar, median, and radial nerves are common sites for the development of mononeuropathies.

Mononeuritis multiplex is an asymmetric neuropathy that involves two or more isolated peripheral nerves. Involvement of multiple nerves after thermal burns has also been noted among patients with greater than 40% total body surface area. The number of nerves involved per patient ranged from 3 to 7. Upper-extremity nerves were more commonly involved than lower-extremity nerves. Mononeuritis multiplex in burn patients is thought to result from a combination of circulating neurotoxins, metabolic factors, and mechanical compression (11).

Polyneuropathy in burn patients has also been frequently observed. Polyneuropathy is caused by a combination of direct thermal injury on the nerves, circulating neurotoxins, and changes in the distribution of fluid and electrolytes. Critical illness polyneuropathy in burn patients has also been observed. Critical illness polyneuropathy often has a strong link to sepsis, multiple organ failure, and slow ventilatory weaning (09). A review on critical care polyneuropathy in burn-injured patients that included a total of 2755 subjects revealed 128 (4.4%) critical care polyneuropathy patients. The factors associated with critical care polyneuropathy in burns were prolonged ventilation, large burns, and sepsis (30).

In the presence of preexisting diabetic neuropathy, the management of lower-extremity burn injuries becomes difficult. Diabetes-associated factors significantly hamper the healing of such wounds. Many of these patients require amputations after their burn injury (40). It has been noted that among patients with isolated lower limb burns, preexisting diabetes mellitus adversely affects the outcome. Patients with lower limb burns and pre-existing diabetes mellitus had longer hospitalization and increased amputations (36).

Pruritus is a common disabling symptom in the late phases of burns. The exact mechanism of pruritus is not well known. In a prospective cohort study, among 510 burn patients, the reported prevalence rates of mild to severe itching were as high as 87%, 70%, and 67% at 3, 12, and 24 months post-burn event. Significant predictors of itching were deep dermal injury and early posttraumatic stress symptoms. Along with these, total burned surface area and female gender were predictors at 3 months post-burn (43). Axonal sprouting in the dermis is considered a proposed mechanism of pruritus in burn patients.

Burn scars can cause intense pain, even without evidence of underlying nerve damage. The extent of damage by burn injury is the important predicting factor for pain in scars. Scar pain has characteristics of neuropathic pain and is considered caused by an imbalance in C-fibers subtypes. The scar possibly alters the nerve fiber distribution in the damaged tissues, resulting in pain (04). In a retrospective study, 1880 adult burn patients were analyzed (23). In this study, 113 (6%) of the burn patients developed chronic neuropathic pain over 5 years. Old age, alcohol, substance abuse, smoking, large and severe burns, mechanical ventilation, corrective surgeries, and long hospital stays predicted chronic neuropathic pain following burn injury.

Prognosis and complications

In a retrospective review of 1665 patients with acute burn injuries, authors developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. Three risk factors for death were identified: (1) age greater than 60 years, (2) more than 40% of the body-surface area burned, and (3) inhalation injury. The mortality formula predicts a 90% mortality if all three risk factors are present (38). Approximately 75% of deaths following burn are related to wound infection. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis (10).

All survivors of burn injuries who had encephalopathic features showed complete neurologic recovery despite severe and prolonged symptoms (03). However, several burn patients suffer long-term cognitive dysfunctions, like memory defect. Cognitive dysfunctions affect quality of life. Several reasons have been ascribed for the cognitive dysfunction in the post-burn period; cerebral inflammation, resulting in the destruction of the blood-brain barrier, is considered a dominant reason (48). Neuropathy after burn injury can affect strength and function. Studies highlight CNS reorganization involving inflammation, afferent dysfunction, and pain as key factors. Emphasizing CNS-focused research and noninvasive brain stimulation methods could significantly enhance treatment and quality of life for burn survivors (37).

Psychiatric disorders are common among burn patients. A study observed that more than 50% of the survivors had some kind of psychiatric disorder 10 years after the burn (34). Posttraumatic stress disorder and depression are common psychiatric disorders in these patients. Body image dissatisfaction is also common in patients with burn injuries. Pain is another serious problem for burn survivors, particularly during the early phases of burn care (12).

Biological basis

Etiology and pathogenesis

The most common types of thermal injuries are caused by flames, hot liquid spills, hot solid materials, and steam. Other types of burn injuries are caused by chemicals, electricity, and radiation. These types of injuries may also damage tissues in a similar manner.

The local and systemic responses to thermal injury are extremely complex. These inflammatory responses result in both local tissue damage and systemic effects. In the acute phase, key features are capillary leak, inhalation injury, and the development of multiple organ failure.

Local responses. There are three concentric zones of tissue injury in fresh burn wounds: (1) maximally damaged tissue in the zone of coagulation; (2) decreased tissue perfusion in the zone of stasis; and (3) edematous tissue in the zone of hyperemia. Tissue in the zones of stasis and hyperemia is at risk for necrosis; it is potentially salvageable unless there is severe sepsis or prolonged hypoperfusion (20). Lack of proper treatment may lead to a partial-thickness burn converting to full-thickness burn. Systemic factors like shock, hypoxia resultant from pulmonary insufficiency, and massive wound sepsis promote burn wound progression.

Systemic responses. The inflammatory reaction starts almost immediately after the burn injury. Extensive burns (30% of total body surface area) are often associated with stress and inflammatory and hypermetabolic changes that lead to hyperdynamic circulation, increased body temperature, glycolysis, proteolysis, lipolysis, and futile substrate cycling. These burn-induced metabolic and inflammatory changes may persist for 3 years after the injury. The relevance of post-burn hypermetabolism and inflammation is that they induce insulin resistance, increased fracture risk, increased liver-size, growth and development retardation, increased cardiac work, cardiac dysfunction, impaired strength and muscle function, hormonal abnormalities, increased risk for infections, and sepsis. All may contribute to causes of morbidity and mortality in burn patients. Cytokines are the primary mediators of this inflammatory reaction to injury. Studies have found a marked increase in serum cytokines in response to burn injury. These cytokines demonstrated an up to 2000-fold increase immediately post-burn and remained significantly high for an extended period of time. Persistently increased glucose and insulin levels are of serious clinical concern as hyperglycemia is often associated with impaired wound healing, increased skin graft loss, increased muscle protein loss, and increased infections. Determination of serum osteocalcin and parathyroid hormone levels also demonstrated significant decreases for 9 and up to 36 months, respectively; these changes were associated with profound decreases in bone mineral content and bone mineral density. Jeschke and colleagues found that urinary norepinephrine, epinephrine, and cortisol increased markedly immediately after burn trauma (21). These changes in catecholamine, glucocorticoid, and glucagon secretion are responsible for a hypermetabolic state. Large burns may adversely affect immune status of the patients.

Cardiovascular changes in patients with burns are characterized by marked tachycardia, increased myocardial oxygen consumption, and increased cardiac output. Cardiac changes are mediated by increased catecholamines. Increased capillary permeability leads to loss of intravascular proteins and fluids into the interstitial space. Myocardial contractility is decreased. Peripheral and splanchnic vasoconstriction occurs. Fluid loss from the wound along with cardiac changes produces systemic hypotension and end-organ hypoperfusion. A large amount of circulating catecholamines is considered detrimental to the myocardium (45). Respiratory changes in burns are often caused by inhalation injury. Several changes 24 to 72 hours after burn injury include pulmonary arterial hypertension, bronchial obstruction, increased airway resistance, reduced pulmonary compliance, atelectasis, and increased pulmonary shunt fraction. Inflammatory mediators may also be responsible for bronchoconstriction. In severe burns, adult respiratory distress syndrome may evolve.

Epidemiology

According to World Health Organization estimates, 180,000 deaths occur annually due to burn injury (47). The majority of burn-related deaths occur in low- and middle-income countries, and almost half occur in Southeast Asia. In 2008, over 410,000 burn injuries occurred in the United States, with approximately 40,000 requiring hospitalization. The higher risk for females in low- and middle-income countries is associated with open-fire cooking or inherently unsafe cookstoves, which can burn loose clothing. Children are particularly vulnerable to burns. Burns are the 11th leading cause of death of children aged 1 to 9 years. The majority (80% to 90%) of burns occur at home. Other factors make people vulnerable for burns include hazardous occupations, poverty, overcrowding, lack of proper safety measures, medical conditions (eg, epilepsy, peripheral neuropathy, and physical and cognitive disabilities), alcohol abuse and smoking, use of kerosene as a fuel source for nonelectric domestic appliances, and inadequate safety measures for liquefied petroleum gas and electricity (47). In Europe, the annual incidence of severe burns was 0.2 to 2.9/10,000 inhabitants. Mortality was usually between 1.4% and 18%. Deaths were more frequent in older age, in patients with a larger burned surface area, and in patients with chronic diseases. Multiorgan failure and sepsis were the most frequent causes of death (07).

Patients with epilepsy have higher incidence and severity of burn injury. In a retrospective study, the authors compared patients with and without seizure disorder in a burn unit. Prevalence of seizure disorder was 10.7% among burn patients. Flame injury was most common in patients with seizure disorder, whereas scalds predominated among patients without seizure disorder. Mortality did not differ between the groups, but mean length of hospital stay was longer for patients with seizure disorder (06).

Management

Airway, breathing, and circulation. It is crucial to maintain a patent airway. The airway should be cleared of any foreign material. If the patient is comatose, open the airway with a chin lift and jaw thrust. Patients with severe burns require endotracheal intubation. Urgently, 100% oxygen should be administered. Intravenous access should be established as quickly as possible (16; 17; 08).

Neurologic status. All patients should be quickly evaluated for responsiveness with the help of Glasgow coma scale. There may be several reasons for unresponsiveness or delirium. These include hypoxia, hypovolemia, carbon monoxide poisoning, intoxication (alcohol or drugs), or shock.

Exposure with environment control. Hypothermia can be detrimental. It is important to ensure that the patient is kept warm and covered. All clothing and jewelry should be removed.

Fluids resuscitation. Fluid resuscitation is needed for a patient who has sustained a burn over more than 10% of body area for children, more than 15% for adults; Rule of Nines is a good, quick way of estimating the burn area in adults. Fluid management of major burns improves the survival rates in these patients. The “Parkland” formula is used to calculate the amount of fluid required to resuscitate the patient. During the initial 24 hours, Ringer’s lactate solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn for children should be administered. In next 24 hours, colloid infusion of 5% albumin 0.3 to 1 ml/kg/% burn/16 per hour is provided. Urine output is measured to evaluate the adequacy of fluid resuscitation (16; 17; 08).

Pain control. Pain should be managed with intravenous morphine. Oral analgesics may be used in patients with minor burns.

Wound management. Proper wound management requires cleansing of wound surface, debridement, and dressing. Prophylactic antibiotics are not routinely given to burn patients.

Pruritus. Oral antihistamines are the most frequently prescribed drug for pruritus in burn patients. Pharmacological evidence suggests the involvement of neuropathic mechanisms in burn-related pruritus; gabapentin has been found effective (01).

Beta-blocker. While recovering from massive burns, patients may develop profound sarcopenia, secondary to epinephrine-dependent burn-induced hypermetabolism. Use of the nonselective beta-blocker propranolol may help in suppressing epinephrine-mediated burn-induced hypermetabolism; however, the exact role of beta-blockers in such patients is not established (05).

Special considerations

Pregnancy

The exact incidence of burn during pregnancy is not known, but it can be devastating to both mother and fetus. Several factors, such as the depth and size of the burn, the woman's underlying health and age, associated inhalation injury, and the estimated gestational age of the fetus are likely to affect maternal and fetal outcomes (22). Maternal and perinatal mortality increases significantly when greater than 50% of the total body surface area is burned. However, pregnancy does not seem to alter maternal outcome, and maternal survival is often accompanied by fetal survival (35). A retrospective review presented data from eight patients burned during pregnancy. The total body surface area burned ranged from 1% to 85% in these patients, and all survived the injury. All patients gave birth to healthy children except the most severely burned patient, whose child suffers from cerebral palsy. Authors recommended that all pregnant ladies with burns should be subjected to a prompt fluid resuscitation, early supplemental oxygen administration, early delivery if the pregnancy is in the third trimester, and high suspicion and aggressive treatment for venous thrombosis and sepsis (14).

Anesthesia

Adequate fluid resuscitation and airway management during surgery are of prime importance in burn-injured patients. Pain management through all phases of care is a prime concern of anesthesia care. Total intravenous anesthesia is frequently used for surgeries requiring general anesthesia in severe burn patients. Ketamine is the intravenous anesthetic agent of choice for excision and grafting of the burn wound. Ketamine is preferred in burn patients because it reduces opioid usage and decreases the hemodynamic and respiratory side effects. Ketamine results in increased CNS sympathetic activity and enhanced release of catecholamines. Thus, it has a positive effect on blood pressure and heart rate (02; 29).

Media

References

01: Anand S. Gabapentin for pruritus in palliative care. Am J Hosp Palliat Care 2013;30(2):192-6. PMID 22556282
02: Anderson TA, Fuzaylov G. Perioperative anesthesia management of the burn patient. Surg Clin North Am 2014;94(4):851-861. PMID 25085092
03: Antoon AY, Volpe JJ, Crawford JD. Burn encephalopathy in children. Pediatrics 1972;50(4):609-16. PMID 5073011
04: Bijlard E, Uiterwaal L, Kouwenberg CA, Mureau MA, Hovius SE, Huygen FJ. A systematic review on the prevalence, etiology, and pathophysiology of intrinsic pain in dermal scar tissue. Pain Physician 2017;20(2):1-13. PMID 28158149
05: Blears E, Ross E, Ogunbileje JO, Porter C, Murton AJ. The impact of catecholamines on skeletal muscle following massive burns: friend or foe? Burns 2021;47(4):756-64. PMID 33568281
06: Boschini LP, Tyson AF, Samuel JC, et al. The role of seizure disorders on burn injury and outcome in Sub-Saharan Africa. J Burn Care Res 2014;35(6):e406-12. PMID 24918949
07: Brusselaers N, Monstrey S, Vogelaers D, et al. Severe burn injury in Europe: a systematic review of the incidence, etiology, morbidity, and mortality. Crit Care 2010;14(5):R188. PMID 20958968
08: Cancio LC. Initial assessment and fluid resuscitation of burn patients. Surg Clin North Am 2014;94(4):741-754. PMID 25085085
09: Chan Q, Ng K, Vandervord J. Critical illness polyneuropathy in patients with major burn injuries. Eplasty 2010;10:e68. PMID 21119768
10: Church D, Elsayed S, Reid O, et al. Burn wound infections. Clin Microbiol Rev 2006;19(2):403-34. PMID 16614255
11: Dagum AB, Peters WJ, Neligan PC, et al. Severe multiple mononeuropathy in patients with major thermal burns. J Burn Care Rehabil 1993;14(4):440-5. PMID 8408169
12: Dalal PK, Saha R, Agarwal M. Psychiatric aspects of burn. Indian J Plast Surg 2010;43(Suppl):S136-42. PMID 21321649
13: Evans EI, Purnell OJ, Robinett PW, et al. Fluid and electrolyte requirements in severe burns. Ann Surg 1952;135(6):804-17. PMID 14924536
14: Guo SS, Greenspoon JS, Kahn AM. Management of burn injuries during pregnancy. Burns 2001;27(4):394-7. PMID 11348752
15: Hattery E, Nguyen T, Baker A, Palmieri T. Burn Care in the 1800s. J Burn Care Res 2015;36(1):236-9. PMID 25102233
16: Hettiaratchy S, Papini R. Initial management of a major burn: I--overview. BMJ 2004a;328(7455):1555-7. PMID 15217876
17: Hettiaratchy S, Papini R. Initial management of a major burn: II--assessment and resuscitation. BMJ 2004b;329(7457):101-3. PMID 15242917
18: Hughes B, Natalwala I, Kiely J, et al. Posterior ischemic optic neuropathy following a major burn injury and review of the literature. J Burn Care Res 2021;42(4):821-4. PMID 33245361
19: Hung TY, Lee YK, Huang MY, Hsu CY, Su YC. Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan. Scand J Trauma Resusc Emerg Med 2016;24:44. PMID 27052491
20: Jackson DM. The diagnosis of the depth of burning. Br J Surg 1953;40:588. PMID 13059343
21: Jeschke MG, Gauglitz GG, Kulp GA, et al. Long-term persistence of the pathophysiologic response to severe burn injury. PLoS One 2011;6(7):e21245. PMID 21789167
22: Kennedy BB, Baird SM, Troiano NH. Burn injuries and pregnancy. J Perinat Neonatal Nurs 2008;22(1):21-30. PMID 18287898
23: Klifto KM, Dellon AL, Hultman CS. Prevalence and associated predictors for patients developing chronic neuropathic pain following burns. Burns Trauma 2020;8:tkaa011. PMID 32377542
24: Ko A, Song J, Golovko G, et al. Higher risk of acute kidney injury and death with rhabdomyolysis in severely burned patients. Surgery 2022;171(5):1412-6. PMID 35078633
25: Kowalske K, Holavanahalli R, Helm P. Neuropathy after burn injury. J Burn Care Rehabil 2001;22(5):353-7. PMID 11570537
26: Marchiori PE, Lino AM, Hirata MT, et al. Occurrence of nervous system involvement in SIRS. J Neurol Sci 2006;250(1-2):147-52. PMID 17028030
27: Marquez S, Turley JJ, Peters WJ. Neuropathy in burn patients. Brain 1993;116 ( Pt 2):471-83. PMID 8384917
28: McCann MR, Hill WF, Yan J, Rehou S, Jeschke MG. Burn injury and multiple sclerosis: a retrospective case-control study. Burns 2019;45(1):247-52. PMID 30477818
29: McGhee LL, Maani CV, Garza TH, et al. The intraoperative administration of ketamine to burned US Service members does not increase the incidence of post-traumatic stress disorder. Mil Med 2014;179(8 Suppl):41-6. PMID 25102548
30: Mc Kittrick A, Kornhaber R, Harats M, Cleary M, Visentin DC, Haik J. Critical care polyneuropathy in burn injuries: an integrative review. Burns 2017;43(8):1613-23. PMID 28838678
31: Medina MA 3rd, Moore DA, Cairns BA. A case series: bilateral ischemic optic neuropathy secondary to large volume fluid resuscitation in critically ill burn patients. Burns 2015;41(3):e19-23. PMID 25406887
32: Mohnot D, Snead OC 3rd, Benton JW Jr. Burn encephalopathy in children. Ann Neurol 1982;12(1):42-7. PMID 6810748
33: Naylor I L, B Curtis B, Kirkpatrick JJ. Treatment of burn scars and contractures in the early seventeenth century: Wilhelm Fabry's approach. Med Hist 1996;40(4):472–486. PMID 8952291
34: Palmu R, Suominen K, Vuola J, et al. Mental disorders after burn injury: a prospective study. Burns 2011;37(4):601-9. PMID 21081260
35: Polko LE, McMahon MJ. Burns in pregnancy. Obstet Gynecol Surv 1998;53(1):50-6. PMID 9440130
36: Rotman S, Lapaine P, Rehou S, et al. Comparison of clinical outcomes of lower extremity burns in diabetic and nondiabetic patients: a retrospective analysis. J Burn Care Res 2022;43(1):93-7. PMID 34329452
37: Rowe G, Allahham A, Edgar DW, et al. Functional brain changes following burn injury: a narrative review. Neurorehabil Neural Repair 2023:15459683231215331. PMID 38044625
38: Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338(6):362-6. PMID 9449729
39: Schneider JC, Qu HD. Neurologic and musculoskeletal complications of burn injuries. Phys Med Rehabil Clin N Am 2011;22(2):261-75. PMID 21624720
40: Sen S, Barsun A, Romanowski K, Palmieri T, Greenhalgh D. Neuropathy may be an independent risk factor for amputation after lower-extremity burn in adults with diabetes. Clin Diabetes 2019;37(4):352-56. PMID 31660008
41: Thomsen M. Historical landmarks in the treatment of burns. Br J Plast Surg 1977;30(3):212-7. PMID 329930
42: Tu Y, Lineaweaver WC, Zheng X, Chen Z, Mullins F, Zhang F. Burn-related peripheral neuropathy: a systematic review. Burns 2017;43(4):693-9. PMID 28347546
43: Van Loey NE, Bremer M, Faber AW, et al. Itching following burns: epidemiology and predictors. Br J Dermatol 2008;158(1):95-100. PMID 17986307
44: Villaverde Doménech ME, Simón Sanz E, Pujol Marco C, et al. Pellagra. A challenging differential diagnosis in burn. J Tissue Viability 2014 Feb;23(1):37-41. PMID 24405724
45: Williams FN, Herndon DN, Suman OE, et al. Changes in cardiac physiology after severe burn injury. J Burn Care Res 2011;32(2):269-74. PMID 21228708
46: Winkelman MD, Galloway PG. Central nervous system complications of thermal burns. A postmortem study of 139 patients. Medicine (Baltimore) 1992;71(5):271-83. PMID 1522803
47: World Health Organization. Burns. Key facts 13 October 2023. https://www.who.int/news-room/fact-sheets/detail/burns. Accessed January 6, 2024. WHO 2023.
48: Xie C, Hu J, Cheng Y, Yao Z. Researches on cognitive sequelae of burn injury: current status and advances. Front Neurosci 2022;16:1026152. PMID 36408414

Contributors

All contributors' financial relationships have been reviewed and mitigated to ensure that this and every other article is free from commercial bias.

Author

Ravindra Kumar Garg DM FRCP

Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.
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Editor

Peter J Koehler MD PhD

Dr. Koehler of Maastricht University has no relevant financial relationships to disclose.
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Patient Profile

Age range of presentation: 0 month 65+ years
Sex preponderance: male=female
Heredity: none
Population groups selectively affected: none
Occupation groups selectively affected: none

ICD & OMIM codes

ICD-9: Burns: 940.0 - 949.5 (Burns classified according to extent of body surface involved)
ICD-10: Burns: T31 (Burns classified according to extent of body surface involved)

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Neurologic aspects of burn injuries

Associated Disorders

inhalation injury
multi organ failure
sepsis
shock
wound infection

Differential Diagnosis

asphyxia
head injury
carbon monoxide poisoning
cyanide poisoning
other causes of metabolic encephalopathy
- pellagra

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Clinical Categories

General Neurology

Neurologic aspects of burn injuries

Neurologic aspects of burn injuries

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Editor

Patient Profile

ICD & OMIM codes

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Neurologic aspects of burn injuries

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Diagnostic workup

Management

Special considerations

Pregnancy

Anesthesia

Media

References

Contributors

Author

Editor

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Neurogenetics and genetic and genomic testing

Acute traumatic spinal cord injury

Tumors of the skull base

Toxic and nutritional deficiency optic neuropathies

Third nerve palsy

Nystagmus

Brain death/death by neurologic criteria

Outpatient rehabilitation of chronic neurologic conditions

This is an article preview.
Start a Free Account
to access the full version.