Classifications

Burn depth classification

1st degree

2nd degree
(partial-thickness)
-Superficial

Depth

Appearance

Surface

Sensation

Time to healing

Epidermis

Pink or red

Dry

Painful

Days

Epidermis +
pars papilare

Pink, clear
blister

Moist

Painful

14-21 days

Pink,
hemorrhagic
blister, red

Moist

Painful

Weeks, or may
progress to 3rd
degree, require
graft

-Deep

Epidermis +
pars retikulare

3rd degree (fullthickness)

Epidermis +
dermis

White, brown Dry

Insensate

Require excision

4th degree

Skin,
subcutaneos
fat, muscle,
bone

Brown,
charred

Insensate

Require excision

Dry

Depth of Burn
Superficial Burn
Partial Thickness Burn
Full Thickness Burn

Burn Depth
Superficial Burn:
1st Degree Burn
Signs & Symptoms
Reddened skin
Pain at burn site
Involves only
epidermis

Burn Depth
Partial-Thickness
Burn: 2nd Degree
Burn
Signs & Symptoms

Intense pain
White to red skin
Blisters
Involves epidermis
& dermis

Burn Depth
Full-Thickness Burn:
3rd Degree Burn
Signs & Symptoms
Dry, leathery skin
(white, dark brown, or
charred)
Loss of sensation (little
pain)
All dermal
layers/tissue may be
involved

Determining Severity of Injury

Size (surface area)

Depth
Prior status of health of victim
Age
Location of burn
Severity of associated injury

Classifications of burn injury

First-degree burns
Painful, red, dry, and blanch with pressure
Typically occur secondary to prolonged exposure to
low-intensity heat or short-duration flash exposure to a
heat source
Only a superficial layer of epidermal cells is destroyed
They slough (peel away from healthy tissue underneath
the wound) without residual scarring
Usually heal within 2 to 3 days

Second-degree burns

Superficial partial-thickness burns

a) Characterized by blisters
b) Commonly caused by skin contact with the following:
(1) Hot but not boiling water
(2) Other hot liquids
(3) Explosions producing flash burns
(4) Hot grease
(5) Flames

c) Injury extends through the epidermis to the

dermis
(1) Basal layers of the skin are not destroyed
(2) Skin regenerates within a few days to a
week

d) Edematous fluid infiltrates dermal-epidermal

junction, creating blisters
e) Intact blisters provide a seal that protects the
wound from infection and excessive fluid loss
f) Injured area is usually red, wet, and painful, and
may blanch when tissue around the injury is
compressed
g) In the absence of infection these wounds
generally heal without scarring, usually within 14
days

2) Deep partial-thickness burns

a) Depth of burn involves the basal layer of the dermis
(1) Sensation in and around the wound may be diminished
because of the destruction of basal-layer never endings
b) Depending on the degree of vascular injury, wound may
appear red and wet, or white and dry

c) Major complications are wound infection and subsequent

infection

d) If uncomplicated, injury generally heals within

3 to 4 weeks
e) Skin grafting may be necessary to promote
timely healing and to prevent scar tissue
formation
(1) Scar tissue may severely restrict joint
movements and cause persistent pain and
disfigurement

Third-degree burns
1) Because the entire thickness of the epidermis
and dermis is destroyed, skin grafts are
necessary for timely and proper healing
2) Injury is characterized by coagulation necrosis of
cells and appears pearly white, charred, or
leathery
3) Definitive sign is a translucent surface in the
depths of which thrombosed veins are visible
4) Eschar is present in these injuries

5) Sensation and capillary refill are absent because small

blood vessels and nerve endings are destroyed
a) Often results in large plasma volume loss, infection,
and sepsis
6) Natural wound healing may produce contracture
deformity and severe scarring
7) Surgical intervention with skin grafting is necessary to:
a) Close full-thickness wounds
b) Minimize complications
c) Allow restoration of maximal function

Burn Severity

http://emcrit.org/030-064/056-thermal.burn.htm

Rules of Nine

Lund & Browder Chart

http://www.medstudentlc.com/uploaded_images/Lund%20Browder%20Rakel.gif

Pathophysiology

Limit cell tolerance

44oC no significant damage
> 51oC tissue damage is very great speed
> 70oC although cellular damage in a very
short period of exposure

Area burns
Coagulation area area cells have been
damaged, the maximum damage points
Static area damage and leakage of blood
vessels, are impaired perfusion, there are cells
that can still be saved
Hyperemia area consists of cells damaged
and less money to complete recovery

Pathogenesis
Increased capillary permeability

Isotonic fluid & protein transudation into extracapsuler

Reduction in circulating plasma volume

Edema

Curah output

Peripheral vascular resistance

SYSTEMIC RESPONSE
Due to the release of cytokines and other inflammatory mediators at the site of injury
Cardiovascular
changes

Capillary permeability loss of intravascular proteins and fluids

into the interstitial compartment
Peripheral and splanchnic vasoconstriction occurs
Myocardial contractility is << (due to release of TNF-)
These changes, coupled with fluid loss from the burn wound, result in
systemic hypotension and end organ hypoperfusion hypovolemic
shock

Respiratory changes

Inflammatory mediators bronchoconstriction

In severe burns, ARDS can occur

Metabolic changes

BMR > 3x normal

This, coupled with splanchnic hypoperfusion, necessitates early and
aggressive enteral feeding to decrease catabolism and maintain gut
integrity

Immunological
changes

Non-specific down regulation of the immune response occurs,

affecting both cell mediated and humoral pathways

Bodys Response to Burns

Emergent Phase (Stage 1)
Pain response
Catecholamine release
Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety

Fluid Shift Phase (Stage 2)

Length 18-24 hours
Begins after Emergent Phase
Reaches peak in 6-8 hours

Damaged cells initiate inflammatory response

Increased blood flow to cells
Shift of fluid from intravascular to extravascular space
MASSIVE EDEMA
Leaky Capillaries

Bodys Response to Burns

Hypermetabolic Phase (Stage 3)
Last for days to weeks
Large increase in the bodys need for nutrients
as it repairs itself

Resolution Phase (Stage 4)

Scar formation
General rehabilitation and progression to
normal function

Diagnose
Calculation extensive burns and deep burns
Lab and radiology tests (Chest X-Ray)

Diagnostic
Anamnesis
History of trauma / exposure
to the heat source (flame, hot
water, hot oil, chemicals,
electricity, radiation)
History trapped in a confined
space
History of exposure to a blast
History of falls from a certain
height after exposure to heat
sources

Physical examination
Primary Survey : ABC
Secondary Survey
Embed also:
1. The degree and extent of burns
2. Causes burns
3. As well as the problems that exist
at the time of the first inspection,
the example problem:
- inhalation injury
- Eskar around his chest
- shock

 Lab. blood examination of peripheral blood (hemoglobin,

hematocrit, leukocyte count, platelet count), blood gas analyzer,
function system / organ (metabolic function, liver, kidney)
Lab.urin urine specific gravity, pH, sediment
Microbiological culture and resistance with the material from the
wound, where entry intravenous line and catheter urine
Radiology photo upright piston AP / half sit for pulmonary
evaluation:
Detection of the ARDS and pulmonary edema (usually done after
the fifth day)

Laboratory
Hb, Ht pd every 8 hours the first 2 days and
then every 2 days to 10 days
Liver and kidney function every week
Examination of electrolytes each day during
the first week.
Examination of blood gases when
breathing> 32x/menit
Tissue culture on days I, III, VIII.

Laboratory
hemoglobin, hematocrit, electrolit (do as soon as
possible to repair the body fluids)
Complete blood
Renal function (BUN and creatinine)
Liver function
Blood gas analysis with carboxy hemoglobin levels
(HbCO2)
Profiles of blood clots
Analysis of urine
Creatine phosphokinase (CPK) and myoglobin urine

Treatment

Treatments Based on the Degree of

Severity

Systemic Complications
Hypothermia
Disruption of skin and its ability to thermoregulate

Hypovolemia
Shift in proteins, fluids, and electrolytes to the burned tissue
General electrolyte imbalance

Eschar
Hard, leathery product of a deep full thickness burn
Dead and denatured skin

Systemic Complications
Infection
Greatest risk of burn is infection

Organ Failure
Release of myoglobin

Special Factors
Age & Health

Physical Abuse
Elderly, Infirm or Young

Prognosis
Will depend on depth of burn and the body
surface area affected.
Superficial burns usually heal within two
weeks without surgery.
Risk factors for death include age over 60
years, more than 40% of body surface area
affected and inhalation injury.
Death may result from severe extensive burns
or electric shock.

Chemical burns
Can result from exposure to acidic, alkaline or
petroleum products.
Alkali burns tend to be deeper and more serious
than acid burns.
Immediately flush away the chemical with large
amounts of water for at least 20 to 30 minutes
(longer for alkali burns). Alkali burns to the eye
require continuous irrigation during the first eight
hours after the burn.
If dry powder is still present on the skin, brush it
away before irrigation with water.

Electrical burns
Are often more serious than they appear on the
surface.
Rhabdomyolysis results in myoglobin release, which
can cause acute renal failure. If the urine is dark, start
therapy for myoglobinuria immediately.
Fluid administration should be increased to ensure a
urinary output of at least 100 ml/hour in the adult.
Metabolic acidosis should be corrected by maintaining
adequate perfusion and adding sodium bicarbonate.

Inhalation Injury
Toxic Inhalation
Synthetic resin combustion
Cyanide & Hydrogen Sulfide
Systemic poisoning
More frequent than thermal inhalation burn

Carbon Monoxide Poisoning

Colorless, odorless, tasteless gas
Byproduct of incomplete combustion of carbon products
Suspect with faulty heating unit

200x greater affinity for hemoglobin than oxygen

Hypoxemia & Hypercarbia

Inhalation Injury
Airway Thermal Burn
Supraglottic structures absorb heat and prevent lower airway
burns
Moist mucosa lining the upper airway

Injury is common from superheated steam

Risk Factors
Standing in the burn environment
Screaming or yelling in the burn environment
Trapped in a closed burn environment

Symptoms

Stridor or Crowing inspiratory sounds

Singed facial and nasal hair
Black sputum or facial burns
Progressive respiratory obstruction and arrest due to swelling