BURNS

PATHOPHYSIOLOGY
TYPES
DEGREE
PERCENTAGE

62019

Pathophysiology
Burns are tissue injuries resulting from direct
contact with flames, hot liquids, gases, or surfaces;
chemicals; electricity; or radiation.
Most commonly, the skin is injured, which
compromises its function as a barrier to injury and
infection and as a regulator of body temperature,
fluid loss, and sensation.
However it can damage airway and lungs with life
threatening consequenses.
Airway injuries
Respiratory system injury

Amount of tissue destruction depends

on time of exposure and temperature.
It takes 6 hours for skin maintained at
44c to suffer irreversible changes, but
surface temp of 70c for 1 second is
all needed to produce epidermal
destruction.

At temperatures greater than44 C(111F), proteins

begin losing their three-dimensional shape and start
breaking down. This results in cell damage. The direct
health effects of a burn are usually secondary to those
caused by the disruption in the normal functioning of the
skin. The skin has a number of important functions
including: prevention of water loss through evaporation,
temperature control, and sensation. Disruption of cell
membranes causes cells to lose potassium to the spaces
outside the cell and to take up water and sodium. This
results in tissueedema.Damage to the cells may also
result in the release of pro-inflammatory mediators.Water
loss leads to blood becoming more concentrated.

 Burned

skin activates a web of inflammatory cascades.The release of

neuropeptides and activation of complement are initiated by the
stimulation of pain fibres and alteration of proteins by heat.
On a cellular level, complement causes degranulation of mast cells
and coats the protein altered by the burn.This atttracts neutrophils,
which also degranulate,with release of large quantities of free radical
and proteases.These can further damage the tissue .
Mast cell also release primary cytokines such as tumor necrosis factor
alpha .These act as chemotactic agents to inflammatory cells and
subsequent release of many secondary cytokines.These inflamatory
factors alter the permeability of blood vessels. The increased
permeability is such that large protein molecules escapes with ease.

The damaged collagen and these extravasted protein increase

the oncotic pressure within the burned tissue, further
increasing the flow of water from intravascular space to
extravascular space.
The flow occurs over first 36 hours after injury but does not
include RBC.
The volume of fluid lost is dircetly proportional to area of burn.
In small burn these reaction is localized but when it
approaches 10-15% of total body surface area, loss of
intravascular fluid can cause a level of circulatory shock. If it is
more than 25% of TBSA, then inflammation occurs even in the
blood vessels remote to the burn, causing greater fluid loss.

Degreeof burns
First-degree burns are limited to the
epidermis. The skin is painful and red.
There are no blisters. These burns
should heal spontaneously in 3 to 4
days.

Second-degree burns, which are subdivided

into superficial and deep partial- thickness burns,
are limited to the dermal layers of the skin.
Superficial partial-thickness burns involve the
papillary dermis. They appear red, warm,
edematous, and blistered, often with denuded,
moist, mottled red or pink epithelium. The injured
tissue is very painful, especially when exposed to
air. Such burns frequently arise from brief contact
with hot surfaces, liquids, flames, or chemicals.

superficial partial thickness

Deep partial-thickness burns involve the reticular

dermis and thus can damage some dermal
appendages (e.g., nerves, sweat glands, or hair
follicles). Hence, such burns can be less sensitive, or
hairs may be easily plucked out of areas with deep
partial-thickness burns. Nonetheless, the only
definitive method of differentiating superficial and
deep partial-thickness burns is by length of time to
heal.
Superficial burns heal in less than 2 weeks
without residual scarring; deep ones require at least
3 weeks and usually lead to hypertrophic scarring.
Furthermore, any partial-thickness burn can convert
to full-thickness injury over time, especially if early

Full-thickness (third- or fourth-degree) burns involve all

layers of the skin and some subcutaneous tissue.
In third-degree burns, all the skin appendages, including hair
follicles and sweat and sebaceous glands, and sensory fibers
for touch, pain, temperature, and pressure are destroyed. This
results in an initially painless, insensate dry surface that may
appear either white and leathery or charred and cracked, with
exposure of underlying fat.
Fourth-degree burns also involve fascia, muscle, and bone.
They often result from prolonged contact with thermal
sources or high electrical current.
All full-thickness burns are managed surgically, and
immediate burn expertise should be sought

Types
Major burn

Moderate burn

Minor burn

Size-Partial
Thickness

>25% adults
>20% children

15-25% adults
10-20%
children

<15 adults
<10 children

Size-Full
Thickness

>10%

2-10%

<2%

Inhalation
injury

If present or
suspected

Not suspected

Not suspected

Associated
injury

If present

Not present

Not present

Co-morbid
factors

Poor risk patient

Relatively
good risk
patient

Not present

Generalized
hospital
With
designated

As out patient

Miscellaneou Electrical
s
injurues
Treatment
environment

Usually
especialized
burn care
facillity

Percentage of body surface area (BSA)

estimation

The accurate and timely assessment of BSA

is a critical aspect of the initial evaluation of
burned patients in the emergency
department. It will determine whether
transfer to a specialized burn center is
required as well as the magnitude of initial
fluid resuscitation and nutritional
requirements

Rule-of-Nines Estimation of Percentage of Body

Surface Area
Trunk
Head and neck Anterior Posterior

adult
Infant

18

18

18

18

18

Extremity
Upper Lower
9
4

Genital
18
9

1
-

Small areas: palm of patient's hand

equals 1% of BSA.
Large areas: rule of nines: Regions of
the body approximating 9% BSA or
multiples . Note that infants and babies
have a proportionally greater
percentage of BSA in the head and neck
region and less in the lower extremities
than adults