Burn

A burn is a type of injury to flesh or skin caused by heat, electricity, chemicals, light, radiation or friction. Most burns affect only the skin (epidermal tissue). Rarely, deeper tissues, such as muscle, bone, and blood vessels can also be injured. Burns may be treated with first aid, in an out-of-hospital setting, or may require more specialized treatment such as those available at specialized burn centers. Managing burn injuries properly is important because they are common, painful and can result in disfiguring and disabling scarring, amputation of affected parts or death in severe cases. Complications such as shock, infection, multiple organ dysfunction syndrome, electrolyte imbalance and respiratory distress may occur. The treatment of burns may include the removal of dead tissue (debridement), applying dressings to the wound, fluid resuscitation, administering antibiotics, and skin grafting.

Classification of Burns Burns are classified based upon their depth. A first degree burn is superficial and causes local inflammation of the skin. Sunburns often are categorized as first degree burns. The inflammation is characterized by pain, redness, and a mild amount of swelling. The skin may be very tender to touch. Second degree burns are deeper and in addition to the pain, redness and inflammation, there is also blistering of the skin. Third degree burns are deeper still, involving all layers of the skin, in effect killing that area of skin. Because the nerves and blood vessels are damaged, third degree burns appear white and leathery and tend to be relatively painless.
Names First degree Layers involved Epidermis Appearance Redness (erythema) Texture Dry Sensation Painful Time to healing 1wk or less Complications Increased risk to develop skin cancer later in life Local infection/cellulit is

Second degree (superficial partial thickness) Second degree

Extends into superficial (papillary) dermis Extends into deep

Red with clear blister. Blanches with pressure Red-andwhite with

Moist

Painful

2-3wks

Moist

Painful

Weeks may

Scarring, contractures

(deep partial thickness) Third degree (full thickness) Fourth degree

(reticular) dermis Extends through entire dermis Extends through skin, subcutaneous tissue and into underlying muscle and bone

bloody blisters. Less blanching. Stiff and white/brown Black; charred with eschar

progress to third degree Dry, leathery Dry Painless Requires excision Requires excision

Painless

(may require excision and skin grafting) Scarring, contractures, amputation Amputation, significant functional impairment, possible gangrene, and in some cases death.

Burns are not static and may mature. Over a few hours a first degree burn may involve deeper structures and become second degree. For example a sunburn that blisters the next day. Similarly, second degree burns may evolve into third degree burns. Regardless of the type of burn, inflammation and fluid accumulation in and around the wound occur. Moreover, it should be noted that the skin is the body's first defense against infection by microorganisms. A burn is also a break in the skin, and the risk of infection exists both at the site of the injury and potentially throughout the body. Only the epidermis has the ability to regenerate itself. Burns that extend deeper may cause permanent injury and scarring and not allow the skin in that area to return to normal function.

Significance of the Amount of Body Area Burned In addition to the depth of the burn, the total area of the burn is significant. Burns are measured as a percentage of total body area affected. The "rule of nines" is often used, though this measurement is adjusted for infants and children. This calculation is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total (and the total body area of 100% is achieved):

Head = 9% Chest (front) = 9% Abdomen (front) = 9%

Upper/mid/low back and buttocks = 18%

Each arm = 9% Each palm = 1%

Groin = 1%

Each leg = 18% total (front = 9%, back = 9%)

Extent of Body Surface Area Burned How much total body surface area is burned is determined by one of the following methods: Rule of Nines: an estimation of the total body surface area burned by assigning percentages in multiples of nine to major body surfaces. Lund and Browder method: a more precise method of estimating the extent of the burn; takes into account that the percentage of the surface area represented by various anatomic parts(head and legs) changes with growth. Palm method: used to estimate percentage of scattered burns, using the size of the patients palm (about 1% of body surface area) to assess the extent of burn injury. As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body. Only second and third degree burn areas are added together to measure total body burn area. While first degree burns are painful, the skin integrity is intact and it is able to do its job with fluid and temperature maintenance. If more than15%-20% of the body is involved in a burn, significant fluid may be lost. Shock may occur if inadequate fluid is not provided intravenously. The Parkland formula (named for the trauma hospital in Dallas) estimates the amount of fluid required in the first few hours of care following a burn:

4cc x kg of weight x % burn = initial fluid requirement in the first 24 hours, with half given in the first 8 hours.

As the percentage of burn surface area increases, the risk of death increases as well. Patients with burns involving less than 20% of their body should do well, but those with burns involving greater than 50% have a significant mortality risk, depending upon a variety of factors, including underlying medical conditions and age.

Location of a Burn: Burn location is an important consideration. If the burn involves the face, nose, mouth or neck, there is a risk that there will be enough inflammation and swelling to obstruct the airway and cause breathing problems.

If there are circumferential burns to the chest, as the burn progresses, the tissue involved may not allow enough motion of the chest wall to allow adequate breathing to occur. If circumferential burns occur to arms, legs, fingers, or toes, the same constriction may not allow blood flow and put the survival of the extremity at risk. Burns to areas of the body with flexion creases, like the palm of the hand, the back of the knee, the face, and the groin may need specialized care. As the burn matures, the skin may scar and shorten, preventing full range of motion of the body area. Electrical Burns Electrical burns may cause serious injury that is not readily apparent. Often the entry and exit points for the electrical shock may not be easily found. Electricity flows more easily through tissues in the body that are designed to deal with electricity. Nerves and muscles are "wired" for this task and often are damaged. If significant muscle damage occurs, muscle fibers and chemicals can be released into the bloodstream causing electrolyte disturbances and kidney failure. Chemical Burns Burns can also occur when chemicals are spilled onto the body and generate a reaction that creates heat. Chemical burns may be classified by their pH or acidity.

Acids are those with pH less than 7 and include common household compounds like acetic acid, hydrochloric acid, or sulfuric acid.

Bases or alkali compounds have a pH greater than 7. Ammonia is a common alkali found in the home.

First aid for burns For major burns (second and third degree burns) 1. Remove the victim from the burning area, remembering not to put the rescuer in danger. 2. Remove any burning material from the patient. 3. Activate the emergency response system in your area if needed. 4. Once the victim is in a safe place, keep them warm and still. Try to wrap the injured areas in a clean sheet if available. DO NOT use cold water on the victim; this may drop the body temperature and cause hypothermia.

Burns of the face, hands, and feet should always be considered a significant injury (although this may exclude sunburn. For minor burns (first degree burns or second degree burns involving a small area of the body)

Gently clean the wound with lukewarm water. Though butter has been used as a home remedy, it should NOT be used on any burn.

Rings, bracelets, and other potentially constricting articles should be removed (edema, or swelling from inflammation may occur and the item may cut into the skin).

The burn may be dressed with a topical antibiotic ointment like Bacitracin or Neosporin.

If there is concern that the burn is deeper and may be second or third degree in nature, medical care should be accessed.

Tetanus immunization should be updated if needed.

For electrical burns Victims of electrical burns should always seek medical care. For chemical burns 1. Identify the chemical that was involved. 2. Many chemical burns may be treated with local wound care. Some chemicals can cause life- and limb-threatening injuries and need emergent intervention. 3. Victims with chemical burns to their eyes should always seek emergency care.