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Innovation and clinical specialities: burns
Partial-thickness (2nd
degree) burns involve
the dermis and
the epidermis. Partialthickness
injuries
classified into two types:
superficial and deep. All
second-degree injuries
involve some amount of
dermal damage, and
the division is based on
the depth of injury into
this structure.
Superficial dermal
burns are erythematous,
painful, may blanch to
touch, and often blister.
Examples include
Figure 1: Burn Depth Burns are usually
classified into superficial, superficial
partial thickness, deep partial thickness
Figure 3: Lund and Browder chart 11
and full thickness. Here we have given
then letters A, B, C, D and E 1
Figure 2: Adult compared to
child burn surface areas
scald injuries from overheated
bathtub water and flash flame
burns from open carburetors.
These wounds will spontaneously
re-epithelialize from retained
epidermal structures in the rete
ridges, hair follicles, and sweat
glands in 7–14 days. The injury
will cause some slight skin
discoloration.
Deep dermal burns into the
reticular dermis will appear more
pale and mottled, will not blanch to touch, but will remain painful to
pinprick. These burns will usually heal in 14–28 days by reepithelialization
from hair follicles and sweat gland keratinocytes,
often with severe scarring. Some of these will require surgical
treatment 20 .
A full-thickness (3rd degree) burn generally is identified by a dry
and leathery appearance, although a plastic-like texture and a
hemorrhagic or purpuric pattern may also be seen. Classically, fullthickness
burn wounds have been described as insensate,
although there is often mixed distribution patterns which make
sensation determination less reliable as a defining characteristic. 19
Deep dermal and full-thickness burns require excision and
grafting with autograft skin to heal the wounds in a timely fashion 19 ,
thus minimizing morbidity from protein loss, sepsis, and
contracture. Since all the elements of the epidermis have been
obliterated in full-thickness wounds, healing can occur only
through wound contraction and/or spreading epithelialization from
the wound edges. In a sizable wound, this process will take weeks
to months to years to complete. 21
Fourth-degree burns involve other organs beneath the skin,
such as fat, muscle, bone, and the brain.
In adults, the rule of nines can be used to quickly estimate the
size of a burn. The anterior and posterior trunk is each l8%, each
of the lower extremities is 18%, each upper extremity is 9%, and
the head is 9%. This is depicted clearly in Figure 2. Unfortunately,
the rule of nines is somewhat inaccurate in children and may
overestimate burn size because the head accounts for a greater
portion of the body surface area (BSA). In a 2-year-old child, this is
19% of the TBSA Diagrams such as the Lund and Browder charts
(Figure 3) are more accurate and should be used for calculating the
burn size in children. 18 In small burns, the surface of the patient’s
hand can be used to estimate the extent of the burn; it represents
approximately 1% of the TBSA (from fingertips to wrist).
Patient selection
Patient selection is the key to improving the outcomes of burn
injury within the resource constraints of a given environment. The
mortality of a given size of burn injury increases in infants and the
elderly. It is difficult to cite what size of burn constitutes a lethal
injury as mortality varies so much around the world, but local
experience will suggest what magnitude of injury is likely to be
survivable given the treatments available. For patients with clearly
lethal burn/inhalation injury it is humane to withhold fluid
resuscitation and airway intervention and provide palliation with
dressings and generous amounts of intravenous morphine.
Depending on circumstances it may be prudent to ask a
colleague to examine the patient and note their concurrence with
the lethality of the prognosis. Patients with severe, but not clearly
lethal burn injuries pose a difficult problem: they can consume an
inordinate amount of scarce hospital resources (ICU days, total
length of stay, dressing supplies, nursing and operating room
time), and still die or have dreadful outcomes. Consultation and
possible referral to a burn centre is helpful. Treatment with pain
control, dressings, prevention of infection, nutritional support,
good splinting and early mobilization of affected joints, and careful
selection of patients for surgical intervention is a sound
policy. Small but potentially disabling burns, especially in children,
should be the main focus of surgical attention. It is in this group
of patients that early surgery, meticulous graft care, splinting,
pressure garments and aggressive physiotherapy will produce the
most gratifying (and cost effective) outcomes.
Fluid resuscitation
The most commonly used formula for adults, for fluid resuscitation
after a burn, is the Parkland formula. To calculate daily fluid
requirements, a crystalloid solution at the rate of 4 mL/kg/%TBSA
burn is given intravenously. The first half of the calculated amount
of fluid is administered within the first 8 hours after the burn, and
the remaining is given over the next 16 hours. In the first 24 hours
post-burn, the initial resuscitation fluid is Lactated Ringers, which
is isotonic to plasma.
56 Hospital and Healthcare Innovation Book 2009/2010