IN THE NAME OF GOD

Looks and tastes great, right? You should see what a hot liquid will do to a child’s skin when the two come into contact.

Be sure to keep hot liquids out of reach of small children.

The skin, the largest organ of the body, consists of two layers-the epidermis and dermis. The depth or degree of burn depends on which layers of skin are damaged or destroyed. The epidermis is the outer layer that forms the protective covering. The thicker or inner layer of the dermis contains blood vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the dermis is destroyed, so are the nerve endings that allow a person to feel pain, temperature, and tactile sensation.

The burn/wound center includes an expanded reception area for children receiving outpatient care.

BSA estimation: “Rule of 9s”

Mechanism/Type: Chemical Burn

Mechanism/Type:Electrical Burn

• - direct contact with electrical current

                  entry & exit wounds

Superficial BurnSuperficial Burn

Deep Burn

Burn Assessment Lund & Browder Chart

Burns

Welcome to the burns module!

Burns constitute a major global problem and are a leading cause of trauma deaths in children. Minor burns, if poorly treated, cause devastating complications with lifelong morbidity.

Understanding how burns cause tissue damage and how the skin heals is vitally important in ensuring that the right diagnosis is made and the right treatment given.

Typical burns from hot water in a child

Anatomy of skin (1)

Epidermis

Dermis

The skin is made up of two layers, the outer layer (epidermis) and inner layer (dermis). Between the epidermis and dermis is the basement membrane which is semi permeable and acellular. It provides support, flexibility and regulates the transfer of substances across the dermal-epidermal junction.

Under the skin is the subcutaneous layer which allows the skin to be loosely attached to the underlying fascia. It increases mobility and is especially important over joints.

basement membrane

Subcutaneous layer

Anatomy of skin – Epidermis (1)A protective barrier of stratified squamous epithelium consisting of 5 layers1. Stratum corneum: 20-30 rows

of dead cells continually shed2. Stratum lucidum: 3-4 layers

clear flat dead cells3. Stratum granulosum: Cells

degenerating with production of keratin

4. Stratum spinosum: 8-10 rows of cells that produce protein but can not duplicate

5. Stratum basale: Columnar cells continually dividing, gradually migrating to surface

EPIDERMIS

There are three other cell types within the epidermis: melanocyte, Langerhan and Merkel cells

Anatomy of skin – Dermis (1)The dermis consists of 2 layers:• Papiliary dermis: The upper layer of

dermis. It has extensions protruding into the epidermis called Rete pegs which also contain small capillary loops

• Reticular dermis: The lower layer of dermis. It is made up of collagen, elastin and ground substance as well as hair follicles, sweat and sebaceous glands

Fibroblasts are the predominant cell type in the dermis and produce collagen and elastin which provide strength and flexibility to the skin.

In addition, there are blood vessels, sebaceous glands, sweat glands, hair follicles, sensory receptors and fat cells.

Functions of the skin

Physical barrier

Temperature control

Immunity

Sensation

Vitamin D production

Identity

Local effects of burn injury (1)Summary of local effects:

– Cell death/disturbed function– Release of inflammatory mediators– Increased capillary permeability– Microvascular thrombosis

1. Cell death/disturbed function

Cellular function is disturbed when the temperature rises above 43oC. The higher

the temperature and more prolonged the contact, the more cells die. An

instantaneous full thickness burn occurs at a temperature of 700C or greater.

Due to differences in skin thickness with age, at 55C, severe damage occurs after 10 seconds in a child and 30 seconds in an adult. Skin thickness is also reduced in older people and in certain conditions (e.g. steroid therapy).

Local effects of burn injury (3)3. Increased capillary permeability

When capillaries are damaged, they leak protein-rich fluid which results in oedema.

Normal skin; normal capillary permeability

Burn wound oedema with increased capillary permeability

and protein leakage

Local effects of burn injury (4)4. Microvascular Thrombosis

Release of thrombogenic factors such as thromboxane, together with a hypovolaemic state cause sludging in the smallest blood vessels. This in turn leads to further tissue ischaemia, increased cell death and can cause extension of the depth and surface area of the burn.

Area of burn increases due to sludging in blood

vessels and ischaemia

Systemic effects of burn injury (2)

Click each box

Respiratory system

Cardiovascular system

Renal system

Haematological system

Immune system

Psychological system

Gastrointestinal system

Assessing TBSA - Rule of Nines

This method divides the body into areas each of which

equates to 9% of the total body surface area:

• the whole of one arm (anterior and posterior surfaces

including the hand) is 9%, therefore 2 arms = 18%

• the entire head including face, scalp and neck is 9%

• anterior trunk is 18%

• posterior trunk including buttocks is 18%

• the whole lower limb (anterior and posterior surfaces,

including the thigh, leg and foot) is 18%; therefore both lower

limbs = 36%.

This totals 99% with the perineum making the final 1%.

Beware: this method is unreliable in young children.

Assessing TBSA in children

Why might the “rule of 9’s” be unreliable in children?

Body proportions change with age. In a child, the head represents a much greater proportion

of the total body surface area.Click to Reveal AnswersClick to Reveal Answers

Assessing TBSA - Lund and Browder charts

These take account of the

patient’s age and provide a

more detailed mapping system

for the burnt area

AREA AGE 0 1 5 10 15 ADULT

A = ½ OF HEAD 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ 3 ½

B = ½ OF ONE THIGH 2 ¾ 3 ¼ 4 4 ½ 4 ½ 4 ¾

C = ½ OF ONE LEG 2 ½ 2 ½ 2 ¾ 3 3 ¼ 3 ½

Assessing TBSA - Palm size

Another useful way, especially for small burns is to use the palm of the patient’s hand (with fingers extended). This equates to approximately 1% of the body surface area.

Assessing TBSA - Unburnt area

In very large burns, it is often easier to measure the area of skin that is unburnt and then subtract this from 100%.

Circumferential burns of the limbs can cause distal ischaemia; of the chest, can compromise breathing

Area of the body involvedNot only is the surface area or size of burn important, but also the specific part of the body affected

Face: Facial oedema can lead to airway obstruction. Scarring can cause significant psychosocial problems

Perineum: problems with urogenital function and psychosexual

Hands: Problems with feeding and hygiene

Feet: Mobility problems

Eyes: Burns to the eyes (especially chemical) can cause blindness.

Depth of burn - Superficial (erythema)

Involves epidermis only:

• Painful

• Red

• No blistering

• Heals rapidly (reversible injury)

• No permanent scars

Note that erythema is NOT included when assessing TBSA

Depth of Burn – superficial partial thickness

Patches of skin that would come off on cleaning

Glistening moist red/pink

appearance typical of superficial injury

Typical hot water scald

Involves epidermis and upper dermis:

• Red

• Blistering, moist

• Painful

• Heals by epithelialization

• Healing complete within 14 days

• Minimal or no permanent scars

but can leave discolouration

Depth of Burn - superficial partial thickness

Blister

Pin-point bleeding

Pink surface; blanches on

pressure

Depth of Burn – deep partial thickness

Involves epidermis, upper dermis and varying degrees of lower dermis:

• Pale, mottled appearance

• Fixed staining (no blanching)

• May be painful or insensate (depending on depth)

• Heals by combination of epithilialization and wound contracture

• May take weeks to heal

• Can leave significant scars and contractures over joints depending on time taken to heal

Deep dermal area, reddish with fixed staining

Depth of Burn – full thickness

• Involves all of epidermis and all of dermis

• Dry, leathery (white, dark brown or charred)

• Insensate

• Heals by contraction

• Delayed healing

• Hypertrophic or keloid scars

• Leads to contractures Dry, leathery, charred appearance of a full

thickness burn

Circumferential full thickness burn

Typical position of hand in full thickness

burns with metacarpophalangeal joints extended and

interphalangeal joints flexed

Black, charred skin

Depth of Burn – mixed thickness

Assess the depth of the

burn in areas A, B and C

( C )(B)

(A)

Depth of Burn – Mixed thickness

Deep dermal with pale pink and white patches, non blanching

Superficial partial thickness showing pink blanching

Full thickness, dry white leathery appearance

Zones of Burn Injury

• Zone of Coagulation – Inner Zone – Area of cellular death (necrosis)

• Zone of Stasis – Area surrounding zone of coagulation – Cellular injury: decreased blood flow & inflammation– Potentially salvable; susceptible to additional injury

• Zone of Hyperemia– Peripheral area of burn– Area of least cellular injury & increased blood flow– Complete recovery of this tissue likely.

Superficial-Thickness Burns

• Involves the epidermis– Wound Appearance:

• Red to pink • Mild edema • Dry and no blistering• Pain / hypersensitivity to touch

– i.e. Classic sunburn

• Desquamation (peeling of dead skin) occurs 2-3 days post-burn

– Wound Healing:• In 3 to 5 days (spontaneous)• No scarring / other complications

Superficial, Partial-Thickness Burns

• Involves upper 1/3 of dermis– Wound Appearance:

• Red to pink

• Wet and weeping wounds

• Thin-walled, fluid-filled blisters

• Mild to moderate edema

• Extremely painful

– Wound Healing:

• In 2 weeks (spontaneous)

• Minimal scarring; minor pigment discoloration may occur

Full-Thickness Burns

• Involves the entire epidermis and dermis – Wound Appearance:

• Dry, leathery and rigid• + Eschar (hard and in-elastic)• Red, white, yellow, brown or black• Severe edema • Painless & insensitive to palpation

– Wound Healing:• No spontaneous healing;

weeks to months with graft– Wound Management:

• Surgical excision & skin grafting

The Rule of Nines

Lund-Browder Method

A Child Suffering From Marasmus.

Kwashiorkor Produces Characteristic Oedematous

Protruding Abdomen In Children.

A Badly Infected Deep Burn Wound (Streptococcus faecalis & Pseudomonas

aeruginosa) In An Elderley Patient.

Necrotic Tissue May Have To Be Removed/Excised To Treat The Infection.

Burn Wound Infected With Pseudomonas spp. After Application

Of A Graft.

Burn Wound Infected With Staphylococcus spp.

A Chronic Non-Healing Burn Wound Due To A Protein Dietary Deficiency.

Pale Granulating Areas Are Becoming Larger. Surrounding Epithelium Is Becoming White (*), Macerated & Non-Adherent.

Inadequate Nutrition In A Patient With Extensive Burns.

One Year After The Injury.

Inadequate Nutrition In A Patient With Extensive Burns.One Year After The Injury.

Wounds Have Become Over-Granulated And Epithelialisation Is Not Seen At The Wound Margins.

Appearance After Three Months Of Nasogastrc Feeding

Wounds Have Healed Without The Need For Grafts – Though There Has Not Been Any Significant Increase In Body Mass.

Appearance Of The Patient One Month Later.

Adequate Nutrition & Healing Allow The Person To Support Their Own Weight Though Joint Deformity Remains.