Degree of Burns

Definition Burns can be caused by flame, UV radiation, hot liquids, electricity, lightning and certain chemicals. Major burns are a medical emergency and require urgent medical attention. In some cases, skin graft surgery is needed (Atkinson A. , 1998) . Different types of burns There are four types of burns: * Thermal burns caused by fire, hot objects, hot liquids, and gases; or by nuclear blast or fireball Thermal burn treatment . enlarge | info | Fig. 1 Thermal burn – full thickness scald burn of feet secondary to immersion in bath tub * Electrical burns caused by electrical wires, current, or lightning .

enlarge | info | Fig. 2 Full thickness high voltage wiring injury with fasciotomy * Chemical burns caused by contact with wet or dry chemicals or white phosphorus (WP)—from marking rounds and grenades Chemical burns . * Radiation (UV, radiotherapy, laser burns) (eye [ocular] injury) Ocular burns (Dowsett C, 2002) . Degrees of burns Burns that meet the criteria for outpatient management may be treated initially in the emergency department, after which arrangements should be made for close follow-up on an outpatient basis.

A. First-degree burns Minor burns Thermal burn treatment enlarge | info | Fig. 3 Thermal burn – I-II degree burns from exploded alcohol B. Partial thickness or second degree burns There are five categories of second-degree burn typically used to characterize the depth of injury. Each corresponds with healing time, treatment modalities and outcome. 1. Superficial Second Degree Minor burns 2. Mid Second Degree (Mid Dermal) enlarge | info | enlarge | info | enlarge | info | Fig. 4 Burns – II degree Minor burns 1.

Indeterminate (Mid Second Degree versus Deep Second Degree) Minor burns 2. Deep Second Degree (Deep Dermal) Minor burns 3. Indeterminate (Deep Second Degree Versus Third Degree) Minor burns 4. Full Thickness (Third Degree Burn) enlarge | info | 5. enlarge | info | 6. Fig. 5 Burns – III degree 7. Both layers of skin are completely destroyed leaving no cells to heal except fibroblasts for scar formation. Wounds can partially heal by contraction from the edges (2-3 cm) but any significant burn will require excision and grafting. Table 2: Burn depth and outcome.

Second degree | Cause< | Appearance | Pain | Healing | Scar| Superficial| Hot liquid, short exposure| Wet, pink, blisters| severe| 10-14 days| minimal| Mid-dermal| Hot liquid, longer exposure, flash flame| Less wet, red blisters| moderate| 2-4 weeks| moderate| Indeterminate (mid or deep) | As above| Red with patchy, white arms| moderate| 2-6 weeks| moderate or severe| Deep-dermal| Chemicals, direct contact flames| Dry, white| minimal| 3-8 weeks| severe (needs graft)| Indeterminate (2nd or 3rd)| Chemicals, flames| Dry, white| none| -| -| Third degree.

(full thickness)| Chemicals, flames, explosion, with very high temperature| Dry, white, or char| none| need graft| mild to severe, depending on timing and type of graft| Details Superficial second degree or partial thickness burn Definition: Second-degree burns are defined as those burns in which the entire epidermis and variable portions of the dermis layer are heat destroyed. A superficial second-degree (partial thickness) burn is characterized by heat injury to the upper third of the dermis leaving a good blood supply. Most Common Cause: Hot water.

Appearance: The micro vessels perfusing this area are injured resulting in the leakage of large amounts of plasma, which in turn lifts off the heat-destroyed epidermis, causing blister formation. The blisters will continue to increase in size in the post-burn period as cell and protein breakdown occurs. A light pink, wet-appearing, very painful wound is seen as blisters are disrupted. Frequently, the epidermis does not lift off the dermis for 12 to 24 hours and what appears initially to be a first degree is actually a second-degree burn. Minor burns Hot Water Superficial to Mid Second Degree.

Definition: A mid second degree extends to the mid portion of the dermis. Longer exposure to hot liquids (5-10 seconds) or flash flames (not direct contact of flames with skin) are the most common causes. Cause:Brief exposure to flames or flash explosion: hot water in infant or elderly.

Appearence:The burn surface may have blisters but is more red, less wet and only moderately painful. Minor burns Deep Dermal Burn Deep Partial Thickness (Deep Second Degree) Burn Definition: A deep partial thickness or deep second-degree burn extends well into the dermal layer and fewer viable epidermal cells remain.

Therefore re epithelialization is extremely slow, sometimes requiring months. Grafting is often the preferred treatment for long-term function. Appearance: In these patients, blister formation does not characteristically occur because the dead tissue layer is sufficiently thick and adherent to underlying viable dermis that it does not readily lift off the surface. The wound surface may be red and dry in appearance with white areas in deeper parts (dry since fewer blood vessels are patent).

There is a marked decrease in blood flow making the wound very prone to conversion to a deeper injury and to infection. It is often not possible to distinguish a deep partial from a full thickness burn by initial appearance. Frequently the wound is a mixed second and third degree. Direct contact with flames is a common cause. Most chemical burns are also deep.

The appearance of the deep dermal burn changes dramatically over the next several days as the area of dermal necrosis along with surface coagulated protein turns the wound a white/yellow colour. Minor burns Indeterminate (Deep Full Thickness)

Definition:A deep burn, which cannot be clinically distinguished as deep dermal or full thickness. Often there are components of both, as is evidenced during tangential excision and grafting. Appearance: Dry, white but no charring. There may be some sensation. Minor burns Mixed Deep Dermal (Second) and Full Thickness Looks superficial with blisters but mechanism suggests deep burn. C.

Third degree (full thickness burn) Definition: A full thickness or third degree burn occurs with destruction of the entire epidermis and dermis, leaving no residual epidermal cells to repopulate.

This wound will therefore not re epithelialize and whatever area of the wound is not closed by wound contraction will require skin grafting. Appearance: A characteristic initial appearance of the avascular burn tissue is a waxy white colour. If the burn produces char or extends into the fat as with prolonged contact with a flame source, a leathery brown or black appearance can be seen along with surface coagulation veins. Direct exposure to a flame is the usual cause of a third degree burn.

However, contact with hot liquids such as hot grease, tar or caustic chemicals will also produce a full thickness burn. The burn wound is also painless and has a coarse non pliable texture to touch. A major difficulty is distinguishing a deep dermal from a full thickness (third degree) burn that extends just through the dermis.

This burn is termed an indeterminate burn. (Phipps A, 1998) (Kao CC, Garner WL, 2000) (Rose JK, Herndon DN, 1997) . Minor burns Burn Classification Note: The list below shows 4 burn degrees. While most of the public does not recognize the 4th degree, it is the correct term.

The table below, with 3 degrees, is also correct. Both are acceptable. Determining burn depth is important. Things to consider are temperature, mechanism, duration of contact, blood flow to skin, and anatomic location. Epidermal depth varies with body surface, which can offer varying degrees of thermal protection. Older adults and young children also have thinner skin First degree: * Includes only the outer layer of skin, the epidermis * Skin is usually red and very painful * Equivalent to superficial sunburn without blisters * Dry in appearance.

* Healing occurs in 3-5 days, injured epithelium peels away from the healthy skin * Hospitalization is for pain control and maybe fluid imbalance Second degree: Can be classified as partial or full thickness. * Partial thickness * Blisters can be present * Involve the entire epidermis and upper layers of the dermis * Wound will be pink, red in color, painful and wet appearing * Wound will blanch when pressure is applied * Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal * Full thickness * Can be red or white in appearance, but will appear dry.

* Involves the destruction of the entire epidermis and most of the dermis * Sensation can be present, but diminished * Blanching is sluggish or absent * Full thickness will most likely need excision & skin grafting to heal Third degree: * All layers of the skin is destroyed * Extend into the subcutaneous tissues * Areas can appear, black or white and will be dry * Can appear leathery in texture * Will not blanch when pressure is applied * No pain Fouth degree: Full thickness that extends into muscle and bone. | First| Second (Superficial or Deep)| Third (Full Thickness)|.

Depth (how deep the burn is) | Epithelium| Epithelium and top aspects of the dermis| Epithelium and dermis| How the wound looks | No blisters; dry pink| Moist, oozing blisters; Moist, white, pink, to red| Leathery, dry, no elasticity; charred appearance| Causes | Sunburn, scald, flash flame| Scalds, flash burns, chemicals| Contact with flame, hot surface, hot liquids, chemical, electric| Level of Pain (sensation) | Painful, tender, and sore| Very painful| Very little pain, or no pain| Healing Time | Two to five days; peeling| Superficial: five to 21 days.

Deep: 21-35 days| Small areas may take months to heal; large areas need grafting. | Scarring | No scarring; may have discoloration| Minimal to no scarring; may have discoloration| Scarring present| Burn injury is the destruction of the layers of the skin and associated structures. | | | | 1st Degree Burn| 2nd Degree Burn| 3rd Degree Burn| | | | Rule of Nines | Emergencies – Burns | The rule of nines is a standardized method used to quickly assess how much body surface area (BSA) has been burned on a patient.

This rule is only applied to partial thickness (2nd degree) and full thickness (3rd degree) burns. The diagram below depicts BSA percentages for adults and infants of one year or less. For children over the age of one year, please see the formula below. For children over the age of one year, for each year above one, add 0. 5% to each leg and subtract 1% for the head. This formula should be used until the adult rule of nines values are reached. For example, a 5-year old child would be +2% for each leg and -4% for the head.

An alternative method to calculating the BSA is to compare it to the size of the patient’s palm, which equates to approximately 1% BSA. For example, if a burn area is the size of (5) palm surfaces, the burn would be roughly 5% BSA. This method can be used to estimate the BSA for both adults and pediatrics. In most cases, you may find it more useful to use the rule of nines when evaluating larger burn areas and the “palm” method for smaller burn injuries. |

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