in the name of god. looks and tastes great, right? you should see what a hot liquid will do to a...
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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.