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Another classification describes burns as partial-thickness wounds in which the epithelializing elements remain intact, and full-thickness wounds in which all of the epithelializing elements and those lining the sweat glands, hair follicles, and sebaceous glands are destroyed. A deep thermal burn is a deep partial-thickness wound that may have the white, waxy appearance of a full-thickness burn.
It is difficult to determine the depth of a wound at first glance, but any burn involving more than 15 per cent of the body surface is considered serious. Because surface area as well as depth is important in evaluating a burned patient's status, a method called the rule of nines has been developed to determine surface area involvement. The head and each arm are figured at 9 per cent. The anterior and posterior trunk and the two legs comprise 18 or (2×9) per cent each, and the perineum is figured as 1 per cent. An improvement on the rule of nines, the berkow formula, takes into account the age of the burn victim.
In a burn the crust is the dry, scablike covering that forms over a superficial burn. eschar is a hard layer of tissue that results from full-thickness injury. It is considered to be a protective covering over the wound, serving as a barrier to bacterial invasion. Research indicates that eschar may be viable tissue that can contribute to healing and the prevention of scarring.
The victim should be wrapped in a clean, preferably sterile, sheet. A blanket is used to cover the unaffected areas and to maintain normal body temperature if possible. If available, an intravenous infusion of Ringer's lactate solution is begun. If intravenous therapy is not available and the victim is conscious and able to swallow, fluids can be given by mouth. Nausea, vomiting, and ileus contraindicate the administration of any food or liquids.
Clothing is removed from the burned area only if this does not further traumatize the skin. Burned clothing should be sent to the burn center, as it may help determine the chemicals and other substances that either caused or entered the wound. Absorbent cotton, oily salves, ointments, and creams should not be applied to moderate and severe burns. Blisters are not opened or disturbed in any way.
If the area affected is the eye, it is held open and flushed gently but thoroughly with water. Then it is covered with a sterile dressing and medical aid is sought immediately.
In electrical burns, shock is the main danger. It may be necessary to use artificial respiration. This should be begun as soon as contact with the current has been broken. A person stricken by lightning also requires artificial respiration if the shock has been severe enough to interfere with normal breathing.
In the United States, most severely burned patients are given emergency care in a local hospital and then transferred to a large burn center for intensive long-term care. Patients who show signs of trauma to the respiratory tract must be watched closely for signs of developing laryngeal edema and obstruction of the air passages. This condition can develop any time from 4 to 48 hours after the accident. When wheezing on inhalation or other signs of respiratory distress occur, intubation, frequent suctioning, and ventilator assistance may be needed.
Fluid loss by the evaporation of free water through the burned area causes disturbances in the extracellular and intracellular fluids. This can lead to burn shock, renal damage, and other life-threatening conditions. In addition to a loss of body water and changes in fluid composition, there are alterations in the composition of blood and the development of metabolic acidosis. If untreated, the changes in volume, concentration, and composition of extracellular fluid can be fatal. Information about the specific kinds of intravenous fluids that should be administered should be obtained from the burn center to which the patient will be transferred so that there is no break in the continuity of patient care.
In order to avoid nausea, vomiting, and the gastric and intestinal distention resulting from decreased peristaltic activity, a nasogastric tube is inserted and gentle suction applied. A retention catheter is inserted into the urinary bladder to obtain accurate measurement of output and periodic urine specimens for the determination of specific gravity and the presence of protein and blood.
In the emergency department, the burn wounds are cleansed according to established protocol, using clean technique and avoiding excessive loss of body heat. The cleansed wounds are then usually covered with dry sterile dressings, or with saline-soaked dressings that are covered with dry bandages before the patient is transferred. Exposed bone and tendon must be kept moist at all times with sterile saline-soaked dressings.
The major cause of death in burn victims is infection. Immunization against tetanus by administration of tetanus toxoid is recommended. If the patient has not received basic immunization prior to injury, he is also given tetanus immune globulin (Hyper-Tet).
The kind of environment provided in special burn units in large medical centers varies, but all have the objectives of avoiding contamination of the wound. Some special units use complete reverse isolation precautions and elaborate laminar air flow systems to maintain an environment that is as free of microorganisms as possible.
When the patient is cared for in a general hospital, it is recommended that some form of reverse isolation be used. Every effort should be made to protect the patient from autocontamination as well as from contamination from others and from the environment. It has been estimated that more than half of all burn wound infections can be traced to contamination by microorganisms such as Staphylococcus that originate in the patient. Physically isolating the patient from others should not be allowed to foster neglect and failure to attend to basic principles of cleanliness and good personal hygiene in day-to-day care.
Burn wounds can be treated in either of two ways: open or closed methods of therapy. In the open, exposed method of treatment no dressings are applied. Every effort is made to avoid disturbance of the eschar and the introduction of pathogenic microorganisms into the wound. If, however, the eschar causes a circumferential constriction of the trunk or an extremity, an escharotomy is indicated to prevent ischemic necrosis. antimicrobial agents are given systemically and, if the open method is used, they are applied topically. Examples of these topical medications include silver nitrate, silver sulfadiazine cream, and mafenide acetate.
The closed method of treatment may involve the application of dry occlusive dressings or wet dressings soaked in saline or some other solution preferred by the physician. The wet dressings require frequent changes when there is much exudate from the wound.
Immersion in water is especially helpful in cleansing the wound, removing debris and caked creams, and therapeutic exercise is essential to avoid orthopedic deformities. See also hydrotherapy.
Skin grafting is done soon after the initial injury. The donor skin is best taken from the patient, but when this is not possible, the skin of a matched donor can be used. Prior to grafting, or in some cases as a substitute for it, the burn may be covered with either cadaver or porcine (pig) skin to keep it moist and free from exogenous bacterial infection.
The patient must be protected from extremes of heat and cold whether dry or wet dressings are used. Dry dressings, which do not allow for circulation of air, can cause a buildup of body heat, especially in a febrile patient. The patient receiving wet dressings must be protected from drafts and other conditions that could produce chilling.
Careful and accurate taking and recording of vital signs is done periodically and any significant change reported immediately. An accurate record of intake and output is of primary importance. Because large amounts of body fluids and many essential minerals and salts can escape through burn wounds, it is imperative that a record be kept of fluids excreted through the kidneys or intestinal tract or by emesis. Observations should include not only the amount but also the color, concentration, unusual odor, or any other characteristic of the urine, emesis, or liquid stool.
A high-protein diet with supplemental vitamins and minerals is prescribed to aid in the repair of damaged tissue. Ingenuity and imagination may be needed to encourage the patient to eat meals as well as the between-meal feedings prescribed.
The patient who has suffered disfigurement from burns will have additional emotional problems in adjusting to a new body image. Burn therapy can be long and tedious for the patient and family. They will need emotional and psychological support as well as attention to their spiritual needs as they work their way through the many problems created by the physical and emotional trauma of a major burn.
burnverb A popular term for infecting someone with a sexually transmitted infection.
See also: rule of nines
First degree: a superficial burn in which damage is limited to the outer layer of the epidermis and is marked by redness, tenderness, and mild pain. Blisters do not form, and the burn heals without scar formation. A common example is sunburn.
Second degree: a burn that damages partial thickness of the epidermal and some dermal tissues but does not damage the lower-lying hair follicles, sweat, or sebaceous glands. The burn is painful and red; blisters form, and wounds may heal with a scar. See: illustration
Third degree: a burn that extends through the full thickness of the skin and subcutaneous tissues beneath the dermis. The burn leaves skin with a pale, brown, gray, or blackened appearance. The burn is painless because it destroys nerves in the skin. Scar formation and contractures are likely complications.
Fourth degree: a burn that extends through the full thickness of the skin and into underlying bone, fat, muscles, and tendons. Third- and fourth-degree burns are best managed at specialized burn centers. See: illustration
Sloughing of skin, gangrene, scarring, erysipelas, nephritis, pneumonia, immune system impairment, or intestinal disturbances are possible complications. Shock and infection must always be anticipated with higher-degree or larger burns. The risk of complication is greatest when more than 25% of the body surface is burned.
Burns may result from ultraviolet radiation, bursts of steam, heated liquids and metals, chemical fires, electrocution, or direct contact with flame or flammable clothing.
A person in burning clothing should never be allowed to run. The individual should lie down and roll. A rug, blanket, or anything within reach can be used to smother the flames. Care must be taken so that the individual does not inhale the smoke. The clothing should be cut off carefully so that the skin is not pulled away. Synthetic fabrics that have melted into the burn wound are best removed later in the emergency department or burn center. Jewelry should be removed even if not near the burn wounds due to concerns for fluid shifts and swelling. Blisters should not be opened, as this increases the chance for infection. Patients with large burn areas or third- and fourth-degree burns must receive appropriate tetanus prophylaxis.
In severe, widespread burns, the patient must be transferred to a burn center as soon as is practical.
The first responsibility in the care of the burn patient is to assess the patency of the airway and to ensure that breathing is unimpaired. If smoke inhalation or airway injury is suspected, intubation should be performed before edema makes this impossible. Airway injury is most likely to occur after facial burns or smoke inhalation in closed spaces. A cough productive of soot or charred material increases the likelihood of inhalational injury.
The second task in burn care is to ensure cardiac output and tissue perfusion. Volume resuscitation with crystalloid is given per standard protocols; at the same time, urinary output, blood pressure and pulse, body weights, and renal function are closely monitored to ensure adequate hydration.
The immediate care of the burn itself involves the removal of any overlying clothing and jewelry and the irrigation of the affected tissues with cool water, taking care to avoid excessively cooling the body. To help prevent hypothermia and infection, cover the burn wounds with sterile dressings if available, or a clean sheet, separating burn wound surfaces. Gentle tissue débridement should be followed by application of nonadherent dressings, skin substitutes, topical antiseptics, or autografts, as dictated by circumstances. Tetanus prophylaxis is routinely given, usually with both tetanus toxoid and tetanus immune globulin.
In specific circumstances, additional interventions such as hyperbaric oxygen therapy for carbon monoxide intoxication, escharotomy for circumferential burns, antibiotic therapy for infections, pressor support for hypotension, or nutritional support may be needed.
Patients with large or complex burn injuries should be transferred to regional burn centers or to the care of surgeons with special interest in burn management.
During rehabilitation, individually fitted elastic garments are applied to prevent hypertrophic scar formation, and joints are exercised to promote a full range of motion. The patient is encouraged to increase activity tolerance, obtain adequate rest, strive for physical and emotional independence, and resume vocational and social functioning. Referrals for occupational therapy, psychological counseling, support groups, or social services are often necessary. Reconstructive and cosmetic surgery may be required. Support groups and services are available to assist the patient with life adjustments.
Patients' previous psychological states may predispose them to injury and may have an adverse effect on recovery. Patients with burn injuries demonstrate a wide range of emotional responses including anger, frustration, irritability, and psychological states (delirium, anxiety, depression, and grief). Posttraumatic stress disorder (PTSD) may occur after a burn injury. Often, the PTSD patient will need help from primary or specialized care providers to recover psychologically. Explain patient needs and care concerns to family to help alleviate their cares and concerns (and varied psychological responses). Involve them with you in patient care as permissible. Family members should be encouraged to sit with the patient, and to touch, speak to, read to, and otherwise communicate with the patient. Providing patients with a sense of purpose will help to alleviate feelings of helplessness and will provide both patient and family with more comfortable and comforting memories.
The provision of optimal nutrition to burn patients is an important component of recovery. Because of protein losses, the total protein consumed by a burn patient should be at least 2.5 g/kg of body weight daily. Total caloric needs may exceed 30 kcal/kd/daily. The risk of infections may be reduced by the provision of dietary supplements, esp. arginine and glutamine.
The burn area should be flushed with large volumes of water. For further details of definitive treatment, see under sulfuric acid poisoning.
burn of aerodigestive tract
The burn is irrigated with large volumes of water and dressed.
CAUTION!Be careful to brush dry powder off the skin before applying water, as some chemicals, such as lye, react with water.
Loose dirt is carefully brushed away and the area is cleansed with soap and water. An antiseptic solution or ointment is applied and covered with a dressing. Tetanus toxoid or antitoxin is given if required. A brush burn is also informally called a “road rash” as in the case of a motorcyclist who slid across the pavement.
Irrigate with large quantities of water.
burn of eye
The eye should be washed immediately with the nearest available supply of water, even if it is not sterile. Irrigation may need to be continued for hours if burn is due to lye. Care must be taken to prevent runoff from draining into the uninjured eye.
inhalation burnInhalation injury.
x-ray burnSee: radiation burn
Patient discussion about burn
Q. How do you define burns? I know there are first, second and third degree burns, but I'm not sure what that means. And how do you calculate the percentage of your body burned? ("he has 18% second degree burn")
Doctors determine the severity of the burn by estimating the percentage of the body surface that has been burned. Special charts are used to show what percentage of the body surface various body parts comprise. For example, in an adult, the arm constitutes about 9% of the body.
Q. How to treat minor burns? I got burned the other day while cooking. How do I treat minor burns in the best way?
Q. How to prevent burns from babies? I have a 4 month old baby and when I gave him a bath last night, he turned red because of the hot water. After the bath the color faded but now I am worried, can this burn him?