Introduction to burns

The skin has an important role to play in the fluid and temperature regulation of the body. If enough skin area is injured, the ability to maintain that control can be lost.The skin also acts as a protective barrier against the bacteriaandvirusesthat inhabit the world outside the body.Theanatomyof the skin is complex, and there are many structures within the layers of the skin. There are three layers:1.Epidermis, the outer layer of the skin2.Dermis, made up of collagenand elastic fibers and where nerves, blood vessels, sweat glands, and hair follicles reside.3.Hypodermis or subcutaneous tissue,where larger blood vessels and nerves are located. This is the layer of tissue that is most important in temperatureregulation.The amount of damage that a burn can cause depends upon its location, its depth, andhow much body surface areathat it involves.

How are burns classified?

Burns are classified based upon their depth.A

first degree burn

is superficialand causes local inflammation of the skin. Sunburns often are categorized as first degree burns. The inflammation ischaracterized by pain, redness, and a mild amount of swelling. The skin may be verytender to touch.

Second degree burns

are deeper and in addition to the pain, redness andinflammation, there is also blistering of the skin.

Third degree burns

are deeper still, involving all layers of the skin, in effect killingthat area of skin. Because the nerves and blood vessels are damaged, third degree burns appear white and leathery and tend to be relatively painless.Burns are not static and may mature. Over a few hours a first degree burn mayinvolve deeper structures and become second degree. Think of asunburnthat blistersthe next day. Similarly, second degree burns may evolve into third degree burns.Regardless of the type of burn, inflammation and fluid accumulation in and aroundthe wound occur. Moreover, it should be noted that the skin is the body's first defenseagainst infection by microorganisms. A burn is also a break in the skin, and the risk of infection exists both at the site of the injury and potentially throughout the body.Only the epidermis has the ability to regenerateitself. Burns that extend deeper may cause permanent injury andscarringand not allow the skin in that area to return tonormal function.

What is the significance of the amount of body area burned?

In addition to the depth of the burn, the total area of the burn is significant. Burns aremeasured as a percentage of total body area affected. The

"rule of nines"

is oftenused, though this measurement is adjusted for infants and children. This calculation is based upon the fact that the surface area of the following parts of an adult body eachcorrespond to approximately 9% of total (and the total body area of 100% isachieved):

•

Head = 9%

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Chest (front) = 9%

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Abdomen (front) = 9%

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Upper/mid/low back and buttocks = 18%

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Each arm = 9%

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Each palm = 1%

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Groin = 1%

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Each leg = 18% total (front = 9%, back = 9%)As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest andabdomen were burned, this would involve 55% of the body.

Only second andthird degree burn areas are added together to measure total body burn area. While first degree burns are painful, the skin integrity is intact and it is ableto do its job with fluid and temperature maintenance.If more than15%-20% of the body is involved in a burn, significant fluid may be lost.Shock may occur if inadequate fluid is not provided intravenously. The Parklandformula (named for thetraumahospital in Dallas) estimates the amount of fluidrequired in the first few hours of care following a burn:

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4cc/ kg of weight/% burn = initial fluid requirement in the first 24 hours, withhalf given in the first 8 hours.

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As an example: A 175lb (or 80kg) patient with 25% burn will need 4cc x 80kgx 25%, or 8000cc of fluid in the first 24 hours, or more than 7 pounds of fluid.As the percentage of burn surface area increases, the risk of death increases as well.Patients with burns involving less than 20% of their body should do well, but thosewith burns involving greater than 50% have a significant mortalityrisk, depending upon a variety of factors, including underlying medical conditions and age.

How important is the location of a burn?