Skin - important role in the fluid and temperature regulation

- protective barrier

Skin Layers
1. Epidermis - outermost
- responsible for keeping water in the body, keep out pathogens & harmful chemicals out
2. Dermis - layer that lies underneath the epidermis, and it is composed entirely of living cells.
- It consists of bundles of tough fibers which give skin its elasticity, firmness and strength.
- contains hair follicles, nerves (contains the sense organs for touch, pressure, pain and
temperature), glands, lymphatic tissue & blood vessels which feed vital nutrients to these
areas
3. Subcutaneous layer/Hypodermis
- It is made up of loose connective tissue, including a tissue called the adipose. (50% body
fat), helps to insulate the body by monitoring heat gain and heat loss

BURN
- a type of injury to the skin caused by heat cold, electricity, chemical, light, radiation or friction
- most burns only affect the skin (epidermal tissue and dermis)
- rarely involve deeper tissues such as muscle, bone and blood vessels
- important because they are common, painful and can result to disfigurement, disability &
scarring
- can be complicated by shock, infection, multiple organ dysfunction syndrome, electrolyte
imbalance & respiratory distress

A. Classification according to degree (depth of skin involved)

1. First Degree Burn
- superficial and causes local inflammation of the skin (epidermis), skin is intact
- characterized by pain, redness (erythema) & mild amount of swelling
- skin may be very tender to touch (sunburn)
2. Second Degree Burn
- involves epidermis and dermis (papillary layer)
- in addition to pain, redness & inflammation, skin is moist and there is blistering
3. Third Degree Burn
- involves deeper dermis (reticular layer), subcutaneous layer with damaged underlying
nerves and blood vessels
- appear pearly white, tend to be relatively painless with decreased sensation
4. Fourth Degree Burn*
- involves muscles and bones
- appear charred-blackish, leathery, painless
- eschar formation (a scab or dry crust that results from trauma, such as a thermal or
chemical burn)
- requires skin grafts

* It should be noted that although fourth-degree is not a technical term, it is often used to describe
burns that reach muscle and bone. Third-degree sufficiently describes all burns of this nature
Nomenclature Traditional Depth Appearance Sensation Healing Scarring
nomenclatur time
e
Superficial First Degree Epidermis Dry and Painful 3 to 6 None
thickness involvement red; days
blanches
with
pressure
Partial Second Superficial Blisters; Painful to 7 to 20 Unusual;
thickness – Degree (papillary) moist,red air and days potential
superficial dermis and temperature pigmentary
weeping; changes
blanches
with
pressure
Partial Third Degree Deep Blisters Perceptive More Severe
thickness – (reticular) (easily of pressure than 21 (hypertrophic)
deep dermis, unroofed); only days risk of
subcutaneous wet or waxy contracture
layer dry;
variable
color
(patchy to
cheesy
white to
red); does
not blanch
with
pressure

Full thickness Fourth Epidermis, Waxy white Deep Never Very severe
Degree Dermis, and to leathery pressure (if the risk of
complete gray to only burn contrac ture
destruction to charred and affects
subcutaneous black; dry more
fat, muscles, and than 2
bone tissue inelastic; percent
does not of the
blanch with total
pressure surface
area of
the
body)

B. Classification according to cause:

1. Thermal
- caused by exposure to dry heat (flames) or moist heat (hot liquids or steam)
- most commonly occurring from exposure to high temperature tap water in baths or showers or
spilled hot drinks
- highest risk to suffering from scalding are young children, with their delicate skin, and the elderly
over 65 years of age.
2. Chemical burn
- caused by strong acids or bases.
- bases such as sodium hydroxide or silver nitrate, and acids such as sulfuric acid.
- hydrofluoric acid can cause damage down to the bone and its burns are sometimes not
immediately evident.

3. Electrical burn
- caused by alternating current, direct current, lightning
- severity of injury depend on type and duration of current and amount of voltage
- common occurrences of electrical burns include workplace injuries, or being defibrillated or
cardioverted without a conductive gel.

4. Radiation burn
- caused by protracted exposure to UV light (as from the sun), tanning booths, radiation therapy
(as patients who are undergoing cancer therapy), sunlamps, radioactive fallout, and X-rays.
- most common burn associated with radiation is sun exposure, specifically two wavelengths of
light UVA, and UVB, the latter being more dangerous.
- more severe cases of sun burn result in what is known as sun poisoning.

Stages of Burn

First Stage: Shock/Fluid Accumulation Phase/Emergent Phase

- first 48 hours
- fluid shifts from IVC – ISC
- generalized dehydration
- hypovolemia due to plasma loss -->  CO –> fall of BP
- hemoconcentration -  Hematocrit
- oliguria ( renal tissue perfusion)
- hyperkalemia – release of K from damaged cells
- hyponatremia – Na trapped in edema fluids
- metabolic acidosis – due to hypoNa, Na is unavailable thus HCO3 is excreted

Second Stage: Diuretic/Fluid Remobilization Phase

- after 48 hours
- fluid shifts from ISC to IVC
- hypervolemia -> hemodilution ->  Hematocrit
- diuresis ( renal tissue perfusion)
- hypokalemia – K moves back into the cells
- hyponatremia – Na still trapped in edema fluid
- metabolic acidosis

Third Stage: Recovery

- 5th day onwards
- Hypocalcemia – lost in exudates and utilization in granulation tissue (scar)
- Negative Nitrogen Balance -  protein catabolism due to stress (Burn)
- protein demands  for healing
- protein intake may be inadequate
- Hypokalemia – goes back inside the cells, decreasing K serum levels
Interpreting % of Burns

TBSA = Total Body Surface Area

*Rule of 9's for Adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18%
for back torso.

*Rule of 9's for Children: 9% for each arm, 14% for each leg, 18% for head, 18% for front torso,
18% for back torso.
Collaborative Management
1. Promote respiratory function
- establish an open airway

2. Promote fluid-electrolyte and acid-base balance

3. Relieve the pain

- Morphine Sulfate
- use bed cradle
- avoid exposure of affected areas to draft

4. Prevent infection
- practice asepsis
- reversed/protective isolation
- Tetanus immunization, immune globulin

5. Maintain adequate nutrition

- NPO for first 48 hours to prevent gastric dilatation, paralytic ileus & water intoxication
- diet  calorie carbohydrate protein

6. Provide wound care

* Methods:
a. Open method
b. Semi-open method
c. Closed method
* Antimicrobials
a. Furacin (Nitrofurazone)
- With good eschar penetration
- presents some advantages for the ambulatory patient. Tissue granulation begins sooner
and crusts separate more rapidly,
b. Sulfamylon (Mafenide Acetate)
- With an excellent antimicrobial activity and the best eschar penetration of any agent
- efficiently penetrates cartilage, which makes it an excellent choice for use in burned ears
and noses.
c. Silvadene (Silver Sulfadiazene)
- With an excellent spectrum of activity, low toxicity, and ease of application with minimal
pain, still the most frequently used topical agent.
d. Silver Nitrate
- applied to the dressing not directly on wound, stains

* Hydrotherapy

* Debridement – wet to dry dressing

* Skin Grafting
a. Isograft/Syngeneic graft – twin
b. Autograft – self
c. Homograft/Allograft – another human
d. Heterograft/Xenograft - animal
7. Promote G.I. support
- prevent stress ulcer (Curling’s ulcer)
- NGT, antacids

8. Fluid replacement
- prevent hypovolemic shock
- Colloids, LR, D5W

* Baxter and Parkland Formula (Crystallized Resuscitation)

- children with TBSA > 10% & adults with TBSA > 15%
- formula: 4 mls. LR x weight in kg. x % of burns
- allocation of fluid replacement for the first 24 hours
1ST 8 hours 50%
2nd 8 hours 25%
3rd 8 hours 25%

9. Rehabilitation
- priority goal: prevent/minimize scarring
- prevent contractures, promote activity tolerance, improve body image & self concept