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Presented to: Dr. Manzar Hassan

Topic: An introduction to Burns
By: Farah Iqbal Lodhi
From: 2nd yr, CC.
 The integument is composed of skin and its

associated tissues, sweat glands, sebaceous

glands, hair, and nails.
 Largest organ of the body; ~16% of the body

 Covers the entire body

 Continuous with the digestive system (lips

and anus), respiratory system (nose), and

urogenital system (urethra).
The skin often mirrors the
health of the whole body.
The skin is the largest
organ of the body and is
as indispensable as the
body's other major organs.
A radiant clear
complexion begins with
proper nutrition, efficient
digestion and assimilation
of nutrients by the body
and regular elimination.
The skin consists of:
1) Epidermis:-
 The epidermis is the outermost

layer and is a microscopic 0.2 mm

(8/1000 inch) thick on the face.
The surface consists of dead cells
which are in the process of flaking
away and new ones which are
growing to take their place.
Between the epidermis and dermis
lies the basal layer, where new
epidermal cells are formed and
progress to the surface. It takes
approximately twenty-eight days
for a new cell to reach the top.
2) Dermis:-
The dermis also varies in
thickness depending on the
location of the skin. It is .3
mm on the eyelid and 3.0
mm on the back. The dermis
is composed of three types
of tissue that are present
throughout - not in layers.
The types of tissue are:
 collagen

 elastic tissue

 reticular fibers
Layers of the Dermis
The two layers of the dermis are the
papillary and reticular layers.
 The upper, papillary layer contains a thin
arrangement of collagen fibers.
 The lower, reticular layer is thicker and
made of thick collagen fibers that are
arranged parallel to the surface of the skin.
 The hypodermis is composed of

loose connective tissue with large

numbers of adipose cells.
 The hypodermis provides insulation,
shock absorption, energy storage, and
the ability of skin to slide over joints.
 It also contains the major blood
vessels of the skin.
 Many epidermal appendages extend
into the hypodermis. These provide a
source of keratinocytes when the
epidermis is destroyed by abrasion or
Epidermal appendages: The
epidermal appendages include
hair follicles, various glands,
and nails.
 Hair is composed of dead
epidermal cells that have
undergone a modified
epidermal keratinization
including the expression of
specific keratin proteins that are
highly cross linked by disulfide
bonds. It is derived from hair
follicles, which are epidermal
invaginations that project into
the dermis or hypodermis.
 Sebaceous glands are appendages
of hair follicles and are embedded in
the dermis and hypodermis
throughout the body except on the
hands and soles. They are
prominent in the face, neck and
upper body.
 They consist of several acini that join in
a short duct that empties into hair
 They secrete by holocrine secretion in
which the entire cell contents becomes
the secretion due to autolysis. The dead
cells are replenished by mitosis at the
periphery of the gland.
 The secretion is sebum, a wax-like
mixture of triglycerides and cholesterol.
It likely functions as a protective agent
and to maintain skin texture and hair
 Eccrine sweat glands are simple coiled
tubular glands located in the deep dermis or
underlying hypodermis and are present
throughout the body. Their primary function is
evaporative cooling.
 They develop as invaginations of the epithelium of the
epidermal ridge and grow into the dermis. The deep aspect
becomes the glandular portion of the sweat gland.
 Eccrine sweat glands have two regions: a secretory region
and a duct region. The secretory portion is comprised of
simple coils of cuboidal epithelium containing two kinds of
 Adults produce between 0.5-10 liters/day.
 Apocrine sweat glands are
simple tubular glands that
empty into hair follicles in
axillary and anogenital
regions. The secretion is a
mixture of proteins,
carbohydrates, and ferric
ions that is odorless when
secreted, but is acted on by
commensal bacteria. They
begin to function at
puberty; but their function
is unknown.
The Function of skin are as follows:
 Physical barrier against friction and shearing forces.
 Protection against infection, chemicals, ultraviolet irradiation,
 Prevention of excessive water loss or absorption
 Ultraviolet-induced synthesis of vitamin D - Sensible
exposure to sunlight synthesizes the production of vitamin D
through interaction with ergosterol, a naturally occurring fat
found in the skin. Vitamin D absorption helps metabolize
calcium and phosphorous, which is important to bone and
tooth health.
 Temperature regulation - It is also very involved in
maintaining the proper temperature for the body to function
 Sensation (pain, touch and temperature)
 Antigen presentation/immunological reactions/wound healing.
Any injury to the tissue resulting due to exposure
and absorption of heat comes under the
heading of burn injury.
 Fire burn
 Electricity burn
 Chemical burns
 Sunburns
 Burns due to contact of skin with extreme hot
materials, like frying pan, oven's grill, etc
 Radiation
 Scalds burn (steam, hot bath water, tipped-
over coffee cups, cooking fluids, and so on).
Burns are generally put into
three categories. These
classes are first, second and
third degree burns. The
burn category indicates the
severity of the burn along
with the amount of body
area covered by the burn
 First Degree Burn
 Second Degree Burn
 Third Degree Burn
1) First-Degree Burns:-
First-degree burns, the mildest of the three, are limited to the
top layer of skin: These burns produce redness, pain, and
minor swelling. The skin is dry without blisters. Healing time
is about 3 to 6 days; the superficial skin layer over the burn
may peel off in 1 or 2 days.
2) Second-degree burns:- are subdivided into
superficial and deep partial-thickness burns.

a) Superficial partial-thickness burn injury:-

involves the papillary dermis, containing pain-
sensitive nerve endings. Burn management,
burns, burn Blisters or bullae may be present,
and the burns usually appear pink and moist.
This burn management, burns, burn injuries
heal with little or no scarring.
b) Deep partial-thickness burn injury:- damages both the
papillary and reticular dermis. These injuries may not be burn
management, burns, burn painful and often appear white or
mottled pink. Deep partial-thickness burns can produce burn
management, burns, burn significant scarring.
3) Third-degree burns or Full-thickness:-
involve all layers of the epidermis and dermis
and may destroy subcutaneous structures.
They appear white or charred. These burns are
usually insensate because of destruction of
nerve endings, but the surrounding areas are
extremely painful. Third-degree burns are best
treated with skin grafting to limit scarring.
Damage to the pulmonary parenchyma caused
by inhalation of substances such as very hot
air, toxic gas, asbestos, and chemical products
of plastic manufacture.
Various methods can be used to determine the
percent of the body burned:
• palm method
• rule of nine
* The palm method provides a
rough estimate in the field. The
surface area of an adults palm is
equal to 1% of her BSA. By
holding a palm over burns and
adding up the areas, you can
estimate total bum size.

(Palm of Pt = 1%)
* The rule of nine is another method used by
many rescue teams and EDs. In this system,
the body is divided into groups equal to about
9% of BSA (for example, the head and neck
count as 9% of BSA), and the size of the bum
is estimated as a percentage. Because BSA
changes with age, a pediatric version of the
rule of nines must be used for children.
You can estimate the body surface area on an
adult that has been burned by using multiples
of 9.
An adult who has been burned, the percent of the
body involved can be calculated as follows:
 Head = 9%
 Chest (front) = 9%
 Abdomen (front) = 9%
 Upper/mid/low back and buttocks = 18%
 Each arm = 9%
 Each palm = 1%
 Groin = 1%
 Each leg = 18% total (front = 9%, back = 9%)
The main determinants of mortality after burn
injury that can be measured on admission
include age, total burn size (% burn), and
inhalation injury (INHAL). Other variables,
measured during resuscitation, may provide
additional information about injury severity.
BTS = (Age of Pt. + TBSA + Co-morbid
 When skin is burned, it loses its ability to protect,

which increases the risk of infection. So it is

important that the damaged area be thoroughly
cleansed within the first six hours, and that the area is
kept clean while it is healing.
 If, after a few days, there are signs of an infection - ie

the skin is becoming increasingly red, hot, and

swollen, and the victim experiences a throbbing pain
- contact a doctor or your practice nurse.
 Severe burns can cause scarring.

 In cases of extensive severe burns, the body may lose

large quantities of fluid. This can disturb the blood

circulation and cause problems with the body's salt
balance. Such injuries should be assessed at your
local Accident and Emergency department.
First Aid for Minor Burns:
• Cool the burn with running water or a cold damp cloth. Do not
use ice--this may result in more damage to the skin.
• Do not use butter, grease, oils, or ointments on the burn.
• Cover the burn with sterile gauze or a clean cloth.
• Do not use a fluffy cloth such as a towel or blanket.
• Take an over-the-counter pain reliever, like acetaminophen
(Tylenol)/ Panaram (Paracetamol).
• Do not break or pop any blisters. This may result in an
• If you see signs of infection, get medical attention. Signs of
infection include:
o Increased pain
o Redness
o Fever
o Swelling
o Oozing of pus
Once a minor burn is completely cooled you can consider using a
fragrance free lotion or moisturizer to prevent drying and make
the area more comfortable.
Special Cases:
First Aid for Chemical Burns:
 If the chemical causing the burn is a powder, brush the powder
away from the skin first.
• Check the package insert for emergency information. For
certain dry or powdered chemicals it may not be appropriate to
flush the skin with water.
• If indicated, flush the skin with cool running water for 20
minutes or more.
• Remove any contaminated clothing or jewelry while flushing
the skin.
• If the eyes are affected, flush eyes with cold water until
medical help arrives.
• Cover burn with sterile gauze or a clean cloth. Do not use a
fluffy cloth such as a towel or blanket.
• Do not break or pop any blisters.
• Keep the person from becoming chilled or overheated.
Take the person to the nearest hospital if there are any signs of
shock, difficulty in breathing, or if the chemical burn occurred
on the eye, hands, feet, groin, face, buttocks, or over a major
joint. Emergency medical assistance is also indicated if the
chemical caused a partial-thickness burn greater than 2-3
inches in diameter, or if you are unsure if a substance is toxic.
First Aid for Electrical Burns:
• Stop the electrical current by unplugging the appliance from
the electrical outlet. Do not touch the person until the current
has been stopped.
• If you cannot turn off the source of the electricity, move the
source away from you and the person by using a no conducting
object, such as cardboard, plastic, or wood.
• Once you and the person are clear of the source of electricity,
check the person for airway, breathing, and circulation. Start
CPR if necessary and call 911.
• Cover burn with sterile gauze or a clean cloth. Do not use a
fluffy cloth such as a towel or blanket.
• Do not break or pop any blisters.
• Keep the person from becoming chilled or overheated.
All patients with electrical burns or jolts need to go to a hospital
immediately. Electrical burns can cause serious internal damage,
without much evidence on the skin. In such cases, people need
to be evaluated for heart rhythm disturbances as well as burns.
Exit wound
Entrance wound
A → Airway
B → Breathing
C → Circulation
D → Deformity or Disability
E → Exposure with environmental control
F → Fluid Resuscitation
 Assess burn size and depth.
 Establish good intravenous access and give fluids.
 Give analgesia.
 Catheterize patient or establish fluid balance
 Take baseline blood samples for investigation.
 Dress wound.
 Perform secondary survey, reassess, and exclude or
treat associated injuries.
 Arrange safe transfer to specialist burns facility.
 Initiation of fluid resuscitation should precede initial
wound care. In adults, IV fluid resuscitation is usually
necessary in second- or third-degree burns involving
greater than 20% TBSA. In pediatric patients, fluid
resuscitation should be initiated in all infants with
burns of 10% or greater TBSA and in older children
with burns greater than 15% or greater TBSA.
 Two large-bore IV lines should be placed. Lactated
Ringer's solution is the most commonly used fluid for
burn resuscitation.
 The Parkland formula is used to guide initial fluid resuscitation
during the first 24 hours. The formula calls for 4 cc*kg*TBSA
burn (second and third degree) of lactated Ringer's solution over
the fast 24 hours. Half of the fluid should be administered over
the first eight hours post burn, and the remaining half should be
administered over the next 16 hours. The volume of fluid given
is based on the time elapsed since the burn.
 The Parkland formula is used to guide initial fluid resuscitation
during the first 24 hours. The formula calls for 4 cc*kg*TBSA
burn (second and third degree) of lactated Ringer's solution over
the fast 24 hours. Half of the fluid should be administered over
the first eight hours post burn, and the remaining half should be
administered over the next 16 hours. The volume of fluid given
is based on the time elapsed since the burn.
 Urine output should be used as a measure of renal perfusion and
to assess fluid balance. In adults, a urine output of 0.5-1.0
mL/kg/h should be maintained. Patients with significant burns
should have a Foley catheter inserted in order to monitor urine