Burn

Salient features

·        Burns are common in adults and kids; most are small and managed in the outpatient setting with dressing changes.

·        Serious burns require inpatient care, ideally in a verified burn center.

·        Large burns are managed in 4 general phases:

o   Initial evaluation and resuscitation.

o   Wound debridement and biologic closure.

o   Rehabilitation and reconstruction.

o   Long-term outcome quality tends to be very good in patients surviving large burns.

 

CLINICAL AND PATHOLOGIC FEATURES OF THERMAL BURNS
Type	Depth	Clinical features	Pathology
First degree	Epidermis only	Pain, tenderness, erythema No blistering Heals without scar	Upper epidermal necrosis
Second degree – superficial	Epidermis and superficial dermis	Severe pain, tenderness, serous or hemorrhagic bullae, deep rubor, erosion, and exudation Heals in 10–21 days with mild but variable scarring	More extensive epidermal necrosis with vertical elongation of keratinocytes Necrotic areas may have serous crust with neutrophils, fibrin, and cellular debris Subepidermal bullae possible
Second degree – deep	Epidermis and most of dermis destroyed, including deep follicular structures	Intense pain but reduced sensation, deep red to pale and speckled in color Serosanguineous bullae and erosions May appear devitalized initially Prolonged healing time Hypertrophic scars and marked wound contracture	Destruction of entire epidermis, dermal collagen, and most of adnexal structures Collagen bundles may be fused, with eosinophilic appearance Thrombosis of deep vessels common Granulation tissue present at junction of normal and injured tissue
Third degree	Full-thickness epidermal and dermal destruction	Dry, hard, charred, non-blanching, insensitive areas of coagulation necrosis Small lesions heal with significant scarring Most require surgical correction	Necrosis of entire epidermis and dermis, with extension into subcutis Inflammatory infiltrate at interface between burned and normal skin If scar forms, it exhibits hyalinized collagen, decreased elastic tissue, loss of arrectorpili muscles

 

In adults, an estimate of burn extent is often based upon this surface area distribution chart. Infants and children have a relatively increased head: trunk surface area ratio. These estimates are also used for primary cutaneous disorders.

 

Management

 

Initial management of burn victims includes assessment of cardiopulmonary status as well as the extent and depth of the burn.  For first- and second-degree burns, the burn wound itself should initially be rinsed with cold running water for 20 minutes in order to ease pain, reduce heat, and reduce burn depth. Then the wound should be gently cleansed to remove any foreign material. The next step is prevention of infection, followed by creation of a proper healing environment. Topical anti­microbial agents shown to be effective in burn wound care include silver sulfadiazine, mafenide acetate, and silver nitrate. Silver sulfadiazine has gained wide acceptance for both pediatric and adult burn treatment, but it is known to be cytotoxic and percutaneous absorption can lead to leukopenia. Silver sulfadiazine also produces a pseudoeschar that may interfere with burn depth assessment and prolonged application may lead to localized argyria (skin turns blue or blue-grey). Some experts therefore prefer mafenide acetate.

 

While superficial wounds may require minimal additional therapy, deeper burn wounds need more aggressive therapy, with the standard approach being serial excision and autografting (if there are sufficient donor sites). Third-degree burns are excised early, with indeterminate and deep second-degree wounds delayed until maximum depth and extent are known. Biologic dressings (e.g. pig skin, human allograft) were popular for several years, but have been largely displaced due to higher infection risk and poorer healing. Skin substitutes such as acellular human dermal matrix (Alloderm^®), bilaminar bovine collagen–shark chondroitin sulfate (Integra^®), and cultured epithelial autografts are increasingly being utilized.

 

1^st0 burn: with intact epidermis require a bland ointment.

Topical corticosteroids used to relief inflammation.

Neither topical nor systemic antibiotics are required for 1^st0 burn.

2^nd0 burn: clean and dress.

Aspiration or drainage of fluid, intact blisters left for a day or two as a natural wound dressing. Broken blisters or other dead tissues should be removed. Dressing should consist of Vaseline gauze placed on the affected skin, followed by gauze pads and easily stretched dressing. Topical antibiotic such as silver sulfadiazine cream is often used.

3^rd0 burn: beyond the scope of dermatologist.

Broad spectrum prophylactic antibiotics are given and then adjusted according to C/s reports.

Pain therapy.

High calories diets and give trace elements such as Zinc and Vit C, both of which can be quickly lost.

2^nd0 burn and deeper: scars with contractures are major problem, especially in younger patients.

Scars can be minimized with early physical therapy.

Keloids can be inhibited by the early use of pressure garments or dressings for 6 months or even more in children.

Good skin care with non sensitizing ointments to avoid dryness and fragility. Scars and contractures corrections are best left in the hands of plastic surgeons.