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AUTHORS:
Robert H. Demling, M.D.
Leslie DeSanti R.N., Dennis
P. Orgill, M.D. PhD.
Section
5
INITIAL WOUND ASSESSMENT AND
MANAGEMENT
Burn
Wound
(ANATOMIC ASSESSMENT, PROGNOSIS AND STANDARD
TREATMENT)
Burn
depth is defined based on the depth of coagulation
necrosis into epidermis and dermis (recognizing that
the anatomical depth may change with wound
conversion).
A.
PARTIAL THICKNESS OR SECOND DEGREE BURN
There
are five categories of second degree burn typically
used to characterize the depth of injury. Each
corresponds with healing time, treatment modalities
and outcome.
I.
Superficial Second Degree
Involves
entire epidermis to basement membrane and no more than
the upper third of dermis. Rapid re-epithelialization
occurs in 1-2 weeks. Because of a large number of
remains in epidermal cells and good blood supply there
is a very small zone of injury or stasis beneath the
burn eschar.
II.
Mid Second Degree (Mid Dermal)
Destruction
of the epidermis occurs to the basement membrane plus
the middle third of dermis. Re-epithelization is much
slower (2-4 weeks) due to fewer remaining epidermal
cells and less blood. More collagen deposition will
occur especially if not closed by three weeks. This
depth of wound has a significant risk of conversion.
The zone of stasis is much larger than in the
superficial second degree injury because of less blood
flow and more initial injury to the remaining
epidermal cells.
III.
Indeterminate (Mid Second Degree versus Deep
Second Degree))
One
cannot accurately clinically determine if the wound
will act like mid or deep second degree. The wound
surface has characteristics of both. There is a high
risk of conversion especially if the healing
environment is not optimized by debridement of surface
dead tissue and rapid closure.
IV.
Deep Second Degree (Deep Dermal)
Involves
the entire epidermis and at least two thirds of the
dermis leaving very little dermis and epidermal cells
to regenerate. Spontaneous healing is very slow (4-12
weeks). Sharp debridement is needed to remove eschar.
Scarring is usually severe if not skin grafted and
there is a high risk of infection. Inflammation
induced conversion to a full thickness burn is common.
Function of a re-epithelialized deep second degree
burn is poor due to fragility of the epidermis and the
rigidity of the scar laden dermis.
V.
Indeterminate (Deep Second Degree Versus Third Degree)
Almost
any deep second degree burn can be categorized as a
high likelihood of being full thickness as there is a
high risk of wound conversion.
B.
Full Thickness (Third Degree Burn)
Both layers of skin are completely destroyed leaving
no cells to heal except fibroblasts for scar
formation. Wounds can partially heal by contraction
from the edges (2-3 cm) but any significant burn will
require excision and grafting.
BURN
DEPTH AND OUTCOME
| SECOND
DEGREE |
CAUSE
|
APPEARANCE
|
PAIN
|
HEALING
|
SCAR
|
| SUPERFICIAL |
hot
liquid, short exposure |
wet,
pink, blisters |
severe |
10-14
days |
minimal |
| MID-DERMAL |
hot
liquid, longer exposure, flash flame |
less
wet, red blisters |
moderate |
2-4
weeks |
moderate |
INDETERMINATE
(MID OR DEEP) |
as
above |
red
with patchy, white arms |
moderate |
2-6
weeks |
moderate
or severe |
| DEEP-DERMAL |
chemicals,
direct contact flames |
dry,
white |
minimal |
3-8
weeks |
severe
(needs graft) |
INDETERMINATE
(2nd OR 3rd) |
chemicals,
flames |
dry,
white |
none |
----- |
----- |
THIRD
DEGREE
(FULL THICKNESS) |
chemicals,
flames, explosion, with very high
temperature |
dry,
white, or char |
none |
need
graft |
mild
to severe, depending on timing and type of
graft |
BURN
DEPTH (DIAGNOSIS, TREATMENT)
I.
Superficial Second Degree Or Partial Thickness Burn
Definition:
Second degree burns are defined as those burns in
which the entire epidermis and variable portions of
the dermis layer are heat destroyed. A superficial
second degree (partial thickness) burn is
characterized by heat injury to the upper third of the
dermis leaving a good blood supply.
Most
Common Cause: Hot water.
Appearance:
The micro vessels perfusing this area are injured
resulting in the leakage of large amounts of plasma
which in turn lifts off the heat-destroyed
epidermis, causing blister formation. The blisters
will continue to increase in size in the post-burn
period as cell and protein breakdown occurs. A light
pink, wet-appearing very painful wound is seen as
blisters are disrupted. Frequently, the epidermis does
not lift off the dermis for 12 to 24 hours and what
appears initially to be a first degree is actually a
second degree burn.
Healing
Rate: Despite loss of the
entire basal layer of the epidermis, a burn of this
depth will heal in seven to fourteen days if
non-infected due to repopulation of the epithelial
cells that are also present in skin appendages,
anchored deep in the dermis. Minimal to no scarring is
expected to occur. There is a relatively small zone of
injury and conversion is uncommon except at extreme of
age or chronically ill. Most antibiotic creams will
slow the healing rate.
Treatment
1. Clean, remove small blisters, apply grease gauze
and soft gauze dressing (occlusion, absorbent
dressing, changed daily).
2. On face, perineum, apply bacitracin or neomycin
ointment, applying several times a day.
3. Excellent alternative is the use of a synthetic
adhesive dressing which seals the wound and decreases
pain.
4. Use a water-soluble topical antibiotic if the wound
is grossly contaminated or if one is unsure if the
wound is superficial or deep.
Flash
Burn (Superficial To Mid Second Degree )
Treatment
1) Wash with mild soap
2) Then debride the blisters and only the loose
skin
3) Apply bacitracin (open technique) to burn areas 3
times a day, vaseline to lips; special attention to
ears (no pressure)
4) Ophthalmologic assessment before leaving ED
5) Check if tetanus shot needed
6) Return to clinic within 3 days |
|
|
Superficial
Dermal Burn
1. Necrosis confined to upper third of dermis
2. Zone of necrosis lifted off viable wound by edema
3. Small zone of injury
Treatment
1) Wash
2) Debride blisters and loose skin
3) Closed dressing with xeroform
4) Clinic 1-2 days because dressing will become
saturated
Treatment
1) Cold compress to control pain
2) Gentle wash
3) Xeroform bacitracin followed by thick layer of
gauze (except face)
4) Use flexnet or flexible variant to hold on dressing
5) Clinic 24-48 hrs because of age and difficulty of
home care
|
|
|
Hot
Water Superficial to Mid Second Degree
II. Mid Partial Thickness Burn
Definition: A mid second
degree extends to the mid portion of the dermis.
Longer exposure to hot liquids (5-10 seconds) or flash
flames (not direct contact of flames with skin) are
the most common causes.
Cause: Brief exposure to
flames or flash explosion: hot water in infant or
elderly.
Appearence: The burn surface
may have blisters but is more red, less wet and only
moderately painful.
Outcome: These burns usually
heal in about two to four weeks. The exception is the
very young and elderly where the dermis is thin and
depth of burn is invariably deeper. However, there is
a large zone of injury and risk of conversion. If a
burn heals in two weeks, then minimal to no scarring
is expected. With healing time beyond three weeks
scarring will occur, the degree being greater in dark
skinned individuals.
Treatment:
1. In patients six years to 60 years, without
diabetes, chronic illness etc, treatment is with an
antibiotic ointment and an occlusive dressing. The
depth can be underestimated and a switch to an
antibiotic cream may be needed because of risks of
infection.
2. In very young, and very old patients, or those with
chronic illness, contaminated wounds or perineal
wounds, the traditional choice is a topical cream base
antibiotic. First choice is silver sulfadiazine (silvadene)
with closed dressing technique.
3. New Approach: (a bioengineered skin substitute)
which could increase healing and decrease conversion.
Mid Partial Thickness Scald Burn
Dorsum of Hand
|
Treatment
1. Consider admission for elevation, debridement, pain
control
2. Admit if both hands involved
3. Initially, cold compresses are very effective pain
relief
4. Use topical antibiotic
5. New Approach: Bioengineered skin substitute
|
Mid Partial Thickness Burn
Due To Flash Exposure
|
Treatment
1) Admit to Burn Center due to size i.e., >15% TBS
2) Too big to use cold dressings except for a very
brief initial period
3) Use topical antibiotic in view of age, high risk of
conversion, infection
4) Alternative: bioengineered skin substitute to
generate wound closure
|
|
Mid-Dermal Burn
Characteristics:
1. Necrosis to mid-dermis
2. Large zone of injury (potential conversion)
3. Eschar separated from viable tissue by edema layer |
The schema of a mid dermal burn is shown. There is not
only a larger zone of necrosis but also a larger zone
of injury as dermal elements are more readily injured
by heat or mediators once below the high flow upper
dermis. The edema layer is still quite prominent and
often provides a natural interface for mechanical
debridement leaving a viable wound bed.
|
Indeterminate
(Mixed Mid Deep Dermal) Burn
Definition: A partial
thickness burn which appears mainly to be mid dermal
but has some characteristics of a deep dermal injury.
Cause: Same as mid dermal.
Appearance: The burn surface
is red but less wet and less painful than a
superficial burn. In addition, there are small patchy
whitish areas, usually seen with a deeper burn.
Outcome: Although the wound
surface is initially viable, these bums have a high
risk of conversion to a deep burn due to a larger zone
of injury and increased risk of infection and also
other environmental insults. Healing rate is three to
four weeks or longer depending on the degree of
conversion.
Treatment
1. Standard of care for the burn depth has been a
topical antibiotic and an occlusive, absorbent
dressing.
2. New Alternative: a bioengineered skin substitute
which could increase healing and decrease wound
conversion.
INDETERMINATE MID DERMAL WITH DEEPER AREAS
TREATMENT
1) Traditional treatment has been a topical antibiotic
plus occlusive dressing
2) Too deep for mechanical or synthetic adherence
dressing
3) New alternative would be a bio-engineered temporary
skin substitute which can adhere and protect the zone
of injury
INITIAL
WOUND ASSESSMENT AND MANAGEMENT
Continued
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Mixed Mid and Deep Dermal ( Second Degree) Burns
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Deep
Second Degree Burn
|
Deep
Dermal Burn
Deep Partial Thickness (Deep Second Degree)
Burn
Definition: A deep partial
thickness or deep second degree burn extends well
into the dermal layer and fewer viable epidermal
cells remain. Therefore re epithelialization is
extremely slow, sometimes requiring months. Grafting
is often the preferred treatment for long term
function.
Appearance: In these
patients, blister formation does not
characteristically occur because the dead tissue
layer is sufficiently thick and adherent to
underlying viable dermis that it does not readily
lift off the surface. The wound surface may be red
and dry in appearance with white areas in deeper
parts (dry since fewer blood vessels are patent).
There is a marked decrease in blood flow making the
wound very prone to conversion to a deeper injury
and to infection. It is often not possible to
distinguish a deep partial from a full thickness
burn by initial appearance. Frequently the wound is
a mixed second and third degree. Direct contact with
flames is a common cause. Most chemical burns are
also deep. The appearance of the deep dermal burn
changes dramatically over the next several days as
the area of dermal necrosis along with surface
coagulated protein turns the wound a white to yellow
COIOL The amount of surface coagulurn is accentuated
with the use of a topical antibiotic, making the
deep second degree burn difficult to differentiate
from a third degree burn. The presence of some pain
can assist in the diagnosis because pain is usually
absent in a full thickness injury. Fluid losses and
the metabolic effects of deep dermal bums are
basically the same as that seen with the third
degree burn.
Outcome: A deep dermal
burn will require 6-10 weeks or longer to heal.
Since the epidermis is very thin and not adhered
well to dermis (no rete pegs), wound breakdown is
common. Excision and grafting is the preferred
treatment. Dense scarring is usually seen if the
wound is allowed to heal primarily.
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Deep
Dermal Burn
|
Treatment-
1. Admit, if over 2% in area, due to need for early
grafting.
2. Gentle washing, debridement.
3. SSD using closed dressing twice a day.
4. Cold is not beneficial once the burning has
stopped as pain is minimal.
5. Strongly consider early excision and grafting.
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Characteristics
A
schema of a deep dermal burn is shown above. The
zone of coagulation involves the majority of the
dermal layer. The remaining dermis can be considered
the zone of injury with a high risk of conversion.
Edema is more diffuse throughout the burn and the
necrotic tissue remains adherent requiring either
necrolysis or preferably surgical debridement for
removal.
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V.
INDETERMINATE
(DEEP FULL THICKNESS)
Definition: A deep burn
which cannot be clinically distinguished between
deep dermal and full thickness. Often there are
components of both as is evidence during a
tangential excision and grafting.
Appearance: Dry, white but
no char. There may be some sensation.
Outcome: In general
outcome is poor no spontaneous re-epithelialization.
Treatment- Treatment is
therefore mainly surgical with use of a topical
antibiotic prior to surgery
Mixed Deep Dermal (Second) and Full Thickness
(Waxy
white in middle is full thickness)
Visually Deceiving Burn
Some burns usually caused by contact with flames or
extremely hot T 0 like explosion have the
destroyed epidermis still present in the wound. The
depth can be underestimated unless the wound is
gently washed and debrided after which the size and
depth is more clearly defined.
Flame
Burn (Direct Contact)
Looks
superficial with blisters but mechanism suggests
deep burn.
Gently
Clean Wound
When
gently cleaned, wound is noted to be a combination
of deep second and third degree burn.
Treatment
1. Gentle wash, removing loose epidermis.
2. SSD, preferably twice daily, under closed
dressing.
3. Excision and grafting will be needed for deep
burn
  
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