Chapter 2: Diagnosis

DIAGNOSIS: DATE OF BURN____________

   _____ACUTE BURN?

   TYPE OF BURN_________________________  

   _____%TBSA    ______%FULL THICKNESS

   OTHER CONDITIONS________________________

Estimating Percentage of Total Body Surface Area

Exclude erythema

The Lund-Browder chart is the most accurate method for estimating burn extent, and must be used in the evaluation of all pediatric patients.

LUND-BROWDER CHART
Relative Percentage of Body Surface Area Affected by Growth

 If you lose this book, use the “Rule of Nines” for adults:

Palm trick- Use the patient’s palm size to represent approximately 1% TBSA. Imagine a rectangle the width and length of your entire hand (from wrist to fingertips) and that is the size of “one palm.”

Estimation of Burn Depth

Burns are classified as either first, second or third degree.

Superficial Burns

First Degree-

Injury involving only the outer epidermis layer.  Erythema and mild discomfort.  Resolves in 48-72 hours with comfort measures.  Healing is uneventful. 

Superficial Second Degree-

The entire epidermis and upper third of the dermis are destroyed.  Vessels leak plasma which lifts off the epidermis, causing blister formation.  Wounds are pink, wet, and very painful.  Heals within two weeks via repopulation of epithelial cells present in skin appendages and the deep dermis.

Deep Burns

Deep Second Degree-

The injury extends into the dermis, leaving few viable epidermal cells.  Reepithelialization is very slow.  Wounds require months to heal.  Blisters do not form because the dead tissue layer is thick and does not easily lift off the surface.  Wounds are red with scattered deeper white areas throughout.  The marked decrease in blood flow makes the wound very prone to conversion to a third degree wound.  Dermal necrosis with coagulated proteins turns the wound a white to yellow color (called coagulum).  Topical antibiotics can add to this color change and make the wound difficult to differentiate from a third degree burn.  Wound breakdown is common since the rete pegs have been destroyed; thus, what little epidermis is left is thin and not well adherent.  Dense scarring is seen if the wound heals primarily. 

Third Degree- 

A full thickness burn.  The entire epidermis and dermis are destroyed.  No epidermal cells present for reepithelialization.  Initially, wound appears waxy and white, unless burn extends into the fat, in which case a leathery brown or black appearance is seen along with coagulated subcutaneous veins.  The wound is painless and will not heal unless very small (smaller than 2 X 2cm).

Other Burn Injuries

Chemical Burns

These burns cause progressive tissue damage until inactivated or flushed with water.  Acids cause protein coagulation, limiting further penetration., whereas alkali burns combine with cutaneous lipids causing tissue saponification, which continues to injure the skin.    Until proven otherwise, chemical burns should be considered deep.

Electrical burns

Electrical injuries are of three major types which may occur in combination:

1) true electrical injury exists when electricity passes through the body.  An entrance and exit wound is produced, along with significant deep-tissue destruction.  The quantity of heat produced is expressed in Joule’s Law:  J=I²RT, where (J) is the heat produced, I is the current, R is resistance, and T the duration of contact.  Therefore when performing  the history and physical examination, record the voltage and duration of contact with the source.

2) arc burns occur when electrical current jumps from one part of the body to another, producing scattered spots of injury which may be deep

3) flame burns are caused by sparks sufficient to ignite clothing

High-voltage, high-current source electrical injuries (>1000 volts and >5000mA) cause significant soft tissue damage.  Low voltage, low current (<1000volts and 5-60mA) cause less soft tissue damage but are noted to more commonly cause cardiac fibrillation.

Complications of electrical injuries include tetanic muscle contractions with resulting muscle fractures and dislocations, or falls with crush injuries.  Intraperitoneal damage occurs, perhaps due to the low-resistance mesenteric vascular system.  Cardiac dysfunction may be seen initially in as many as one third of electrically injured patients, and ECG changes may be present,[i] including RBBB, SVT, and other focal ectopic dysrhythmias.[ii]  Electrical injuries may also cause delayed neurologic changes and cataract formation.[iii]          

Radiation burns

Accidents involving ionizing radiation are not common.  Most frequently they are the result of a local accident (laboratory), from an industrial accident (Chernobyl, Russia in 1986), or from the detonation of a nuclear device. 

Whole-body exposure of more than 100 rads causes acute radiation syndrome, marked by nausea, vomiting, diarrhea, fever, fatigue, and headache within hours of exposure.  This is followed by a latent period, and then by hemopoietic, GI, and vascular complications.