Assessment of the depth of burns.

The classification of burns into superficial and deep (degrees 3 b, 4) is primarily based on the skin’s capability of regenerating through epithelization in superficial burns cap.

Within the first few hours or even days following injury, it is difficult to assess the depth of burns. The evaluation of skin sensation is used.

In superficial burns, pain sensation at the affected areas is intact or somewhat reduced.

In deep burns, unaffected areas below the affected ones become oedematous. The method of infrared thermography can also be used to determine the depth of burns (the areas with deep burns emit heat at a lesser degree that normal ones). The depth of burns can be established on 7-14 days following the injury.

Evaluation of severity of burns

In adults, the rule of 100 can be used (the age in general and burns area in %):

- 60 – good prognosis;

- 61-80 – relatively good prognosis;

- 81-100 – doubtful prognosis;

- 101 – poor prognosis.

 

Names	Layers involved	Appearance	Texture	Sensation	Time to healing	Complications
First degree	Epidermis	Redness (erythema)	Dry	Painful	1wk or less	Increased risk to develop skin cancer later in life
Second degree (superficial partial thickness)	Extends into superficial (papillary) dermis	Red with clear blister. Blanches with pressure	Moist	Painful	2-3wks	Local infection/cellulitis
Second degree (deep partial thickness)	Extends into deep (reticular) dermis	Red-and-white with bloody blisters. Less blanching.	Moist	Painful	Weeks - may progress to third degree	Scarring, contractures (may require excision and skin grafting)
Third degree (full thickness)	Extends through entire dermis	Stiff and white/brown	Dry, leathery	Painless	Requires excision	Scarring, contractures, amputation
Fourth degree	Extends through skin, subcutaneous tissue and into underlying muscle and bone	Black; charred with eschar	Dry	Painless	Requires excision	Amputation, significant functional impairment, possible gangrene, and in some cases death.

Burn disease is a constellation of clinical signs that result from superficial burns (degrees 2-3a) with a burns area of above 15% body surface and in deep burns of more than 10% body surface.

The four periods of the disease are identified:

1. burn shock;

2. acute burn toxaemia;

3. septicaemia;

4. recovery.

First aid in burns should aim at terminating of burning process and cooling the burnet area.

Cooling is achieved with cold water, ice packs, and snow is to be continued for at least 10-15 minutes. After the pain has subsided, aseptic dressing should be applied locally, and analgesics and non – steroidal inflammatory drags, warm tea and mineral water are given to the patient. During this period, topical treatment (i.e. therapeutic bandages) should be avoided.

Apart from analgetics, the patient is given neuroleptic and antihistamines prior to transportation that should be before an hour if the patient is to be transported for a long distance, he/she has to be given intravenous infusion of plasma substitutes and solutions of electrolytes, oxygen therapy and general anaesthesia, large amount of alkaline drinks and cardio- vascular agents.

Local treatment

The two topical (closed and open) methods are used for burns. First, primary the wound toileting is done. The skin around the burnt areas is cleansed with swabs soaked in 0,25% ammonium, 3-4% boric acid, benzene or warm soapy water, with subsequent application of alcohol. Pieces of clothing, foreign bodies, peeling epidermis are removed from the wound; large blisters are opened to drain their contents, minor ones being left alone. Fibrin deposits are usually left intact since it is under these where regeneration takes place. Excessively dirty burnt areas are cleansed with 3% hydrogen peroxide. Sterile gauze or tissues are used to dry the burnt surface.

As a rule, the primary wound toileting is done after 1-2 ml of promedol or omnopon have been injected subcutaneously.

The closed method (bandaging or covering with dressing material) is the most commonly used and has a number of advantages as follows:

- isolation of the wound;

- provision of optimum conditions for the application of topical agents;

- the possibility of active movement of patients with extensive burns during transportation.

Its pitfalls are the following:

- labour intensiveness;

- the expenditure of large amounts of dressing material;

- painful change of dressing.

The open method avoids these disadvantages. In addition, it promotes formation of the thick eschar on the burnt surface, which is treated by free flow of air over the area, ultraviolet rays or the use of agents that dry it and coagulate protein. It is difficult, however, to implement this method when dealing with patients with deep and wide areas of burns as it requires the use of special equipment (e.g. chambers, cage with electric lamps).

Moreover, there is always a high risk of wound infection (e.g. nosocomial).

When treated by the open method, superficial (degrees 2-3a) burns tend to spontaneously healing. The open method is indicated for facial, genital or perineal burns. The open method requires the use of ointments containing antibiotics (5 and 10% synthomycin emulsions) and antiseptics (0,5% furacilin, 10% sulphacyl) three to four times a day. Suppurated wounds should be dressed. If granulation is found in the areas of deep burns treated with the open method, the closed method should be added.

Each of these methods has its specific indications. At the same time, they can be combined, whenever necessary.

In burns degree 2 it takes 7-12 days for the epithelium to form, while in 3a degree 3 to 4 weeks.

In deep burns, eschar, either as wet or dry necrosis, forms for 3-7 days.

Surgical treatment involves several operations:

- early necrectomy,

- autodermaplasty,

- amputation,

- reconstructive operations

Chemical burns

They are caused by concentrated solutions of acids and alkali (base), which leads to necrosis of the skin and mucosal membranes that may extend to deeper lays.

Acids cause- dry or coagulation necrosis, while alkali cause - wet or colliquative necrosis.

Electric burns

High-voltage electric current can cause electric burns at the entry and exit sites of the current. These kinds of burns are always deep, and here the underlying tissues are more damaged than the skin itself. All the tissues on the way of the current get necrotic, the major vessels get thrombosed in addition. In view of these the extent of burn is not established by the skin damage, which is limited to about 2-3 cm in diameter, but by the damage caused to the deep lying tissues that come into contact with the current. When major vessels are damaged there can be tissue necrosis, gangrene of an organ.

On the sites of entry and exit of the current “currentsigns” form - burn wounds are the type of “sign”which differs: circular, oval, with a normal diameter of 2-3 cm with the centre drawn in; in lightning treelike type. “Current signs” consist of grey or dark brown coloured eschars with depressed centres and oedema (edema) of the adjacent tissue. Skin sensivity is decreased. The “figures” of lightning consist of dark grayish brown tree like forms.

After the cardiac and respiration functions have been restored, dry sterile dressing is applied to the burnt areas. All persons after rescue from an electric shock must be sent to the hospital.

In thermal burns as a result of breathing in hot air or gaseous substances or smoke there can be burns of the respiratory tract.

Frost bite

Frostbite is the medical condition where localized damage is caused to skin and other tissues due to freezing. Frostbite is most likely to happen in body parts farthest from the heart and those with large exposed areas. The initial stages of frostbite are sometimes called "frost nip".

1. Dept of damage:

- degree 1 – blood circulatory disorders and the development of reactive inflammations;

- degree 2 – damage to the epithelium up till the germinal layer which is intact;

- degree 3 – complete skin necrosis and partial necrosis of the subcutaneous layer;

- degree 4 – skin necrosis and necrosis of deep lying tissues.

2. According to the disease period (period of frost bite):

- latent (pre-reactive) period;

- reactive period.

Degrees 1 and 2 are superficial, while degrees 3 and 4 are deep.

In first degree frost bite there is blood circulation disorders without necrotic changes in the tissues. Full recovery is usually evident on days 5-7.

In second degree - the superficial layers of skin are damaged, the germinal layer is intact. Skin damage is fully healed within 1-2 weeks.

In third degree - skin regeneration is impossible, and after the eschar has fallen off a skin defect forms, which is covered by granulation tissue and unless skin grafting is done to cover the defect, the wound heals with the formation of a scar.

In fourth degree - a dry or wet gangrene of the affected organ occurs.

Patient with 1-degree complain of pain occasionally burning and unbearable during the warming period. As the patient warms, skin pallor turns into hyperaemia and becomes warm to touch, tissue oedema is minimal, limited to the damaged areas and do not progress. All types of sensation and movement are intact.

Patients with 2-degree complain of itching, burning sensation, tension in the tissues, which persist for several days. Blister formations, which commonly appears in the first days, occasionally on the second day, and rarely on the third-fifth day, is a characteristic sign. Blister are filled with transparent contents, when there are opened a red or pink papilla layer of the skin that iss occasionally covered with fibrin shows. When the bare layer at the base of the blister is touched the patient experiences severe pain. Skin oedema spreads beyond the damaged area.

In 3-degree, pain is more severe and long lasting; there is a history of staying in the cold for long. The skin in the reactive period is violet bluish and cold to touch. During the first days or even hours, all types of sensation are lost. When the blister are opened violet-bluish surface of the blister base that is not sensitive to skin prick or irritation by gauze swabs soaked with alcohol is found. Subsequently dry or wet skin necrosis sets in; and when they peel off granulation tissue forms.

The 4-degree is unlikely to be distinguished from that of the third degree. The damaged skin looks pale or bluish. All types of sensation are lost and cold to touch. Blisters can appear in the first hours and are friable, filled with haemorrhagic dark contents. Oedema develops very fast 1-2 or a few hours after warming. Subsequently dry or wet gangrene develops. After a week, oedema subsides and the demarcation line appears (intact side and necrotic areas).

Treatment:

- first aid;

- infusion therapy;

- detoxication;

- immune stimulators;

- antibacterial therapy;

- surgical treatment (necrotomy, necrectomy, amputation of the damaged segment, plastic and reconstruction surgeries – skin transplant on the granulated wound, restoration of cosmetic defects);

- local treatment.

Classification

There are several classifications for tissue damage caused by extreme cold including:

· Frostnip is a superficial cooling of tissues without cellular destruction.

· Chilblains are superficial ulcers of the skin that occur when a predisposed individual is repeatedly exposed to cold

· Frostbite involves tissue destruction.

 Signs and symptoms

At or below 0 °C (32 °F), blood vessels close to the skin start to constrict, and blood is shunted away from the extremities via the action of glomus bodies. The same response may also be a result of exposure to high winds. This constriction helps to preserve core body temperature. In extreme cold, or when the body is exposed to cold for long periods, this protective strategy can reduce blood flow in some areas of the body to dangerously low levels. This lack of blood leads to the eventual freezing and death of skin tissue in the affected areas. There are four degrees of frostbite. Each of these degrees has varying degrees of pain.

  Causes

Inadequate blood circulation when the ambient temperature is below freezing leads to frostbite. This can be because the body is constricting circulation to extremities on its own to preserve core temperature and fight hypothermia. In this scenario the same factors than can lead to hypothermia (extreme cold, inadequate clothing, wet clothes, wind chill) can contribute to frostbite. Or poor circulation can be due to other factors such as tight clothing or boots, cramped positions, fatigue, certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes.

Exposure to liquid nitrogen and other cryogenic liquids can cause frostbite as well as prolonged contact with Aerosol Sprays (see deodorant burn).

6. MATERIALS FOR SELF-CONTROL:

А. Questions for self-checking: 1. Schema of a structure of a skin for definition of depth of a thermal trauma. 2. A photo of victims with burns and frostbite of the face.3. Schemas of inspection the victims who have suffered with burns.

B. Tasks for self-checking: 1. The wounded has received a burn of the face and a neck during explosion of a napalm bomb. Objectively: in a site of the nose and wings, a superciliary arches and lips he has a deep necrosis of soft tissues. The surfaces epidermis is exfoliate and lays like fold. Put the preliminary diagnosis. (The answer: a napalm burns of the face and a neck, III degrees).

2.The delivered wounded in two hours after a trauma from the center of napalm defeat. Bandages on the face, on the neck and the hands. The consciousness confusing. A voice hoarse, silent. Breath frequently, loudly. On what prime measures the victim demands? (The answer: the antishock therapy).

3. The military man burnt by a flame. He has hyperemia and edema of the skin of the face. It is revealed different size the bubbles filled with a transparent liquid. What degree of the burn of the skin of the face? (The answer: ІІ degree).

C. Material for the test control. Test tasks with single right answer (α =П): 1. Burns depending on genesis subdivide (into): A. Radiative and electrical. B. Chemical and thermal. C. Radiative and thermal. D. Electrical both chemical. E. Physical and chemical. (Correct answer: Е)

2. Consequences of the burns of the face ІІ degrees with aseptic current: A. The ugly scars, deformation of lips, eyebrows, ears, wings of a nose. B. Skin changes a little, the peeling and pigmentation is sometimes marked. C. Epithelization of a skin, which rather sensitive at contact and easily injured. D. Hypertrophic scars. E. Keloid scars. (Correct answer: С)

3. That does not concern to the periods of burns disease: A. Burns shock. B. Acute burns toxemia. C. Sepsis. D. The period of recovery (convalescence). E. Chronic burns sepsis. (Correct answer: Е)

D. Educational tasks of 3 th levels (atypical tasks): 1. The victim, 45 years, has received a burn of the face and a neck during explosion of the canister with gasoline. Fainted. Objectively: in area of the external nose and wings, superciliary arches, auricles and lips he has deep necrosis. On other sites of burns surfaces he has bubbles. They are filled with a liquid, some where the  epidermis exfoliated and lays like fold. The eyelids of both eyes edematous and he can not open it. Put the diagnosis. How you can explain the irregularity of the burn surface? Where the patient should be treated? (The answer: The burn of the face and necks, a degree II, III, IV. Features of maxillofacial area. In the burns center).

2. The victim of 24th years in clinic with a burn of the face. A trauma has received in consequence the action of an open flame. Complains of a pain and burning in the face region. Objectively: hyperemia of the skin of the face, on a chin, on a nose, on a forehead, cheekbones. There are many bubbles with a transparent liquid. What tactics of the doctor in relation to bubbles? (The answer: Do open bubbles).