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Burns 215
Table 33.1: Classification of burn injuries.

First degree Second degree Third degree

Superficial Superficial Deep Full thickness
Flame, immersion scald,
Cause Very short flash, ultraviolet exposure Short flash, spill scald Flame, scald chemical contact, electric
current
Entire epidermis and part of Entire epidermis and part Epidermis and dermis
Injured tissue Epidermis only dermis; dermal appendages of dermis; very few dermal destroyed; no dermal
intact appendages intact appendages

Blisters, bullae, oedema, Leathery, charred skin with
Clinical appearance Skin erythematous Blisters, bullae, oedema
pseudo-eschar thrombosis of vessels
Pain Pain gone in 48–72 hours Painful Painful No pain

Healing time 1 week 2–3 weeks More than 3 weeks Requires grafting to heal

Large scar, hypertrophic may Chronic wound, incapable of
Minimal or no scarring;
Results of healing No scarring develop into keloids and healing without intervention;
dyspigmentation may occur
contractures contractures result
Eschar Depth of Burn and Disability: Assessment of the depth of the burn
An eschar is the necrotic tissue resulting from a burn. It separates is discussed under “Secondary Survey” in this chapter. A thorough
slowly from underlying viable tissue and can serve as the substrate for neurological examination sets a baseline, especially in the setting of
invading microorganisms. Left untreated, it becomes colonised and an associated head injury. Mental status changes or a history of loss of
eventually infected. Infection attracts white blood cells, which digest consciousness in the setting of a flame burn is most likely due to carbon
the interface and cause separation of the eschar from the underlying monoxide poisoning. Administration of 100% oxygen, or hyperbaric
viable tissue. Circumferential eschars around limbs may impair blood oxygen where available, may be life saving.
circulation, and if unrelieved may cause distal ischaemia. Immediate Extent of Injury(s) and controlled Exposure of body: The full extent of
relief is obtained by performing an escharotomy by placing vertical the burn should be determined and the child examined for additional
incisions through the eschar along the sides of the limb. Chest and injuries. The child should be kept warm at all times.
abdominal eschars restrict respiration and may also require escharoto- An “F” should be added to ABCDE for paediatric patients:
mies along the sides of the chest wall. There should be no hesitation in For children:
early escharotomy if physiologic compromise is suspected.
• Children have larger heads and smaller limbs in terms of body sur-
Blisters face area (BSA) compared to adults.
Burn blister management is controversial. Small blisters may be left
• Hypothermia is more common due to larger evaporation because
alone to serve as biological dressings. Larger blisters require debride-
the total BSA (TBSA)-to-height ratio in children is higher.
ment to prevent an impairment of function and release the fluid that is
rich in potentially deleterious proinflammatory substances. • Children have smaller glycogen stores, so hypoglycaemia is a risk.
Initial Resuscitation and Management • Adequate tetanus prophylaxis must be ensured.
As with any trauma, the principles of Advanced Trauma Life Support • For any unusual injury patterns, consider child abuse.
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(ATLS ) must be implemented to ensure that all life-threatening injuries
are prioritised and managed. The ABCDE of ATLS must be followed: Inhalational Injuries
The possibility of inhalational injury should be considered early dur-
Airway: Early intubation should be considered in patients with extensive
burns requiring intensive care unit (ICU), those with extensive facial ing burn resuscitation because such patients may require early intuba-
burns, and those with inhalation injuries. Progressive airway oedema is tion. Inhalation injury results from exposure of the respiratory tract to
common in these situations. superheated steam or air, toxic gases, chemicals, and particulate matter
of smoke. Clinical diagnosis is difficult, but inhalational injury should
Breathing: Deep chest and abdominal burns, especially when be suspected when the child had been trapped in a closed space and in
circumferential, severely impair chest wall breathing and ventilation. burns involving the head and neck. Characteristic symptoms indicat-
Escharotomies should be performed urgently when indicated. Associated ing severe upper airway injury include hoarseness, change in voice,
chest and abdominal injuries may also impair chest wall excursion. complaints of throat pain, and odynophagia. The child may cough up
Circulation: Large-bore intravenous (IV) access should be placed through carbonaceous sputum and may demonstrate tachypnoea, wheezing,
nonburned tissues. Venous cutdowns are frequently necessary for IV crepitations, rhonchi, and use of accessory respiratory muscles. When
access for initial resuscitation. As an alternative route, intraosseous (IO) available, early diagnostic bronchoscopy will identify most victims.
access may be used in the paediatric population. The doctor providing The presence of inhalational injury is the major predictor of morbidity
burn care must be conversant with the relevant techniques and anatomy. and mortality after burn injury. The pathogenesis can be differentiated
Isotonic salt solutions, most commonly lactated Ringers solution, should into direct pulmonary and upper airway inhalation injury, and secondary
be used for resuscitation and maintenance. (indirect) pulmonary injury due to activation of the systemic inflammatory
response. In addition, secondary delayed pulmonary injury can be caused