[SPECON] Burn Rehabilitation

What is the most common cause of burns in children (1-5 years)?

Scalds and hot liquids

What is the most common cause of burns in adolescents and adults?

Accidents from hot liquids

What population has the highest prevalence of burns?

Males between 16-40 years old

Aside from the age groups already mentioned, what is the leading cause of burns in other age groups?

Fires in homes and structural dwellings

What is the most common cause of death associated with burns?

Inhalation injury

What are the percentages of the age groups most commonly involved with burns?

• <1 year

• 2-14 years

• 25-44 years

• <1 year (24%)

• 2-14 years (25%)

• 25-44 years (25%)

What type of burns are most common?

Scale burns (43%)

When were majority of wounds commonly treated?

24 hours of the injury (89%)

What is the fatality rate of burns?

9%

What is the most common cause of death due to burns?

Multiple organ system disruption (MOSD) (40%)

*inhalation still top

What are the significant factors associated with mortality rate due to burns?

• %TBSA (total body surface area)

• Inhalation injury

• Involvement of the head, lower extremity, and perineum

What is the relationship between %TBSA and mortality rate?

Increased TBSA = increased mortality rate

Among the significant factors associated with mortality in burns, which is the worse one?

• %TBSA (total body surface area)

• Inhalation injury

• Involvement of the head, lower extremity, and perineum

Inhalation injury

What are the risk factors for burns?

• Occupations that increase exposure to fire

• Poverty, overcrowding, and lack of safety measures

• Placement of young girls in household roles such as cooking and care of small children

• Underlying medical conditions including epilepsy, peripheral neuropathies, and physical and cognitive disabilities

• Alcohol abuse and smoking

• Easy access for chemicals used for assault (such as acid violence attacks)

• Use of kerosene as a fuel source for non-electric domestic appliances

• Inadequate safety measures for liquefied petroleum gas and electricity

This is the usual fuel source of low-income households that act as a risk factor for burns.

Kerosene

Read: In the Philippines (2010-2012):

• 883 fires

• 43% of fires occurred in the first 4 months of the year (summer time)

• Highest incidence occurs at 12:01 - 3:00 am (everyone was asleep)

What was the most common cause of fires in the Philippines in 2010-2012?

Faulty electrical wiring and neglected open flames

What areas were most commonly affected by fires in the Philippines in 2010-2012?

Residential areas

What was the worst fire in Philippine history?

Ozone Disco Fire

This is the largest organ of the body.

Follow Up Question: What are the functions of this organ?

Skin

• Protective shield against heat, light, injury, and infection

• Regulation of body temperature

• Storage of fat and water (can lead to dehydration)

• Prevents entry of bacteria

This structure secretes sebum to lubricate and waterproof the skin and hair.

Sebaceous (oil) gland

This produces sweat to cool the body down through evaporation.

Eccrine sweat glands

These small muscles that pull hair upright to create "goosebumps".

Arrector pili muscle

These are sensitive nerve endings that detect when a hair moves.

Hair follicle receptor

This is where the fatty tissue that stores energy and acts as a shock absorber is.

Adipose tissue

This is a network of blood vessels that supplies nutrients and helps regulate body temperature.

Cutaneous vascular plexus

This is the opening on the surface where sweat is released.

Pore of sweat gland

This is the surface or outer layer of the skin that serves as a barrier between our body and the environment.

Epidermis

What are the layers of the epidermis?

• Stratum corneum

• Stratum lucidum

• Stratum granulosum

• Stratum spinosum

• Stratum germinativum or stratum basale

This is the layer of the skin where cells are produced.

Stratum germinativum or basale

This is the layer of skin beneath the epidermis.

Follow Up Question: How many times thicker is it than the epidermis?

Dermis

20-30 times thicker

The dermis is comprised of what and contains what?

Contains epidermal appendages

Comprised mainly of interwoven collagen and elastin fibers

What are the two layers of the dermis?

• Papillary layer

• Reticular layer

Identify its location and function: free nerve endings

• Location: epidermis and dermis

• Function: pain and itch

Identify its location and function: Merkel’s disks

• Location: epidermis (stratum spinosum)

• Function: touch

Identify its location and function: Meissner’s corpuscles

• Location: papillary dermis

• Function: touch

Identify its location and function: Ruffini’s endings

• Location: papillary dermis

• Function: warm receptors

Identify its location and function: Krause end bulb

• Location: papillary dermis

• Function: cold receptors

Identify its location and function: Pacinian corpuscles

• Location: reticular dermis

• Function: pressure and vibration receptors

This is the layer that lies below the dermis.

Follow Up Question: What does it consist of?

Hypodermis or subdermis

Loose connective tissue, elastin, and fat

What are the functions of the hypodermis?

Padding and insulation (because of the fat)

What is the mechanism of injury of burns?

Alteration of vascular integrity (injured cell releases its content, leading to the release of cytokines) → vasodilation occurs due to the release histamine, migrating of blood to the tissues → edema occurs and usually leads to LOM (which can also occur due to contractures)

What does skin destruction depend on?

• Temperature

• Length of time he was burned

• Type of insult (flame, liquid, chemical, electrical)

• Extremes of age — skin is affected easier

What are the types of burns?

• Thermal burns

• Electrical burns

• Chemical burns

What are the usual causes of thermal burns?

Scalds, flame, and contact

This makes up 70% of burns in children and occurs due to spilling hot drinks or liquids, or hot water in baths.

Follow Up Question: How deep are the burns that this lead to?

Scalds

Causes superficial to superficial thickness burns

This makes up 50% of adult burns and is associated with an inhalation injury and other concomitant trauma.

Follow Up Question: How deep are the burns that this lead to?

Flame

Deep or full thickness

The depth of heat injury in contact burns depends on what factors?

Follow Up Question: How deep are the burns that this lead to?

Degree of heat exposure and depth of heat penetration

Deep dermal or full thickness

This is the most devastating type of burn.

Electrical burns

Fill in the Blanks: In electrical burns, an electrical current will travel through the body from one point to another, creating “______” or “______” points.

Follow Up Question: Electrical burns vary according to what?

In electrical burns, an electrical current will travel through the body from one point to another, creating “entry” or “exit” points.

• Type of current

• Intensity of the current

• Area of the body that the current passes through

From most resistant to least resistant, what is the ranking of electrical resistance of the tissues of the body?

1. Bone

2. Cartilage

3. Tendon

4. Skin

5. Muscle

6. Blood

7. Nerve

[electricity usually travels where there is less resistance]

What are the two types of electrical burns and how many volts of current travel through the body?

Follow Up Question: What do the electrical burns lead to?

• Low-voltage electrical burns (500-1000 volts of current)

  • V-fib

• High-voltage electrical burns (greater than 1000 volts)

  • Apnea, deep tissue destruction, renal failure

Differentiate a true from a flash high-voltage electrical burn.

• True — electricity really went through the patient

• Flash — only happened beside the patient

In electrical burns, this often results in amputation.

Follow Up Question: What is most commonly affected or amputated?

Extensive muscle and soft tissue necrosis

UE most common, usually the (R) UE

In high voltage electrical burns, these problems may not be present initially but may occur late after.

PNS and CNS problems

What are the complications associated with electrical burns due to being struck by lighting?

• Myelopathy and encephalopathy

• Sensorineural and mechanical hearing loss

What are the ocular complications associated with electrical burns?

• Cataracts

• Macular holes

What are the cardiac manifestations of electrical burns?

• Immediate cardiac arrest

• Pseudo infarction

• Myocardial ischemia without necrosis

• Dysrhythmia

• Conduction abnormalities

• Acute hypertension

• Nonspecific ECG abnormalities

• Sinus tachycardia

What are other manifestations of electrical burns?

• Diaphragm paralysis

• Inhibition of the breathing centers in the midbrain

• Extensive fluid loss

• Loss of consciousness

• Impaired recall and PTSD

• Blood clotting

• Compartment syndrome

• Rhabdomyolysis

This occurs secondary to injured muscles, leading to increased pressure inside the extremity.

Compartment syndrome

This condition is a serious, potentially fatal condition involving rapid skeletal muscle breakdown, releasing toxic contents like myoglobin into the bloodstream, which causes kidney damage.

Follow Up Question: How is it treated?

Rhabdomyolysis

Treated through dialysis or increasing fluid intake

These usually occur as a result of an industrial accident, but it may occur with household chemical products.

Chemical burns

Which one more commonly causes burns? Alkali or acidic products?

Alkali products

These are one of the leading causes of death, accounting for more than half of the burn-related deaths per year.

Follow Up Question: How are they classified?

Inhalation injuries

Carbon monoxide poisoning, heat, or smoke inhalation injuries

What are the signs of inhalation injuries?

• Facial burn

• Singed nasal burn

• Harsh cough

• Hoarseness

• Abnormal breath sounds

• Respiratory distress

• Carbonaceous sputum — black sputum

• Hypoxemia

What are the three zones of local response?

• Zone of coagulation

• Zone of stasis

• Zone of hyperemia

This zone occurs at the point of maximum damage and is characterized by irreversible tissue loss.

Zone of coagulation

This zone is characterized by decreased tissue perfusion.

Follow Up Question: What is the goal of this zone?

Zone of stasis

To increase perfusion

This is the outermost zone, where the tissue will recover unless there is severe sepsis.

Zone of hyperemia

Read: Pathophysiological changes during hypermetabolic/hyperdynamic phase of burn (>48 hr)

What is the old classification of burns?

• First degree

• Second degree

• Third degree

• Fourth degree

Identify the classification based on the old classification:

• Superficial injury

• Red and sometimes painful

Follow Up Question: Until what layer is the extent of cell damage?

First degree

Epidermis

Identify the classification based on the old classification:

• Skin may be red and blistered and swollen

• Very painful

Follow Up Question: Until what layer is the extent of cell damage?

Second degree

Epidermis and parts of the dermis

Identify the classification based on the old classification:

• Whitish, charred, or translucent

Follow Up Question: Until what layer is the extent of cell damage?

Third degree

Epidermis and dermis

What sensation is lost in third degree burns?

Pin prick sensation on the burned area (due to affected free nerve endings)

Identify the classification based on the old classification:

• Deep and potentially life-threatening

Follow Up Question: Until what layer is the extent of cell damage?

Fourth degree

Skin and underlying tissues

What is the new classification of burns?

• Epidermal

• Superficial partial thickness

• Deep partial thickness

• Full thickness

• Subdermal

Identify the classification based on the new classification:

• Skin appears to be red or erythematous

• Dry surface

• Absent blisters

• Minimal edema

Follow Up Question: Until where is the cell damage?

Epidermal

Epidermis

Fill in the Blanks: In epidermal burns, there is a ______ in the development of pain.

Follow Up Question: When does it peel off and desquamates and how is the healing and scar tissue formation?

In epidermal burns, there is a delay in the development of pain.

3-4 days; spontaneous healing with no scar tissue

Identify the classification based on the new classification:

• Intact blisters

• Blanching

• Moderate erythema

• Extremely painful

Follow Up Question: Until where is the cell damage?

Superficial partial thickness

Epidermis into the papillary layer of the dermis

How is the desquamation, healing, and scarring of superficial partial thickness burns?

Follow Up Question: How long does it take to completely heal?

Desquamation occurs due to topical agents, residual skin color occurs due to destruction of melanocytes, and minimal scarring

7-10 days

Identify the classification based on the new classification:

• Most of the nerve endings, hair follicles, and sweat ducts are injured

• Mixed or waxy white

• Marked edema

Follow Up Question: Until where is the cell damage?

Deep partial thickness

Epidermis and papillary dermis with damage to the reticular layer

Deep partial thickness burns will have findings on the sensory test due to damage to the nerve endings. What sensations are diminished and what are spared?

Light touch or sharp/dull pressure; retains deep pressure

What is the main problem in patients with deep partial thickness burns?

Dehydration (large amount of evaporative water loss [15-20x])

How does healing and scarring occur and when does it heal in deep partial thickness burns?

Hypertrophic scar formation and re-epithelialization within 3-5 weeks if not infected

Identify the classification based on the new classification:

• Presence of eschar

Follow Up Question: What is the extent of cell damage and what structures are destroyed and damaged?

Full thickness

• Epidermal and dermal layers completely destroyed

• Hair follicles are completely destroyed

• All nerve endings are destroyed

• Damage to the peripheral vascular system

This is a hard, parchment-like, black or brown covering of the area.

Eschar

Identify the classification based on the new classification:

• Complete destruction of all tissue from the epidermis to the subcutaneous tissue

Follow Up Question: What does this occur due to?

Subdermal burn

Prolonged contact with a heat source or contact with electricity

When muscles and bones are burned in a subdermal burn, what are these subjected to?

Necrosis

What is the main implication of subdermal burns in terms of the patient’s safety?

No sensation

When is skin grafting required for burns?

In third and fourth degree burns.

Getting the total body surface area (TBSA) is more practical in the emergent triage of a patient with an acute burn injury. How do we get the patient’s TBSA?

Using the Rule of 9 — divide the body into areas of 9%

This tool divides the body into much smaller areas and gives the sizes that are associated with differently aged patients, accounting for a continuum age and to accommodate for growth of different body segments. It is a more accurate mean to determine the extent of burns.

Modified Lund and Browder Method

What is the TBSA for minor, moderate, and major burn injuries in children and elderly?

• Minor: <10% TBSA

• Moderate: 10-20% TBSA

• Major: >20%

What is the TBSA for minor, moderate, and major burn injuries in adults?

• Minor: <15%

• Moderate: 15-25%

• Major: >25%

In terms of full thickness burns, differentiate a mild, moderate, and major burn injury.

• Minor: 2% not involving the EEHFP

• Moderate: 2-10%, except EEHFP, electrical, or inhalation

• Major: >10% except EEHP, electrical, or inhalation

Is the burn injury minor, moderate, or major in a patient with suspected inhalation injury?

Moderate

Is the burn injury minor, moderate, or major in a patient with known inhalation injury?

Major

Is the burn injury minor, moderate, or major in a patient with an electrical burn?

Major

Is the burn injury minor, moderate, or major in a patient with burns in the eyes, ears, face, perineum, or hands?

Major