Академический Документы
Профессиональный Документы
Культура Документы
Based on the original burn depth classification by Dupuytren in 1832,22 burn wounds are commonly
classified as
superficial (first-degree),
partial-thickness (second-degree),
full thickness (third-degree), and
fourth-degree burns, which affect underlying soft tissue.
Partial-thickness burns
are classified as either superficial or deep partial-thickness burns by depth of involved dermis.
Second-degree burns have dermal involvement and are extremely painful with weeping and blisters,
and
is the most severely burned portion and is typically in the center of the wound.
As the name implies, the affected tissue is coagulated and sometimes frankly necrotic, much
like a third- or fourth-degree burn, and will need excision and grafting.
with variable degrees of vasoconstriction and resultant ischemia, much like a second-degree
burn. Appropriate resuscitation and wound care may help prevent conversion to a deeper
wound, but infection or suboptimal perfusion may result in an increase in burn depth.
This is clinically relevant because many superficial partial thickness burns will heal with
expectant management
the majority of deep partial-thickness burns require excision and skin grafting.
which will heal with minimal or no scarring and is most like a superficial or first-degree burn.
Unfortunately, even experienced burn surgeons have limited ability to accurately predict the healing
potential of partial thickness burns soon after injury; one reason is that burn wounds evolve over the
48 to 72 hours after injury.
Numerous techniques have been developed with the idea that better early prediction of burn depth
will expedite appropriate surgical decision making.
One of the most effective ways to determine burn depth is full thickness biopsy, but this has several
limitations; not only is the procedure painful and potentially scarring, but accurate interpretation of the
histopathology requires a specialized pathologist and may have slow turnaround times.
Laser Doppler can measure skin perfusion to predict burn depth with a positive predictive value of up
to 80% in some studies.
Noncontact ultrasound has been postulated as a painless modality to predict nonhealing wounds and
has the advantage of easily performed serial measurements.
Unfortunately, none of these newer therapies have proven adequately superior to justify their cost
and as yet have not substituted serial examination by experienced burn surgeons
Classification of Burns
Burns are commonly classified as thermal, electrical, or chemical burns, with thermal burns consisting
of flame, contact, or scald burns.
Flame burns
are not only the most common cause for hospital admission of burns, but also have the highest
mortality.
This is primarily related to their association with structural fires and the accompanying
inhalation injury and/or CO poisoning.
Electrical burns
make up only 4% of U.S. hospital admissions but have special concerns including the potential
for cardiac arrhythmias and compartment syndromes with concurrent rhabdomyolysis. A
baseline ECG is recommended in all patients with an electrical injury, and a normal ECG in a
low-voltage injury may preclude hospital admission.
Because compartment syndrome and rhabdomyolysis are common in high-voltage electrical
injuries, vigilance must be maintained for neurologic or vascular compromise, and fasciotomies
should be performed even in cases of moderate clinical suspicion.
Long-term neurologic and visual symptoms are not uncommon with high-voltage electrical
injuries, and ophthalmologic and neurologic consultation should be obtained to better define a
patient’s baseline function
Chemical burns
are less common but potentially severe burns. The most important components of initial
therapy are careful removal of the toxic substance from the patient and irrigation of the
affected area with water for a minimum of 30 minutes, except in cases of concrete powder or
powdered forms of lye, which should be swept from the patient to avoid activating the
aluminum hydroxide with water.
The offending agents in chemical burns can be systemically absorbed and may cause specific
metabolic derangements.
Formic acid has been known to cause hemolysis and hemoglobinuria, and hydrofluoric acid
causes hypocalcemia.
Hydrofluoric acid is a particularly common offender due to its widespread industrial uses.
Calcium-based therapies are the mainstay of treating hydrofluoric acid burns, with topical
application of calcium gluconate onto wounds and IV administration of calcium gluconate for
systemic symptoms.
Intra-arterial calcium gluconate infusion provides effective treatment of progressive tissue
injury and intense pain.
Patients undergoing intra-arterial therapy need continuous cardiac monitoring. Persistent
refractory hypocalcemia with electrocardiac abnormalities may signal the need for emergent
excision of the burned areas
Treatment of the Burn Wound
Silver sulfadiazine
Mafenide acetate,
Silver nitrate
Increasingly, Dakin’s solution (0.5% sodium hypochlorite solution) is being used as an inexpensive
topical antimicrobial.
For smaller burns or larger burns that are nearly healed, topical ointments such as bacitracin,
neomycin, and polymyxin B can be used. These are also useful for superficial partial thickness facial
burns as they can be applied and left open to air without dressing coverage. Meshed skin grafts in
which the interstices are nearly closed are another indication for use of these agents, preferably with
greasy gauze to help retain the ointment in the affected area.
All three have been reported to cause nephrotoxicity and should be used sparingly in large burns.
The recent media fascination with methicillin-resistant Staphylococcus aureus (MRSA) has led to
widespread use by community practitioners of mupirocin for new burns. Unless the patient has known
risk factors for MRSA, mupirocin should only be used in culture-positive burn wound infections to
prevent emergence of further resistance.
Silver-impregnated dressings such as Acticoat (Smith & Nephew, London, United Kingdom), Aquacel
Ag (Convatec, Princeton, NJ), and Mepilex Ag (Mölnlycke Health Care US, LLC, Norcross, GA)
are increasingly being used for donor sites, skin grafts, and partial-thickness burns. These may
be more comfortable for the patient, reduce the number of dressing changes, and shorten
hospital length of stay, but they do limit serial wound
examinations.
Biologic membranes such as Biobrane (DowHickham, Sugarland, TX) provide a prolonged barrier
under which wounds may heal. Because of the occlusive nature of these dressings, these are
typically used only on fresh superficial partial-thickness burns that are clearly not contaminated