History and Physical Examination
Burn depth
The depth of a burn is classified according to the extent to which it involves the epidermis and dermis (see the image below):
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Superficial (first degree)
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Partial thickness (second degree), which is further divided into superficial, intermediate, and deep
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Full thickness (third degree)
Superficial burns
These burns have sunburn-like features with no open wounds and should not be taken into account in calculating the total body surface area (TBSA) burned for resuscitation purposes.
Partial-thickness burns
Superficial partial-thickness burns are characterized by injury to the epidermis and superficial dermis. These are second-degree burns and are characterized by ruptured weeping blisters. They are also erythematous and painful. Superficial partial-thickness burns spontaneously heal within 1-3 weeks, usually without scarring (see the image below).
Deep partial-thickness burns are characterized by injury to the epidermis and deeper dermis, but with some viable dermis remaining. They are also considered second-degree burns but are whiter and less erythematous as the depth of penetration into the dermis increases. Distinguishing between deep partial-thickness burns and full-thickness burns may initially be difficult.
Deep partial-thickness burns heal spontaneously but often after 3-4 weeks. The degree of scarring is related to the length of time needed for reepithelialization. (See the image below.)
Full thickness
Injury to the epidermis and entire dermis occurs. These are the third-degree burns that typically are white, brown, or black. The eschar is leathery and insensate. (See the image below.) These burns do not heal spontaneously (except for very small wounds that heal by contraction).
Injury types
Thermal burns
These occur most frequently as a result of scalds (hot liquids, steam), contact with a hot surface, or flash-flame/flame.
Electrical burns
Low-voltage injuries result from sources of less than 1000 V and include oral injuries from biting electrical cords, outlet injuries from placing objects into wall sockets, and injuries from contacting live wires or indoor appliances. High-voltage injuries are caused by sources of more than 1000 V and result from contact with a live wire outdoors or from being struck by lightning.
Children who have sustained high-voltage electrical injury require admission to the hospital with cardiac monitoring, serial electrocardiography (ECG), urinalysis, and determination of creatine kinase and urine myoglobin levels.
Myoglobinuria and hemoglobinuria should be aggressively treated with hydration, osmotic diuretics, and alkalinization of the urine to avoid renal failure. Extremities must be carefully monitored for the development of compartment syndrome, necessitating escharotomy or fasciotomy. Appropriate radiographic examinations should be performed to exclude concomitant long bone injury.
Many children who have sustained low-voltage electrical injury can be treated as outpatients as long as the following are true:
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The patient has no cardiac dysfunction, loss of consciousness, or history of tetany or wet skin during the accident
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The patient remains asymptomatic after 4 hours of observation in the emergency department
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The wounds are manageable in an outpatient setting
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The patient can return for a wound check the following day
Parents of children with oral commissure burns must be instructed in the application of pressure to the lip in the event that the burn erodes into the labial artery, a complication that usually does not develop until several days after the injury.
Frostbite
Frostbite results from prolonged exposure to severe cold and usually affects the ears, nose, hands, and feet. Ice crystal formation in the tissues results in cellular dehydration, venous dilation and vasoconstriction causing peripheral blood pooling, and, finally, tissue necrosis.
Signs and symptoms of frostbite include the following:
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Red, blue, or pale skin
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Prickling sensation with superficial frostbite
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Painless rigid skin with deep frostbite
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Functional impairment
Treatment involves placing the patient in a warm environment, removing clothing from the affected region, and rewarming the affected region by immersion in water at 100-105°F for up to 30-45 minutes. The frozen part should not be rewarmed with massage or dry heat.
Chemical burns
Saturated clothing should be removed, powdered chemicals should be brushed off the skin, and the contaminated area irrigated with copious amounts of water for at least 20 minutes, and until the patient experiences a decrease in pain in the wound. [8]
Chemical injuries to the eye are treated by forcing the eyelid open and flushing the eye with water or saline.
With gasoline injuries, the petroleum products may cause severe full-thickness cutaneous tissue damage, and absorption of the hydrocarbon may cause pulmonary, hepatic, or renal failure.
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Skin histology diagram.
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Superficial partial-thickness burn.
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Deep partial-thickness burn.
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Full-thickness burn.
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Pediatric Rule of Nines.
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Lund and Browder Chart.
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Endotracheal tube immobilization in children. The figure demonstrates a method using umbilical tape to secure a pediatric endotracheal tube in patients with facial burns.
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Dental device to anchor the endotracheal tube.
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Application of Mepilex Ag foam dressing.
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Aquacel Ag adherent to burn wounds.
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Use of Aquacel Ag. Appearance of healed burns 10 days later.
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Escharotomy sites.
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Left, Arm escharotomy. Right, Leg escharotomy.
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Chest wall escharotomy.
