3 Be sure to keep hot liquids out of reach of small children. Looks and tastes great, right? You should see what a hot liquid will do to a child’s skin when the two come into contact.Be sure to keep hot liquids out of reach of small children.
4 The SkinThe skin, the largest organ of the body, consists of two layers-the epidermis and dermis. The depth or degree of burn depends on which layers of skin are damaged or destroyed. The epidermis is the outer layer that forms the protective covering. The thicker or inner layer of the dermis contains blood vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the dermis is destroyed, so are the nerve endings that allow a person to feel pain, temperature, and tactile sensation.
5 The burn/wound center includes an expanded reception area for children receiving outpatient care.
12 Typical burns from hot water in a child Welcome to the burns module!Burns constitute a major global problem and are a leading cause of trauma deaths in children. Minor burns, if poorly treated, cause devastating complications with lifelong morbidity.Understanding how burns cause tissue damage and how the skin heals is vitally important in ensuring that the right diagnosis is made and the right treatment given.Typical burns from hot water in a child
13 Anatomy of skin (1)Epidermisbasement membraneDermisSubcutaneous layerThe skin is made up of two layers, the outer layer (epidermis) and inner layer (dermis). Between the epidermis and dermis is the basement membrane which is semi permeable and acellular. It provides support, flexibility and regulates the transfer of substances across the dermal-epidermal junction.Under the skin is the subcutaneous layer which allows the skin to be loosely attached to the underlying fascia. It increases mobility and is especially important over joints.
14 Anatomy of skin – Epidermis (1) A protective barrier of stratifiedsquamous epithelium consisting of 5layersStratum corneum: rows of dead cells continually shedStratum lucidum: 3-4 layers clear flat dead cellsStratum granulosum: Cells degenerating with production of keratinStratum spinosum: 8-10 rows of cells that produce protein but can not duplicateStratum basale: Columnar cells continually dividing, gradually migrating to surfaceEPIDERMISThere are three other cell types within the epidermis: melanocyte, Langerhan and Merkel cells
15 Anatomy of skin – Dermis (1) The dermis consists of 2 layers:Papiliary dermis: The upper layer of dermis. It has extensions protruding into the epidermis called Rete pegs which also contain small capillary loopsReticular dermis: The lower layer of dermis. It is made up of collagen, elastin and ground substance as well as hair follicles, sweat and sebaceous glandsFibroblasts are the predominant cell type in the dermis and produce collagen and elastin which provide strength and flexibility to the skin.In addition, there are blood vessels, sebaceous glands, sweat glands, hair follicles, sensory receptors and fat cells.
16 Functions of the skin Physical barrier Vitamin D production Immunity SensationIdentityTemperature control
17 Local effects of burn injury (1) Summary of local effects:Cell death/disturbed functionRelease of inflammatory mediatorsIncreased capillary permeabilityMicrovascular thrombosis1. Cell death/disturbed functionCellular function is disturbed when the temperature rises above 43oC. The higher the temperature and more prolonged the contact, the more cells die. An instantaneous full thickness burn occurs at a temperature of 700C or greater.Due to differences in skin thickness with age, at 55C, severe damage occurs after 10 seconds in a child and 30 seconds in an adult. Skin thickness is also reduced in older people and in certain conditions (e.g. steroid therapy).
18 Local effects of burn injury (3) 3. Increased capillary permeability When capillaries are damaged, they leak protein-rich fluid which results in oedema.Normal skin; normal capillary permeabilityBurn wound oedema with increased capillary permeability and protein leakage
19 Local effects of burn injury (4) 4. Microvascular Thrombosis Release of thrombogenic factors such as thromboxane, together with a hypovolaemic state cause sludging in the smallest blood vessels. This in turn leads to further tissue ischaemia, increased cell death and can cause extension of the depth and surface area of the burn.Area of burn increases due to sludging in blood vessels and ischaemia
20 Systemic effects of burn injury (2) Click each boxPsychological systemRespiratory systemCardiovascular systemImmune systemRenal systemGastrointestinal systemHaematological system
21 Assessing TBSA - Rule of Nines This method divides the body into areas each of which equates to 9% of the total body surface area:the whole of one arm (anterior and posterior surfaces including the hand) is 9%, therefore 2 arms = 18%the entire head including face, scalp and neck is 9%anterior trunk is 18%posterior trunk including buttocks is 18%the whole lower limb (anterior and posterior surfaces, including the thigh, leg and foot) is 18%; therefore both lower limbs = 36%.This totals 99% with the perineum making the final 1%.Beware: this method is unreliable in young children.
22 Assessing TBSA in children Why might the “rule of 9’s” be unreliable in children?Click to Reveal AnswersBody proportions change with age. In a child, the head represents a much greater proportion of the total body surface area.
23 Assessing TBSA - Lund and Browder charts These take account of the patient’s age and provide a more detailed mapping system for the burnt areaAREAAGE 0151015ADULTA = ½ OF HEAD9 ½8 ½6 ½5 ½4 ½3 ½B = ½ OF ONE THIGH2 ¾3 ¼44 ¾C = ½ OF ONE LEG2 ½3
24 Assessing TBSA - Palm size Another useful way, especially for small burns is to use the palm of the patient’s hand (with fingers extended). This equates to approximately 1% of the body surface area.
25 Assessing TBSA - Unburnt area In very large burns, it is often easier to measure the area of skin that is unburnt and then subtract this from 100%.
26 Area of the body involved Not only is the surface area or size of burn important, but also the specific part of the body affectedEyes: Burns to the eyes (especially chemical) can cause blindness.Face: Facial oedema can lead to airway obstruction. Scarring can cause significant psychosocial problemsFeet: Mobility problemsHands: Problems with feeding and hygienePerineum: problems with urogenital function and psychosexualCircumferential burns of the limbs can cause distal ischaemia; of the chest, can compromise breathing
27 Depth of burn - Superficial (erythema) Involves epidermis only:PainfulRedNo blisteringHeals rapidly (reversible injury)No permanent scarsNote that erythema is NOT included when assessing TBSA
28 Depth of Burn – superficial partial thickness Typical hot water scaldInvolves epidermis and upper dermis:RedBlistering, moistPainfulHeals by epithelializationHealing complete within 14 daysMinimal or no permanent scarsbut can leave discolourationGlistening moist red/pink appearance typical of superficial injuryPatches of skin that would come off on cleaning
29 Depth of Burn - superficial partial thickness Pin-point bleedingPink surface; blanches on pressureBlister
30 Depth of Burn – deep partial thickness Involves epidermis, upper dermis and varying degrees of lower dermis:Pale, mottled appearanceFixed staining (no blanching)May be painful or insensate (depending on depth)Heals by combination of epithilialization and wound contractureMay take weeks to healCan leave significant scars and contractures over joints depending on time taken to healDeep dermal area, reddish with fixed staining
31 Depth of Burn – full thickness Involves all of epidermis and all of dermisDry, leathery (white, dark brown or charred)InsensateHeals by contractionDelayed healingHypertrophic or keloid scarsLeads to contracturesDry, leathery, charred appearance of a full thickness burn
32 Circumferential full thickness burn Black, charred skinTypical position of hand in full thickness burns with metacarpophalangeal joints extended and interphalangeal joints flexed
33 Depth of Burn – mixed thickness (A)Assess the depth of the burn in areas A, B and C
34 Depth of Burn – Mixed thickness Full thickness, dry white leathery appearanceDeep dermal with pale pink and white patches, non blanchingSuperficial partial thickness showing pink blanching
35 Zones of Burn Injury Zone of Coagulation Zone of Stasis Inner ZoneArea of cellular death (necrosis)Zone of StasisArea surrounding zone of coagulationCellular injury: decreased blood flow & inflammationPotentially salvable; susceptible to additional injuryZone of HyperemiaPeripheral area of burnArea of least cellular injury & increased blood flowComplete recovery of this tissue likely.
36 Superficial-Thickness Burns Involves the epidermisWound Appearance:Red to pinkMild edemaDry and no blisteringPain / hypersensitivity to touchi.e. Classic sunburnDesquamation (peeling of dead skin) occurs 2-3 days post-burnWound Healing:In 3 to 5 days (spontaneous)No scarring / other complications
37 Superficial, Partial-Thickness Burns Involves upper 1/3 of dermisWound Appearance:Red to pinkWet and weeping woundsThin-walled, fluid-filled blistersMild to moderate edemaExtremely painfulWound Healing:In 2 weeks (spontaneous)Minimal scarring; minor pigment discoloration may occur
38 Full-Thickness Burns Involves the entire epidermis and dermis Wound Appearance:Dry, leathery and rigid+ Eschar (hard and in-elastic)Red, white, yellow, brown or blackSevere edemaPainless & insensitive to palpationWound Healing:No spontaneous healing; weeks to months with graftWound Management:Surgical excision & skin grafting
41 A Child Suffering From Marasmus. The word marasmus is derived from a Latin word meaning to decay. Marasmus is seen when an individual (a child or adult) is essentially starving, typically energy intake would fall short of energy usage - Notice the absence of body fat and looseness of skin (e.g. over the surface of the arms) which can indicate sudden or extreme weight loss.
42 Kwashiorkor Produces Characteristic Oedematous Protruding Abdomen In Children.
43 A Badly Infected Deep Burn Wound (Streptococcus faecalis & Pseudomonas aeruginosa) In An Elderley Patient.Necrotic Tissue May Have To Be Removed/Excised To Treat The Infection.
44 Burn Wound Infected With Pseudomonas spp. After Application Of A Graft. Pseudomonal infections frequently produce a green discolouration.
45 Burn Wound Infected With Staphylococcus spp. In hospital environments Staphyloccoccus spp. maybe resistant to one, or several, antibiotics. Burned regions may therefore be regularly swabbed and screened for antibiotic resistance/susceptibility should an infection occur.
46 A Chronic Non-Healing Burn Wound Due To A Protein Dietary Deficiency. Pale Granulating Areas Are Becoming Larger.Surrounding Epithelium Is Becoming White (*),Macerated & Non-Adherent.Clarke John. A colour atlas of burns injuries. Chapman & Hall Medical. P60(*) This individual is white.
47 Inadequate Nutrition In A Patient With Extensive Burns. One Year After The Injury.One year after the injury gross emaciation is evident (i.e. severe muscle wasting & stiffening at the joints) in addition to the large areas of unhealed areas of skin that were previous damaged by this thermal injury.
48 Inadequate Nutrition In A Patient With Extensive Burns Inadequate Nutrition In A Patient With Extensive Burns. One Year After The Injury. Wounds Have Become Over-Granulated And Epithelialisation Is Not Seen At The Wound Margins.Spontaneous healing is expected if adequate levels of nutrition are introduced & maintained.
49 Appearance After Three Months Of Nasogastrc Feeding Wounds Have Healed Without The Need For Grafts – Though There Has Not Been Any Significant Increase In Body Mass.
50 Appearance Of The Patient One Month Later. Adequate Nutrition & Healing Allow The Person To Support Their Own Weight Though Joint Deformity Remains.Clarke John. A colour atlas of burns injuries. Chapman & Hall Medical. P60