Burn Injuries and Treatment

Burn Categories, Debridement Techniques and Surgical Excision

A burn is damage to the skin’s tissues, usually caused by excessive heat. Recognising different types of burns and having a basic knowledge of how to treat them can minimise injury and prevent fatalities. Apart from direct fire, heat, in its different forms, represents significant danger and is the most obvious cause of burn injuries. This can be direct contact with fires, radiators or hot liquids, but also the radiated heat from an extreme source of heat, such as a furnace or open fire. Burns can also be caused by chemicals, electricity, the sun’s rays, friction (rubbing or chafing) or extreme cold.

Burns usually affect the skin, but other important areas of the body can also be injured. For example, the airways and lungs can be damaged as a result of inhaling hot fumes and gases. The severity of a burn depends on how deeply it has affected the tissue.

Electrical burns from electric current, either alternating current (AC) or direct current (DC), are among the most serious burns and require immediate medical attention. They occur when electric current flows through tissue or bone, generating heat that causes tissue damage. The human body cannot dissipate the heat generated by current flowing through the resistance of the tissue and therefore burns occur.

The skin is the largest organ of the body and has many important functions. It is composed of three layers, with each layer performing specific functions.

• The Epidermis is the thin outer layer of the skin which consists of three parts; the Stratum Corneum, Keratinocytes and the Basal Layer.

• The Dermis is the middle layer and contains blood vessels, lymph vessels, hair follicles, sweat glands, collagen bundles, fibroblasts and nerves.

• The Subcutis is the deepest layer of the skin. The Subcutis, consisting of a network of collagen and fat cells, helps conserve the body's heat and protects the body from injury by acting as a 'shock absorber'.

Burns are categorised as first, second and third-degree, depending on how deep and severely they penetrate the skin's surface. The three main factors which determine the mortality of a burn patient are; the size of the burn, the age of the patient and the presence of smoke inhalation, which can cause airways to swell so badly the patient suffocates.

First-degree (superficial) burn

Previously referred to as a first-degree burn, a superficial burn is limited to the epidermis. It is characterised by heat, pain, moistening and reddening of the burned surface, but rarely shows blistering or charring of tissue. Superficial burns, which heal by regeneration of the epidermis often heal in three to seven days and seldom scar. Typical superficial burns include sunburn and minor scalds.

Second-degree (partial thickness) burn

Sometimes referred to as partial thickness burns, second-degree burns are characterised as either ‘superficial’ or ‘deep’. Both types penetrate deeper than a first-degree burn and destroy the epidermal layers, extending into the dermis layer. They can cause damage to sweat glands and hair follicles and are extremely painful, often with intense swelling.

Skin that has incurred a superficial second-degree burn is moist, red and weepy. Most superficial second-degree burns heal in ten to twenty one days, but leave a change in skin colour and pigmentation. A deep second-degree burn can be ivory or pearly white in colour and may require a process known as debridement and additional skin grafting treatments.

In debridement, dead tissue is removed so that the remaining living tissue can adequately heal. Dead tissue exposed to the air will form a hard black crust, called an eschar. Deeper tissue will remain moist and may appear white, or yellow and soft, or flimsy. The four major debridement techniques are surgical, mechanical, chemical and autolytic.

Surgical Debridement

Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut dead tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalised infection (sepsis) that has entered the bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or close to another organ, however, or if the patient is experiencing extreme pain, the procedure may be performed in an operating room. Surgical debridement is generally performed by a physician, but in some countries an advanced practice nurse or physician assistant may perform the procedure.

The physician will begin by flushing the area with a saline (salt water) solution and will then apply a topical anaesthetic gel to the edges of the wound to minimise pain. Using a forceps to grip the dead tissue, the physician will cut it away bit by bit with a scalpel or scissors. Sometimes it is necessary to leave some dead tissue behind rather than disturb living tissue. The physician may repeat the process again at another session.

Mechanical Debridement

In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away with the dressing. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as non-living tissue. Because mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healing cells is already developing.

Chemical Debridement

Chemical debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes its own enzyme, collagenase, to break down collagen, one of the major building blocks of skin. A pharmaceutical version of collagenase is available and is highly effective as a debridement agent. As with other debridement techniques, the area is first flushed with saline. Any crust of dead tissue is etched in a cross-hatched pattern to allow the enzyme to penetrate. A topical antibiotic is also applied to prevent introducing infection into the bloodstream. A moist dressing is then placed over the wound.

Autolytic Debridement

Autolytic debridement takes advantage of the body's own ability to dissolve dead tissue. The key to the technique is keeping the wound moist, which can be accomplished with a variety of dressings. These dressings help to trap wound fluid that contains growth factors, enzymes and immune cells that promote wound healing. Autolytic debridement is more selective than any other debridement method, but it also takes the longest to work. It is inappropriate for wounds that have become infected.

Third-degree (full thickness) burn

A third-degree burn, also known as a full thickness burn, destroys all the epidermal and dermal skin layers. The tissue damage extends below hair follicles and sweat glands to subcutaneous (fat) tissue. With this degree of burn, the skin becomes charred and leathery and often appears depressed relative to surrounding tissue. The skin can be bright red, waxy white, tan or brown; there are no blisters and third-degree burns may cause massive swelling. Perhaps surprisingly, third-degree burns are usually not painful because the injury has destroyed nerve endings. Skin grafting or other replacement options are required for treatment of a third-degree burn.

When a burn injury is deep enough to involve muscle, bone, tendon and/or ligament, it is sometimes classified as a fourth-degree burn. These burns are often life threatening and may require amputation.

Surgical Excision

Excision is usually an option for burn wounds determined to be deep second or full thickness third-degree. This process surgically removes dead tissue in order to prepare the wound for a skin graft or other skin replacement procedures. Using specialised instruments, a surgeon will remove thin layers of burned skin until living tissue is exposed. The wound is then cleaned and prepared for grafting.

Early excision of the burn eschar (dead tissue) has been one of the most significant advances in modern burn care. Historical advances in understanding of the pathophysiology of burn injury and the systematic inflammatory response fueled by the burn wound and refinements in the techniques of tangential and fascial excision, have led to earlier excision and grafting of the burn wound with improvements in morbidity and mortality. Efforts to control blood loss and good operative planning and attention to special areas, can lead to the safe excision and grafting of large burns.

Agency for Clinical Innovation (ACI) - Publication

The Agency for Clinical Innovation is the lead New South Wales Government agency for innovation in clinical care, bringing patients, clinicians and managers together to support innovation, design and implementation. Their vision is to create the future of healthcare and healthier futures for the people of New South Wales.

ACI's published document, "Burn Patient Management: Summary of Evidence", provides a comprehensive summary of the available evidence to support the Burn Patient Management and the Minor Burn Management guidelines developed by the ACI Statewide Burn Injury Service (SBIS).

Download Burn Patient Management: Summary of Evidence.

What to do if a Person Sustains Burn Injuries

Personal safety should be the first priority of anyone offering first-aid to a person with burns. It is important to be aware of any ongoing risks of fire, chemicals or electricity. There may also be risk of toxic fumes or explosion, for example, due to nearby petrol or gas supply.

The next step is to stop the burning process. Any clothing that is not stuck to the burn should be carefully removed. The affected body surface areas should then be flooded with cold water until medical help, if necessary, is available. The skin usually swells after a burn so it is important to remove anything constricting such as jewellery.

Do not attempt to burst any blisters that form on burnt skin. If a burn is caused by a chemical, the chemical should be removed, by brushing it away as if it were a dry powder or flooding with large amounts of cold water.

In the Event of Electrocution

The first and most important point is NOT to touch the victim. If a person is receiving an electric shock, anybody rendering assistance will receive the same electric shock.

Before assistance is administered the power supply must be turned off. If this is not possible for any reason, the person rendering assistance should use a non-conductive item such as a wooden chair or wooden broom handle to either pull or push the victim away from the source of electrocution. Once done, medical assistance should be immediately called. The victim should then be laid on their back and checked to determine whether they are breathing and whether a pulse is evident on the wrist or neck. If the victim is not breathing, CPR should be performed until medical assistance arrives or the victim begins to breath.

If the victim is breathing -

• With the victim lying on their back, elevate their feet and loosen clothing.

• Cover the victim with a coat or blanket if available.

• Do not apply anything to the burns and do not allow the victim to drink.

• Continually check the victim's breathing and wait for medical assistance to arrive.

When to Seek Medical Help

Medical help is required:

• For all second and third-degree burns.

• For first-degree burns covering an area larger than the palm of the hand.

• For burns on the face, hands or in the groin.

• Where there is any doubt about the extent of the burn or how to deal with it.

Hospital Treatment

At the hospital, medical staff will continue first-aid measures and protect the damaged skin with dressings. Healthy skin prevents loss of fluid from the tissues underneath and is also a very effective barrier against infection. These functions are lost when the skin is burned. After severe burns, large quantities of fluid can be lost through the skin which can have a serious affect on the heart and circulation. This is the reason why people with serious burns need to be closely monitored and often require intravenous fluids to help circulation.

Severe burns need to be cared for in specialist burns units where other specialist treatments can be given to help look after patients. Burns may become infected because the skin is less able to protect itself from infection by bacteria. This is the reason why more serious burns need to be dressed and kept clean to help prevent this while the skin heals. If infection is suspected, treatment with antibiotics might be required. Most recently, major advances have been realised using the new super-oxidised water technology called Microcyn® to clean and debride the wound while minimising the pain traditionally experienced by burn victims.

The Microcyn®-based family of products are generated through a unique, patented electrochemical treatment of dilute saltwater. A pH neutral solution of hypochlorous acid, and its sodium salt, hypochlorite, is generated. The hypochlorous acid in Microcyn®, similar to the natural hypochlorous acid produced by the human body, preserves the Microcyn® solution.

The unique solution chemistry imparted through the patented Microcyn® manufacturing system provides superior product stability. Standard electrochemical processes used in the manufacture of other hypochlorous acid-containing products, cannot come close to matching this stability.

Recovering from Burns

The time taken for burns to heal depends on how serious they are. Most superficial burns heal within about two weeks and do not usually leave a scar. Deeper burns take longer to heal and sometimes require skin grafts. This is a plastic surgery technique using skin from an unaffected part of the body to repair an injured area of skin that is not going to be able to heal itself. Third-degree burns tend to result in scars that can be difficult to treat. Specialist treatment by plastic surgeons in these cases is aimed at minimising such scars.

Other types of treatment or support may be required as part of rehabilitation after burns. Physiotherapy can help restore movement to burnt areas, especially the hands. Advice on how to apply specialist products for camouflaging scars is available from staff in dermatology departments.

Generally, burn rehabilitation begins during the acute treatment phase and may last days to months to years, depending on the extent of the burn. Rehabilitation is designed to meet each patient's specific needs and therefore each program is different. The goals of a burn rehabilitation program include helping the patient return to the highest level of function and independence possible, while improving the overall quality of life: physically, emotionally and socially. In order to help reach these goals, burn rehabilitation programs may include:

• Complex wound care.

• Pain management.

• Physical therapy for positioning, splinting and exercise.

• Occupational therapy for assistance with activities of daily living.

• Cosmetic reconstruction.

• Skin grafting.

• Psychological treatments such as counselling can help patients come to terms with having been in an accident or with any serious changes to their appearance. Counselling also deals with common emotional responses during convalescence, such as depression, grieving, anxiety, guilt and insomnia.

• Patient and family education counselling.

• Nutritional counselling.

A Compelling Story About One Man's Survival (courtesy Johns Hopkins Magazine) 

When Bryan Fultz set himself on fire in an office accident, his girlfriend helped put out the flames. After that, it was up to the Johns Hopkins Burn Center staff not just to save his life but to give it back to him. Fultz had burns to 55 percent of his body, 42 percent of which were third-degree.

Read Fultz's story titled After The Fire and learn more about burn treatment and rehabilitation programs. These programs are vital for patient survivability and a necessary 'evil' for assisting patients to hopefully get their life back.

Skin Grafts

Treatment of severe burns often requires skin grafting. Skin grafts involve taking skin from unburned sites on the body, referred to as donor sites and grafting that skin onto the burn wound. The grafted skin attaches to the underlying tissue and effectively closes the wound.

A graft ‘takes’ when new blood vessels and tissue form in the injured area. Sometimes, skin grafts do not take because of complications such as infection (the most common cause of graft failure) or shearing (pressure causing a graft to detach from the skin). While grafting is a proven and effective treatment, it is important to understand that all grafts leave some scarring at both the donor and recipient sites.

By using a patient's own skin to cover a burn wound, the risk of tissue rejection is eliminated. However, skin grafts are often a challenge for patients with severe burns across large portions of their body. In these instances there may not be sufficient donor site skin to immediately cover all of the individual's wounds.

Skin flaps are a complex type of skin graft that attach donor skin and underlying tissue by surgically connecting blood supply from the wound to the transferred skin. Skin flaps and other skin replacement methods are sometimes used in situations where standard skin grafts are not possible or where alternative methods are preferred.

Depiction of a Patient Skin Graft

Acknowledgement

Medical information posted in this section has been reproduced with acknowledgement to Oculus Innovative Sciences (Sonoma Pharmaceuticals NASDAQ: SNOA).

Oculus Innovative Sciences is a commercial healthcare company that designs, produces and markets innovative, safe and effective healthcare products. Oculus is pioneering innovative solutions in multiple markets including dermatology, surgical, wound care, animal healthcare and others and has commercialised products in the United States, Europe, India, China and Mexico and select Middle East countries. The company's headquarters are in Petaluma, California, with manufacturing operations in the United States and Latin America.

This website section clearly demonstrates why corporations must commit to hazard risk assessments to determine the best selection of protective work wear for their particular workplace conditions. The purpose of FR clothing worn by a worker should be to minimise the severity and percentage of body burn injury when exposed to electric arc, flash fire or molten metal splash. Third-degree burn injury should be prevented while second-degree burns should be minimised. This will create the best chance for worker survivability.

The following graph shows how minimising the percentage of body burn injury can greatly increase a worker’s chance of survival. Once the percentage of body burn injury rises above 50 percent, the survival rate reduces significantly in all age groups.