Chief Complaint: 8-year-old girl admitted for severe second- and third-degree burns
following her rescue from a burning house.
History: Angela Creighton, an 8-year-old white female, was transported by ambulance
to the emergency room after being rescued from her burning house. She was asleep at
night when a spark from the family fireplace started a fire, leaving her trapped in her
bedroom. By the time the fire rescue squad arrived, she had suffered severe burns and
excessive smoke inhalation.
In the emergency room, Angela was unconscious. She had second-degree burns over
5% of her body and third-degree burns over 15% of her body -- both covering her
thoracic and abdominal regions and her right elbow. Her vital signs were quite unstable:
blood pressure = 55 / 35; heart rate = 210 beats / min.; and respiratory rate = 40 breaths
/ min. She was quickly deteriorating from circulatory failure. Two IVs were inserted and
fluids were administered through each. Her vital signs stabilized and she was
transported to the pediatric intensive care unit (ICU).
Angela regained consciousness the following morning, surprisingly complaining of only
minor pain over her trunk. Following debridement of her burns and application of a
broad-spectrum, topical antibiotic, a plastic epidermal graft was applied over the burned
areas. Despite treatment with a broad-spectrum antibiotic, she developed a systemic
staphylococcal infection, necessitating a switch to a different antibiotic.
Angela began a long, slow recovery. Her position in bed had to be changed every 2
hours to prevent the formation of decubitus ulcers (i.e. bedsores). She lost 9 pounds
over the next 3 weeks, despite nasogastric tube feeding of 5000 calories ("Kcals") per
day. After 9 weeks, sheets of cultured epidermal cells were grafted to her regenerating
dermal layer. By the 15th week of her hospitalization, her epidermal graft was complete,
and she was back on solid foods, her antibiotics were discontinued, and she was
discharged from the hospital with a rehabilitation plan for both physical and occupational
therapy at home, as well as twice-weekly visits by a nurse.
Questions:
1. Briefly describe the three major layers that make up healthy skin.
A. Epidermis - this layer is composed of keratinized, stratified, squamous epithelium. It provides a
thick, water-proof, protective covering over the underlying layers of skin.
B. Dermis - this layer is composed primarily of dense, irregular, fibrous connective tissue that is
rich in collagen (for strength) and elastin (for elasticity). The dermis contains blood vessels, nerve
endings, and epidermally derived cutaneous organs such as sweat glands, sebaceous glands,
and hair follicles.
C. Hypodermis ("subcutaneous layer") - this layer is composed primarily of loose, areolar
connective tissue and adipose tissue. The fat layer provides mechanical cushioning and a thermal
insulation layer for underlying organs.
2. Briefly describe the extent of damage seen in first-degree burns, second-degree burns, and
third-degree burns.
A. First-degree burns - burns in which the damage is limited to the epidermal layer. These burns cause
redness, swelling, and pain in the involved area, and are often followed by a period of desquamation (i.e.
excessive shedding of epidermal cells). They typically heal within a few days. Sunburn is an example of a
first-degree burn.
B. Second-degree burns - burns that damage the epidermis and the upper layer of the dermis (i.e. "partial
thickness" burns). More severe than first-degree burns, these burns often cause blistering of the skin and
take longer to heal. These burns usually heal within four weeks, and long-term scarring does not occur.
C. Third-degree burns - the most severe of all, these are burns that damage the entire epidermis, dermis,
and often the subcutaneous layer (i.e. "full-thickness" burns). The burned skin, called the "eschar," may
appear charred, blanched, or bright red.
3. Why was this girl relatively pain-free when she woke up?
The burned areas of Angela's body may actually feel numb because of destruction of the dermal
nerve endings. However, she may have considerable pain around the margins of her third-degree
burn in areas of second-degree burn, where pain nerve endings are still capable of firing
impulses.
4. Explain why this patient's blood pressure was so low and her heart rate so high upon
arrival at the emergency room.
Angela suffered from third-degree burns over 15% of her body surface. In other words, she has lost the
water-tight, protective covering over a significant percentage of her body surface area. Furthermore, the
intense inflammatory response in the area of the burn causes surviving blood vessels to leak fluid into
surrounding tissues. Thus, there has been a significant shift of water from her bloodstream to the
interstitial spaces, leaving Angela hypovolemic (i.e. with reduced blood volume). The reduced blood
volume lowers her blood pressure, but Angela's body attempts to raise blood pressure to an adequate
level by increasing her heart rate. The severe swelling of tissues alluded to above can impair circulation
(particularly in circumferential burns of the limbs) and respiration (particularly in torso burns). An
escharotomy is often performed in these cases to relieve some of the tissue pressure. In this procedure,
an incision is made at strategic points in the burned skin.
5. Why was it important to immediately administer intravenous fluids to this girl?
Angela will require intravenous fluids to replace the fluid lost from her bloodstream. If she doesn't receive
IV fluids, she may go into hypovolemic shock, a condition in which the blood pressure is so low that her
organs do not receive sufficient bloodflow to survive.
6. What is a "broad-spectrum" antibiotic, and why did she need it? Is healthy skin normally
colonized by bacteria?
A broad-spectrum antibiotic is a medication given to treat and / or prevent infections from a wide variety of
bacteria. Angela's third-degree burns place her at considerable risk for infection because she no longer
has a protective covering against bacterial invasion. The skin is normally colonized with bacteria (the socalled "normal flora"). On intact skin, these bacteria cause no problem, and may, in fact, protect us from
more dangerous microorganisms. In damaged skin, however, these normally harmless bacteria can
cause severe blood-borne infections. For this reason, broad-spectrum antibiotics are given both topically
over the skin and by intravenous injection.
7. Why was skin-grafting necessary in this patient? (Why not just let the skin heal on its own?)
Skin that is severely damaged by third-degree burns often requires weeks to months to heal. Because the
healing process is so slow, the patient would often succumb to complications of the burn (e.g.
hypovolemic shock, systemic infection, or severe electrolyte imbalance causing life-threatening
dysrhythmias of the heart) were it not for the development of skin grafts which help speed up the healing
process.
8. Describe the series of events that occur in skin which is healing with the help of a skin-graft.
Initial treatment of a third-degree burn requires the debridement of the burned skin (called the eschar)
and administration of topical antibiotics. The debridement process is often accomplished by placing the
burned body part (or even the entire patient) in a hydrotherapy tank - - the jet-like propulsion of the water
can help gently remove the burned tissue. Then, to minimize fluid loss and the risk of infection, cadaveric
skin, pig skin, or a human amniotic membrane is temporarily placed over the debrided area. This
temporary covering is removed after the patient is stabilized and, depending on the size of the burn, it is
replaced by skin harvested from elsewhere on the patient's body or by a synthetic skin graft. In synthetic
skin graft placement, a plastic meshwork covered with collagen and ground cartilage is placed onto the
damaged skin. Over time, the patient's own dermal blood vessels grow into the synthetic graft.
Macrophages follow, digesting the graft's collagen and cartilage while fibroblasts migrating in lay down
new connective tissue. As this process continues, healthy epidermis is harvested from non-burned parts
of the patient's body and allowed to proliferate in the laboratory. Given the appropriate, nutrient-rich
environment, these harvested epidermal cells can form fairly large sheets of tissue. As the tissue in the
synthetic dermis is reorganized, these harvested sheets of epidermal cells are placed over the top and
allowed to proliferate until the entire burned surface is re-covered with epidermis. While complete healing
is the ultimate goal, severe scarring of the skin often results from third-degree burns.
9. Why are bedridden patients at risk for developing decubitus ulcers? Where on the body do
such ulcers most commonly occur?
Patients who are bedridden and immobile often lie in the same position for prolonged periods of time.
This continual pressure on the skin over bony prominences can impair dermal blood flow, slow down the
rate of epidermal cell division, and lead to ulceration of the skin (i.e. forming a decubitus ulcer, or
"bedsore"). The most common locations for these ulcers are over the scapular spines, elbows, sacrum,
greater trochanters, medial and lateral malleoli, and heels. Adequate fluids and nutrition, as well as skin
massaging and frequent position changes, can reduce Angela's risk of developing decubitus ulcers.
10. Why did the patient lose so much weight despite being on a very high-calorie diet?
Angela's body is undergoing a major inflammatory and healing response which requires a substantial
calorie intake to provide the energy necessary for this response. It is not unusual for a severe burn victim
to require two to three times his/her normal calorie intake during the healing phase
11. What long-term problems may the patient have as a result of extensive scar tissue formation
over her trunk and her right elbow?
Long-term scarring over Angela's trunk may make it difficult for her to expand her thorax during inhalation.
The proliferation of scar tissue around her elbow may limit mobility at this joint.