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 broadspectrum, 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 so-called "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. 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
join