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How to use this
module
2.
Learning
outcomes
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
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Burns
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3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
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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
Learning outcomes
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By the end of the module, you should be able to:
2.
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outcomes
• describe the structure of the skin
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
treatment required (outpatient, inpatient or specialist
10.
End of Module
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care)
Home
• outline the local and systemic effects of burn injury
• assess the size of burns accurately
• assess the depth of burns accurately and relate how
this determines the way in which it heals
• classify burn injuries according to the type of
Anatomy of skin (1)
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Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
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Epidermis
basement
membrane
Dermis
Subcutaneous
layer
The 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.
Anatomy of skin (2)
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Local effects of
burn injury
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Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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Thickness of skin increases from birth until approximately 40
years of age, then it starts to thin again. It also varies over
different parts of the body.
Which of the following areas do you
think has a thin epidermis?:
a. Eyelid
b. Palm
c. Foot
Click to Reveal Answers
The eyelid has a thin epidermis
(~0.05mm). The palm and foot have
a thick epidermis (>1.5mm).
Anatomy of skin – Epidermis (1)
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burn injury
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Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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EPIDERMIS
A protective barrier of stratified
squamous epithelium consisting of 5
layers
1.
Stratum corneum: 20-30 rows
of dead cells continually shed
2.
Stratum lucidum: 3-4 layers
clear flat dead cells
3.
Stratum granulosum: Cells
degenerating with production of
keratin
4.
Stratum spinosum: 8-10 rows
of cells that produce protein but
can not duplicate
5.
Stratum basale: Columnar
cells continually dividing,
gradually migrating to surface
There are three other cell types within the epidermis: melanocyte,
Langerhan and Merkel cells
Anatomy of skin – Epidermis (2)
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Local effects of
burn injury
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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Other cell types within the epidermis:
1.
Melanocytes: Produce melanin pigment causing brown colouration of skin
and protects skin from UV light damage
2.
Langerhan cells: Immune cells which help in defence. Situated in stratum
spinosum, they help process and present foreign antigens to the immune
system
3.
Merkel cells: Within the basal layer, close to hair follicles; involved in touch
sensation
Click to Reveal Answers
(a)
(b)
(c)
Who do you think has more
melanocytes (a), (b) or (c)?
None of them! All racial
groups have the same
number of melanocytes, but
dark skin individuals have
more metabolically active
cells which produce more
melanin.
Anatomy of skin – Dermis (1)
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Local effects of
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
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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 loops
• Reticular dermis: The lower layer of
dermis. It is made up of collagen,
elastin and ground substance as well
as hair follicles, sweat and sebaceous
glands
Fibroblasts 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.
Anatomy of skin – Dermis (2)
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There are other cell types and structures within the dermis:
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• Myofibroblasts - contractile, important in healing of wounds
3.
Anatomy and
function of skin
• Macrophages - derived from vascular leucocytes;
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
• Mast cells - contain histamine
6.
Assessing the
burn surface area
• Lymphocytes - mediate immune function
7.
Assessing the
depth of the burn
• Sensory receptors
8.
Classification of
burn injury
Meisners
Khause
Ruffins
Paccinian
9.
Information
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Texture
Cold
Heat
Vibration &
deep pressure
10.
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phagocytic and stimulate fibroblasts
Functions of the skin
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Local effects of
burn injury
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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Physical barrier
Vitamin D production
Immunity
Sensation
Identity
Temperature control
Remember P V I S I T !
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Local effects of burn injury (1)
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Local effects of
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Systemic effects
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Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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Summary of local effects:
–
Cell death/disturbed function
–
Release of inflammatory mediators
–
Increased capillary permeability
–
Microvascular thrombosis
1. Cell death/disturbed function
Cellular 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 55C,
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).
Local effects of burn injury (2)
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Local effects of
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Systemic effects
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burn surface area
7.
Assessing the
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8.
Classification of
burn injury
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2. Release of inflammatory mediators
Potent vasoactive mediators are released from the burn wound. These include
vasoconstrictors and vasodilators, histamine, serotonin, kinins, prostaglandins
and oxygen free radicals
•
Thromboxane: causes platelet aggregation and microvascular thrombus formation
•
Histamine: released by mast cells; causes increase in capillary permeability
•
Prostaglandins: result in arteriolar dilatation
•
Kinins: increases vascular permeability
•
Serotonin: increases vascular resistance and venous hydrostatic pressure leading
to oedema
•
Oxygen free radicals: increase vascular permeability
Local effects of burn injury (3)
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Local effects of
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Systemic effects
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Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
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10.
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3. Increased capillary permeability
When capillaries are damaged, they leak protein-rich fluid which results in
oedema.
Normal skin; normal
capillary permeability
Burn wound oedema with
increased capillary permeability
and protein leakage
Local effects of burn injury (4)
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Local effects of
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
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10.
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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
Systemic effects of burn injury (1)
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Local effects of
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Systemic effects
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Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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When a burn is large (>20% of total body surface area), in
addition to the local response, there is also a systemic
response
With large burns, the loss of
circulating blood volume
will rapidly lead to
HYPOVOLAEMIC
SHOCK, unless
resuscitation is started
Loss of
circulating
blood
Ischaemia
Vascular
permeability
Vasoactive substances are released that act not just locally
in the burned tissue, but in non-burned tissue as well.
Systemic effects of burn injury (2)
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Systemic effects
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6.
Assessing the
burn surface area
Immune system
7.
Assessing the
depth of the burn
Renal system
8.
Classification of
burn injury
9.
Information
Sources
10.
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Psychological system
Respiratory system
Cardiovascular system
Gastrointestinal system
Haematological system
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Learning
outcomes
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
Assessing total burn surface area
(TBSA)
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The area of this burn is about 3-5% of
total body surface area.
How much of the
body surface
area is burnt?
There are several ways to assess the size of a burn. They all consider the burnt
area as a percentage of the total body surface area and are supported by
mapping the burnt area on a diagram. In the next couple of slides, we will be
looking at the following methods of assessment:
1.
The rule of 9’s
2.
Lund and Browder charts
3.
Palm of hand
4.
Unburnt area
Assessing TBSA - Rule of Nines
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This method divides the body into areas each of which
2.
Learning
outcomes
equates to 9% of the total body surface area:
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
• 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%
5.
Systemic effects
of burn injury
• anterior trunk is 18%
6.
Assessing the
burn surface area
• posterior trunk including buttocks is 18%
7.
Assessing the
depth of the burn
• the whole lower limb (anterior and posterior surfaces,
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
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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.
Home
Assessing TBSA in children
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Local effects of
burn injury
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
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10.
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Why might the “rule of
9’s” be unreliable in
children?
Body proportions change with age. In a child,
the head represents a much greater proportion
of the total body surface area.
Assessing TBSA - Lund and
Browder charts
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These take account of the
3.
Anatomy and
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patient’s age and provide a
4.
Local effects of
burn injury
more detailed mapping system
5.
Systemic effects
of burn injury
for the burnt area
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
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10.
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AREA
AGE 0
1
5
10
15
ADULT
A = ½ OF HEAD
9½
8½
6½
5½
4½
3½
B = ½ OF ONE THIGH
2¾
3¼
4
4½
4½
4¾
C = ½ OF ONE LEG
2½
2½
2¾
3
3¼
3½
Assessing TBSA - Palm size
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burn injury
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Systemic effects
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6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
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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.
Assessing TBSA - Unburnt area
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burn injury
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Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
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In very large burns,
it is often easier to
measure the area of
skin that is unburnt
and then subtract
this from 100%.
Area of the body involved
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Assessing the
burn surface area
7.
Assessing the
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Classification of
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Not only is the surface area or size of burn important, but also
the specific part of the body affected
Eyes: Burns to the
eyes (especially
chemical) can cause
blindness.
Face: Facial oedema
can lead to airway
obstruction. Scarring
can cause significant
psychosocial problems
Feet: Mobility
problems
Perineum: problems with
urogenital function and
psychosexual
Hands: Problems with
feeding and hygiene
Circumferential burns of the limbs can cause distal ischaemia; of the
chest, can compromise breathing
Depth of burn
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The depth of a burn determines its treatment and how long it
takes to heal.
For this reason, it is important to be able to assess the depth
as:
 Superficial
 Partial thickness
6.
Assessing the
burn surface area
• Superficial partial thickness
7.
Assessing the
depth of the burn
• Deep partial thickness
8.
Classification of
burn injury
9.
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 Full thickness
Depth of burn - Superficial (erythema)
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burn injury
Involves epidermis only:
•
Painful
•
Red
Systemic effects
of burn injury
•
No blistering
6.
Assessing the
burn surface area
•
Heals rapidly (reversible injury)
7.
Assessing the
depth of the burn
•
No permanent scars
8.
Classification of
burn injury
9.
Information
Sources
Note that erythema is NOT included when
assessing TBSA
10.
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5.
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Depth of Burn – superficial partial
thickness
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Local effects of
burn injury
Typical hot water scald
Involves epidermis and upper
dermis:
•
Red
•
Blistering, moist
5.
Systemic effects
of burn injury
•
Painful
6.
Assessing the
burn surface area
•
Heals by epithelialization
7.
Assessing the
depth of the burn
•
Healing complete within 14 days
8.
Classification of
burn injury
•
Minimal or no permanent scars
9.
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End of Module
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but can leave discolouration
Patches of skin
that would come
off on cleaning
Glistening moist
red/pink
appearance typical
of superficial injury
Depth of Burn - superficial partial
thickness
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burn surface area
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Assessing the
depth of the burn
8.
Classification of
burn injury
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Pin-point
bleeding
Blister
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Pink surface;
blanches on
pressure
Depth of Burn – deep partial thickness
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burn injury
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Systemic effects
of burn injury
Involves epidermis, upper dermis and
varying degrees of lower dermis:
•
Pale, mottled appearance
•
Fixed staining (no blanching)
•
May be painful or insensate
(depending on depth)
•
Heals by combination of
epithilialization and wound
contracture
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
•
May take weeks to heal
8.
Classification of
burn injury
•
9.
Information
Sources
Can leave significant scars and
contractures over joints depending
on time taken to heal
10.
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Deep dermal area, reddish
with fixed staining
Depth of Burn – full thickness
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5.
•
Involves all of epidermis and all of
dermis
•
Dry, leathery (white, dark brown or
charred)
Systemic effects
of burn injury
•
Insensate
6.
Assessing the
burn surface area
•
Heals by contraction
7.
Assessing the
depth of the burn
•
Delayed healing
8.
Classification of
burn injury
•
Hypertrophic or keloid scars
9.
Information
Sources
•
Leads to contractures
10.
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Dry, leathery, charred
appearance of a full
thickness burn
Circumferential full thickness burn
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burn surface area
7.
Assessing the
depth of the burn
8.
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burn injury
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Black, charred skin
Typical position of
hand in full thickness
burns with
metacarpophalangeal
joints extended and
interphalangeal joints
flexed
Depth of Burn – mixed thickness
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(A)
Assess the
depth of the
burn in areas
A, B and C
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(B)
(C)
Depth of Burn – Mixed thickness
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Assessing the
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Full thickness,
dry white
leathery
appearance
Superficial partial
thickness showing
pink blanching
Deep dermal with pale pink and
white patches, non blanching
Classifying the patient
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7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
Quiz
Home
First you should assess the severity of the
burn injury according to
• TBSA
• depth
• position
• presence of infection
• time since the burn
• presence or absence of inhalation injury
Combine this information with patient factors:
• age
• associated injuries
• other medical problems
• nutritional status
Finally consider social and family factors to
classify the patient according to how and
where to provide treatment.
A guideline for patient classification
Partners in Global Health Education
1.
How to use this
module
2.
Learning
outcomes
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
Quiz
Home
Factors
Burn injury
• TBSA
Small
Moderate
Large
• depth
Superficial
Partial thickness
Full thickness
Localised
Critical area
Systemic
mild
severe
• position
• presence of infection
• inhalation injury
Non-critical area
Absent
Absent
Patient factors
• age
Adult or older child
Extremes of age
• associated injuries
none
significant
• other medical problems
none
significant
• nutritional status
Social / family factors
Malnourished
Normal
Able to care for oneself
Out-patient
Unable to care for oneself
In-patient
Specialist
Sources of information
Partners in Global Health Education
1.
How to use this
module
2.
Learning
outcomes
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
Quiz
Home
• Some images have been
adapted from CorelDraw clipart
• See www.interburns.org for more
information
End of Module Quiz
Partners in Global Health Education
1.
How to use this
module
2.
Learning
outcomes
3.
Anatomy and
function of skin
4.
Local effects of
burn injury
5.
Systemic effects
of burn injury
6.
Assessing the
burn surface area
7.
Assessing the
depth of the burn
8.
Classification of
burn injury
9.
Information
Sources
10.
End of Module
Quiz
Home
Well done!
Now that you have completed the burns module you
may wish to try these questions to assess your
learning.
First, print-out the questions and write down your
answers to each one.
Then look at the answer sheet to assess your
learning.
Questions
Answers