Pediatric emergency medicine trisk 804

Areas of partial- and full-thickness injuries should be recorded on an
anatomic chart and then a percentage of TBSA computed. First-degree
burns are not included. BSA calculations are inexact, and some burns may
progress over time, so BSA estimates should be reassessed.
Description of Burn. The language used to describe burn severity has
evolved over time, from a nomenclature of degrees to a description of the
anatomic depth of the burn ( Fig. 104.2 ).
A superficial burn (formerly called first degree) occurs when the
epidermis is injured but the dermis is intact. These burns are characterized
by redness and a mild inflammatory response confined to the epidermis,
without significant edema or bulla formation ( Fig. 104.3A ). Superficial
burns are not included in the calculation of burn surface area used for
therapeutic decisions. These minor burns may be painful and usually
resolve in 3 to 5 days without scarring.
In a partial-thickness burn (formerly called second degree), the dermis is
partially injured. Partial-thickness burns can be characterized as either
superficial or deep. Superficial partial-thickness burns expose the rich
capillary network in the dermis resulting in a pink-red color and moist
appearance. Blistering is often present ( Fig. 104.3B ). Increased capillary
permeability, resulting from direct thermal injury and local mediator
release, results in edema. These injuries are usually painful because intact
sensory nerve receptors are exposed. Healing occurs in about 2 weeks, and
scarring is usually minimal.


FIGURE 104.1 Estimation of surface area burned on the basis of age. This
modification by O’Neill of the Brooke Army Burn Center diagram shows the change in
surface of the head from 19% in an infant to 7% in an adult. Proper use of this chart
provides an accurate basis for subsequent management of the child with burn injury.

Deep partial-thickness burns involve destruction of the epidermis and

most of the dermis. Edema can lessen the exposure of sensory nerve
receptors, making some partial-thickness burns less painful and tender,
although there should be some intact pain sensation. Deep partial-thickness
burns have a paler, drier appearance than superficial injuries, at times
making them difficult to distinguish from full-thickness injury ( Fig.
104.3C ). Thrombosed vessels often give deep partial-thickness burns a
speckled appearance. Burns evaluated immediately may appear to be
partial-thickness injuries and subsequently become full-thickness injuries,
especially if secondary damage from infection, trauma, or hypoperfusion


ensues. Deep partial-thickness burns can take many weeks to heal
completely. Significant scarring is common and skin grafting may be
necessary to optimize cosmetic results.
Full-thickness burns (formerly called third degree) involve destruction of
the epidermis and the entire dermis. They usually have a pale or charred
color and a leathery appearance ( Fig. 104.3D ). Important for recognition is
the fact that destruction of the cutaneous nerves in the dermis makes them
nontender, although surrounding areas of partial-thickness burns may be
painful. Full-thickness burns cause a loss of skin elasticity. The burned skin
cannot expand as tissue edema develops during the first 24 to 48 hours of
fluid therapy. Circumferential or near-circumferential burns of the torso,
abdomen, or extremities can therefore cause respiratory distress, abdominal
compartment syndrome, and vascular insufficiency of the distal extremities,
respectively. Full-thickness burns cannot reepithelialize and can heal only
from the periphery. Most require skin grafting.