by Jacob Gerlitz, NP
In the past few decades there has been a marked improvement in the management of burns. But, burns are still a complex condition that requires medical care coordination between EMS, hospitals, specialists and primary care providers.
Skin Anatomy and Function
The skin is considered an organ, and it’s actually the largest organ of the body. The skin contains three main tissue layers: the epidermis, the dermis and subcutaneous tissue. The outermost layer, the epidermis acts as a barrier to prevent the entry of microorganisms and other toxic substances to enter the body. It also functions to maintain balance of the body’s fluids and electrolytes. The dermis – which also helps with fluid and electrolyte balance – possesses an extensive network of blood vessels, nerves, glands, and collagen. The subcutaneous tissue is the deepest structure of the skin. It contains fatty connective tissue, glands and hair follicles.
When skin is burned, the protective elements of the skin are damaged which allows the invasion of microorganisms and prevent local immune responses. Severe burn injuries diminish the body’s systemic immune response which can lead to serious infections.
Burn injuries are usually classified according to degrees: first-degree burns, second-degree burns, third-degree burns and fourth-degree burns.
First-degree burns, there is only minor damage to the most superficial, outermost aspect of the skin. In first-degree burns the epithelium is intact, but there is redness, tenderness and pain. There is no blistering. These types of burns heal by themselves within a few days and do not produce scarring. The skin integrity is intact so there is no risk of infection. Sunburns are a common causes of first-degree burns.
Second-degree burns are partial-thickness burns. There are two types of second degree burns: superficial and deeper. The superficial second degree burn involve the epidermis and the dermis but elements of the dermis are intact which allow for full healing without scarring. These burns are pink, wet, blister, and are very painful. They heal in approximately 2-3 weeks, usually without scarring. Deeper second degree burns also heal without the need for skin grafts and have minor risk of scarring, but they take longer to heal, usually 3-6 weeks. If a deeper second degree burn is overlying a joint it could lead to skin contraction that could limit range of motion. Deeper second-degree burns are also at greater risk of infection and usually require antimicrobial dressings. Scalding from hot water splashing is a common cause of second-degree burns.
Third-degree burns destroy both the epidermis and dermis and are therefore called full-thickness burns. The blood supply of the dermis is destroyed leading to skin that has a white or leathery appearance. These burns require skin grafts. Common causes of third-degree burns are: hot water Immersion scalds, flame burns, and chemical and high-voltage electrical injuries.
Fourth-degree burns are full-thickness burns that also include the subcutaneous tissue and the underlying fascia, muscle, bone, or other structures. Fourth-degree burns are complex burns that require highly specialized treatment including reconstruction and result in prolonged disability. The causes of fourth-degree burns are the same as third-degree burns but are more severe.
The severity of a burn injury depends on a few factors: depth, and location of burn injury; age of the patient; the causative agent that produced the burn; the presence of inhalation injury (smoke); and coexisting injuries or comorbidities. Based on these five factors the American Burn Association has established guidelines that classify burn severity into three general categories: major, moderate, and minor. “Minor” in this categorization does not mean a first degree burn such as a sunburn. First degree burns are not included in the categorization. It means a second-degree burn that involves less than 15% of an adult body, or less than 10% of a child or elderly person’s body. Minor burn injury also cannot pose functional dysfunction or cosmetic risks.
Minor burn injury can be treated in an outpatient setting such as an appropriately staffed and stocked urgent care center.
Professional Medical Care
Burns need emergency medical care if they are partial or full thickness burn (second or third degree burns) that involves the genitals, eyes, ears, hands, or feet, or burns over major joints regardless of size. Also seek emergency care for burns that look deep and are dry, painless or look charred (black); pain is uncontrollable; or deep burns that are larger than the size of ones palm; burns that include the face that cause breathing problems; smoke inhalation; any electrical burn.