Make your own free website on

Classification of Burn
Size of burn
Effects of Heat
Complications of Burn
Hand Burns
Electrical Burn
Patient Management

top home back

 Classification of burn according to Causative agent:
1. thermal burns – used when the burn is caused by: 
	a. heat as in flame burns or by hot steam
	b. cold as in frostbites from dry ice
2. electrical
3. chemical – as in burns due to sulfuric acid
4. radiation as in burns due to radiation therapy like cobalt therapy

Classification of Burns according to depth

1. Superficial partial thickness burn
	- damage occurs through the epidermis and into the pappilary layer
                    of the dermis
	- common sign: presence of intact blisters over the area that has
                    been injured
	- bright pink or red, mottled red
	- inflamed dermis
	- erythematous with blanching and capillary refill
	- moist surface, weeping/glistening 
	- painful
	- sensitive to changes in temperature, exposure to air currents,
                    light touch
	- moderate edema
	- spontaneous healing
	- minimal scarring 2-3 days desquamation period
	- complete healing: 7-10 days

2.Deep partial thickness burn
	- destruction of epidermis with damage of the dermis down into the
                     reticular layer
	- mixed red / waxy white color
	- the deeper the injury, the more white it will appear
	- wet surface from broken blisters and alteration of the dermal
          vascular network which leaks plasma fluid
	- marked edema
	- large amount of evaporative water loss because of tissue and
          vascular destruction
	- diminished sensation to light touch or soft pin-prick
	- retains sense of deep pressure due to the location of Pacinian
          corpscle deep in to the reticular dermis
	- healing occurs through the scar formation and
	- heal in 3-5 weeks
	- development of hypertrophic and keloid scars

3. Full Thickness burn
	- epidermal and dermal layers are destroyed completely
	- subcutaneous layer may be damaged 
	- hard, parchment-like eschar covering the area
	- eschar- devitalized tissue consisting of dessicated coagulum of
          plasma and necrotic cells
	- color of eschar vary from black to deep red to white
	- thrombosis of superficial blood vessel is apparent
	- no blanching of the tissue
	- deep red color of the tissue is due to the hemoglobin fixation
          liberated from destroyed red blood cells
	- all nerve endings an the dermal tissue are destroyed
	- damage to the peripheral vascular system because of large
          amounts of fluid leaking into the interstitial space
	- escharotomy – midlateral incision of the eschar
	- no sites for re-epithelialization

American Burn Association Classification according to Burn severity

1. Minor Burn
	- less than 15% body surface area(BSA) partial thickness burn in
          adult; less than 10% in a child
	- less than 2% BSA full thickness burn not involving the
          eyes, ears, face or perineum

2. Moderate Burn
	- all 15-25% BSA partial thickness burns in an adult; 10-20% in a
	- 2-10% BSA full thickness burn not involving the eyes, ears, face
          or perineum

3. Major Burn
        - all >25% BSA partial thickness burn in an adult; >20% BSA
          in a child
	- > or = 10% BSA full thickness burns
	- burns involving the face, eyes, ears, feet, and perineum
	- all electrical burns and burns with inhalation injury
 	- all burns with associated fracture or major tissue trauma
	- all burns where patient is a poor risk secondary to age or

top home back

SIZE OF BURN: rule of nine
	Head – 9% BSA 
	Each Upper Extremity – 9% BSA
	Each Lower Extremity – 18% BSA
	Anterior Trunk – 18% BSA
	Posterior Trunk – 18% BSA
	Perineum – 1% BSA

top home back

Local effects of heat
	1. histamine release
           - causes vasoconstriction
           - few hours, vasodilation and increase permeability of 
           - permits plasma to escape into the wound the more fluid, the 
             more hydrostatic pressure is produced damage cells swell
           - causing edema
	2. platelets and leukocytes aggregation
           - causing thrombotic ischemia and further damage
	3. damage cells swell / die
	4. Fluid evaporation
           - loss of massive amounts of body fluids through open wounds
           - it will results heat loss and large caloric drain on 
             the patient
	5. Bacterial Contamination
           - local burn wound sepsis results

 Amount of tissue destroyed depends on:
	1. local and systemic reactions to heat damage
	2. duration and intensity of thermal exposure
	3. characteristics of area burned

Systemic effects of heat
	1. Acute Hypovolemia
	2. Hyperventilation
	3. Upper airway obstruction
	4. Blood viscosity increases and platelets increase their 
	5. Acute gastric dilation and Gastrointestinal ileus
	6. Decrease immune system
	7. Increase risk of infection

top home back

1. osteophyte formation
2. abnormal sweating
3. cold intolerance
4. heat intolerance 
5. abnormal hair growth
6. callus formation
7. majolins ulcer
8. abnormal sensation
9. pruritus
10. easy fatigue
11. lack of endurance

top home back

Burn injuries to the hands have a profound effect on the patient’s 
return to normal function; therefore, hand therapy is stressed during 
both acute and post-acute phases. A comprehensive medical/surgical and
hand treatment protocol including splinting, post-graft immobilization, 
web spacers, compression gloves, and exercise in warm water or silicone 
gel produced good functional recovery and reduced need for 
reconstructure surgery.

- major cause of the typical clawed burned hand with hyperextension of 
  the metacarpophalangeal joints, flexion of proximal and distal 
  interphalangeal joints, 
  thumb in adduction and external rotation
- protein rich edema fluid appears to form a gel after about 
  12 hours, leading to obstruction of local lymphatic vessels and 
  impairing edema clearance
- anti-deformity position: with a resting hand splint, position 
  the wrist in slight extension, the MCP joints in 60-90 degrees 
  flexion, the proximal and distal IP joints in full extension, and 
  the thumb in palmar abduction
- treatment: elevation and active exercise

Exposed tendon and joints
- a serious problem because patient can dehydrate rapidly, denature, 
  and subsequently rupture
- if the dorsal hood mechanism is exposed, the IP joints should 
  be splinted in extension
- if joint capsules are exposed but not open, there should be 
  active gentle exercise and protectively splinted
- if the joint is open or draining, it will probably undergo 
  spontaneous ankylosis; therefore, functional positioning should 
  be encouraged

- intrinsic muscle stretching by mobilizing the metacarpals and 
  stretching the intrinsic muscles by hyperextension of the 
  MCP joint in combination with flexion of the proximal IP joint
- traction applied to the joints with passive movement allows 
  for additional ligamentous stretch
top home back

- mechanism of injury:
     Electrical injuries constitute only a small number of most burn 
     unit admissions; however, they probably represent the most
     devastating type of thermal injury. These injuries are arbitrarily
     divided into low voltage, those no greater than 500 to 1,000 
     volts, and high voltage, those greater than 1,000 volts. Home 
     injuries usually involve 110 to 220 volts with 60-cycle current 
     and cause little cutaneous and very rare deep muscle damage. 
     These low-voltage accidents, however, can be associated with 
     cardiac standstill or rhythm irregularities. The most common 
     low-voltage burn injury is in the child who bites an electrical 
     cord and sustains a burn of the commissure of the lips. Damage 
     is related primarily to tissue resistance and sensitivity to heat. 
     The most resistant or non-conductive tissue is bone, followed 
     by cartilage, tendon, skin, muscle, blood, and nerve. Blood 
     vessels and nerves offer little resistance, which produces 
     higher current flow. These structures also seem to be 
     particularly sensitive to heat damage and sustain injury 
     despite their low resistance.  

- soft tissue and bone damage:
     Tissue destruction is always greatest in areas of the body
     with small volume such as fingers, toes, wrists, and ankles.
     The acute surgical treatment is early diagnosis and debridement 
     of necrotic tissue. In all burn patients, the greatest number of 
     amputations occur from electrical injuries. Bone that is exposed 
     must be covered with moist dressings to prevent desiccation of 
     the periosteum. Some surgeons drill burr holes in exposed bone 
     to stimulate granulation tissue formation for eventual bone 

- systemic effects produce by electric currents:
	  - osteophyte formation
	  - premature fusion of epiphysis
	  - acceleration of growth

	  - conduction block
	  - right bundle branch block
	  - rhythm abnormality
	  - premature beat
	  - coma
	  - loss of memory
	  - depression
	  - personality changes 
	  - cataract

	  - sustained muscle contraction

	Gastrointestinal tract
	  - hemorrhage
	  - ileus
	  - necrosis

	  - acute tubular necrosis
	  - renal failure

	  -peripheral injury

top home back

Acute Phase

1. resuscitation
   – total percentage of SA burned is a priority in management
     to determine if intravenous fluid therapy is needed to prevent 
     or treat burn shock
   – shift of body fluids can cause intarvasular hypovolemia and 
      massive edema
   – formula of calibrating fluid requirement: BROOKE, EVANS. BAXTER
   – it is important that the fluid replacement be completed within 
      48 hours

2. escharotomy
   - an incision through the burned tissue to relieve increase tissue
   - massive edema of the extremities can cause neurovascular 
     compromise, which could result in amputation
   - fasciotomies – to prevent compartment syndrome
   - indicated when tissue pressures exceed to 40 mmHg

3. Wound Coverage
      A.Topical antibacterial agents
          - Materide
          - Silver nitrate
          - Gentamicin
          - Povidine iodine
          - Silver sulfadiazine
       B. Biological Dressings
           - skin substitute used for temporary coverage of the burn 
           - skin grafts from cadaver, human fetal membranes, and pigs
           - recommended usage of these dressings:
                i. for immediate coverage of a superficial partial 
                   thickness burn
                ii. wound debridement
                iii. test dressing
                iv. for wound coverage after excision of burn eschar
           - it prevents fluid loss
           - it decrease pain
           - it inhibits bacterial growth on clean wounds
           - it encourages growth of granulation tissue
           - should be change every several days because it may 
             incorporated to the burn wound

      C. Synthetic dressings
          - develop to cover open wounds until the wound healed or 
            until it could be autografted
          - used in place of xenografts and homografts
          - criteria to be effective:
                i. a product was needed must be readily available
                ii. non-allergenic
                iii. relatively expensive
                iv. easily removable had permeable membrane
                v. it comes in large sheets
          - ex. Biobrane ( has a bilaminar structure with silicone on the 
            outside and nylon bonded to the bottom, which is covered 
            with collagen)
          - ex. Opsite ( composed of thin, transparent, elastic, 
            adhesive-coated polyurethane film that is permeable to
            water vapor)

      D. Artificial skin
         - has dermal and epidermal layer
         - dermal layer is porous collagen fibrous matrix on which the 
           patient’s own fibroblasts and epidermal cells are seeded and 
           grow into an epidermal replacement
         - employed in cases of very large, full thickness or deep 
           partial thickness injuries with minimal donor sites for 


1. Debridement 
    - removal of devitalized tissue down to a viable tissue level to 
      prepare the wound bed for definitive coverage
    - removal of eschar aids in healing by preventing bacterial 
         A.Mechanical Debridement
            - best accomplished either during hydrotherapy or 
              immediately following
            - removal of dressings when they are dry is effective in 
              debridement of dead tissue because it adheres to the 

         B.Enzymatic Debridement
            - ex. Sutilains 
            - there is increased fluid drainage through the wound with 
              enzymatic debridement
            - side effects: bleeding, body temperature elevation, pain
            - not used in conjunction with hexachloropene or iodine

         C.Surgical Debridement
            - Fascial Excision (removes nonviable burn tissue and  a 
              variable amount of viable tissue and is reserved for 
              patient with very deep buns;skin grafts adhere much 
              better to fascia than to fat; side effects: fat does not 
              regenerate, can cause severe cosmetic deformities)
            - Tangential Excision (performed at 1- 10 days post-burn; 
              shave thin layers of eschar sequentially until viable 
              tissue is apparent:used to control bleeding, micro-
              crystalline collagen, thrombin, epinephrine, electro-
              cautery; ex. Tourniquets)

2. Skin Grafting
      a. Autograft – removal of skin from one part of the body 
	            and its transfer to another part
      b. Full thickness graft – for reconstructive procedure
      c. Split-thickness graft – used primarily
      d. tanner mesh graft – expandable skin that can be used 
	                     to cover large wounds
      e. postage stamp graft – application of squares/ rectangles 
	                      of various dimensions spread evenly over 
                              the wound
      f. sheet graft – involves using a piece of split-thickness skin
	               without meshing or cutting it into small squares; 
                       used in smaller burn wounds and on the face, neck, 

Wound Care
    - aggressive wound care is important to delineate wounds before 
      early surgical intervention, to protect and promote good 
      granulation tissue or to promote rapid healing in moderate to 
      deep partial-thickness wounds
    - goals to wound care: to prevent infection; to preserve as much 
      tissue as possible; to prepare the wound for earliest possible 
      closure by primary healing or grafting

    - neck extension
    - shoulder 90 degrees abduction and 15-20 degrees forward 
    - shoulder external rotation
    - elbow extension
    - forearm supination
    - hip neutral, slight abduction
    - knee full extension
    - ankle dorsiflexion

    - exposed tendons should be splinted in a slack position in an 
      attempt to prevent rupture 
    - exposed joints should be splinted for protection
    - major splints used in acute phase: resting hand splint; dorsi-
      flexion splints to ankles for tight heelcords and peroneal nerve 
      palsies; knee extension dorsiflexion splints to prevent “frog leg”; 
      elbow extension splints for limited elbow extension with the 
      precaution that the patient should have close to full elbow 

Exercise and Ambulation
    - convalescence, gentle, sustained stretch
    - exercise program: 3-4 times
    - active exercises to the lower extremity, whether burned or not, 
      to prevent thrombophlebitis
    - acute period: trunk mobilization is needed to prevent robot-type 
    - burns to the anterior trunk can cause rounding of the shoulder 
      with a sunken chest and shoulder elevation as well as limited 
      trunk rotary movements 
    - 1-2 weeks bed rest after lower extremity grafting

top home back