Burn Depth

Based on the original burn depth classification by Dupuytren in 1832,22 burn wounds are commonly
classified as

 superficial (first-degree),
 partial-thickness (second-degree),
 full thickness (third-degree), and
 fourth-degree burns, which affect underlying soft tissue.

Partial-thickness burns

 are classified as either superficial or deep partial-thickness burns by depth of involved dermis.

Clinically, first-degree burns are painful but do not blister,

Second-degree burns have dermal involvement and are extremely painful with weeping and blisters,
and

Third degree burns are leathery, painless, and non blanching.

Jackson described three zones of tissue injury following burn injury.

1. The zone of coagulation

 is the most severely burned portion and is typically in the center of the wound.
 As the name implies, the affected tissue is coagulated and sometimes frankly necrotic, much
like a third- or fourth-degree burn, and will need excision and grafting.

2. Peripheral to that is a zone of stasis

 with variable degrees of vasoconstriction and resultant ischemia, much like a second-degree
burn. Appropriate resuscitation and wound care may help prevent conversion to a deeper
wound, but infection or suboptimal perfusion may result in an increase in burn depth.

 This is clinically relevant because many superficial partial thickness burns will heal with
expectant management
 the majority of deep partial-thickness burns require excision and skin grafting.

3. The last area of a burn is called the zone of hyperemia,

 which will heal with minimal or no scarring and is most like a superficial or first-degree burn.

Unfortunately, even experienced burn surgeons have limited ability to accurately predict the healing
potential of partial thickness burns soon after injury; one reason is that burn wounds evolve over the
48 to 72 hours after injury.
Numerous techniques have been developed with the idea that better early prediction of burn depth
will expedite appropriate surgical decision making.

One of the most effective ways to determine burn depth is full thickness biopsy, but this has several
limitations; not only is the procedure painful and potentially scarring, but accurate interpretation of the
histopathology requires a specialized pathologist and may have slow turnaround times.

Laser Doppler can measure skin perfusion to predict burn depth with a positive predictive value of up
to 80% in some studies.

Noncontact ultrasound has been postulated as a painless modality to predict nonhealing wounds and
has the advantage of easily performed serial measurements.

Unfortunately, none of these newer therapies have proven adequately superior to justify their cost
and as yet have not substituted serial examination by experienced burn surgeons
Classification of Burns

Burns are commonly classified as thermal, electrical, or chemical burns, with thermal burns consisting
of flame, contact, or scald burns.

Flame burns

 are not only the most common cause for hospital admission of burns, but also have the highest
mortality.
 This is primarily related to their association with structural fires and the accompanying
inhalation injury and/or CO poisoning.

Electrical burns

 make up only 4% of U.S. hospital admissions but have special concerns including the potential
for cardiac arrhythmias and compartment syndromes with concurrent rhabdomyolysis. A
baseline ECG is recommended in all patients with an electrical injury, and a normal ECG in a
low-voltage injury may preclude hospital admission.
 Because compartment syndrome and rhabdomyolysis are common in high-voltage electrical
injuries, vigilance must be maintained for neurologic or vascular compromise, and fasciotomies
should be performed even in cases of moderate clinical suspicion.
 Long-term neurologic and visual symptoms are not uncommon with high-voltage electrical
injuries, and ophthalmologic and neurologic consultation should be obtained to better define a
patient’s baseline function

Chemical burns

 are less common but potentially severe burns. The most important components of initial
therapy are careful removal of the toxic substance from the patient and irrigation of the
affected area with water for a minimum of 30 minutes, except in cases of concrete powder or
powdered forms of lye, which should be swept from the patient to avoid activating the
aluminum hydroxide with water.
 The offending agents in chemical burns can be systemically absorbed and may cause specific
metabolic derangements.
 Formic acid has been known to cause hemolysis and hemoglobinuria, and hydrofluoric acid
causes hypocalcemia.
 Hydrofluoric acid is a particularly common offender due to its widespread industrial uses.
 Calcium-based therapies are the mainstay of treating hydrofluoric acid burns, with topical
application of calcium gluconate onto wounds and IV administration of calcium gluconate for
systemic symptoms.
 Intra-arterial calcium gluconate infusion provides effective treatment of progressive tissue
injury and intense pain.
 Patients undergoing intra-arterial therapy need continuous cardiac monitoring. Persistent
refractory hypocalcemia with electrocardiac abnormalities may signal the need for emergent
excision of the burned areas
Treatment of the Burn Wound

Multitudes of topical therapies exist for the treatment of burn wounds.

Silver sulfadiazine

 is one of the most widely used in clinical practice.

 has a wide range of antimicrobial activity, primarily as prophylaxis against burn wound
infections rather than treatment of existing infections.
 It has the added benefits of being inexpensive and easily applied and has soothing qualities.
 It is not significantly absorbed systemically and thus has minimal metabolic derangements.
 Silver sulfadiazine has a reputation for causing neutropenia, but this association is more likely
due to neutrophil margination from the inflammatory response. True allergic reactions to the
sulfa component of silver sulfadiazine are rare, and at-risk patients can have a small test patch
applied to identify a burning sensation or rash.
 Silver sulfadiazine destroys skin grafts and is contraindicated on burns or donor sites in
proximity to newly grafted areas.
 Also, silver sulfadiazine may retard epithelial migration in healing partial-thickness wounds.

Mafenide acetate,

 either in cream or solution form, is an effective topical antimicrobial.

 It is effective even in the presence of eschar and can be used in both treating and preventing
wound infections; the solution formulation is an excellent antimicrobial for fresh skin grafts.
 Use of mafenide acetate may be limited by pain with application to partial-thickness burns.
 Mafenide is absorbed systemically, and a major side effect is metabolic acidosis resulting from
carbonic anhydrase inhibition.

Silver nitrate

 has broad-spectrum antimicrobial activity as a topical solution.

 The solution used must be dilute (0.5%), and prolonged topical application leads to electrolyte
extravasation with resulting hyponatremia. A rare complication is methemoglobinemia.
 Although inexpensive, silver nitrate solution causes black stains, and laundry costs may offset
any fiscal benefit to the hospital.

Increasingly, Dakin’s solution (0.5% sodium hypochlorite solution) is being used as an inexpensive
topical antimicrobial.

For smaller burns or larger burns that are nearly healed, topical ointments such as bacitracin,
neomycin, and polymyxin B can be used. These are also useful for superficial partial thickness facial
burns as they can be applied and left open to air without dressing coverage. Meshed skin grafts in
which the interstices are nearly closed are another indication for use of these agents, preferably with
greasy gauze to help retain the ointment in the affected area.

All three have been reported to cause nephrotoxicity and should be used sparingly in large burns.
The recent media fascination with methicillin-resistant Staphylococcus aureus (MRSA) has led to
widespread use by community practitioners of mupirocin for new burns. Unless the patient has known
risk factors for MRSA, mupirocin should only be used in culture-positive burn wound infections to
prevent emergence of further resistance.

Silver-impregnated dressings such as Acticoat (Smith & Nephew, London, United Kingdom), Aquacel
Ag (Convatec, Princeton, NJ), and Mepilex Ag (Mölnlycke Health Care US, LLC, Norcross, GA)

 are increasingly being used for donor sites, skin grafts, and partial-thickness burns. These may
be more comfortable for the patient, reduce the number of dressing changes, and shorten
hospital length of stay, but they do limit serial wound
examinations.

Biologic membranes such as Biobrane (DowHickham, Sugarland, TX) provide a prolonged barrier
under which wounds may heal. Because of the occlusive nature of these dressings, these are
typically used only on fresh superficial partial-thickness burns that are clearly not contaminated