Dermal injury that is termed “burn” can occur from thermal (heat and cold), chemical, electrical, and radiation sources, and while the clinical presentations have some similarities, the medical management of each condition is unique and specialized. The transfer of kinetic energy from any of these sources to the cellular structures of the skin causes a local inflammatory state, and the extent of exposure to the offending source and the amount of tissue damage can also result in systemic pathophysiologic processes. There are two important factors common to all of these conditions. First, any damage to the skin disrupts the body’s natural barrier from the external environment and its microbes; therefore, infection is of utmost concern in treating any burn wound. Second, there are individual patient factors that affect the ability to heal, including nutrition, oxygenation, fluid resuscitation, age, co-morbidities, and stress.1 Each one of these factors has to be evaluated and treated in the overall management of patients with burn injuries. This chapter reviews the tissue and systemic changes that occur with each type of burn, the classification systems used to describe tissue damage, and the medical and wound management for each type of dermal destruction in order to preserve both function and esthetics for the patient.
Evaluation of a patient with a burn injury begins with determining the mechanism of burn, the anatomical location of tissue damage, and the total burn surface area (TBSA). Figures 6-1 and 6-2 illustrate the two methods used to determine TBSA—Rule of Nines and Lund and Browder chart. In addition, the Palmar Surface Area (PSA) technique equates the patient’s own palm and fingers to 1% TBSA and is useful for smaller and scattered patterns.2 The depth of penetration, TBSA, and location are used to determine those patients who need to be referred immediately to a regional burn center for a higher level of care3 (Table 6-1). Burns that are >10% TBSA may require systemic treatment and resuscitation, beginning with ABC evaluation. Burns that involve more than 30% TBSA are more likely to develop a systemic inflammatory response syndrome (SIRS).1 Tachycardia, labored breathing, or respiratory distress require immediate treatment with endotracheal intubation and mechanical ventilation.
Rule of Nines.
The Rule of Nines is used to determine total body surface area that is burned and estimates that each upper extremity accounts for 9 percent of the total burn surface area or TBSA, and each lower extremity, 18 percent. In addition, the anterior and posterior trunk is predicted to be 18 percent, the head and neck 18 percent, and the perineum 1%. For burns spanning anatomical regions, the volar surface area of the hand may be considered 1% of the TBSA.
Reproduced with permission from Hamm RL: Text and Atlas of Wound Diagnosis and Treatment, 2nd ed. New York, NY: McGraw Hill; 2019.