Burns: New Treatments!

Burn injuries have afflicted mankind since the dawn of history.  Today, they represent one of the most potentially devastating and challenging conditions in medicine. Over one million burn injuries occur annually in the United States, with the majority being treated in an outpatient setting.  Children up to 4 years of age and working age adults comprise nearly 90% of patients with burn injuries. Injuries to children largely involve scald injuries whereas flame burns are predominant in the working age population.  Their presentation varies considerably, from simple sunburns requiring no more than counseling and a topical agent to extensive tissue loss resulting in multi-organ system failure and a protracted ICU course.  In more serious cases, it is imperative that burn care extend far beyond the initial insult. Burns can significantly alter quality of life and are a common cause of disability.  Debilitating contractures and cosmetically unacceptable scars can have long-lasting physical and psychological consequences, requiring the physician to be supportive and dedicated to continuing patient care.
Careful assessment of burn depth is a critical step in determining appropriate management.  It is important to keep in mind that most burns represent a mixture of different depths.  Superficial or first-degree burns involve only the epidermis.  They are painful and have an erythematous, glistening appearance without blister formation.  Capillary refill is brisk, as is bleeding on pin-prick.  The classic example is a sunburn, although superficial burns are frequently caused by flash burns as well.

Partial-thickness or second-degree burns involve the epidermis and part of the dermis. They are further subdivided into superficial and deep partial thickness burns depending on the depth of dermal involvement.  Superficial partial-thickness burns are pink and painful with delayed capillary refill.  They will generally heal in 2 to 3 weeks without any significant amount of scarring, although depigmentation of the affected skin is possible.  Scald burns typically result in superficial partial-thickness burns.
Deep partial-thickness burns are characterized by injury extending into the reticular (upper) dermis.  They appear "cherry red" or pale and dry with mottling. Sensation is variable and these burns are generally less painful to touch.  They will not blanch with gentle pressure and bleeding from pin-prick will be delayed.  The rate of healing is variable, depending on the number of intact adenexal structures left in the skin.  As a result, thin, hairless skin (e.g. eyelids) will heal more slowly than thick or hairy skin (e.g. back, scalp).  Typically, these burns will heal in 1 to 3 months, but with a significant amount of scarring and possible contractures.  Often, they are best treated by excision and grafting.

Full-thickness or third-degree burns extend through the entirety of the dermis. They appear dry, leathery and can be white, brown, or black.  These wounds are insensate, do not blanch, and do not bleed upon pin-prick.  Thrombosed vessels may be visible and are pathognomonic for third-degree burns.  Some clinicians describe fourth degree burns, which extend completely through the skin and subcutaneous tissues, affecting underlying muscle and bone.

Assessing burn depth requires experience and often takes several days of observation to determine the appropriate management.  Patients may be admitted for observation and re-examined every day as the appearance of the wound becomes clearer.  Generally, the wounds that appear likely to heal within three weeks can be managed conservatively, whereas those that will take longer may require grafting.



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