In 2011, U.S. emergency departments saw 486,000 burn patients, accounting for 0.4 percent of all ED visits.[1] Burns are grouped based on the layer of tissue the burning extends into and are divided into four main classifications known as “degrees”.[2]
Classification of burns by depth and breadth
First-degree burns involve only the outermost layer of the skin, known as the epidermis (“epi” is Greek for “on” or “over”). A common example of a first degree burn is a sunburn, where the outer layer of skin turns pink or red.
A second-degree burn is split into two categories, “partial thickness” and “full thickness.” The thickness indicates how far down into the skin tissue (dermis) the burn has gone. A partial thickness burn will present with blisters on the surface and significant skin redness and pain.
A full thickness burn extends through the whole depth of the dermis. These burns are red or white in color and may present with decreased sensation depending on the level of nerve damage the patient has sustained.
Another way to differentiate between full and partial thickness burns is the speed at which they blanch, or turn white, when pressed on or when the burned area is moved. A partial thickness burn will blanch normally while a full thickness burn will blanch slowly. You can think of blanching like checking capillary refill in reverse. You are looking for the speed at which the skin turns white rather than the speed at which the color returns to normal.
Third-and-fourth-degree burns are those which have moved through all of the layers of skin and into the fatty tissue (third degree) and muscle and bone (fourth degree) below. Patients with these burns generally do not have any pain at the site of worst injury because the nerves in the dermis have been destroyed. Burns will be black or white and there will be no blanching when the wound is pressed on.
It is important to note that with thermal burns, a burn may be surrounded by burns of lesser severity. For example, a third-degree burn will often be ringed by second and first-degree burns depending on how concentrated the heat source was.
General treatment for thermal burns
The initial goal of treatment in burn care is to stop the burning process. First ensure the patient is removed from the heat source. Then consider dousing the area in cool (but not ice) water.
Immediate cooling of a thermal burn with tap-temperature water has been shown to be an effective means of reducing the temperature of the wound and can speed also speed tissue recovery.[3] It is important to note, however, that cooling large burns (> 10 percent total body surface area) may actually result in poorer patient outcomes.
The skin serves to assist in temperature regulation and damage to large areas of tissue can compromise the ability of the body to thermoregulate. In these circumstances cooling can overcome the body’s compromised ability to maintain homeostasis.[3]
After cooling the burned area, the wound should be covered with sterile dressings. Local practice may differ on when to use dry and wet dressings, be sure to refer to your local protocols or consult your medical director. Patients meeting burn criteria based on local protocols may be transported to a specialty burn center.
Treatment for cook’s burned hands
Based on your clinical findings during Carl’s assessment, you determine that he has partial thickness second-degree burns. This determination is made as a result of the destruction of the epidermis (skin sloughing or sliding off the wound from ruptured blisters) as well as the consistent amount of pain across the burn indicating that there is probably not extensive nerve damage. Since the burn occurred approximately 10 minutes before your arrival, you have Carl place his hands under cool running water. While allowing the water to run, you carefully remove Carl’s wedding ring in anticipation of his fingers swelling. As the ALS transport unit pulls up on scene you apply a sterile dressing to the burn.
After listening to your report, the ALS crew starts an IV and begins to administer fluid and provide narcotic pain management. Carl is assisted to the gurney and moved to the ambulance. The crew follows local trauma triage guidelines and transports Carl to the regional burn center because the burn involves his hands and will require specialty care.
References
1. Centers for Disease Control and Prevention. (2011). National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. Retrieved from: http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf
2. (n.d.). Burn classification. Retrieved from University of New Mexico Hospitals website: http://hospitals.unm.edu/burn/classification.shtml
3. Prehospital Trauma Life Support Committee Of The National Association Of Emergency Medical Technicians In Cooperation With The Committee On Trauma Of The American College Of Surgeons. (2014). Burn injuries. In PHTLS: Prehospital trauma life support - eighth edition (pp. 406-428). Burlington, MA: Jones & Bartlett Learning.
