1. Burns can be caused by flames, scalds, radiation, chemicals, or electricity. Most burn patients are male between ages 16-40. Inhalation injuries carry the highest risk of mortality. 2. The skin is composed of two layers - the epidermis and dermis. The epidermis contains keratinocytes that produce keratin and melanocytes that produce pigment. The dermis contains collagen, elastin, blood vessels and nerves. 3. Burns are classified by depth as superficial, partial thickness, or full thickness depending on the extent of skin layer damage. Deeper burns carry higher risks of scarring and poor healing outcomes.

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Burns
Epidemiology
- Most burn patients are male (70%) with the mean age of 33 years.
- Most injuries covered less than 10% of total body surface.
- Increasing age, burn injury over higher TBSA and the presence of inhalation are associated
with increased mortality
(Braddom, 2011)
- 1-5 y/o usally due to scalds and hot liquids
- Adolescent and adults due to accidents with flammable liquids; highest incidence is male ages
16-40.
- Cause of death inhalation injury
(Dra. Papa notes, 2014)
Basic Science
Skin and body membranes (refer to basics notes for in depth discussion :)
Body membranes
- Cover surfaces, line body cavity and form a protective sheet around organ.
- 2 major groups:
1. Epithelial membranes (cutaneous[skin/integumentary], mucous, and serous membrane)
2. Connective tissue membrane (synovial membranes)
Integumentary system(skin)
- Skin and its derivatives[ sweat and oil glands, hair and nails]
(Marieb, E., 2006)
- It is the largest organ of the body. It varies greatly in thickness, flexibility, presence and
amount of hair degree of pigmentation[…] (Pendlenton, H., Schultz-Krohn, W., 2013)
Basic skin function
- Integument (covering)
- Protect deeper tissue from mechanical damage(bumps)
- Chemical damage(acids and bases)
- Bacterial damage
- UV radiation
- Thermal damage (cold or hot)
- Desiccation (drying out)
- Aids in body heat loss or retention(controlled by CNS)
- Aids in excretion of urea and uric acid
- Synthesis Vit. D

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Structure of the skin
- Composed of 2 kind of tissue:
o Outer epidermis composed of stratified squamous epithelium ->capable of
keratinizing or becoming hard or tough
o Dermis is mostly composed up of dense connective tissue
- Epidermis
o Composed of 5 zones or layer called strata (from inside out)
 Stratum basale
 Also called as stratum germinavitum
 Closest to the dermis
 Receive most adequate nourishment via diffusion from the dermis
 Constantly undergoing cell division
 Melanin are found
 Spinosum
 Keratinocyte in this layer have a well develop capacity for
phagocytosis thus helps in controlling infection
 Melanin granule are present in certain cytoplasm in this layer. It give
skin and hair its color.
(Pendlenton, H., Schultz-Krohn, W., 2013)
 When skin is exposed to sunlight it stimulates melanocytes to produce
more of melanin pigment thus tanning occur. It shields the skins
genetic material (DNA) from damaging effect of UV ray.
 Granulosum
 Flattened and accumulate many large keratin granules termed
kerohyalin.
 Cell lose there nucleus ; change from viable to nonviable
 Lucidum
 Seen best in glabrous skin( thicker tougher, hairless skin; sole of the
feet and the palmar surface of the hand.
 Corneum
 Outer most layer
 Composed of tightly packed dead keratinocytes
 Protects deeper cell from hostile environment and from water loss.
o It has no blood supply of its own
o Most are keratinocytes (produce keratin)
o Time taken of keratinocyte to pass from deepest layer to the surface is estimated to
be 45 -75 days.
- Dermis
o Fibrous connective tissue that made of collagen and elastin and contains numerous
capillaries, lymphatics, and nerve endings.

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o Collagen fiber is for toughness of the dermis ; attract and binds water thus keeps skin
hydrated.
o Elastic fibers- gives elasticity when young
o Strong, stretchy envelopes that helps to hold the body together.
o 2 major region: papillary and reticular
o Papillary layer:
 upper dermal layer
 Has fingerlike projection from the epidermis called dermal papillae.
 Contains capillary loops which furhish nutrients to the epidermis
 house pain receptor (free nerve ending)
 touch receptor (meissner corpuscle)
 in palms and soles of feet is arrange in definite pattern that increases friction
and enhance gripping.
 Ridge in the finger tips are well develop with sweat pores and leave a unique
identifying films of sweat called finger prints.
o Reticular layer
 Deepest layer
 Contains blood vessel, sweat and oil glands.
 Deep pressure receptor (pacinian corpuscle) found here
Etiology
- Most common is flames and scalds. (Braddom, 2011)
- Thermal burns: due to external heat sources which raise the temperature of the tissue and
causes cell death or charring. Hot meals scalding liquids
- Radiation burns: due to prolonged exposure to UV rays of the sun or other sources.
- Chemical burns: due to strong acids etc. coming in contact with the skins
- Electrical burns: from electrical currents either alternating current (AC) or direct (DC)
o Also called as ice burg
o Current follows course of least resistance offered by various tissue
o Body tissue differs in resistance
o Level of resistance:
 Blood vessel  least resistance
 Nerves
 Muscle
 Skin
 Tendon
 Fat
 Bone most resistance
- Classification of burns:
- Based on depth (assessment: appearance, sensitivity, pliability of wound.)
o Traditional: first, second, third, fourth degree burn.

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o Present: superficial, superficial partial thickness, deep partial thickness, full thickness,
subdermal.
Burn depth Common
causes
Tissue depth Clinical
finding
Healing time Scare
potential
Superficial
(first degree)
Sunburn,
brief flash
burnm brief
exposure to
hot liquids
or chemicals
Superficial
epidermis
Erythema,
dry, no
blisters,
short term
moderate
pain, tender
3-7 days No potential
for
hypertrophic
scars or
contractures
Superficial
partial
thickness
(superficial
second
degree) and
donor site
Severe
sunburn or
radiation
burn,
prolonged
exposure to
hot liquids,
brief contact
with hit
viscous
liquids
Epidermis,
upper dermis
(upper 3rd
of
the dermis)
Erythema,
blisters ,
significant
pain
Less than 2
weeks
Minimal
potential for
hypertrophy
or
contractures
if healing is
not delayed
by secondary
infection or
further
trauma.
Deep partial
thickness(
deep second
degree)
Flames, firm
it prolonged
contact with
hot metal
object,
prolonged
exposure to
hot, viscous
liquids.
Epidermis
and upper
2/3 of the
dermis
(nonviable
dermis but
survival of
skin from skin
appendages.
Erythema,
larger,
usually
broken
blisters on
skins with
hair, on the
glabrous skin
of the palm
and sole of
the feet,
large
possibly
intact
blisters over
beefy red
dermis,
sever pain
even to light
touch.
Longer than 2
weeks, may
convert to full
thickness with
onset of
infection
High potential
for
hypertrophic
scarring and
contracture
across joints,
web spaces
and facial
contours,
high rish of
boutonniere
def if dorsal
surface is
involve.
Full
thickness
(3rd
degree
burn)
Extreme
heat or
prolonged
exposure to
heat, hot
objects or
Epidermis,
entire
dermis:
nonviable
skin
appendages
Parchment
like,
leathery,
rigid dry,
anesthetic,
body hair
Surgical
intervention is
required for
wound closure
in larger
areas(skin
Area
depressed,
high potential
for
hepertrophic
scarring or

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chemical for
extended
period
from which
the skin
regenerate.
pull out
easily, dry
grafting) contractures,
depending on
the method
of closure.
subdermal Electrical
burns and
severe long
duration
burns
(house fires)
Full thickness
burn with
damage to
the
underlying
tissue
Charring of
noniable
surface,
presence aof
external
wound on
tendons,
muscle, loss
of
subdermal
tissue and
Peripheral
nerve ending
Requires
surgical
intervention
for wound
closure, may
require
amputation or
significant
reconstruction.
Similar to full
- Percent Total Body Surface Area (TBSA) involved
o Extent of burn is classified as a percentage of (%TBSA) burned.
o 2 common method: “rule of nines” and lund and browder chart