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A
Partial
A
'"
Hair shaft
>
()
Epldennl.-{
Denn�-{
()
>
"
m
Z
0
Sweat
�
0
gland
0
r.
�
Bone
0
"
(a) Superflcial bum
(b) Partial thickness bum
�
partiel{
J:
-<
�
�
r
i!
Deep
m
thickness
Full
�
bum
thickness
�
bum
(e) Deep partial thickness bum
(d) Full thk:kness bum
Figure 7-5. The depth o( bum inJuries (rom fA) superficial to (D) (ull thick"ess. (With permissio" (rom M Walsh [edt. Nurse Practitioners: Clmical Skills and Pro(essional Issues. Oxford, UK: Butterworth-Heinemann, 1999;28.)
Table 7-5. Burn Depth Characteristics
Deprh
Appearance
Healing
Pain
Su perficial (first-degree)-epidermis
Pink to red
3-5 days by epithel
Tenderness to
injured
With or without edema
ialization
tOuch or
Dry appearance without blisters
Skin appears intact
painful
Blanches
Sensation intact
Skin intact when rubbed
Moderate partial-thickness (second
Pink ro mortied red or red with edema
5 days to 3 wks by
Very painful
degree)-superficial dermis injured
Moist appearance with blisters
epithelialization
Blanches with slow capillary refill
Pigmentation changes
Sensation intact
are likely
Deep partial-thickness (second
Pink ro pale ivory
3 wks to mas by
Very painful
degree)-deep dermis injured with
Dry appearance with blisters
granulation tissue
hair follicles and sweat glands
May blanch wirh slow capillary refill
formation and
intact
Decreased sensation ro pinprick
epithelialization
Hair readily removed
Scar formation likely
�
Full-thickness-entire dermis injured
White, red, brown, or black (charred if
Not able to regenerate
No pain, perhaps
�
(third degree) or fat, muscle, and
fourth degree)
an ache
�
>
bone injured (fourth degree)
Dry appearance without blanching
5
May be blistered
"
Insensate to pinprick
Depressed wound
�
Source: Data from P Wiebelhaus, SL Hansen, Burns: handle with care. RN 1999;62:52-75.
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450 ACtJTE CARE HANDBOOK FOR I'HYSICAI. nIERAI'ISTS
care is optimal for the patient. The American Burn Association recommends medical care at a burn center if the patient has any of the following":
•
Second- and third-degree burns that are greater than or equal to
10% of TBSA in patients younger than I 0 years of age or older
than 50 years of age
•
Burns of any type that are greater than 20% of TBSA in patients
between 10 and 50 years of age
• Full-thickness burns that are greater than or equal to 5% of
TBSA
•
Second- and third-degree burns of the face, hands, feet, genitalia, perineum, or major joints
•
High-voltage electrical or lightning injury
•
Inhalation injury or other trauma
•
A significant chemical burn
•
Pre-exisring disease in which rhe burn could increase morraliry
Resuscitative Phase
The objectives of emergency room management of the patient who has
a major burn injury include simultaneous general systemic stabilization and burn care. The prioritization of care and precautions during this initial time period have a great impact on survival and illustrate
some key concepts of burn care. General systemic stabilizacion involves
( 1) the assessment of inhalation injury and carbon monoxide (CO)
poisoning and the maintenance of the airway and vemilation with supplemental oxygen (see Appendix III-A) or mechanical ventilation (see Appendix lII-B), (2) Auid resuscitation, (3) the use of analgesia (see
Appendix VI), and (4) the treatment of secondary injuries.16
Inhalation In;ury and Carbon Monoxide Poisoning
The inhalation of smoke, gases, or poisons, which may be related to
burn injuries, can cause asphyxia, direct cellular injury, or both. Inhalation injury significantly increases mortality and varies depending on the inhalant and exposure time. There is no strict definition of inhalation injury. Inhalation injury is suspected if the patient was exposed to noxious inhalants, especially in an enclosed space, or if the patient
