PATHOPHYSIOLOGY

OF BURNS
Dr. Shiara Ortiz-Pujols
Burn Fellow
NC Jaycee Burn Center

Objectives

PART 1

Anatomy
Overview
Causes of Burns
Estimating Burns
(Depth & %)
Categories &
Zones

PART 2

Physiologic
Implications
Pathophysiology
Resuscitation
Post-Resuscitation
Board Questions

Anatomy

Adult skin surface 1.5-2.0 m2 (0.2-0.3 in

newborns); largest organ
Skin thickness 1-2 mm; peaks age 30-40;
M> F
Functions include:

protection from external environment

maintenance of fluid/electrolyte homeostasis
Thermoregulation
immunologic function
sensation
Metabolic organ (i.e., Vit D synthesis)

Causes of Burns

Usually caused by heat, electricity,

chemicals, radiation, and friction
Thermal burns are caused by steam, fire, hot
objects or hot liquids.

Most common burns for children and the

elderly

Electrical burns are the result of direct contact

with electricity or lightning
Chemical burns occur when the skin comes in
contact with household or industrial chemicals
Radiation burns are caused by over-exposure to
the sun, tanning booths, sun lamps, X-rays or
radiation from cancer treatments
Friction burns occur when skin rubs against a
hard surface, e.g. carpet, gym floor, concrete or
a treadmill

Effect of Heat
Temporal and quantitative
40-44C, enzymes malfunction,
proteins denature and pumps
fail
> 44C, damage occurs faster than
repair mechanisms can keep up with
Damage continues even when
the source is withdrawn

Effect of Electricity
Effects of current
depend on several
factors
- Type of circuit
- Voltage
- Resistance of
body
- Amperage
- Pathway of
current
- Duration of
contact

High voltage (>1000V)

causes underlying tissue
damage. Deep tissues
act as insulators and
continue to be injured.
Resistance of various
tissues from LH:
nerve, vessels,
muscle, skin, tendon,
fat, bone
Ohms Law- V=IR
Damage more related to
cross-sectional area
which explains extremity
injuries without trunk
injuries.

Electrical Storms/Lightning

Burns are characteristically

superficial and present as a
spidery or arborescent
pattern.

Cardiopulmonary arrest is
common following lightning
injury.

Coma and neurologic defects

are also common but usually
clear in a few hours or days.

Watch for tympanic

membrane rupture

Usually lethal in 1/3 of

patients.

World record for surviving

lightning strikes is Roy C.
Sullivan who was a park
ranger from VA. Roy was
struck 7 times from 19421977.

Electrical Pruning

Effect of Chemicals

Acids and alkalis cause injury via

different mechanisms.
Petroleum products can cause
delipidation and depth of
wound 2 tendency to adhere to
skin
Acids:
coagulation necrosis

denaturing proteins upon tissue

contact

area of coagulation is formed

and limits extension of injury
exception is hydrofluoric
acid, which produces a
liquefaction necrosis similar to
alkalis.
Acid damaged skin can look
tanned and smooth; do not
mistake for a suntan.

Alkalis:
liquefaction necrosis
potentially more
dangerous than acid
burns

liquefy tissue by
denaturation of proteins and
saponification of fats

In contrast to acids, whose

tissue penetration is
limited by the formation of
a coagulum, alkalis can
continue to penetrate very
deeply into tissue
Can cause severe
precipitous airway edema
or obstruction.

Inhalation Injury

Heat dispersed in upper airways leads to

edema
Cooled smoke and toxins carried distally
Increased blood flow to bronchial arteries
causes edema
Increased lung neutrophils mediators
of lung damage release proteases
and oxygen free radicals (ROS)
Exudate in upper airways formation of
fibrin casts

Stages of Inhalation Injury

Stage 1 acute pulmonary insufficiency

Stage 2 72-96 hrs after presentation

(ARDS picture)

Signs of pulmonary failure at presentation

extravasation of water
Hypoxemia
Lobar infiltrates

Stage 3 bronchopneumonia

Early Staph pneumonia (frequently PCN

resistant)
Late - Pseudomonas

Inhalation Injury

Bronchoscopy:
- erythema
- intraglottic soot
- ulceration

Grading of Burn Wounds

Mild: < 5% TBSA

Moderate: 5-15% TBSA
Severe: > 15% (95% of burns seen)
May require Burn Unit care because of
potential for disability despite small
TBSA (face, hands, feet, perineum)

Area of Burn Rule of

9s
Note that a patient's palm is approximately 1% TBSA and can be used for estimating patchy areas.

Area of Burns - Pediatric

Estimation of Burn Wound

Depth

Initial assessment is often unreliable

Ignore mild erythema when calculating
fluid requirements
Pink areas that blanch are usually
superficial
Deeper wounds are dark red, mottled or
pale and waxy
Insensate areas are usually deep (3rd
degree or greater)

Factors Influencing Wound

Depth

Temperature and duration

Thickness of skin (thin on eyelids, thick on
back)
Age (children and elderly have
proportionally thinner skin in comparison
to adults)
Vascularity
Agent oil vs water; acidic vs alkalotic
Time to definitive care

Burn Zones

Circumferential zones radiating from primarily burned

tissues, as follows:
1.

2.

3.

Zone of coagulation - A nonviable area of tissue at the

epicenter of the burn
Zone of ischemia or stasis - Surrounding tissues (both deep
and peripheral) to the coagulated areas, which are not
devitalized initially but, 2 microvascular insult, can progress
irreversibly to necrosis over several days if not resuscitated
properly
Zone of hyperemia - Peripheral tissues that undergo
vasodilatory changes due to neighboring inflammatory mediator
release but are not injured thermally and remain viable

Zone of
Hyperemia

Zone of
Ischemia

Zone of
Coagulation

Layers of the Skin

Categories of Burns First

degree

Burns are divided into 4 categories, depending on the depth

of the injury, as follows:
First-degree burns are limited to the epidermis.
A typical sunburn is a first-degree burn.
Painful, but self-limiting.
First-degree burns do not lead to scarring and require
only local wound care.

First degree Burn

Categories of Burns Second

degree

Second-degree burns
point

of injury extends into the dermis,

with some residual dermis remaining
viable

Partial thickness or Full thickness

those requiring surgery vs those which do

not

Superficial Second degree

Burn

Deep Second degree Burn

Categories of Burns Third

degree

Third-degree or full-thickness burns

involve destruction of the entire
dermis, leaving only subcutaneous
tissue exposed.

Third degree Burn

Escharatomy Sites
Preferred sites for escharotomy incisions. Dotted lines
indicate the escharotomy sites. Bold lines indicate areas
where caution is required because vascular structures and
nerves may be damaged by escharotomy incisions. (From
Davis JH, Drucker WR, Foster RS, et al: Clinical Surgery.
St. Louis, CV Mosby, 1987.)

Categories of Burns 4th

degree
-

Fourth-degree burn is usually associated with

lethal injury.
Extend beyond the subcutaneous tissue,
involving the muscle, fascia, and bone.
Occasionally termed transmural burns, these
injuries often are associated with complete
transection of an extremity.

4th degree Burn

PART 2
Physiologic Implications
Pathophysiology
Resuscitation
Post-Resuscitation
Board Questions

Physiologic Implications of
Burn Injury

Predictable changes
Related to period of injury
Can be anticipated

Pathophysiology of Burns

Cell damage and death causes vasoactive

mediator release:
Histamines
Thromboxanes
Cytokines
Increasing capillary permeability causes edema,
third spacing and dehydration
Possible obstruction to circulation (compartment
syndrome) and/or airway

Resuscitation Period

early ebb with late flow; days 0-3

Hypodynamic, with need for close fluid resuscitation monitoring

Massive, diffuse capillary leak 2 to inflammatory mediators;

abates 18-24 hrs after injury and volume requirements abruptly
decline

leak can be seen in those with delayed resuscitation 2 systemic

release of O2 radicals upon reperfusion

Extravascular extravasation of fluid, lytes, colloid molecules

Other variables affect resuscitation: preexisting fluid deficits, delay

until treatment, inhalation injury, depth of wound

Must reevaluate resuscitation progress and endpoints frequently;

do not just use a formula

Resuscitation Guidelines

Postresuscitation Period

Day 3 until 95% wound closure

Hyperdynamic, febrile, protein catabolic state

Tachycardia can be normal in burn patients

Blood pressure may be hard to obtain due to

circumferential burns

Release of more inflammatory mediators, cortisol,

glucagon, catecholamines, bacteria from wound

High risk of infection and pain

Remove non-viable tissue or close wounds to avoid sepsis

Nutritional support essential

Maintain and support body temperature with high ambient

temps and humidity

Recovery Period

95% wound closure until 1 year postinjury

Continued catabolism and risk of nonhealing wound
Anticipate septic events, treat
complications, and continue nutritional
support

Pathophysiology of
Electrical Burns

Small cutaneous lesions may overlie extensive areas of damaged

muscle myoglobin ARF.
Monitor for at least 48 hours after injury for cardiopulmonary arrest
May see vertebral compression fractures from tetanic
contractions or other fractures from a fall.
Visceral injury is rare but liver necrosis, GI perforation, focal
pancreatic necrosis and gallbladder necrosis have been reported.
Look for motor and sensory deficitsmotor nerves are affected
more than sensory nerves.
Thrombosis of nutrient vessels of the nerve trunks or spinal cord
can cause late onset deficits. Early deficits are direct neuronal
injury.
Delayed hemorrhage can occur from affected vessels
Cataracts may form up to 3 or more years after electrical injury
Microwave radiation damages tissues via a heating effect.
Subcutaneous fatty tissue is often spared given its lower water
content.

Burn Edema and

Inflammation

Generalized edema found in burns >

30% TBSA
Heat directly damages vessels and
causes permeability
+
Heat activates complement histamine
release and more permeability
thrombosis and coagulation systems

Systemic Response to Burn

Injury

Accelerated fluid loss 2 leaky capillaries

Host resistance to infection
Multisystem Organ Failure
Infections in burns <20% TBSA are well
tolerated.
> 40% TBSA with infection has very low
survival rate
Initially CO, subsequent hypermetabolic
state w/ doubling of CO in 24 48 hours

OR Pictures

Burn Questions

Select the true statements regarding

the epidemiology of a burn injury
a. Scald burns are the most frequent forms of
burn injury.
b. Flame burns are the most frequent forms of
burn injury admitted to burn centers.
c. Burn injuries are most common among adults
d. About 15% of pediatric burn injuries are
attributed to abuse or neglect.
e. Burn-related deaths are highest among adults.

Select the true statements regarding

the depth of burn
a. First-degree burns are physiologically
important and therefore considered
when calculating TBSA.
b. Second-degree burns always affect the
epidermis and dermis of the skin.
c. Third-degree burns are very painful.
d. All first-degree burns heal within 2 to 3
days.

A 50 year-old man sustains a flame burn

involving the entire upper left extremity,
entire anterior trunk, genital area, and half
of the left lower extremity. Approximately
what percentage of the total body surface
area is burned?
a. 24%
b. 28%
c. 37%
d. 45%
e. 30%

According to American Burn Association

criteria, which of the following patients
should be referred to a burn center?
A. Second- and third-degree burns involving more than
20% of the total body surface area (TBSA) in patients
younger than 10 or
older than 50 years of age.
B. Full-Thickness burns that involve 2% of the TBSA in
patients of any
age.
C. Significant burns of the face, hands, feet, genitalia,
perineum, or skin overlying major joints.
D. Burn Injury in children with suspected or actual child
abuse or
neglect.
E. Acute massive skin loss syndromes (e.g., StevensJohnson
syndrome/toxic epidermal
necrolysis, large traumatic de-gloving
injuries)

All of the following are true regarding

the Pathophysiology of thermal injury,
except?
A. Increased capillary permeability is due
to direct
effect of heat and the liberation of
vasoactive
mediators.
B. Increased pulmonary vascular
resistance occurs
during the immediate postburn period.
C. Elevated thyronine (T3) and thyroxine
(T4) levels.
D. Elevated interleukin-6 (IL-6) level
E. Decreased immoglobulin G (IgG) level

A 60-year-old, 80-kg man has sustained a seconddegree burn to 40% TBSA with a significant inhalation
injury. He was admitted to the burn unit 30 minutes after
the accident. According to the Parkland formula,
resuscitation was started with lactated Ringers solution
at 800 ml/hr. Six hours later the patient was found to be
oliguric. What should be the next step in resuscitation of
this patient?
A. Swan-Ganz catheter placement and measurement of
pulmonary
wedge pressure.
B. Trial of small dose of furosemide
C. Low does of dopamine (2-3 ug/kg/min).
D. Increase in volume of the lactated Ringers solution
infusion.
E. Bolus of colloid solution

Which of the following statements is/are

true regarding resuscitation of patients
with burn injury during the first 24 hours?
a. Parkland formula uses a balanced electrolyte solution
& the fluid requirement is calculated as 3 ml/kg
body weight per %TBSA burned.
b. Patients with 15% or more TBSA burn require
intravenous fluid resuscitation.
c. Adequate urine output implies hemodynamic stability
and adequate organ perfusion.
d. Crystalloid resuscitation restores cardiac output more
rapidly
than colloid alone.
e. Late pulmonary morbidity and mortality are higher in
colloidresuscitated patients.

Match the items in two columns

Topical Agents
A. Sodium mafenide
(Sulfamylon)
B. Silver nitrate 0.5%
Solution
C. Silver sulfadiazine
(Silvadene)

Characteristics
A. Limited eschar
penetration, resistant
organisms neutropenia,
thrombocytopenia
B. Painful application,
hyperchloremic reactions
good eschar penetration
C. Hyponatremia,
hypokalemia,
hypocalcemia,
methemoglobinemia

Which of the following statements

is/are true regarding metabolism in
the burn patient?
a. Postburn hypermetabolism is mediated by catecholamine
release.
b. IL-1 and IL-6 are elevated in burn injuries and enhance the
hypermetabolic response by increasing oxygen
consumption.
c. Elevated core and skin temperature and lower core-to-skin
heat transfer are manifested in postburn hypermetabolism.
d. Increased blood flow to the muscles in the burned limb.
e. The burn wound preferentially utilizes glucose by
anaerobic glycolytic pathways despite increased blood
flow to the wound.

Which of the following can minimize

metabolic expenditure in burn
patients?
A. Nursing the patients at ambient
temperature below 30oC.
B. Adequate analgesia and sedation.
C. Early excision of the burn and complete
wound closure.
D. Early diagnosis and treatment of
infection.
E. Use of B-adrenergic blockers.

Select the correct statements

regarding nutrition in burn patients.
a. The optimal calorie/nitrogen ratio
varies between 150:1 & 160:1.
b. Fat is the best source of non-protein
calorie.
c. Glutamine deficiency results in
atrophy of
gut mucosa
d. Long-chain triglycerides for
maintaining lean body mass.
e. Overfeeding is associated with
hyperventilation.

Which of the following statements

is/are true for invasive burn wound
infection?
a. Common in burns larger than 30% total body
surface area.
b. Characterized by conversion of a partialthickness burn to full-thickness burn.
c. Definitive diagnosis can be made if quantitative
culture of the biopsy recovers more than 10 5
organisms per gram on tissue.
d. Incidence of Candida wound infection has
increased owing to topical antimicrobial
chemotherapy.
e. Topical antimicrobial agents have markedly
decreased the incidence of invasive burn wound
infection.

Select the true statements

regarding infection in the burn
patient
a. Infection if the most frequent cause of
death in the
burn patients.
b. Cell-mediated immunity is not altered in
major burn injuries.
c. Hematogenous pneumonia is the most
common
pulmonary infection in burn
patients.
d. Diminished granulocyte chemotaxis is an
important factor in burn infection.
e. Suppurative thrombophlebitis can be a
major source of sepsis.

Which of the following statements

is/are true regarding administration of
antibiotics to burn patients?
a. Prophylactic systemic antibiotics are
indicated in patients with extensive burns.
b. With invasive burn wound sepsis,
systemic antibiotics should not be
instituted before culture and sensitivity
results are available.
c. Positive wound cultures should be
treated with systemic antibiotics.
d. Antibiotics effective against anaerobic
organisms are always indicated for burn
wound sepsis.
e. Subtherpeutic serum antibiotic levels are
common in burn patients.

Which of the following statements

is/are true
regarding burn wound
excision?
A. Excision is indicated for deep partial-thickness and fullthickness burn wounds.
B. Early excision and closure of burn wounds has been
shown to
reduce the incidence in invasive burn
wound infection,
shorten the hospital stay, reduce
pain, and improve
functional recovery.
C. Excision should be performed after successful fluid
resuscitation.
D. Tangential excision involves sequential excision of
the eschar
down to bleeding, viable tissue.
E. Excision of more than 10% of TBSA single procedure
is associated with significantly morbidity.

Which of the following statements

is/are true
regarding burn wound
closure?

A. Split-thickness autograft is contraindicated if

wound
culture is positive B-hemolytic
streptococci.
B. Xenograft is the most frequently used and
effective
biologic dressing when an autograft is
not
available.
C. Allograft dressings promote bacterial
proliferation.
D. Cultured autologous keratinocyte sheets can be
used for permanent wound coverage with good
results.
E. Dermal substitutes provide better temporary
wound

Select the true statements

regarding inhalation injury.
A.
Presence of carbonaceous sputum is a
specific sign of
inhalation injury.
B Normal carbon monoxide level on admission
excludes
inhalation injury.
C.
Chest radiography is sensitive for
diagnosing inhalation injury.
D.
Combined fiberoptic bronschosocpy and
133 Xe
ventilation-perfusion lung scan has a
diagnostic
accuracy of more than 96%
E. Pulmonary infection is the most frequent cause
of
morbidity and mortality with inhalation
injury.

Select the correct statements

regarding electrical injury.
a. Depth of tissue injury is related to density and
duration of the current flow.
b. High-voltage electric injury results in more
severe injury to
the trunk than the
extremities.
c.Risk of acute renal failure is relatively high with
an
electrical injury due to myoglobinuria
and
underestimation of fluid needs.
d. Incidence of cholelithiasis is high in patients
after
electrical injury.
e. With a lightening injury cardiopulmonary
arrest is
common, and burns are
characteristically superficial.

Which of the following statements

is/are true regarding chemical injuries?
a.
Immediate wound care involves
application of a
neutralizing agent.
b.
Acid burns cause liquefaction necrosis.
c. Alkali burns produce deeper injuries than acid
burns.
d.
Hydrofluoric acid burn is treated with
local calcium gluconate gel.
e. Coal tar burn is best treated with immediate
application of a petroleum-based ointment.

Select the true statements

regarding post burn sequelae
A.
All second & third degree burns produce
permanent scarring.
B.
The incidence of hypertrophic scar
formation is less after
excision and skin
grafting than with wounds that heal
spontaneously.
C.
Hypertrophic scars are best treated by
early excision and wound closure.
D.
Basal cell carcinoma is the most common
carcinoma in an old
burn scar.