Chapter 162: Burns and Other Skin Injuries

BACKGROUND

Injuries to skin and adjacent deeper tissues often require the expertise of surgeons, usually with specific training in plastic surgery, trauma, or burn care. However, hospitalists are often involved in the initial evaluation, stabilization, and management of these children when they present to the hospital or require admission. Three major types of injuries are the focus of this chapter: thermal and chemical burns, electrical injuries, and intravenous infiltrates.^1-3

Burns cause significant morbidity and mortality in the pediatric population throughout the world.⁴ For children under 14, unintentional burns are among the top 10 causes of death due to unintentional injury, and burns are among the top 10 causes of non-fatal injuries for children under 4 treated in emergency departments.⁵ Burns are most common among infants and toddlers, with scald injuries predominating in this age group.⁶ Approximately 78% of these burns are accidental injuries caused by the child, 20% are accidental injuries caused by another person, and 2% to 3% are acts of abuse.⁷ Burns due to thermal causes (flame, contact, scald, or steam) require similar but distinct management from chemical or electrical burns. Careful attention must be paid to both the acute and chronic phases of burn care, because many injuries require long-term rehabilitation and an interdisciplinary approach to minimize their functional, cosmetic, and emotional impact.

THERMAL BURNS

PATHOPHYSIOLOGY

Following a thermal injury, the body responds locally and systemically. Locally, there are three zones of injury. The zone of coagulation necrosis is an eschar, with irreversible surface tissue injury from the direct heat insult. The zone of stasis is an area of reversible, salvageable cell injury due to a microvascular reaction in the dermis associated with vasoconstriction and thrombosis. Cell damage is not complete, but inflammatory mediators and injured microcirculation put viable tissue at risk. Beyond this is the zone of hyperemia, which lacks direct cell injury but exhibits vasodilation secondary to the surrounding inflammatory cascade. Full recovery in this zone is expected in the absence of additional insults. Systemically, the loss of an effective skin barrier leads to fluid losses, decreased resistance to infection, and the release of vasoactive mediators, affecting hemodynamic status and creating a hypermetabolic state.

Bacterial colonization of burned tissue can cause focal and systemic infection. Vulnerability to infection ensues not only because of disruption of the protective epidermal layer but also because burns are relatively ischemic; thus defensive elements of the innate immune system as well as systemic antibiotics are unable to penetrate burned tissue.

CLINICAL PRESENTATION

The diagnosis of a thermal injury is usually evident from the history and is obvious on presentation, although the relevant history may be lacking owing to caregiver absence or subterfuge. Thermal injuries are typically divided into first-, second-, third- and fourth-degree burns (Figure 162-1).