Second Degree Burns
Burns are classified according to depth. First degree burns are superficial, involving the epidermis only. These burns are akin to a sunburn and heal quickly without scarring, although they can be quite painful. Third degree burns (full thickness burns) extend beyond the dermis and into the hypodermis, and may damage structures below the skin, such as bone, tendon and ligaments. These burns are disfiguring and often require skin grafting.
Second degree burns (partial thickness burns) can be divided into two categories: superficial and deep. Superficial second degree burns involve the superficial dermis, while deep second degree burns extend deeply into the dermal layer. Deep second degree burns generally take longer than 3 weeks to heal and should be evaluated by a surgeon, else severe hypertrophic scarring may occur. These burns may require grafting.
Treatment of second degree burns begins with evaluating airway, breathing and circulation. Only after these, as well as assessment for spinal cord damage, are ascertained to be stable should burns be evaluated. Special attention should be paid to the airway if the victim was involved in a fire and was a victim of smoke or chemical inhalation. These patients may require intubation. To evaluate the extent of burns, the Rule of Nines is used. The Rule of Nines allows for rapid calculation of the body surface area burned. Children with burns over > 10% of their body surface area and adults with burns over 15% of their body should be transferred to a specialized burn unit (most countries have stringent criteria as to which patients require treatment in a burn center).
Fluid volume resuscitation is crucial in those patients described above. Lactated Ringer’s solution should be used according to the Parkland formula: 4 ml of solution x % of body surface area burned. Half of this calculated volume is infused in the first 8 hours; the rest is given in the following 16 hours. Blood pressure and other vital signs, as well as electrolytes and other lab values that measure blood volume should be followed meticulously, and fluid volume should be adjusted according to these measurements, as well as urine output and central venous pressure if available. Providing too much fluid may be as harmful as providing too little fluid, and studies have documented that many burn victims are over-hydrated in the first few hours.
Wounds should be assessed and treated as soon as possible after injury. Wounds should be cleansed and dressed to prevent infection, and those that require grafting should be seen by a surgeon or burn specialist as soon as is feasible. Burns can be a source of infection until they are healed, therefore wound closure is important. Burns that are circumferential may require escharotomy, especially those surrounding the chest that may impede breathing and those that threaten circulation to digits or limbs.
Pain control is important, as second degree burns can be very painful. Analgesia should be offered frequently and titrated until the patient is comfortable. Narcotics given intravenously can be used, as these can be titrated easily and can also be reversed if the patient becomes overly sedated. Morphine and Fentanyl are often used to control pain. Pain medication should be offered before every dressing change.
The outcome of second degree burns is dependent upon many factors: the age of the patient, their previous health, the extent of the burns, success of skin grafting and whether infection develops. Many second degree burns heal successfully but may leave scarring. Disfigurement may have psychological consequences, therefore the support of family, friends and professional is crucial.