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CHAPTER9 Assessment ofburn surface area
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2
2
2
1
3
2
2
2
2
1
15
1
3
Fig.9.2 Hand burns surface area:a rule of thumb.
Diagram of surface areas of the hand, showing estimated thumbprint (T)areas on each surface,
including web spaces and radial/ ulnar surfaces of digits.
Reproduced from Dargan D, Mandal A, Shokrollahi K.Hand burns surface area:a rule of thumb.
Burns (in press, March 2018)with permission from Elsevier.
Table9.2 Rule ofthumb
Surface areas of the hand Thumbprints (T) % TBSA
Palm (excluding digits) 15 0.5
Dorsum (excluding digits) 15 0.5
Radial, ulnar palmar and dorsal
aspects of each digit (20 surfaces)
First web space 2 0.066
2nd, 3rd, 4th web spaces 1 on each space (total 3) 0.033(0.1)
Ulnar border of palm 3 0.1
Whole hand 80 2.66
*Volar surface of ring and middle nger 3T each.
2 on each surface, on
each digit* (total 42)
2
2
1
1
15
2
2
0.066(1.4)
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ASSESSMENT OFTBSA
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CHAPTER9 Assessment ofburn surface area
Newer techniques
Technologies such as smartphone apps and similar strategies have been employed successfully to give accurate and rapid assessments with less margins
of error, such as the validated Mersey Burns App which can be used as
an app or simply via the weblink on any computer or smart device, www.
merseyburns.com.
Fig.9.3 Mersey Burns App image of burns to chest, back and right upper limb. Full
thickness areas are in red, partial thickness in pink. TBSA Estimated at 15.5% using
the website, www.merseyburns.com.
Reproduced with permission from Mersey Burns.
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FURTHER READING
Further reading
Barnes J, Duy A, Hamnett N, et al. The Mersey Burns A pp: evolving a model of validation.
Emergency Medicine Journal 2015;32:637– 41.
Dargan D, Mandal A, Shokrollahi K. Hand burns surface area:a rule of thumb. Burns 2018;44:1346– 51.
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Chapter10
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Burn depth assessment
Introduction to burn depth assessment 78
Classication 79
Modalities to assess burns 80
Clinical assessment 82
Technology 84
Further reading 88
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CHAPTER10 Burn depth assessment
Introduction toburn depth assessment
Why burn depth assessment?
Burn depth assessment is essential for the planning of care and prevention
of scar formation. This however is a dicult task due to the evolving nature of burns. If a deep burn is not surgically excised it has the potential
to become colonized with bacteria, increasing morbidity and potentially
mortality. Hypertrophic scarring becomes more likely the longer the burn
wound is left, therefore it is important to assess depth as deeper burns will
take longer to heal. Burns which are likely to take longer than 2 weeks to
heal in children and 3 weeks for adults should be considered for intervention as it is after these time frames that the risks of hypertrophic scarring
becomes signicant.
Diculties withburn assessments
Jackson described three zones of a burn wound. These are:
• Zone of coagulation:area of necrosis and irreversible tissue destruction
• Zone of stasis:adjacent to the zone of coagulation which describes
at- risk tissue. This tissue has decreased tissue perfusion, which without
optimal care will progress to necrosis. It is within this area where
deepening of burns occurs over 48 hours
• Zone of hyperaemia:this is the tissue surrounding the zone of stasis
in which inammatory mediators cause widespread dilatation of blood
vessels, clinically, it has the appearance of erythema. After the acute
phase this zone returns to normal perfusion
It is the evolution of the zone of stasis into the zone of coagulation which can
deepen the burn wound and cause diculties with assessing wound depth.
There are various factors which inuence conversion of zones, and hence
increased burn depth. This is usually the result of a reduction in the microcirculation due to changes in blood pressure, localized oedema or thrombosis, which leads to tissue hypoxia.
If the wound is not debrided it is dicult to assess the underlying skin
and depth. Usually burn wounds are not homogenous but a mixed pattern,
thereby complicating assessment.
In an electrical burn the current travels through the body, and creates
entry and exit wounds. Between these two points underlying tissue damage
can result from the heat generated by the current. This damage will not be
visible by inspecting the skin only.
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Classification
There are many dierent ways to describe burn depth. Here we will describe it by histological depth.
Epidermal:rst- degree burns/ erythema
The epidermal burns are erythematous only. They appear as pink, painful
areas which blanch with light pressure and don’t form blisters. These are
not counted as true burns and as such not included in the estimation of total
body surface area. These will heal over a couple of days by the shedding of
the outer layers of the epidermis.
Supercial partial thickness:second- degree burns (2a)/
supercial dermal burns
These involve all of the epidermis and the supercial part of the dermis,
leaving the deeper part of the dermis intact. These will usually have intact
or ruptured blisters, leaving the dermis exposed, shiny, oozy and pink. The
wound will have a capillary rell of less than 2 seconds and become very
painful. Rubbing with a nger may shear o the epidermis. These will usually
heal within 3 weeks and leave no scarring. However, there may be discoloration in pigmented skin and this may take up to 2– 3years to resolve. They
heal by migration of keratinocytes from the base of the burn wound– these
cells travel up from keratinocyte reserves surrounding adnexal structures,
which originate deeper than the level of burn.
Deep partial thickness:second- degree (2b)/ deep dermal
This involves all of the epidermis, supercial dermis, and mid- dermis.
They appear as a dark shade of red (cherry red) due to the thrombosed
blood in the dermal capillaries. This red staining is xed and will not blanch
with pressure. Because the deeper adnexal structures are damaged the reserve of keratinocytes are also lost. This means relying on migration of the
cells from the wound edge and results in healing taking more than 3 weeks.
Full thickness:third- degree/ subdermal
This involves all layers of the epidermis and dermis. Characteristically they
have a leathery eschar which is either white or black (if carbonized) and are
insensate as the sensory nerve endings have been damaged. They heal by
wound contraction and migration of keratinocytes from the wound’s edge.
Circumferential full thickness burns can impair limb circulation and chest
wall expansion by acting as a restrictive band. Re- establishment may require
escharotomies.
Catastrophic:Fourth- degree burns
This term is used to describe full thickness burns which have also damaged
underlying structures (bone, cartilage, organs/ brain, etc.).
CLASSIFICATION
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CHAPTER10 Burn depth assessment
Modalities toassess burns
There are many dierent modalities to assess burn depth.
Clinical
This relies on burnt skin colour, sensation, appearance, blanching, and
blister formation.
Accuracy— depends on the experience of the clinician but can vary between 50% and 80%, with indeterminate dermal burns being the most
dicult to assess. Clinical assessment is highly accurate in very supercial
and very deep burns and these do not require additional technological
methods. Owing to the evolving nature of burn wounds they should be
reassessed after 48 hours to see if there has been any burn depth progression. Accuracy does not vary between 2 and 5days however between 5 and
14days assessment becomes dicult due to the decrease in inammatory
response and the use of topical agents.
Useful adjuncts
Blanching
Pressing on the burn to see the colour disappear and turn white. This is
caused by the occlusion and emptying of the capillaries. In deeper burns the
small capillaries have been burnt and thrombosed, leading to xed staining.
Hair follicles
Hair follicles lie in the deeper part of the dermis. Hairs that are easily dislodged by a small tug with forceps indicate a deeper dermal burn.
Clarke’s sign
Sweat glands originate deep in the dermis and protrude through the epidermal layer, resulting in sweat emerging from the skin. Clarke’s sign says
that when there is sweating of the burn this indicates a more supercial
burn as this indicates the sweat glands are not damaged.
Pinprick tests
Pinprick tests can be a good discriminator between supercial and deep
burns in a number of ways. Pain discriminates well between supercial
(painful) and deep (painless to insensate) burns. The briskness or absence
of bleeding to pinprick is also a good discriminator as delayed or absent
bleeding would signify a deeper burn.
“Test shave” intheatre
Very thin tangential excision of the deepest part of an intermediate depth
burn can be valuable. Adjunctive debridement techniques such as “VersaJet”
hydro- debridement can be used in a similar way.
Remembered by some as “red is dead”, “White is alright”.
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MODALITIES TOASSESS BURNS
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