Dott. Franz W. Baruffaldi Preis

Severe burnings today


Second degree face burning

The problem of heat lesions in Italy as well as in the rest of the industrialized world, can be considered of topical interest in light of the increasing number of burning cases reaching specialized centers. According to a survey of 1986, it seems that in our Country we stroke a roof of about 100,000 scalded people. About 10% of these need hospitalization. The main causes of this concerning phenomenon may be attributed to an excessive frivolity in manipulating dangerous substances and appliances that appear armless only because they have become of very common use in modern life. In fact, while in the last 20 years there has been a progressive reduction of work accidents, thanks to security rules that, when observed, allow to limit danger from heat sources or flammable substances, for what concerns domestic accidents there are alarming data. Consider that they represent about 60% of all the causes of burns and these rates are going to rise in the future. One might therefore affirm that, in periods of peace, the houses, in which a large amount of potential booby-traps is kept, become real powder magazines. We are talking about all those commonly used things that range from simple matches and fireworks to Star War-like electrical appliances. These turn out to be particularly stimulating to any child's mind and rather difficult to use for elderly people. In studying the mechanisms that lead to the most common accidents one infers that in general very little time is devoted to instruct people on how to employ these risky tools. Pots of boiling water and non-insulated electric cables are very common etiological agents, but the real "Molotov bomb" is certainly represented by the alcohol bottle that is too often used to make the fire up in the fire place and kept close to heat sources. It is important to underline how too frequently, out of a stupid game or fatality, one witnesses helplessly human tragedies caused by the inflammation of this diabolic fluid. What's even worse is that, whereas for public buildings the law provides the employment of fireproof materials, when it comes to private houses there are no rules and a simple spark on the carpet can easily give rise to a big fire.

Severity of the burn

 

The degree of burning is normally evaluated through 2 main parameters: the amount of scalded body surface and the depth of the damage. For what concerns the evaluation of how extended the damage is, we employ printed tables that divide the body into areas that correspond to specific values, calculated as a proportion out of the whole body area. While there are standard schemes for the adult, for patients below 15 years of age the parameters need to be modified, according to the age, above all when areas such as head, leg or thigh are concerned. In fact, in the child, the aforementioned areas occupy percentages of body surface different than in the adult. For example the head, which in the child represents 19% of the whole body, in the adult goes down to 9%. For what concerns the depth of the burn, this turns out to be proportional to the temperature of the thermo-damaging agent and to the duration of the contact. Being there a strict relation between the actual appearance of the lesion and the depth of the damage, by means of physical examination it is possible to make a rather precise prognosis in terms of possible complications, expected recovery time and incidental need for surgical procedures.

Classically burns are divided into superficial and deep ones, with the aim of making a rough differentiation between the lesions that will naturally heal without any evident scar and those that will instead call for surgery. The mildest form (first degree) concerns the most superficial layers of the epidermis and is typically characterized by skin reddening (erythema) and edema, that is to say the swelling of the region that underwent thermal modifications. Erythemas induced by excessive UV exposure that often occur at high altitudes or as a result of inconsiderate use of UV lamps are clear examples of this. Fortunately this pathology does not associate with major patho-physiological alterations, being the structure within which lies the liquid permeability barrier (the dermis) preserved. The skin color tends to go back to normal within about a week along with any symptoms of pain. Being the damage limited to a desquamation of the corneal layer, no therapy is required.


Forearm phlyctenah

Second degree burnings concern the epidermis and part of the dermis. It is a kind of lesion that tends to regress spontaneously if there are no infective complications or the patient doesn't carry any basic pathology that might complicate the reparative process. The most characteristic sign is the phlyctenah (or blister) that is to say a "bag" filled up with serum that might also become quite extended. Once it breaks, the bottom of the wound appears bright red and secreting. Re-epithelialization occurs starting from the basal cells that represent, even under physiological conditions, the regenerative layer allowing a constant skin renovation. These cells line the wavy surface of the dermal papillae and go deep down into the hair follicles. The number of cells deputed to regeneration largely depends on the depth of the lesion. Based upon this kind of quantitative rating second degree burnings are classified as superficial or deep. In fact, while the first ones heal quickly, the second ones require more time and tend to turn into full thickness lesions, because their recovery relies on the few surviving cells that can be found at the bottom of the dermal papillae or within the hair follicles. In the superficial second degrees, spontaneous re-epithelialization requires about 10 days. Pain, either spontaneous or compression-evoked, due to the exposition of the nervous fibers, regresses as re-epithelialization occurs but in its place persists a certain hypersensitivity to the physical stimuli for a few weeks. For what concerns deep second-degree burnings, they can be differentiated from the superficial ones because, at the break of the blister, the skin shows light pink areas alternated with reddish ones. Being the reticular dermis largely involved, complete recovery takes at least 20 days. Second degree lesions imply a damage of the skin barrier, both for what concerns permeability to the liquids and bacterial contamination. In the adult, when the lesion covers over 20% of the body surface hospitalization is required, while in the child and in the elderly patient even smaller areas need to be considered at risk. The most severe lesion is that of third degree, where there is complete necrosis of the skin with possible injury of the sub cutis and the deep tissues. Being the nerve endings totally destroyed the patient will paradoxically feel less pain than for more superficial burnings. The bottom of the wound displays a light pink, white or yellowish color, but, within a few days turns into a tough, dark tissue called an eschar. This confirms that the skin is no longer vital. This sign designates the impossibility of any spontaneous healing , unless the lesion is so small as to allow re-epithelialiazion by migration of new cells from the healthy wound margins. In this case also, if the sore doesn't show any sign of healing within 15-20 days from the damaging event, one must take surgery into consideration to avoid any scarring process that may lead to poor aesthetic and functional outcomes. Several factors can affect the healing. There are parts of the body that react to the thermal insults better than others. The hand palms, the foot soles and the back, thanks to the thickness of their tegumentum, are rather resistant to burning. For the same reason, areas lined by thin skin, such as the back of the hands, the face and the genitalia, are very vulnerable. Although the characteristics of the cutis vary from person to person, one must keep in mind that in the child and in the old the cutaneous layer is constantly reduced to about 1/2 the thickness of that of the young adult. This accounts for the fact that in these patients even lesions that start out by being superficial can easily become rather severe and difficult to treat. The nature of the pathogenic agent is also important in determining the gravity of the thermal lesion: in fact, those materials with greater thermal capacity (faculty of storing and transferring the heat) cause more damage. Furthermore tars, plastic materials, metals and resins cause deeper lesions with respect to the liquids, because, since they adhere to the skin, they dispose of a longer damaging time. Another occurrence, within the mechanism of the accident that might increase the patient's difficulty in overcoming the trauma is the inhalation of gases, smokes and toxic vapors, causing injury to the lungs. The inhaled substances, being them toxic or due to their high temperature, exert a demolishing action towards those alveolar structures deputed to the oxygen-carbon dioxide exchange. Therefore, unfortunately, the clinical picture that may have been underestimated due to the limited skin involvement might worsen owing to pulmonary complications.

Therapy

 

As previously mentioned, first degree burnings do not require any therapy but, being oftentimes associated with actinic (solar) keratoconjunctivitis, the patients should rest and keep away from any intense light source while making use of eye drops. Small sized second degree burnings, with phlyctenah no larger than 2 cm, should not be manipulated, since the blister won't normally brake spontaneously thus granting protection to the area. When the amount of serum is conspicuous, so as to form a real pocket, it needs to be opened while the exposed surface must be covered with synthetic, semi-synthetic or sterile biological skin substitutes. Should these materials not be available, can exert a good protective action, both towards infections and mechanical injuries.

In the accidents causing small first and second degree lesions, the patient coming to the Burning Care Unit , has normally already taken some advice from family, friends and neighbors. As a consequence, the damaged area will show to have been spread with a cocktail of different lenitive ointments, oils, spices and miracle herbs. Fortunately, in case of superficial lesions, this does not affect the healing process, but in the most severe and extended cases, these applications may lead to complications and it becomes necessary to remove the poultice with great pain for the patient. The universal recommendation in case of rather severe burnings is that of taking off the clothes covering the interested region, wash it with running water and cover it with a clean cloth before heading for the closest emergency room.

Severe burnings

 

Patients with an area of 2nd -3rd degree burning wider than 20% of the whole body surface must in our opinion be kept under observation at a Specialized Center. When the lesion is extended and deep the therapy follows a precise and fix chronological sequence. In the first phase (acute) the result to get is represented by the overcoming of the hypovolemic shock. It is in this state that the patients are found since, having the capillaries of the scalded area temporarily lost their ability to retain the liquids, they can loose liters of fluids. While awaiting for the restoration of a normal permeability, the body liquid total volume must be re-integrated. In the last 10 years, many progresses have been made in the field of resuscitation and infusion therapy. Besides we now make use of formulas that take into account the importance, for a good re-hydration, not only of the fluids but of the salt balance as well. All this leads to the fact that this initial phase has become rather easy to overcome save the really desperate cases.

The second big obstacle to surmount is the sub-acute phase of the disease that shows the largest amount of therapeutic failures: the infection. The scalded patient can turn into a very good culture medium for microorganisms. This is made easier by the reduced defense ability due to the immune depression and the physical debilitation created by the disease. The situation is aggravated by the fact that in the Burn Centers and in the Intensive care Units there is always a super-selection of bacterial strains that progressively become resistant to the traditional pharmacological therapies. For this reason, if the patient does not undergo very specific antibiotic and antiseptic therapies, tested by means of microbiological essays, there is the risk of what in medical terms is called a "sepsis", that is to say the victory of the bacteria on the immune system. The third phase involves reparation. Deep burnings that do not heal spontaneously need surgical treatment. Modern surgery tends to remove precociously the necrotic tissues to avoid that these become a source of infection and to transplant the wounded areas with autologous skin grafts harvested from healthy sites. The grafts are harvested by means of peculiar instruments called dermotomes adjusting their thickness in order to make it possible for the harvested area to recover spontaneously thanks to the normal action of the above mentioned granulocytes. The grafts can be directly transplanted or rolled over by a tool that turns them into nets. This way, many fenestrations (little fissures) can be created and the graft is spread so as to make it up to 3-4 times more extended than the initial patch. The patient undergoing this procedure with dermo-epidermal grafts will normally (when the grafts take) recover within 10 days. Once the skin mantle has rebuilt its integrity the patient can be discharged from the hospital. Unfortunately this is not the end of the tragic adventure. It is just the beginning of the last long phase that may last for ages and concerns the residual scarring. Scars from burnings are particularly evident and disabling. The modulation of scarring, at least from a pharmacological point of view, has a long way to go in order to give new hopes to those patients whose damages can really be diminished. If therapy starts right after surgery, a compressive therapy performed by means of elastic bandages is associated to motorial rehabilitation. Unfortunately some outcomes require further surgical treatments and constant physiotherapy to avoid the risk of severe functional deficits. These are painful therapies that often discourage the patients. The psychological condition of the subjects affected by this disease must always be taken into great consideration: they often do not accept their appearance or have a hard time being accepted by the others. This reduces to a minimum their whish of being reintegrated into the world of healthy people.

Conclusion

 

As previously described, many are the compulsory steps that a patient with severe burnings must take before going back to feeling healthy. For this reason the burn itself cannot be considered an accident to be solved in emergency but is in every respect a true illness. So far we have had encouraging results, both in light of the new discoveries in the fight against infectious diseases and in all those fields of research studying in vitro (skin cultures) and in vivo (by means of skin expanders located in sub-cutaneous pockets) skin expansion , immune system stimulation and residual scarring modulation. It is important to remind how essential, though often neglected, prevention can be even in this pathology: it is the most effective weapon, easy to employ and, it goes without saying, the least traumatizing for the subject