344 SECTION 3 PAINFUL CONDITIONS

CHAPTER 206
Thermal Injuries

Thermal injuries are damage to tissue as the result of TABLE 206–2 Rule of Nines for Assessment of Total Body
contact of the affected tissue with extreme heat or cold. Surface Area Affected by a Burn—Adult
When a thermal injury occurs, the most superficial areas
Anatomic Structure Surface Area
(i.e., the skin or mucosa) are first affected with the loss of
the barrier function, increasing the patient’s risk for infec- Head 9%
tion. As deeper layers are affected, fluid leaking from
Anterior torso 18%
capillaries leads to fluid loss, edema, and pain.
Thermal injuries are classified according to the depth Posterior torso 18%
of tissue damage. The traditional three-part classification Each leg 18%
of first-, second-, and third-degree burns has been
replaced by a six-part system that more accurately defines Each arm 9%
the extent of injury. Such accurate classification is neces- Perineum 1%
sary when formulating a treatment plan as well as for
forecasting a prognosis. The six-part classification is out-
lined in Table 206-1.

In addition to this classification of burns that focuses on

TABLE 206–1 Classification of Thermal Injuries the degree of tissue damage, the severity of thermal injury is
assessed in terms of the total body surface area (TBSA),
 First-degree burns are usually limited to erythema, limited which is defined as the percentage of the total body affected
pale-white plaque formation, and mild pain at the site of by second-degree or greater burns. The TBSA is easily
injury. First-degree burns extend only into the epidermis. assessed by using the rule of nines, which is outlined in
 Second-degree burns exhibit frank fluid extravasation and
blister formation. Second-degree burns involve the papillary
layer of dermis and may also involve portions of the
deeper reticular dermis layer. TABLE 206–3 Rule of Nines for Assessment of Total Body
 Third-degree burns additionally include charring of the Surface Area Affected by a Burn—Infant
skin and subcutaneous tissues and eschar formation.
Destruction of the pain receptors and nerve endings render Anatomic Structure Surface Area
third-degree wounds less painful than second-degree burns.
Head 18%
Hair follicles and sudoriferous glands are permanently
destroyed, and significant scarring usually occurs. Anterior torso 18%
 Fourth-degree burns are burns in which the majority of
the dermis is destroyed, leaving the underlying muscle and/ Posterior torso 18%
or bone exposed. There is no sensation in the burn area as Each leg 14%
pain receptors and nerve endings are completely destroyed.
Skin grafting and radical débridement of nonviable tissue Each arm 9%
are required, and death may occur.
Perineum 1%
 Fifth-degree burns are burns in which the skin,
subcutaneous tissue, and muscle have been destroyed, The Parkland Formula for Fluid Replacement Following
leaving the underlying bone exposed. Thermal damage to Serious Thermal Injury
the underlying bone further complicates the care and
worsens the prognosis. Fluid = 4 mL  %TBSA  weight (in kg)
 Sixth-degree burns are burns in which all the skin and Half of this fluid as lactated Ringer’s solution should be
subcutaneous tissue as well as muscle are destroyed and given in the first 8 hours post injury and the remainder
there is significant thermal injury to the underlying bone. given in the subsequent 16 hours.
Mortality associated with sixth-degree burns is extremely *Note the %TBSA excludes any first-degree burns and only counts second-
high. degree burns or worse.

Table 206-2. It should be noted that due to the larger head
size of infants relative to their body, a modified rule of nines
calculation is used for infants (Table 206-3).
The first step in the treatment of all thermal injuries is
to remove the offending substance to prevent further
tissue damage. Such items as smoldering clothing, adher-
ent chemicals, or ice are removed as quickly as possible.
The injured areas are carefully cleaned to decrease the risk
of infection, nonviable tissue is debrided, tetanus toxoid is
administered, the wounds are covered with an antibiotic
ointment such as silver sulfadiazine, and sterile dressings
are placed. Large amounts of fluid leakage are associated
with more serious burns, and immediate replacement of
fluids with lactated Ringer’s solution is essential to avoid
dehydration and renal insufficiency. The Parkland formula
is an easy way to estimate the amount of fluid that must be
given, with urine output and vital signs allowing the
CHAPTER 207
Electrical Injuries
The unique effects of supraphysiologic levels of electrical
energy on human tissue create a spectrum of injuries
beyond that associated with thermal injury. The three
major groups of tissue injury associated with electricity
are (1) low-voltage injuries, (2) high-voltage injury, and
(3) injuries caused by lightning. The extent of the tissue
injury induced by electricity is dependent on a number of
variables, which are listed in Table 207-1. It is the inter-
action of each of the variables that ultimately determines
the individual patient’s morbidity and mortality.
In general, the greater the voltage, the greater is the
amount of current that can pass through tissue assuming
the resistance of the tissue remains relatively constant.
TABLE 207–1 Factors Affecting the Extent of Tissue Injury
from Electricity
 Voltage
 Type of current (alternating current [AC] or direct
current [DC])
 Path of the current
 Resistance or conductance of the tissue
 Contact surface area
 Duration of exposure
CHAPTER 207 ELECTRICAL INJURIES 345
clinician to fine-tune the patient’s fluid requirements.
The Parkland formula is outlined in Table 206-3. If
smoke inhalation has occurred, careful attention to the
patient’s upper airway and respiratory status is mandatory.
Intravenous opioid analgesics should be used to help pal-
liate the patient’s pain. For thermal injuries involving
small surface areas, topical local anesthetics can be used
with caution. For more serious burns, rapid transfer of the
patient to a burn center will greatly improve the patient’s
prognosis.
SUGGESTED READING
Papini R: Management of burn injuries of various depths. BMJ
2004;329(7458):158-160.
Because alternating current is an oscillating current in
which the direction of flow rapidly changes, it is approxi-
mately three times as dangerous as an equivalent voltage of
direct current (in the United States, this change in direction
of flow occurs 60 times per second, or 60 cycles per
second). The reason for this increased danger is thought
to be related to the increased ability of alternating current
to produce tetany, making it impossible for the patient to
withdraw the body part making contact with the source of
electricity. The phenomenon of electrical-induced tetany
can occur at a threshold level of approximately 15 mA, and
this threshold level is known as the let-go level. Because
increases in the duration of the contact with the electrical
source increase the amount of tissue damage, voltages
above the let-go level are associated with significantly
higher morbidity and mortality. Levels above 30 mA are
associated with tetany of the cardiac muscle. Alternating
current also has a greater ability to overcome the resistance
of the epidermis compared with direct current, further
increasing its propensity to cause tissue damage.
Because electricity tends to flow through the path of
least resistance, the flow of electricity and its associated
tissue damage will be in large part determined by the
resistance of the tissues through which the electricity
passes. This flow can be caused by either direct or indirect