Burn classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Eman Alademi, M.D.[2]

Classification

The most common system of classifying burns categorizes them as first-, second-, or third-degree. Sometimes this is extended to include a fourth or even up to a sixth degree, but most burns are first- to third-degree, with the higher-degree burns typically being used to classify burns post-mortem. The following are brief descriptions of these classes:The basis of burn classification is depth. When examining a burn, there are four components needed to assess depth: appearance, blanching to pressure, pain, and sensation. Burns can be categorized by thickness according to the American Burn Criteria using those four elements. Burn injuries tend to be a dynamic process. Some burns, especially partial-thickness, may progress over 2 to 4 days, peaking at day 3.

• First-degree burns(Partial Thickness Superficial) are usually limited to redness (erythema), a white plaque and minor pain at the site of injury. These burns only involve the epidermis of the skin.
• Second-degree burns(Superficial partial-thickness) manifest as erythema with superficial blistering of the skin, and can involve more or less pain depending on the level of nerve involvement. Second-degree burns involve the superficial (papillary) dermis and may also involve the deep (reticular) dermis layer. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.
• Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present.
• Third-degree burns(full thickness) occur when most of the epidermis is lost with damage to underlying ligaments, tendons and muscle. Burn victims will exhibit charring of the skin, and sometimes hard eschars will be present. An eschar is a scab that has separated from the unaffected part of the body. These types of burns are often considered painless, because nerve endings have been destroyed in the burned area. Hair follicles and sweat glands may also be lost due to complete destruction of the dermis. Third degree burns result in scarring and may be fatal if the affected area is significantly large. If extensive enough, it can increase the risk of infection, including bacterial, and can result in death. Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.
• Fourth-degree burns damage bone tissue and may result in a condition called compartment syndrome, which threatens both the life of the limb and the patient.charred skin with possible exposed bone.
• Fifth-degree burns are burns in which most of the hypodermis is lost, charring and exposing the muscle underneath. Sometimes, fifth-degree burns can be fatal.charred, white skin, and exposed bone.
• Sixth-degree burns, the most severe form, are burn types in which almost all the muscle tissue in the area is destroyed, leaving almost nothing but charred bone. Often, sixth-degree burns are fatal.loss of skin with exposed bone.

Other Classifications

A newer classification of "Superficial Thickness", "Partial Thickness" (which is divided into superficial and deep categories) and "Full Thickness" relates more precisely to the epidermis, dermis and subcutaneous layers of skin and is used to guide treatment and predict outcome.

Table 1. A Description of the Traditional and Current Classifications of Burns

Template:Bgcolor-gold |Nomenclature	Template:Bgcolor-gold |Traditional nomenclature	Template:Bgcolor-gold |Depth	Template:Bgcolor-gold |Clinical findings
Superficial thickness	First-degree	Epidermis involvement	Erythema, minor pain, lack of blisters
Partial thickness — superficial	Second-degree	Superficial (papillary) dermis	Blisters, clear fluid, and pain
Partial thickness — deep	Second-degree	Deep (reticular) dermis	Whiter appearance, with decreased pain. Difficult to distinguish from full thickness
Full thickness	Third- or fourth-degree	Dermis and underlying tissue and possibly fascia, bone, or muscle	Hard, leather-like eschar, purple fluid, no sensation (insensate)

Table 2. Scald Time (Hot Water)

Template:Bgcolor-gold |Temperature	Template:Bgcolor-gold |Max duration until injury
155F (68.3C)	1 second
145F (62.9C)	3 seconds
135F (57.2C)	10 seconds
130F (54.4C)	30 seconds
125F (51.6C)	2 minutes
120F (48.8C)	5 minutes

Burns can also be assessed in terms of total body surface area (TBSA), which is the percentage affected by partial thickness or full thickness burns (superficial thickness burns are not counted). The rule of nines is used as a quick and useful way to estimate the affected TBSA.

Table 3. Rule of Nines for Assessment of Total Body Surface Area Affected by a Burn - Adult Template:Bgcolor-gold |Anatomic Structure Template:Bgcolor-gold |Surface Area Head 9% Anterior Torso 18% Posterior Torso 18% Each Leg 18% Each Arm 9% Perineum 1%

Table 4. Rule of Nines for Assessment of Total Body Surface Area Affected by a Burn - Infant Template:Bgcolor-gold |Anatomic Structure Template:Bgcolor-gold |Surface Area Head 18% Anterior Torso 18% Posterior Torso 18% Each Leg 14% Each Arm 9% Perineum 1%