Areas of partial- and full-thickness injuries should be recorded on an anatomic chart and then a percentage of TBSA computed First-degree burns are not included BSA calculations are inexact, and some burns may progress over time, so BSA estimates should be reassessed Description of Burn The language used to describe burn severity has evolved over time, from a nomenclature of degrees to a description of the anatomic depth of the burn ( Fig 104.2 ) A superficial burn (formerly called first degree) occurs when the epidermis is injured but the dermis is intact These burns are characterized by redness and a mild inflammatory response confined to the epidermis, without significant edema or bulla formation ( Fig 104.3A ) Superficial burns are not included in the calculation of burn surface area used for therapeutic decisions These minor burns may be painful and usually resolve in to days without scarring In a partial-thickness burn (formerly called second degree), the dermis is partially injured Partial-thickness burns can be characterized as either superficial or deep Superficial partial-thickness burns expose the rich capillary network in the dermis resulting in a pink-red color and moist appearance Blistering is often present ( Fig 104.3B ) Increased capillary permeability, resulting from direct thermal injury and local mediator release, results in edema These injuries are usually painful because intact sensory nerve receptors are exposed Healing occurs in about weeks, and scarring is usually minimal FIGURE 104.1 Estimation of surface area burned on the basis of age This modification by O’Neill of the Brooke Army Burn Center diagram shows the change in surface of the head from 19% in an infant to 7% in an adult Proper use of this chart provides an accurate basis for subsequent management of the child with burn injury Deep partial-thickness burns involve destruction of the epidermis and most of the dermis Edema can lessen the exposure of sensory nerve receptors, making some partial-thickness burns less painful and tender, although there should be some intact pain sensation Deep partial-thickness burns have a paler, drier appearance than superficial injuries, at times making them difficult to distinguish from full-thickness injury ( Fig 104.3C ) Thrombosed vessels often give deep partial-thickness burns a speckled appearance Burns evaluated immediately may appear to be partial-thickness injuries and subsequently become full-thickness injuries, especially if secondary damage from infection, trauma, or hypoperfusion ensues Deep partial-thickness burns can take many weeks to heal completely Significant scarring is common and skin grafting may be necessary to optimize cosmetic results Full-thickness burns (formerly called third degree) involve destruction of the epidermis and the entire dermis They usually have a pale or charred color and a leathery appearance ( Fig 104.3D ) Important for recognition is the fact that destruction of the cutaneous nerves in the dermis makes them nontender, although surrounding areas of partial-thickness burns may be painful Full-thickness burns cause a loss of skin elasticity The burned skin cannot expand as tissue edema develops during the first 24 to 48 hours of fluid therapy Circumferential or near-circumferential burns of the torso, abdomen, or extremities can therefore cause respiratory distress, abdominal compartment syndrome, and vascular insufficiency of the distal extremities, respectively Full-thickness burns cannot reepithelialize and can heal only from the periphery Most require skin grafting