The skin as the outermost covering of the body is subject to injury by innumerable ways. Skin injuries are classified by the type of wounds produced.
Abrasion. The abrasion is a superficial wound which does not involve all layers of the skin. Only the outer part is scratched or scraped off. A clot forms over the area until the processes of healing are complete beneath it, and then it is released. Treatment of abrasions may necessitate the application of dressings after it has been cleaned and treated with an antiseptic.
Incised Wound. The incised wound is a sharp cut through both skin layers. The cut edges are smooth with little damage of the adjacent parts. If the edges gape, repair by suturing is nccessary to hasten healing and minimize scarring.
Lacerated Wound. The laccrated wound is a jagged tearing through both skin layers. This type wound usually requires trimming of the jagged edges and removal of fragments of tissue which have lost their blood supply, before repair by suturing is done. Such trimming is called debridement.
Avulsion Wound. Avulsion wound is the term used when there has been a scraping or pulling away of tissues. Large avulsed areas of skin usually necessitate skin grafting.
Contusion. The contusion is a closed wound where the skin has not been broken but there is damage to the tissues beneath it. If there is an escape of blood into the tissues from rupture of a blood vessel, the wound is called a hematoma (blood-swelling), or more commonly a bruise.
Penetrating Wound. The penetrating wound is a puncture into the body, such as occurs with stepping on a nail or with the bullet which remains lodged in the tissues. The depth and extent of damage of this stabbing type of injury, as judged by the appearance of the skin wound, is often deceiving.
Perforating Wound. The perforating wound is a through-and-through injury. Its entrance is at one point and its exit at another, such as from a bullet which passes through a part. Penetrating and perforating wounds are, of course, associated with skin lacerations.
All injuries with a disruption of the protecting layers of skin must be treated early with antiseptic medicants to kill the germs present, and foreign particles usually must be removed before they are repaired. All dead tissue must be removed. They must be protected against invasion of germs until healing is complete. Most injuries with a broken skin bleed due to disruption of the blood vessels within the area. Control of the blood loss is of primary concern, of course, before any other treatment is attempted.
An injury to the skin and the underlying tissues seen all too frequently is the burn. Bums are caused in a number of ways, and most could be prevented. Carelessness is responsible in the majority of cases.
Burns may be small or involve a very extensive area of the body. They may be of varying severity, depending on the intensity of the agent and the duration of exposure to it. Bums have been classified into three degrees:
- First-degree burns are those resulting in redness of the skin over the area. The bum is superficial and is usually tender, but there is no actual destruction of living tissue.
- Second-degree burns are those with resultant blister (vesicle) formation. This type burn involves greater depths but there is no actual break in the skin covering. The blisters form as pockets of scrum collect between skin layers.
- Third-degree burns arc those where there has been a destruction of the entire skin thickness and even of the deeper layers. There may be actual charring of the tissues. The dead tissue sloughs off.
Many extensive burns are combinations of different severities. One area may be only first- degree while other areas may be of second- or third-degree.
The causative agents of burns are several: Heat burns are the most common. They may be from dry heat such as a flame, or they may result from moist heat such as steam or hot liquids. The majority of these bums occur from accidents in the kitchen.
Chemical burns are those which result from spilling strong acids, strong alkalies, or other chemicals on the skin. These are encountered most commonly in industry.
Electrical burns result from the undue passage of electricity through a body part. The burn sites are noted where the current enters into and exits from the body. The effects vary according to the voltage and the amperage of the current. Electrical burns are difficult to evaluate on first inspection, for deeper structures may be involved than are at first apparent, and the full effects may not be manifested for several days. Disturbances in other body systems, such as the respiratory, circulatory, and nervous systems, may accompany electrical injuries. Many of these are encountered in industry, but many also occur in the home.
Irradiation burns result from undue exposure to ultraviolet light and x-rays. Sunburns and those from sunlamps are common ultraviolet ray burns. These are usually first-degree burns with only temporary effects, but occasionally they are more severe. Bums from the x-ray machine and radium are slow to produce their full effects, frequently appearing years after exposure. With the modern knowledge of x-radia- tion, they are rarely encountered today; in the past, however, they often appeared in the early workers with x-ray and radium. X-ray burns require a definite amount of x-ray exposure. They do not result from the brief exposure for x-ray diagnostic films, and modern methods are accurately calculated so that even deep x-ray therapy will not result in bums.
Frostbite produces tissue changes similar to burns. There is both superficial and deep death of tissues, just as with third-degree burns, but the full effects may not be apparent for a few days. Gangrene from loss of blood circulation may result. Loss of feeling appears early. The toes and the fingers are the most commonly affected parts, and the ears and the nose are sometimes involved. The conditions commonly known as trench foot, shelter foot, and immersion foot are similar conditions.
First aid treatment of burns is frequently performed ill-advisedly, due to anxiety on the part of the patient and his well-meaning helpers, and because of odd and mythical impressions of immediate burn care. Only in the case of chemical bums is prompt action really necessary. Here the involved area should be flushed with water to remove the irritating chemical as soon as possible, to halt its action on the skin. Other chemicals to “neutralize” the chemical action should not be used. (Some surgeons advise treatment of chemical burns with antidote solutions—i.e., apply alkalies to acid burns and vice versa. We, however, believes that the area should be flushed of its remaining chemical, only with neutral solutions. When acids and alkalies react, heat is produced, so a heat burn may be induced in addition to the chemical burn.) It is best to place the part into a stream of running water for a few moments, but if this is not practical, pouring container after container of water over the area is suitable. All garments saturated with the offending chemical should be removed immediately. After the flushing with water, the area should be covered with a clean cloth and the services of a physician sought.
Heat bums and scalds should be covered with the cleanest cloth available, such as a towel, and then promptly taken to skilled medical hands. Applications of home burn remedies and kitchen greases are to be discouraged, for they only hinder the later treatment. After electrical burns, of greatest concern is the victim’s general condition. If breathing is absent, artificial respiration must be given; if unconsciousness is present, call for an ambulance. But local treatment of the burned parts should only include a clean covering of the areas. Irradiation burns are slow to manifest themselves and require no first aid treatment. After frostbite, care should be taken not to warm the parts too rapidly. Never should heat or massage be applied.
Treatment of burns has included innumerable methods in the past. The main objects of any form of treatment are to promote early healing with the least possible scar and deformity, to prevent infection, to prevent fluid loss, from the area, to eliminate and prevent shock, and to control pain.
First-degree burns often require no special care. Scarring does not occur and infection is seldom encountered. The deeper layers of skin are still intact, so the skin regenerates from below upward. The outer destroyed layers are released to “peel off” as they are replaced. Soon the inflammatory reaction is over; the pigment proportions become normal, and the area appears normal. An anesthetic ointment is usually all that is needed to control the pain and keep the area moist. But occasionally dressings are advisable.
Second- and third-degree burns have to be protected against infection and the escape of body protein fluids. The burned area is cleansed and shreds of loose charred tissue are removed under sterile conditions. Compression bandages are then applied. Immediately over the burn is placed the appropriate ointment or salve, or a layer of gauze impregnated with the salve. Often incorporated into it are antiseptic and anesthetic medicants. Over this are several layers of soft padding to provide uniform firm compression. Such dressings are left in place several days without change.
As previously mentioned, many different methods have been proposed for the treatment of burns. Many pastes, ointments, medicants, and dressings have proved effective in many situations. Tannic acid treatments were commonly used for many years to help form a crust over the area while it healed underneath. More recently, plastic sprays have been used to cover the area with a sealed pliable membrane, replacing bulky dressings.
Under some conditions, the “open treatment” of bums is practical even for extensive second- and third-degree burns. With this method the burned area is left entirely exposed from the start. The healing process ensues with nothing coming in contact with the area. Special care and precautions are necessitated with this method.
The effects of burns on the body are more than just in the local area. Shock is common, especially if the injury is accompanied by intense pain or if it covers a wide area. The shock is due to destruction of blood capillaries in the region and dilatation of others, which allow the escape of fluid from the circulating blood. The decrease in blood volume is the basis of shock. The pain also causes dilatation of the smaller vessels throughout the body. In some cases the shock is profound. Shock must be combated early and continuously. Drugs to control pain must be given, and infusions of plasma, whole blood, and other solutions must be administered. Various examinations and blood tests have to be repeated to determine the state of shock and the effectiveness of its treatment. Bum dressings are designed to control the escape of fluid from the injured site.
Healing of injured tissue results in the formation of new flesh called granulation tissue, which finally resolves into scar tissue. This is the process which ensues over areas devoid of normal skin from burns. Scar tissue which so forms protects the area but is not of the same appearance as skin, nor is it elastic like skin. So in many areas it is not nearly so desirable or practical. Skin can regenerate usually to cover an area the size of a half-dollar, but no larger an area. If an area devoid of skin larger than this occurs about the face where scar tissue would be unsightly, or over an area where skin elasticity is essential to normal movement, skin grafts to the burned area must be performed. Skin grafts are done after the granulation tissue has formed but before it changes to scar tissue. Mention of the methods of grafting skin follows.