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Chapter 1: How have burns been part of the human experience?
This is exactly right.
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This episode features descriptions that some listeners might find upsetting. Please listen with Case 1. A lady, aged 20 years, in feeble health, was extensively burned by her mosquito curtains and calico bed cover being set on fire after she had fallen asleep. The flames enveloped her head, neck, and arms and were not extinguished for 20 or 30 seconds.
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Chapter 2: What are the biological responses to burn injuries?
All of these treatments, we have so many different treatments and none seem to have a positive effect. Like if anything, they might have made things worse. Yes. Yeah. The article, if you're interested, is titled History of Two Cases of Burn Producing Serious Constitutional Irritations by Daniel Drake. It was published in 1830.
And the paper that I found this in was called Daniel Drake's Account of His Own Hand Burns by Eric Mooney. That was published in like 1998, I think. So yeah, truly awful stuff. But hi, I'm Erin Welsh. And I'm Erin Allman Updike. And this is This Podcast Will Kill You. Welcome to Burns. Yeah. Part one. Part one.
Yeah.
Two parts because this is a big, this is a big one. I mean, each, there are, as I was working on the second episode and like the way that I split up the history for this is that I did like most of history. Most of history and beyond. Most of everything. And then, like, the last 80 years, basically.
And, like, the various developments in the last 80 years, each one of those could be its own episode. Not to mention burn centers being its own episode. Multidisciplinary, like all these things. Anyway. I know. There's so much. And, like, even in the newer, like, the techniques and the newer technologies and things that we have, like, there's so much more detail. There's so much more detail.
Listen, we've got a lot to cover though today and next week. Yes. Today is Burns part one. Should we tell people like kind of what we're covering today, what we're covering next week? Sure. Sure. Let them know a little bit. Yeah, we can do that. I don't know if you want to know. Here's a preview. Here's a preview.
Today, we're going to talk about the biology of burns, what is happening in our bodies to our bodies when we suffer a burn. And then, Erin, you're going to walk us through, like you said, the most of humanity's history with burns. And then next week, we're going to pick up with more modern history and how we actually treat and deal with burns today. Yeah.
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Chapter 3: How do we categorize burns based on severity?
Yeah. Yeah. There's a lot. There's a lot. There's a lot. And before we can do any of this, it is... It's quarantine-y time. Quarantine-y time. What are we drinking this week? We're drinking By Degrees. By Degrees. It is...
technically still how we measure burns ish okay okay ish we'll get there but kind of okay okay it's still all over the literature it is i when when i was like oh degrees and you were like no we don't talk about that anymore yeah it's like it's fine we're going to okay okay okay Well, by degrees is the name of the quarantini, and the quarantini is a non-alcoholic bee's knees, basically.
So non-alcoholic gin, lots of different varieties out there. Take your pick. Lemon juice, honey. Which is a great antiseptic for wounds. It is. It is historically used as well as today. As well as today. Yep.
Yeah.
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Chapter 4: What historical treatments for burns were used in ancient civilizations?
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For today's episode, I wanted to take us through how exactly we classify burns in medicine and what this classification means for how our body responds to a burn injury. Because although a burn is a type of trauma to our skin, and there's a lot of other traumas that we could get to our skin, right? Scrapes, cuts, etc., Our body's response to burn injuries is actually fairly unique.
Even though it is still the same inflammatory response, it is also unique. It's kind of interesting. And what I really think and what I took away from digging really deep into this is that what burns really show us is just how incredible and how important of an organ our skin is. And how severe damage to that skin has life-threatening consequences and long-lasting consequences.
So I'm going to walk us through the types of burns that we can see, burn severity, and how we actually determine severe versus minor or major versus minor burns, and what is happening to our whole entire body as a result of a burn injury, and then save the, like, what do we do about these burns for next week's episode. Okay?
Okay.
Sounds good.
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Chapter 5: What are the differences between first, second, and third degree burns?
Okay.
And so this is a burn that burns completely through the epidermis and then into the first part of the dermis but does not go like deeply into the dermis.
Okay.
And so this is something that you might get if you burn yourself on a pan or the oven or like really hot, you know, liquid that spills on you or something. These burns are very, very painful. They might be red. They might be blistered. They might be very wet and kind of weep.
And you have to take care of these wounds, but you're not going to need surgery to fix these wounds because the layer of the dermis has not been completely burned through. And so your skin is going to be able to ā it's called re-epithelialize. It's going to be able to make new skin to cover up this wound without a lot of additional help.
Right.
Most of the time, you're not going to get a scar from these types of burns. If you do, it might just be pigmentation changes because of losses of like the melanocytes that are in more of the epidermal layer. Mm-hmm. Okay. Okay. Next is, again, within this considered second-degree burn, is called a deep partial thickness burn.
Okay.
And the deep partial thickness burns actually tend to hurt a little bit less than the first two. And that's because they burn deeply enough that they're actually destroying our pain receptors in our skin. These burns tend to be a lot drier than a superficial partial thickness burn. Okay. So you don't necessarily have blisters. Or if you do, they're just not quite as wet as a superficial burn.
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Chapter 6: How does the body respond to different types of burns?
But total body surface area is how much of your body surface is covered by this burn regardless of the degree. Okay. So you don't need to separate it by, oh, you know, this much surface area was the first degree versus second versus third. Here we're just looking at how much of your skin got burned. And this is actually the most important part in looking at mortality is surface area.
Surface area.
Yeah.
So how we classify something as a so-called minor burn, this is actually a lot more, I won't even say contentious in the literature because I don't think anyone's fighting over it, but it really depends on the situation, whether something is considered a severe or a minor burn. In general, most people don't require hospitalization for burns that cover less than 10 percent of their body surface.
But that's a huge generalization because a burn on the face, a burn on the groin, a burn on the hands, even if it's significantly less than 10 percent, might still require hospitalization as well as depending on the thickness or the degree of that burn. Right. Or other injuries sustained or types of burn that it is. Yeah, exactly. So that that is really an overgeneralization.
Most of the time, if we're thinking about what is going to cause more likely to cause systemic symptoms, then we're looking at burns that are maybe more than 15 or 20 percent of your body's surface area, depending on the person and their age and like how big they are. Right. Like a kid. Right. might have a less body surface area to cause severe effects.
But all of that is really like, it's so depends on the person, right? So there's not like a clear cut definition of like, this is a major burn versus a minor burn or a severe burn versus a non-severe burn. But calculating that body surface area is a really important part of the care of a person and understanding like how severe their outcomes are going to be.
And the way that we do that is there's a couple different ways. There's a fast and ready way kind of that is called the rule of nines. Mm-hmm. And that is that we just split up an adult body area into areas that are about 9%. So our head is about 9% of our body surface. Our chest, the front side of our chest and the front side of our abdomen are each 9%. And same thing with the back.
So that's like 18 and 18. And then the front of our legs are 9%. The back of our legs are 9%. And our two arms put together are 9%. And then an extra 1% for the genitals. The other way that you can do it, though, because that calculation does not hold true for children, because children, their head is a significantly larger body surface, especially for babies.
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Chapter 7: What modern advancements have improved burn treatment?
But the second thing that's going to happen is inflammation. And this is to bring helpers to the area in order to start the repair process. The third step is proliferation. We need to start making new cells to fill in the gaps that are left by this wound. And finally, we have maturation or remodeling.
That's the finishing up that is really scar formation because our skin pretty much always heals by scarring. So in the event of a burn, our body is going to attempt to heal by this similar process. However, because of some specific things that happen, especially in the case of a thermal burn, so a heat-related burn.
Mm-hmm.
as well as the potential for a very large portion of our skin to be affected, the end result is often a pretty dysregulated body response that can be really severe. So unlike, say, a cut or a scrape that just has damage wherever that scrape actually happened, a burned wound actually has several different zones of injury.
In the very center or like where the burn was actually sustained is what's called a zone of coagulation. You can think of this as not necessarily the deepest part of the burn, but like the part that actually had contact with the hot liquid or the flame or whatever it was that caused the injury. And in that area, the tissue is dead. The blood cells are coagulated.
So there's no bleeding in that area because of the strong heat that was applied. And that tissue in that area cannot be completely salvaged. Okay. Okay. Immediately around this, there is a zone of stasis. And in this area, there is a lot of inflammation. So our body is trying to respond to that central area. It knows that there's something wrong here. But there's very low levels of blood flow.
There's a lot less perfusion in this zone because of damage that was sustained and our body's response of kind of clamping down to try and protect that area. Okay. Which has the effect that if that area is not addressed, then the damage from the burn can actually extend out over the next 24 to 48 hours. Okay. How can it do that?
Because that area, that zone of stasis, is not getting enough blood flow. If that blood flow is not restored to that area, then that area is also going to die because of a lack of blood flow. Okay. Does that kind of make sense? I think so, yeah. And then outside of that zone is called the zone of hyperemia. And this is non-damaged tissue where perfusion hasn't been affected.
And this is all like viable tissue, essentially.
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Chapter 8: What can we learn about the historical quest to treat burns?
So then, okay, everything has to be restored. Everything has to be restored. So that's the first challenge is identifying those areas that need restoration, that we need to do something. Otherwise, that repair process is not going to be able to start. That's the first challenge. Right. The second challenge is that all of the surrounding tissue will have a lot of inflammation, right?
Because our body knows that something is going on and they're trying really hard to send in all the troops. That means in the surrounding areas, we have a lot of vasodilation, right? That means our blood vessels are getting larger, and that's to accommodate more flow. We see an increase in vascular permeability.
So that means that our blood vessels are more leaky, and that is to allow all of the plasma that has our white blood cells and the inflammatory markers and the cytokines and all these things into the area to try and help. But unfortunately, what that ends up resulting in is a lot of edema. So a lot of fluid in the area because the degree of inflammatory signals is so high.
And this can be in and of itself very dangerous, especially in the event of like a circumferential burn. So think like a burn that goes around your entire arm, for example. Basically, the fluid has nowhere to go. And so that's going to increase pressure in that area. Does that make sense? Yes. How does blood pressure overall play? Like what happens to your blood pressure? Yeah.
So the pathophysiology of burns, severe burns especially, is divided into two phases. The first phase is in these first 24 to 72 hours. And that's called the hypodynamic phase. And that is when all this inflammation is happening. Our bodies kick into high gear. Inflammatory markers are going everywhere. Vascular permeability is up. So we are at very high risk of going into shock.
And shock, as we learned in our sepsis episode, means a drop in your blood pressure, enough so that all of your other organs are not getting enough blood. So this is incredibly dangerous. It can result in multi-organ failure, kidney failure, liver failure. Your heart is not pumping out enough blood. And really it's because you're not losing blood enough.
So you're not bleeding out, but you are losing so much fluid from this process that your blood pressure just can't keep up. We can also see really bad fluid imbalances and electrolyte imbalances as well. So in this period, what's really important is fluid resuscitation. As well as like management of these wounds to try and prevent all of this stuff from getting worse.
And in the case of those, like if we have circumferential burns and things, there has to be like pressure relief. So you have to do some kind of surgical intervention, even if it's something small, to literally release that pressure so that you don't cause further damage to the tissue or the tissue downstream from that.
Okay. Okay.
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