الفهرس 
Skiin Anattomy and FuncttiionOnly 14 pages are availabe for public view
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Abstract
Burns exert a catastrophic influence on people in terms of human life, suffering, disability, and financial loss. Outcomes for burn patients have improved dramatically over the past 20 years, yet burns still cause substantial morbidity and mortality. Proper evaluation and management, coupled with appropriate early referral to a specialist, greatly help in minimizing suffering and optimizing results.
During the past two decades, deaths from burn injuries have decreased. This decline has been attributed to improved firefighting techniques and improved emergency medical services. Consequently, all medical leaders agree that the best treatment of burn injuries is prevention. Appreciating the major differences between burn management in children and adults is important. Children have nearly 3 times the body surface area (BSA)–to–body mass ratio compared to adults. Fluid losses are proportionately higher in children than in adults. Consequently, children have relatively greater fluid resuscitation requirements and more evaporative water loss than adults. Assessment of burn patients is always considered as a challenge, whether to assess according to burn depth, burn size or the category of the patient. Burn patients’ survival is related to the following factors: burn size/depth, age, presence of inhalation injury, and patient comorbidity. Depth of burn injury is usually classified according to degrees either first, second, third or fourth degree burn.
There is a direct but inverse relationship between age and survival for any burn size. While the mortality of a 40% TBSA burn in a 20-year-old patient is approximately 8%, the mortality of this same injury in someone older than 70 years is 94%. The higher mortality of older patients with burn injuries is attributed to their preexisting medical conditions, including cardiac, pulmonary, renal, and hepatic dysfunction. Similarly, children younger than 1 year survive large burns at a reduced rate. It is well known that early aggressive management of major burns in pediatrics improves long-term survival, especially during the initial hours after the burn injury. When the child arrives in the ED, a rapid initial assessment of respiratory and cardiovascular status is performed in addition to establishment of the extent of burn injury and determination of the need for special procedures. ED treatment focuses on airway and respiratory care and fluid resuscitation. Hospital admission criteria for pediatric patients with thermal injury include the following:
• Partial-thickness burns greater than 10% TBSA
• Full-thickness burns greater than 2% TBSA
• Burns involving the face, hands, genitalia, perineum, or joints
• Circumferential extremity burns
• All high-voltage electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injuries in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality. Such conditions might include, but are not limited to, diabetes, immunosuppression, etc.
• Cases in which it is determined that it is in the best interest to admit the child (i.e., parental inability to care for the burn).
Since the recognition of the phenomenon of burn shock, significant progress has been made in the survival rates of pediatric and juvenile patients. Currently, patients with all but the largest TBSA injuries can be expected to survive when treated promptly. Several very important conceptual differences exist in pediatric burn resuscitation. Intravenous fluid resuscitations are usually required for patients with smaller burns (in the range of 10-20%). Venous access in small children may be a difficult issue, and a saphenous vein cutdown or an intraosseous line is an acceptable alternative in the short term. Children have proportionally larger BSAs than adults; TBSA burns must be estimated using pediatric modifications to Lund- Browder tables , which demonstrate the relatively larger head and small thigh. This results in higher weight-based calculations for resection volume (nearly 6 mL/kg per percentage burn) and has led some to advocate a BSA-based resuscitation in addition to the infusion of a maintenance requirement. Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or have extensive injuries e.g. Morphine sulfate in a dose of 0.1 mg/kg IV q2-4h prn. Applying silver sulfadiazine to the wound for the first 48 hours after initial treatment should be considered. Dressing changes cause further debridement and aid epithelialization. Silver sulfadiazine is most effective against gram-positive organisms and is relatively ineffective against pseudomonads. If the wound develops a greenish drainage or a sweet smell, Pseudomonas aeruginosa colonization or infection could be happened. Other gram-negative pathogens are found commonly in burn wounds. Indications for surgery in pediatric burn patients are fullthickness burns or partial-thickness burns that are unlikely to heal within 3 weeks. If the burn fails to heal in 3 weeks, the risk for hypertrophic scar and contracture formation increases and the healed wound exhibits an aesthetically displeasing scar.
In regions with a dense cross section of dermal appendages, such as the face, scalp, and ears, observation of the burn wound for at least 3 weeks is held to clearly identify its healing potential. When there are circumferential burns of the extremity, emergency escharotomy can salvage an ischemic limb. Historically, survival was the only gauge of success in managing those with serious burns. More recently, the overriding objective of all aspects of burn care has become reintegration of the patient into his or her home and community. This objective has extended the traditional role of the burn care team to well beyond completion of acute wound closure.
The ultimate goal of all burn care is reintegration; therefore, it is important not to lose sight of this. Burn care does not stop with wound closure. Just a few years ago, the goal of the burn team was survival. It was counted as a success if the patient lived to discharge. This is no longer enough. Ideally, the child should be returned to his or her family, schoolmates, and community as if the injury had never occurred. Having this goal means respecting the needs of those attempting to school when planning the timing and type of reconstructive operations. Posttraumatic stress disorder is common in burn patients, and the stress on families is enormous.
Rehabilitation and reconstruction of the patient with serious burns is part of acute care. A burn intensive care unit with a separated reconstructive surgery capability simply cannot generate the quality outcomes for burn patients that are now possible. As it is now defined, successful burn care for the pediatrics requires hard work by a focused multidisciplinary team over the continuum of care, from resuscitation through reconstruction, rehabilitation, and reintegration.