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Chief Complaint: 8-year-old girl admitted for severe second- and third-degree burns following her rescue from a burning house.

History: A 13-year-old female was transported by ambulance to the emergency room after being rescued from her burning house. She was asleep at night when a spark from the family fireplace started a fire, leaving her trapped in her bedroom. By the time the fire rescue squad arrived, she had suffered severe burns and excessive smoke inhalation.

In the emergency room, the patient was unconscious. She had second-degree burns over 5% of her body and third-degree burns over 15% of her body — both covering her thoracic and abdominal regions and her right elbow. Her vital signs were quite unstable: blood pressure = 55 / 35; heart rate = 210 beats / min.; and respiratory rate = 40 breaths / min. She was quickly deteriorating from circulatory failure. Two IVs were inserted and fluids were administered through each. Her vital signs stabilized and she was transported to the pediatric intensive care unit (ICU).

The patient regained consciousness the following morning, surprisingly complaining of only minor pain over her trunk. Following debridement of her burns and application of a broad-spectrum, topical antibiotic, a plastic epidermal graft was applied over the burned areas. Despite treatment with a broad-spectrum antibiotic, she developed a systemic staphylococcal infection, necessitating a switch to a different antibiotic.

The patient began a long, slow recovery. Her position in bed had to be changed every 2 hours to prevent the formation of decubitus ulcers (i.e. bedsores). She lost 9 pounds over the next 3 weeks, despite nasogastric tube feeding of 5000 calories (“Kcals”) per day. After 9 weeks, sheets of cultured epidermal cells were grafted to her regenerating dermal layer. By the 15th week of her hospitalization, her epidermal graft was complete, and she was back on solid foods, her antibiotics were discontinued, and she was discharged from the hospital with a rehabilitation plan for both physical and occupational therapy at home, as well as twice-weekly visits by a nurse.

Guiding Questions
Answer the questions below for the case study:

1. “First, second and third degree” is one way to classify the severity of burns.  “Partial and full thickness” is another. Relate “partial thickness” and “full thickness” to the structure of the skin, and to the classification scheme of first, second and third degree.  Be specific about the integumentary structures/layers that are affected in each.

2. Why do second and third degree burns lead to prominent scars?  Be specific about the cellular processes that lead to scar tissue development.  Be sure to refer to the layers of skin and cells that are involved in this process and how this differs from repair seen in less invasive injuries.

3. What accessory organs of the integumentary system were affected in this case study?  What are the ongoing deficits that this patient might experience as a result of this damage?

4. The integumentary system is highly affected in this case, but what other organ systems are affected as a result of these injuries?  Please keep your response focused on injuries caused by the burns, not by smoke inhalation. Be specific…..

5. Propose a possible treatment for the patient in this case study.  How does this treatment improve conditions for the patient? Are these improvements seen at the cellular, tissue, organ or systemic level?