Accident Emergency

Skin

The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.

Skin has three layers:

  • The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone.
  • The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands.
  • The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The skin’s color is created by special cells called melanocytes, which produce the pigment melanin. Melanocytes are located in the epidermis.

Skin Conditions

  • Rash: Nearly any change in the skin’s appearance can be called a rash. Most rashes are from simple skin irritation; others result from medical conditions.
  • Dermatitis: A general term for inflammation of the skin. Atopic dermatitis (a type of eczema) is the most common form.
  • Eczema: Skin inflammation (dermatitis) causing an itchy rash. Most often, it’s due to an overactive immune system.
  • Psoriasis: An autoimmune condition that can cause a variety of skin rashes. Silver, scaly plaques on the skin are the most common form.
  • Dandruff: A scaly condition of the scalp may be caused by seborrheic dermatitis, psoriasis, or eczema.
  • Acne: The most common skin condition, acne affects over 85% of people at some time in life.
  • Cellulitis: Inflammation of the dermis and subcutaneous tissues, usually due to an infection. A red, warm, often painful skin rash generally results.
  • Skin abscess(boil or furuncle): A localized skin infection creates a collection of pus under the skin. Some abscesses must be opened and drained by a doctor in order to be cured.
  • Rosacea: A chronic skin condition causing a red rash on the face. Rosacea may look like acne, and is poorly understood.
  • Warts: A virus infects the skin and causes the skin to grow excessively, creating a wart. Warts may be treated at home with chemicals, duct tape, or freezing, or removed by a physician.
  • Melanoma: The most dangerous type of skin cancer, melanoma results from sun damage and other causes. A skin biopsy can identify melanoma.
  • Basal cell carcinoma: The most common type of skin cancer. Basal cell carcinoma is less dangerous than melanoma because it grows and spreads more slowly.
  • Seborrheickeratosis: A benign, often itchy growth that appears like a “stuck-on” wart. Seborrheickeratoses may be removed by a physician, if bothersome.
  • Actinic keratosis: A crusty or scaly bump that forms on sun-exposed skin. Actinic keratoses can sometimes progress to cancer.
  • Squamous cell carcinoma: A common form of skin cancer, squamous cell carcinoma may begin as an ulcer that won’t heal, or an abnormal growth. It usually develops in sun-exposed areas.
  • Herpes: The herpes viruses HSV-1 and HSV-2 can cause periodic blisters or skin irritation around the lips or the genitals.
  • Hives: Raised, red, itchy patches on the skin that arise suddenly. Hives usually result from an allergic reaction.
  • Tineaversicolor: A benign fungal skin infection creates pale areas of low pigmentation on the skin.
  • Viral exantham: Many viral infections can cause a red rash affecting large areas of the skin. This is especially common in children.
  • Shingles(herpes zoster): Caused by the chickenpox virus, shingles is a painful rash on one side of the body. A new adult vaccine can prevent shingles in most people.
  • Scabies: Tiny mites that burrow into the skin cause scabies. An intensely itchy rash in the webs of fingers, wrists, elbows, and buttocks is typical of scabies.
  • Ringworm: A fungal skin infection (also called tinea). The characteristic rings it creates are not due to worms.

Skin Problems & Treatments

Skin Tests
  • Skin biopsy: A piece of skin is removed and examined under a microscope to identify a skin condition.
  • Skin testing(allergy testing): Extracts of common substances (such as pollen) are applied to the skin, and any allergic reactions are observed.
  • Tuberculosis skin test(purified protein derivative or PPD): Proteins from the tuberculosis (TB) bacteria are injected under the skin. In someone who’s had TB, the skin becomes firm.
Skin Treatments
  • Corticosteroids(steroids): Medicines that reduce immune system activity may improve dermatitis. Topical steroids are most often used.
  • Antibiotics: Medicines that can kill the bacteria causing cellulitis and other skin infections.
  • Antiviral drugs: Medicines can suppress the activity of the herpes virus, reducing symptoms.
  • Antifungal drugs: Topical creams can cure most fungal skin infections. Occasionally, oral medicines may be needed.
  • Antihistamines: Oral or topical medicines can block histamine, a substance that causes itching.
  • Skin surgery: Most skin cancers must be removed by surgery.
  • Immune modulators: Various drugs can modify the activity of the immune system, improving psoriasis or other forms of dermatitis.
  • Skin moisturizers(emollients): Dry skin is more likely to become irritated and itchy. Moisturizers can reduce symptoms of many skin conditions.

Burn

Aburnis a type ofinjurytofleshorskincaused byheat,electricity,chemicals,friction, orradiation.Burns that affect only the superficial skin are known as superficial or first-degree burns. When damage penetrates into some of the underlying layers, it is a partial-thickness or second-degree burn. In a full-thickness or third-degree burn, the injury extends to all layers of the skin. A fourth-degree burn additionally involves injury to deeper tissues, such asmuscleorbone.

Burn Percentage in Adults: Rule of Nines

The rule of nines assesses the percentage of burn and is used to help guide treatment decisions including fluid resuscitation and becomes part of the guidelines to determine transfer to a burn unit.

You can estimate thebody surface areaon an adult that has been burned by using multiples of 9.

An adult who has been burned, the percent of the body involved can be calculated as follows:

  • Head = 9%
  • Chest (front) = 9%
  • Abdomen (front) = 9%
  • Upper/mid/low back and buttocks = 18%
  • Each arm = 9% (front = 4.5%, back = 4.5%)
  • Groin = 1%
  • Each leg = 18% total (front = 9%, back = 9%)

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two or three days, followed by peeling of the skin over the next few days.Individuals suffering from more severe burns may indicate discomfort or complain of feeling pressure rather than pain. Full-thickness burns may be entirely insensitive to light touch or puncture.[6]While superficial burns are typically red in color, severe burns may be pink, white or black.Burns around the mouth or singed hair inside the nose may indicate that burns to the airways have occurred, but these findings are not definitive.More worrisome signs include:shortness of breath, hoarseness, andstridororwheezing.Itchinessis common during the healing process, occurring in up to 90% of adults and nearly all children.Numbness or tingling may persist for a prolonged period of time after an electrical injury.Burns may also produce emotional and psychological distress

Type[10] / Layers involved / Appearance / Texture / Sensation / Healing Time / Prognosis / Example
Superficial (First degree) / Epidermis / Redwithout blisters / Dry / Painful / 5–10days / Heals well;Repeatedsunburnsincrease the risk ofskin cancerlater in life /
Superficial partial thickness (Second degree) / Extends into superficial (papillary)dermis] / Redness with clearblister. Blanches with pressure. / Moist / Very painful / less than 2–3 weeks / Local infection/cellulitisbut no scarring typically /
Deep partial thickness (Second degree) / Extends into deep (reticular) dermis / Yellow or white. Less blanching. May be blistering. / Fairly dry / Pressure and discomfort / 3–8weeks / Scarring, contractures (may require excision andskin grafting) /
Full thickness (Third degree) / Extends through entire dermis / Stiff and white/brownNo blanching / Leathery / Painless / Prolonged (months) and incomplete / Scarring, contractures, amputation (early excision recommended) /
Fourth degree / Extends through entire skin, and into underlying fat, muscle and bone / Black; charred witheschar / Dry / Painless / Requires excision[10] / Amputation, significant functional impairment and, in some cases, death. /
American Burn Association severity classification[36]
Minor / Moderate / Major
Adult <10% TBSA / Adult 10-20% TBSA / Adult >20% TBSA
Young or old < 5% TBSA / Young or old 5-10% TBSA / Young or old >10% TBSA
<2% full thickness burn / 2-5% full thickness burn / >5% full thickness burn
High voltage injury / High voltage burn
Possible inhalation injury / Known inhalation injury
Circumferential burn / Significant burn to face, joints, hands or feet
Other health problems / Associated injuries

Management[

Resuscitation begins with the assessment and stabilization of the person's airway, breathing and circulation.If inhalation injury is suspected, earlyintubationmay be required.This is followed by care of the burn wound itself. People with extensive burns may be wrapped in clean sheets until they arrive at a hospitalAs burn wounds are prone to infection, a tetanus booster shot should be given if an individual has not been immunized within the last five years.In the United States, 95% of burns that present to the emergency department are treated and discharged; 5% require hospital admission.With major burns, early feeding is important.Hyperbaric oxygenation may be useful in addition to traditional treatments

Wound care[edit]

Early cooling (within 30 minutes of the burn) reduces burn depth and pain, but care must be taken as over-cooling can result in hypothermia.[5][10]It should be performed with cool water 10–25°C (50–77°F) and not ice water as the latter can cause further injury.[5][33]Chemical burns may require extensive irrigation.[10]Cleaning with soap and water,removal of dead tissue, and application of dressings are important aspects of wound care. If intact blisters are present, it is not clear what should be done with them. Some tentative evidence supports leaving them intact. Second degree burns should be re-evaluated after two days.[33]

In the management of first and second degree burns, little quality evidence exists to determine which type of dressing should be used.[46][47]It is reasonable to manage first degree burns without dressings.[33]While topical antibiotics are often recommended, there is little evidence to support their use.[48]Silver sulfadiazine(a type of antibiotic) is not recommended as it potentially prolongs healing time.[47]There is insufficient evidence to support the use of dressings containingsilver[49]ornegative-pressure wound therapy

Medications

Burns can be very painful and a number of different options may be used forpain management. These include simple analgesics (such asibuprofenandacetaminophen) andopioidssuch as morphine.Benzodiazepinesmay be used in addition to analgesics to help with anxiety.[33]During the healing process,antihistamines,massage, ortranscutaneous nerve stimulationmay be used to aid with itching.[8]Antihistamines, however, are only effective for this purpose in 20% of people.[51]There is tentative evidence supporting the use ofgabapentin[8]and its use may be reasonable in those who do not improve with antihistamines.[52]

Intravenousantibioticsare recommended before surgery for those with extensive burns (>60% TBSA).[53]As of 2008, guidelines do not recommend their general use due to concerns regardingantibioticresistance[48]and the increased risk offungal infections.[7]Tentative evidence, however, shows that they may improve survival rates in those with large and severe burns.[48]Erythropoietinhas not been found to be effective to prevent or treat anemia in people with burns.[7]In burns caused by hydrofluoric acid,calcium gluconateis a specificantidoteand may be used intravenously and/or topically.[22]

Surgery

Wounds requiring surgical closure with skin grafts or flaps (typically anything more than a small full thickness burn) should be dealt with as early as possible.[54]Circumferential burns of the limbs or chest may need urgent surgical release of the skin, known as anescharotomy.[55]This is done to treat or prevent problems with distal circulation, or ventilation.[55]It is uncertain if it is useful for neck or digit burns.[55]Fasciotomiesmay be required for electrical burns

Complications

A number of complications may occur, withinfectionsbeing the most common.[15]In order of frequency, potential complications include:pneumonia,cellulitis,urinary tract infectionsand respiratory failure.[15]Risk factors for infection include: burns of more than 30% TBSA, full-thickness burns, extremes of age (young or old), or burns involving the legs or perineum.[63]Pneumonia occurs particularly commonly in those with inhalation injuries.[7]

Anemia secondary to full thickness burns of greater than 10% TBSA is common.[5]Electrical burns may lead tocompartment syndromeorrhabdomyolysisdue to muscle breakdown.[7]Blood clotting in the veins of the legsis estimated to occur in 6 to 25% of people.[7]The hypermetabolic state that may persist for years after a major burn can result in a decrease in bone density and a loss of muscle mass.[34]Keloidsmay form subsequent to a burn, particularly in those who are young and dark skinned.[60]Following a burn, children may have significant psychological trauma and experiencepost-traumatic stress disorder.[64]Scarring may also result in a disturbance in body image.[64]In the developing world, significant burns may result in social isolation,extreme povertyand in childrenabandonment

A head injury may cause a wide range of symptoms depending on how serious the injury is. Symptoms of a severe head injury can range from a temporary loss of consciousness up to a brain injury in the most serious cases.

A severe head injury may also cause:

  • concussion– a sudden, but short lived, loss of mental function
  • fits or seizures – when the body suddenly moves uncontrollably
  • difficulty speaking or staying awake
  • problems with the senses, such as loss of hearing or double vision

If you notice any of these symptoms, particularly a loss of consciousness (even for a short period of time), immediately go to theaccident and emergency (A&E)department of your local hospital or call 999 and ask for an ambulance.

Read more information about thesymptoms of a severe head injury.

Diagnosing a severe head injury

Head injuries are assessed by healthcare professionals using the Glasgow Coma Scale (GCS). This is a scale from 3 to 15 that is used to identify how serious the injury is and how severely the brain has been damaged (with 3 being most severe and 15 least severe).

A head injury is usually classed as being severe if someone has a GCS score of eight or less. Further tests may sometimes be necessary to determine how serious your head injury is. This may include:

  • acomputerised tomography (CT) scan
  • anX-ray
  • amagnetic resonance imaging (MRI) scan

Read more information aboutdiagnosing a severe head injury.

Treating a severe head injury

Severe head injuries should always be treated in hospital. Treatment in hospital will involve:

  • observing the condition for any changes
  • running tests to check for further damage
  • treating any other injuries

Most people (around 97%) are able to go home after 48 hours. However, of the people admitted to hospital due to a head injury, 1-3% could develop a serious complication that may require surgery. Depending on how serious the operation is, you may need to recover in anintensive care unit (ICU).

Read more information abouttreating a severe head injury.

When you are discharged, your doctor will give you advice about the best way to help your recovery when you return home, which will depend on your injury and your individual needs. For some people, this might include therapy to help deal with any lasting symptoms or worries.

Read more information aboutrecovering from a severe head injury.

Complications of a severe head injury

A severe head injury may cause bleeding, blood clots or a build-up of fluid, which puts pressure on the brain. This can sometimes lead to brain damage (brain injury) which can be temporary or permanent. Brain injuries can have emotional, behavioural and physical effects.

A severe head injury can also cause serious complications, including:

  • increased risk of developing an infection after a skull fracture
  • acoma, where a person is unconscious and unresponsive for a long time
  • in rare cases, avegetative state, where a person may seem awake but have no awareness of their surroundings

Read more information aboutcomplications after a severe head injury.

How common are head injuries?

Each year in England and Wales, around 700,000 people attend hospital accident and emergency (A&E) departments with a head injury. While most of these areminor head injuries, around 10% are moderate or severe head injuries.

Head injuries are more common in men and children. The most common causes of head injuries arefalls, assaults and road traffic accidents.

Read more information about thecauses of severe head injuries.

Preventing a head injury

Although it can be difficult to predict or avoid a head injury, there are some steps you can take to help reduce the risk of serious injury to you or your child.

These include:

  • wearing a safety helmet when cycling
  • reducing hazards in the home that may cause a fall
  • ‘childproofing’ your home
  • using the correct safety equipment for work, sport and DIY

Spinal Cord Injury Information


Every year, more than 10,000 people in the U.S. sustain a spinal cord injury (SCI). An SCI changes a person’s life in an instant, creating new challenges for everyday life.Paralyzed Veterans of America membershipoffers resources and benefits to meet the needs of veterans who have sustained these injuries.

What is SCI?

When a person sustains an SCI, the communication between the brain and other parts of the body is disrupted, and messages no longer flow past the damaged area. The extent of the communication breakdown is dependent on both the severity and location of the injury. The human spinal cord is a bundle of nerve cells and fibers approximately 17 inches long that extends from the brain to the lower back. The spinal cord carries messages from the brain to all parts of the body and receives incoming messages from the body as well.