With a flash and flame burn in an enclosed setting, one can be exposed to high levels of carbon dioxide. Large surface area loss of this vital organ interrupts these important processes. The skin plays several important roles in homeostasis including temperature control, and fluid regulation, and it serves as a physical barrier to infection as well as a point of contact to mediate interpretation of our environment. The second process is due to physical skin loss. This can result in life-threatening hypotension, pulmonary edema, and decreased circulation to end organs and the already stressed integument in a response similar to that of severe sepsis and septic shock. The release of systemic inflammatory mediators and cytokines results in increased capillary permeability and wide-scale extravasation of fluid and proteins from the intravascular to the extravascular space. In a large burn, two clinically significant processes occur. The systemic response following a burn can be massive. On the contrary, prolonged periods of hypotension and inadequate wound care can convert the zone of stasis and even the zone of hyperemia into wider and deeper tissue damage. The zone of stasis can recover with proper resuscitation and adequate wound care. The third peripheral zone of hyperemia results from increased circulation as the body responds to injury. Damaged circulation near the zone of coagulation results in a second surrounding zone of stasis. The zone of coagulation is the central contact point of maximal damage in which cell death, denaturation of proteins in the extracellular matrix, and damage to the circulation occur. When excessive heat is transferred to the skin, it radiates outward from the point of initial contact and forms a local response with three zones in all directions. Thermal burn pathophysiology can be broken into local and systemic responses. The skin is the largest organ in the body and is composed of the superficial epidermis, the underlying dermis (further divided into the upper papillary dermis and lower reticular dermis), and the hypodermis, composed of subcutaneous fat and connective tissue.
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