Burns
Burns
Burns
Definition
Cell destruction of the layers of the skin and the resultant depletion of fluids and
electrolytes.
Classifications of burns
Size
Localized burns
o Body’s response is localized or contained to the injured area.
Extensive burns
o 25% or more of the total body surface area (TSBA)
o Body’s response to injury is systematic.
o Affect all major systems of the body.
Burn depth
1. First degree(superficial-partial thickness)
Epidermis, possibly portion of dermis.
Tingling, hyperesthesia
Pain soothed by cooling
Reddened, blanches with pressure
Dry, minimal or no edema, possible blisters; complete recovery within a week,
no scarring, peeling.
2. Second degree (deep-partial thickness)
Epidermis, upper dermis, portion of deeper dermis.
Pain, hyperesthesia
Sensitive to cold air
Blistered
Mottled red bas
Weeping surface
Recovery 2-4 weeks
Some scarring and depigmentation
Contractures, infection may convert it to full thickness.
3. Third degree (full thickness)
Epidermis, entire dermis and sometimes subcutaneous tissue
May involve connective tissue, muscle and bone.
Pain free/Insensate
Shock, hematuria, and hemolysis
Possible entrance and exit wounds (electrical burn)
Dry, pale white, leathery or charred, broken skin with fat exposed.
Edema
Eschar sloughs, grafting necessary
Scarring and loss contour and function, contractures
Extent of burn injury
1. Minor burn injury
Second-degree burns of <15% total body surface body area (TSBA) in adults
or <10% in children.
Third degree burn of <2% of TSBA not involving care areas.
Excludes electrical injury, inhalation injury, or concurrent trauma and all poor-
risk patient.
2. Moderate, Uncomplicated Injury
Second degree burns of 15-25% TSBA in adults or 10-20% in children.
Third degree burns of <10% TSBA not involving special care areas.
Excludes electrical injury, inhalation injury, or concurrent trauma and all poor-
risk patient.
3. Major Burn
Second degree burns >25% TSBA in adults or >20% in children
All degree burns of >10%
All burns involving eyes, ears, face, hands, feet, perineum, joints
liAll inhalation injury, electrical injury, or concurrent trauma, and all poor-risk
patient.
Children
Head – 18%
Arms – 9% each
Legs – 14% each
Chest – 18%
Abdomen - 18%
3. Palm Method
In patients with scattered burns, a method to estimate the percentage of burn is
the palm method. The size of the patient’s palm is approximately 1% of TSBA
S-ize
C-ause
A-ge
L-ocation
D-epth
Types of Burns
1. Thermal burns
Exposure to flames, hot liquids, steam or contact to hot objects.
MOST common type
2. Chemical burns
Tissue contact, ingestion or inhalation of acids alkali.
Systemic toxicity from cutaneous absorption can occur.
3. Electrical burns
Heat generated by electrical energy as it passes through the body (direct
damage).
Results in internal tissue damage
Cutaneous burns cause muscle and soft tissue damage that may be extensive,
particularly in high voltage electrical injuries
Alternating current is more dangerous than direct current because it is associated
with cardiopulmonary arrest, ventricular fibrillation, tetanic muscle contractions,
and long bone or vertebral fracture.
4. Radiation burns
Exposure to UV light , x-rays, or radioactive sources
5. Smoke inhalation burns
Inhalation of superheated air, stream, toxic fumes, or smoke causing respiratory
tissue damage
Assessment
o Facial burn
o Erythema
o Swelling of oro/nasopharynx
o Singed nasal hair
o Stridor, wheezing and dyspnea
o Flaring nostrils
o Sooty sputum and cough
o Hoarse voice
o Agitation and anxiety
o Tachycardia
Carbon monoxide poisoning
Carbon monoxide is colorless, odorless and tasteless gas that has an affinity for
Hgb 200 times greater than that of oxygen.
Oxygen molecules are displaced and carbon monoxide reversibly binds to Hgb to
form carboxyhemoglobin
Can lead to coma and death
Assessment :
o Bright cherry red, in face and upper torso
o Cherry red nail beds, lips and oral mucosa
o Headache
o Muscular weakness
o Palpitations
o Dizziness
Management :
o Oxygen is administered until the carboxyhemoglobin level is less that 5%
Smoke poisoning
Inhalation of by-products of combustion
A localized inflammatory reaction occurs causing a decrease in bronchial ciliary
action and a decrease in surfactant.
Assessment:
o Mucosal edema
o Wheezing on auscultation
o After several hours, sloughing of the trachea-bronchial epithelium
o Hemorrhagic bronchitis
Direct thermal heat injury
Can occur to the lower airways by:
Can occur in upper airways ,w/c appear erythematous and edematous, with
mucosal blisters and ulcerations
Mucosal edema especially during the first 24 hours to 48 hours
Monitored for airway obstruction
ET intubation if obstruction occurs.
PATHOPHYSIOLOGY OF BURNS
Vascular permeability
Edema
IV volume
Hematocrit
Viscosity
Peripheral resistance
Cardiac output
2. SYSTEMATIC RESPONSE:
Fluid and Electrolyte Changes
Local edema caused by thermal injury is often extensive resulting in blister formation.
Patients with more severe burns develop massive systemic edema.
As edema increases, pressure on small blood vessels and nerves in the distal
extremities causes an obstruction of blood flow and consequent ischemia (tourniquet
effect).
Cardiovascular Changes
Cardiac output continues to decrease and the blood pressure drops. This is the onset
of burn shock.
Myocardial contractility may be suppressed by the release of the inflammatory
cytokine necrosis factor.
Respiratory Changes
Inflammatory mediators cause bronchoconstriction
Pulmonary hypertension can develop, resulting in a decrease in the arterial 02 tension
and a decrease in lung compliance.
ARDS can occur.
Metabolic Changes
Basal Metabolic Rate (BMR) increases up to 3 times its original rate.
Immunological Changes
Immune system function is depressed, resulting in immunosuppression and thus
increasing the risk of infection and sepsis.
Sepsis continues to be the leading cause of morbidity and with thermal.
Hemodynamic/ Systemic Changes
Initially hyponatremia and hyperkalemia followed by hypokalemia as fluid shifts occur
and K+ is not replaced.
Hematocrit level increases as a result of plasma loss; this initial increase falls to below
normal at 3rd to 4th day postburn as a result of the RBC damage and loss at the time of
injury.
Initially, body shunts blood from the kidneys, causing oliguria; then the body begins to
reabsorb fluid, and diuresis of the excess fluid occurs over the next days to weeks.
Evaporative fluid losses through the burn wound are greater than normal, and the fluid
losses continue until complete wound closure occurs.
If the intravascular space is not replenished with IV fluids, hypovolemic shock and
ultimately death will occur.
Gastrointestinal Changes
Blood flow to the GIT is diminished, leading to intestinal ileus, GI dysfunction and
Curling's ulcer.
PHASES OF MANAGEMENT OF THE BURN INJURY EMERGENT/RESUSCITATIVE
PHASE
Begins at the time of injury, ends with complete
fluid resuscitation
first 24-48 hours after the injury
Fluid shift from intravascular to interstitial space causing hypovolemia
Goal: Prevent hypovolemic shock and preserve vital organ functioning.
First aid
Fluid resuscitation
Prevention of shock
Prevention of respiratory distress
Detection and treatment of concomitant injuries
Wound assessment and initial care
On the scene care:
Airway
Breathing
Circulating
Emergency Procedure:
Extinguish the flames
"Stop, drop, and roll"
Smother the flames, a blanket, rug, or coat, may be used
Cool the burn
Adherent clothing are soaked with cool water.
Never apply ice directly to the burn.
2ND 24 HOURS:
(0.5mL colloid x weight in kg x TBSA) + 2000ml D5W run concurrently over the 24 hours
period
0.5mt x 70kg x 80 0/0= 2,800ml colloid + 2000 ml D5W
2,800/24 117mL colloid/ h
2,000/ 24 h=84 rnL D5W/ h
PAIN MANAGEMENT
Opioid administration (Morphine Sulfate or Meperidine) via the IV route.
Morphine sulfate remains the analgesic for treatment of acute burn pain.
Avoid 1M or SC routes because absorption through the soft tissue is unreliable when
hypovolemia and large fluid shifts are occurring.
Avoid administering medication by oral route, because of GI dysfunction.
Note: Oral route is preferred when patient is already for discharge and when IV is already
discontinued
Medicate client 30 minutes prior to painful procedures or wound care.
Position burned areas in proper alignment.
NUTRITION
Essential to promote would healing and prevent infection.
Maintain NPO status until bowel sounds are heard; then advance to clear liquids as
prescribed.
Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or
total parenteral nutrition.
Indications for parental nutrition:
Weight loss greater than 10 % of normal body weight.
Clinical Status
Prolonged wound exposure
Malnutrition or debilitated condition before injury.
Diet:
High in protein
High carbohydrates (5000 calories per day)
High calories, vitamins and minerals.
Protein requirements may range from 1.5 to 4.0 g of protein per kilogram of body weight every 24
hours.
Schedule would care and other treatment at least 1 hour before meals.
PREVENT Gl COMPLICATIONS
Assess for signs & symptoms of paralytic ileus
Assist with insertion of NGT to prevent/ control Curling's / stress ulcer; monitor patency & drainage.
Administer prophylactic antacids, Proton Pump Inhibitors (PPI) or H2 blockers as ordered
Monitor bowel sounds
Test stools for occult blood
WOUND CARE
The cleansing, debridement and dressing of the
burn wounds
Place client in controlled sterile environment.
1. Hydrotherapy
Wounds are cleansed by immersion, showering or spraying done for 30 minutes or less, to
prevent increased sodium loss through the burn wound.
Client should be pre- medicated prior to the procedure
Not used for hemodynamically unstable or those with new skin grafts.
The temperature of the water is maintained at 37.8 C.
During the bath, the patient is encouraged to be as active as possible. It provides an
excellent opportunity for exercising the extremities.
2. Wound dressing
Burned areas are patted dry and topical
agents are applied.
Light dressing:
Joint areas to allow motion o Areas with splint
to conform to the body
Circumferential dressing:
o Distally to proximally o Fingers and
toes should be wrapped individually.
Occlusive dressing :
o Thin gauze impregnated with a topical
antimicrobial agent o Used over new
skin grafts o Protects the graft and
promotes adherence of graft to
recipient site. o Remains in place for 3
to 5 days.
o Administer analgesic 20 minutes prior to
dressing changes.
3. Debridement
Removal of eschar
To prevent bacterial proliferation under the eschar.
To promote wound healing.
Natural debridement
The dead tissue separates from the underlying viable tissue spontaneously.
Bacteria that are present at the interface of the burned tissue and the variable tissue
underneath gradually liquify the fibrils of collagen that hold the eschar in place for the
first or second post- burn week.
Mechanical Debridement
Involves the use of surgical scissors, scalpels, and forceps to separate and remove the
eschar.
Debridement by these means is carried out to the point of pain and bleeding.
Coarse-mesh dressings applied dry or wet-to-dry (applied wet and allowed to dry) will
slowly debride the wound of exudate and eschar when removed.
Surgical debridement
Operative procedure involving either primary excision of the full thickness of the skin
down to the fascia or shaving of the burned skin layers to freely bleeding, viable tissue.
Early excision is carried out before the natural separation of eschar is allowed to occur.
The procedure creates a high risk of extensive blood loss (as much as 100 to 125 ml- of
blood per percent of body surface excised.)
4. Escharotomy
A lengthwise incision is made through the burn eschar to relieve constriction and
pressure and to improve circulation.
Usually performed in circumferential burn wounds.
After escharotomy, assess pulses, color, movement, and sensation of affected extremity
and control any bleeding with pressure.
Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as
prescribed.
Apply topical antimicrobial agents as prescribed.
5. Fasciotomy
An incision is made, extending through the SQ tissue and fascia.
Performed if adequate tissue perfusion does not return after an escharotomy.
Performed in OR under General Anesthesia.
6. Topical Antimicrobial Agents
Silver Sulfadiazine (Silvadene) cream
Most bactericidal agent
Minimal penetration of eschar
Use with either open treatment, light or occlusive dressings.
Applied 1 to 3 times daily after thorough wound cleansing.
Observe for and report hypersensitivity reactions (rash, itching, burning sensation in
unburned areas).
May cause transient leukopenia that disappears 2-3 days of treatment.
Anticipate formation of pseudoeschar, which is removed easily after 72 hours.
Store drug away from heat.
Mafenide Acetate 5% or 10%
Cream (Sulfamylon)
Penetrates eschar
Agent of choice for electrical burns.
Painful during and for a while after application. Administer analgesic 30 minutes
before application.
May cause metabolic acidosis.
Not used if >20% TBSA
Open: 2 times a day. Dressed: 4 times a day
Provide daily baths for removal of previously applied cream.
Silver Nitrate 0.5 % Solution
Bacteriostatic, fungicidal
Does NOT penetrate eschar.
Keep dressing wet; cover with
dry gauze.
Remoisten every 2 hours. v/
Redress twice daily.
Handle carefully, solution
leaves a gray or black stain on
skin, clothing and utensils.
Monitor serum sodium (Na+)
and potassium (K+).
Other Topical Dressings v/
Cerium nitrate
Povidone iodine (Betadine)
Gentamycin
Assess vestibular/ auditory
Assess renal functions
Polymyxin B
Bacitracin ointment
Wound Closure
Prevents infection and loss of fluid.
Minimize heat loss through evaporation.
Promotes healing.
Prevents contractures.
Performed on the 5th to 21st day depending on the extent of the burn.
1. Autografting
Permanent wound coverage.
o Surgical removal of a thin layer of the client's own unburned skin, which is then
applied to the excised wound.
o Immobilized after the surgery for 3-7 days to allow time to adhere and attach to
the wound bed.
Care of the graft site
Occlusive dressings are commonly used initially after grafting to immobilize the graft.
The first dressing change is usually performed 2 to 5 days after surgery, or earlier in
the case of purulent drainage or a foul odor.
Care of the donor site
A moist gauze dressing is applied at the time of surgery to maintain pressure and to
stop any oozing.
A thrombostatic agent such as thrombin or epinephrine may be applied directly to the
site as well.
Because a donor site is usually a partial thickness wound, it will heal spontaneously
within 7 to 14 days with proper care.
Donor sites are painful, and additional pain management must be a part of patient's
care.
2. Allograft (Homograft)
Temporary wound covering.
Donated human cadaver skin is harvested w/in 24 hours after death.
Monitor for wound exudates and signs of infection.
Rejection can occur w/in 24 hours.
3. Xenograft (Heterograft)
Temporary wound covering.
Porcine (pig) skin is harvested after slaughter and preserved.
Rejection can occur w/in 24- 72 hours.
Replaced every 2-5 days until the wound heals naturally or until closure with autograft
is complete.