Burns & Burn Management,

Asphyxiation, & Head Injuries

BY: LEOLIN SWIFT-CASTILLO

OBJECTIVES
At the end of this lecture students will:
1. Define terms related to the three disorders.
2. Discuss the etiological agents of each disorders.
3. Discuss the diagnostic tests of each disorder.
4. Discuss the clinical manifestations of each
disorder.
5. Discuss the nursing management of each disorder.
► What is burn?
A burn can be defined as a type of injury
to skin caused by heat, electricity,
chemicals, light, radiation or friction.
The Skin
Superficial

Superficial partial-thickness

Deep partial-thickness

Full-thickness
► Recovery from burn injury involves four major aspects:
burn wound management, physical therapy, nutrition, and
emotional support.
► Classification of Burns
1. Superficial burn – 1st degree
2. Superficial partial thickness – 2nd degree
3. Superficial deep partial thickness – 2nd degree
4. Full partial thickness – 3rd degree
 Superficial Burns

►1st degree burn

►Limited to the epidermis
►Presents with erythema and minimal swelling
►Very painful, dry, red burns which blanch with pressure.

►The most common type of first-degree burn is sunburn.

►Usually take 3 to 7 days to heal without scarring.

►Commonly treated on outpatient basis

 Superficial Partial Thickness

►Very painful burns sensitive to temperature change and

air exposure.

►More commonly referred to as second-degree burns.

►Blister and are moist, red, weeping burns which blanch

with pressure.
►Involves the epidermis and superficial portion of the dermis
•Blistering or easily unroofed burns which are wet or waxy dry, and are painful

to pressure.

•Their color may range from patchy, cheesy white to red, and they do not

blanch with pressure.

•They take over 21 days to heal and scarring may be severe. It is sometimes difficult
to differentiate these burns from full-thickness burns.
•Involves the epidermis and most of the dermis
•Less sensitivity to light touch and pinprick than superficial form
•Extensive time to heal (3-4 wks)
 Full thickness Burns
•involves epidermis, and all layers of dermis, extending down to
subcutaneous tissue
•Appears dry, leathery, and insensate, often without blisters.
•Skin may be waxy white to charred black.
•Can be difficult to differentiate from deep partial-thickness
burns.
• Commonly seen when patient’s clothes caught on fire/ skin
directly exposed to flame; severe scarring
•Usually require referral to burn surgeon; healing is very slow, if
at all, and may need skin grafting to heal.
Fourth degree

► Full-thickness burn extending to muscle

or bone
► Common result of high-voltage electric
injury or severe thermal burns
► Requires hospital admission
Burns is assessed by severity and depth
► Assessing the severity of burns·
► mild: Ⅱ0 <10%TBSA
► moderate: Ⅱ0 10-30%; or Ⅲ0<10%TBSA
► severe: total area 30-50%; or Ⅲ0 10-20%; or with
shock, airway burn, combined injury
► major: total area >50%; Ⅲ0 >20% or with severe
complications
► Using the rule of nine
- after age 1, 1% is taken from the head and added on to
each leg.
► Depth: superficial: Ⅰ0and superficial Ⅱ0
deep: deep Ⅱ0 and Ⅲ0
Pathophysiology of Burns
Local Response

► Zone of coagulation—This occurs at the point of maximum

damage. In this zone there is irreversible tissue loss due to
coagulation of the constituent proteins.
► Zone of stasis—The surrounding zone of stasis is characterized
by decreased tissue perfusion. The tissue in this zone is
potentially salvageable. The main aim of burns resuscitation is
to increase tissue perfusion here and prevent any damage
becoming irreversible. Additional insults—such as prolonged
hypotension, infection, or oedema—can convert this zone into
an area of complete tissue loss.
► Zone of hyperaemia—In this outermost zone tissue
perfusion is increased. The tissue here will invariably
recover unless there is severe sepsis or prolonged
hypoperfusion.
► These three zones of a burn are three dimensional, and
loss of tissue in the zone of stasis will lead to the
wound deepening as well as widening.​

Systemic Response
► The release of cytokines and other inflammatory
mediators at the site of injury has a systemic effect
once the burn reaches 30% of total body surface area.
 Systemic response cont’d
► Cardiovascular changes—Capillary permeability is
increased, leading to loss of intravascular proteins and fluids
into the interstitial compartment. Peripheral and splanchnic
vasoconstriction occurs. Myocardial contractility is
decreased, possibly due to release of tumour necrosis factor
α (TNF). These changes, coupled with fluid loss from the
burn wound, result in systemic hypotension and end organ
hypoperfusion.
► Respiratory changes—Inflammatory mediators cause
bronchoconstriction, and in severe burns adult
respiratory distress syndrome can occur.

► Metabolic changes—The basal metabolic rate

increases up to three times its original rate. This,
coupled with splanchnic hypoperfusion, necessitates
early and aggressive enteral feeding to decrease
catabolism and maintain gut integrity.

► Immunological changes—Non-specific down

regulation of the immune response occurs, affecting
both cell mediated and humoral pathways.​
1. Treatment should begin immediately to cool the
area of the burn. This will help alleviate pain.
2. For deep partial-thickness burns or full- thickness
burns, begin immediate plans to transport the victim
to competent medical care. For any burn involving
the face, hands, feet, or completely around an
extremity, or deep burns; immediate medical care
should be sought. Not all burns require immediate
physician care but should be evaluated within 3-5
days.
3. Remove any hot or burned clothing.
4. Use cool (54 degree F.) saline solution to cool the area for 15-30
minutes. Avoid ice or freezing the injured tissue. Be certain to
maintain the victim’s body temperature while treating the burn.

5. Wash the area thoroughly with plain soap and water. Dry the area
with a clean towel. Ruptured blisters should be removed, but the
management of clean, intact blisters is controversial. You should
not attempt to manage blisters but should seek competent
medical help.

6. If immediate medical care is unavailable or unnecessary,

antibiotic ointment may be applied after thorough cleaning and
before the clean gauze dressing is applied.
 Scalding-typically result from hot water, grease, oil
or tar. Immersion scalds tend to be worse than spills,
because the contact with the hot solution is longer. They
tend to be deep and severe and should be evaluated by a
physician. Cooking oil or tar (especially from the
“mother pot”) tends to be full- thickness requiring
prolonged medical care.
a. Remove the person from the heat source.
b. Remove any wet clothing which is retaining heat.
c. With tar burns, after cooling, the tar should be removed
by repeated applications of petroleum ointment and
dressing every 2 hours.
Flame
a. Remove the person from the source of the heat.

b. If clothes are burning, make the person lie down to keep smoke away
from their face.

c. Use water, blanket or roll the person on the ground to smother the
flames.

d. Once the burning has stopped, remove the clothing.

e. Manage the persons airway, as anyone with a flame burn should be

considered to have an inhalation injury.
Electrical burns:
are thermal injuries resulting from high intensity heat. The skin
injury area
may appear small, but the underlying tissue damage may be
extensive.
Additionally, there may be brain or heart damage or
Musculoskeletal injuries associated with the electrical injuries.
a. Safely remove the person from the source of the electricity. Do not
become a victim.
b. Check their Airway, Breathing and Circulation and if
necessary begin CPR using an AED (Automatic
External Defibrillator) if available and EMS is not
present. If the victim is breathing, place them on their
side to prevent airway obstruction.
c. Due to the possibility of vertebrae injury secondary
to intense muscle contraction, you should use
spinal injury precautions during resuscitation.
d. Elevate legs to 45 degrees if possible.
e. Keep the victim warm until EMS arrives.
 Chemical burns- Most often caused by strong acids or
alkalis. Unlike thermal burns, they can cause progressive
injury until the agent is inactivated.

a. Flush the injured area with a copious amount of water

while at the scene of the incident. Don’t delay or waste
time looking for or using a neutralizing agent. These may
in fact worsen the injury by producing heat or causing
direct injury themselves.
 Phases of Burn Management

❖ Pre-hospital phase
❖ Emergency (Resuscitation) phase
❖ Acute phase
❖ Rehabilitation Phase
Pre-hospital phase
Remove patient from burn area! Stop the burn!
❑ If thermal burn is large--FOCUS on the ABC’s
A=airway
B=breathing- check for adequacy of ventilation
C=circulation-check for presence and regularity
of pulses
❑ Burn too large--don’t immerse in water due to
extensive heat loss
❑ Never pack in ice
❑ Pt. should be wrapped in dry clean material to
decrease contamination of wound and increase
warmth
► Emergency Phase
❑ Lasts from onset to 5 or more days but usually lasts 24-48
hours
❑ It begins with fluid loss and edema formation and
continues until fluid motorization and diuresis begins .
❑ Greatest initial threat is hypovolemic shock to a major
burn patient!
❑ Airway management-early nasotracheal or endotracheal
intubation before airway is actually compromised (usually
1-2 hours after burn)
Replacement of Fluid
Parkland formula (Adult)
► 4 * Patient’s weight in kilos * Percent of body area with
second and third degree burns) = Amount of fluid to
administer in the first 24 hours after burn injury.
► Fluid to administer in first 24 hours divided by 2 = fluid
to administer in first 8 hours
► Finally, if we divide the final number by 8, we’ll know
about how much fluid our patient should receive from
us before we reach the hospital
► Modified Parkland formula – Pediatrics (Parkland
formula plus maintenance fluids, used in patients who
weigh less than 20 kg)

► Resuscitation fluids - 3-4 ml Ringer lactate X weight

(kg) X %TBSA burned (second-degree and third
degree); half administered over the first 8 hours (from
time of injury), remaining half administered over the
next 16 hours>

► Maintenance fluids - Ringer lactate solution with 5%

dextrose at 4 ml/kg/h for 0-10 kg, plus 2 ml/kg/h for
10-20 kg, plus 1 ml/kg/h for each kg more than 20 kg
❑ Ventilator.
❑ 6-12 hours later: Bronchoscopy to assess lower
respiratory tact
❑ Chest physiotherapy, suction
❑ Complications during emergent phase of burn
injury are 3 major complications:
1. Cardiovascular complications
2. Respiratory complications
3. Renal systems complications
Acute Phase

❑ It starts 24-48 hours or more from onset after

the emergency phase ended.
❑ Treatment should include the following:
I- Wound care
i- Debridement:
❑ Cleaning and then dressings are important
aspects.
❑ Silver sulfadiazine (flamazine) dressings is not
recommended as it prolongs healing time
while biosynthetic dressings may speed healing.
Acute Phase cont’d
▣ After the initial resuscitation, up to 75% of
mortality in burns patients is related to infection.

▣ Preventing infection, recognizing it when it

occurs, and treating it successfully present
considerable challenges.

▣ Infective pulmonary complications are now the

commonest types of infection seen in burns
patients, but infection is common in many other
sites.
► Factors contribute to the high frequency and
severity of infection.
► Destruction of the skin or mucosal surface barrier
allows microbial passage.

► Presence of necrotic tissue and exudates provides

a medium to support growth of microorganisms

► Impaired immune function allows microbial

proliferation.
Signs of Wound Infection
▣ Change of wound appearance :
A- Discoloration of surrounding skin
B- Offensive exudates
❑ Delayed healing
❑ Graft failure
❑ Conversion of partial thickness wound to full
thickness
Rehabilitation Phase

Respiratory management:
▣ Prophylactic chest treatment should start on suspicion of
an inhalation injury
Treatment should be aimed to:
A- Remove lung secretions
B- Normalizing breathing mechanics: such as using a
positive respiratory devices, intermittent positive
pressure and positioning.
C-Improving the depth of breathing and collateral alveolar
ventilation by ambulation, tilting table and respiratory
exercise.
▣Physiological needs
- comfort (Pain); Breathing/Oxygen
▣adequate pain control is very important.
▣The aim of analgesic drugs should be to develop a good pain
control to allow functional movement and activities.
▣The use of combined analgesics such as paracetamol, non
steroidal anti-inflammatory drugs and tramadol reduces the
need for increasing doses of narcotics.
▣Codeine should be avoided because of its negative effects.
▣Other pain control methods may be helpful such as
TENS, didynamic, high voltage galvanic and
interferential currents.
► Safety & Security
- Fluid volume deficit
- risk for infection
- risk for electrolyte imbalance

► IV Therapy
► Monitoring V/S- T, P, R & B/P
► Monitor lab values – Na, Cl, K etc
► Self – esteem
► Disturbance in body image
► Psychological /emotional support
ASPHYXIATION

► Definition:

Asphyxiation is the state or process of being

deprived of oxygen, which can result in
unconsciousness or death; suffocation.
Etiology & Pathophysiology

► Choking
► A foreign object lodged in the respiratory system
or throat
► Suffocation
► Strangulation
► Drowning
► The tongue blocking the airway when a person is
unconscious.
Signs and Symptoms

► difficulty breathing
► inability to breathe, developing a cyanosis
► irregular heart rate
► Weakness
► edema of neck and head veins, and seizures.
► Long-term results of asphyxia include
coma and death.
Treatment

► Treat underlying cause

► Nursing
■ Remove obstruction
■ Provide O2 therapy
■ Monitor V/S
■ Assess oropharynx
Head Injuries

► Trauma is one of the leading causes of death and

disability in children. The aetiology of injury
varies with age and children with serious head
trauma often have multiple injuries.
► The most common mechanism for head injuries
globally is from motor vehicle collisions,
however, at birth, the neonate is at risk for
different types of head injuries
Extracranial hemorrhages

► These are one of the most common

complications of instrument assisted deliveries
and are characterized by a bleed that is situated
outside the cranium.
► Risk factors other than instrument-assisted
deliveries include primigravidity, hypoxia,
cephalopelvic disproportion, difficult and
prolonged labor and coagulation disorders
Types of Extra-cranial Hemorrhagic injury

► Cephalhematoma
► Caput Succedaneum
► Subgaleal hemorrhage
► Fracture of the skull
 Cephalhematoma

►Definition

is a traumatic sub-periosteal hemorrhage of blood

that occurs between the periosteum and the skull of
a newborn baby secondary to the rupture of a blood
vessel crossing the periosteum. It is typically over
the parietal bone and can be seen unilaterally (most
often) or bilaterally
► Cephalohematomas are mostly internal with characteristic findings of a firm
and tense mass that does not cross the suture line. The mass may become more
extensive by 2-3 days of age.
► The condition can also be accompanied with intracranial lesions that can lead
to death. sometimes can not be detected with just a physical exam.
 Etiology & Signs/Symptoms
► Pressure on the fetal head during birth
► pressure on the skull or the use of forceps or a vacuum extractor during birth.
Signs & Symptoms
► feel soft and can increase in size initially after birth.
► The boundaries are sharply demarcated do not extend beyond the limits of the
bone. One or both parietal bones may be involved
 Diagnostic Evaluation
► A physical exam which can lead to a diagnosis,
► CT scan is an important means of detecting the hematoma. A CT scan can also
detect linear skull fractures which can be accompanied with
cephalohematomas at around 10-25% of times.
► Cephalohematomas are internal and sometimes cannot be detected by a
physical exam
 Signs & Symptoms

► firm and tense mass that does not cross the

suture line.
► The condition resolves in time period of a
week to two months,
 Nursing Interventions

► Monitoring the vital signs of the Neonate

► Measure the head circumference every 12- 24 hours if
necessary.
► Observe/detect for early signs of complications such as high
bilirubin levels, loss of appetite, fever, anemia and hypotension.
► Perform a physical exam of the head twice a day.
► Observe, record, and report any abnormalities and changes of
the size and place of the mass to the attending physician.
► Educate parents on the etiology, complications and the treatment
options.
Complications
► In rare occasions complications such as anemia, infection, unnatural bulges
and jaundice can be noticed, although it is unlikely for a hematoma to contain
enough blood to affect hemoglobin and bilirubin levels.
► The condition can also be accompanied with intracranial lesions that can lead
to death
 Caput Succedaneum
► is an edema of the scalp caused by a bleed below the scalp and above the
periosteum and involves a serosanguinous, subcutaneous, extraperiosteal fluid
collection with poorly defined margins caused by the pressure of the
presenting part of the scalp against the dilating cervix during labor
Etiology

► incidence increases in difficult or prolonged labor, with

premature rupture of the amniotic membranes, in
primagravidas and in instrument-assisted deliveries.
Signs & Symptoms
► The scalp edema may cross over the sutures lines and the caput is generally
1-2 cm in depth and varies in circumference.
► The most common presentation of caput succedaneum is symptomatic with
findings such as soft or puffy swelling on the scalp, bruising or color change
on the scalp and swelling that extends across the midline and over the sutures
lines. The edema usually heals in hours to days and rarely has any
complications.
Diagnosis

► In order to diagnose a caput succedaneum there is no need to

perform a formal test. Diagnosis is usually made with a
physical examination and inspection of the scalp. The
condition almost always resolves itself in a couple of days, and
there is rarely any long-term complications.
Nursing Interventions
► Nursing care most often involves parent education which includes the cause of
the tissue swelling and complications that might present.
► measure the head circumference every 24 hours
► record and report any possible defects of the scalp. As the edema withdrawals
it is necessary to perform a physical exam of the scalp in order to diagnose any
abnormalities
Complications

► In rare cases if left untreated, the swelling caused by a caput

succedaneum can break down into bilirubin and the neonate
may develop jaundice which can posses a threat if not treated
(kernicterus).
Subgaleal Hemorrhage

► is the most serious extracranial hemorrhage and results in the

accumulation of blood between the skull periosteum and the
galea aponeurotica, due to the rupture of large emmisary veins
Etiology

► Instrument-assisted deliveries-when
vacuum extraction is used.
► Can happen spontaneously.
Diagnosis
► History taking
► Physical examination of the head, including
measuring the circumference of the head and
assessment of the location and characteristics
of any swelling.
► Lab studies – Hb and coagulation studies
(monitored every 4-8hrs).
► CT Scans – identify hemorrhage and any
fractures
Signs & Symptoms
► The hemorrhage usually presents as a firm
fluctuant mass developing over the scalp (occiput)
with superficial skin bruising and spreads across
the suture lines.
► The swelling may increase in size after birth
(12-72 hours after delivery). Rupture of large
emissary veins connecting the dural sinuses and
scalp veins into a large potential space can result
into hemorrhage of 20-40% of total circulating
blood volume, resulting in hypovolemic shock and
may contribute to hyperbilirubinemia.
Nursing Interventions
► Initiate blood transfusion
► If bleeding has progressed to hypovolemic shock-ventilation is required.
► Administer inotropic medications as ordered
► If seizure is present-phenobarbital
► measure the head circumference every 4-8 hours
► inspection of the edema and the ears on a hourly basis
► monitoring the vital signs (especially the heart rate and the blood pressure) and
► measuring the arterial blood gasses (hematocrit or hemoglobin, levels of
oxygen and the blood acidity).
► Assess level of consciousness - use of the Glasgow Coma Scale every hour is
crucial in order to detect any loss of consciousness.
Nursing Interventions

► Anemia in collaboration with loss of consciousness can be indicative of a

hypovolemic shock which has to be treated aggressively.
► Initiate an intravenous line- to administer fluids (saline or blood
components) and drugs (inotropic and other) as prescribed from the
attending physician.
► Provide Oxygen therapy as ordered - to counteract the blood acidity.
► Health education of parents
 Complications

► The condition is rare but really serious advert event that when left undetected can
result in to poor neonatal outcome or even death.
► Infection of the blood clot.
 Neonatal Skull Fractures

Definition
►A skull fracture is any break or indention in the cranial
bone known also as the skull.
Etiology/Risk Factors
►occur more less in vaginal deliveries but the risk increases
with instrument-assisted deliveries.
►Other risk factors that contribute to skull fractures include
primiparity, macrosomia, male sex and difficult or
prolonged labor.
Signs & Symptoms

► swelling and tenderness around the area of impact

► facial bruising
► bleeding from the wound caused by the trauma, near the location of the
trauma, or around the eyes, ears, and nose
► bruising around the trauma site, under the eyes in a condition known
as raccoon eyes, or behind the ears as in a Battle’s sign
► severe pain at the trauma site
► redness or warmth at the trauma site
Diagnostic Test & Treatment

► History Taking
► Physical exam
► X-ray,
► CT Scan
► MRI
Treatment
Is dependent on the age, health, and medical history, as well as the type of
fracture, its severity, and any resulting brain injuries.
 Nursing Intervention

► Monitor Vital Signs for neonate – q.4.h

► Conduct physical examination-pupil inspection
► Measurement of head circumference
► Assess neurological status-Glascow coma scale
► monitor the intracranial pressure or any signs that could suggest high intracranial
pressure (hypersomnolence, loss of appetite, vomiting)
► Monitor seizure activity
► Health education of parents
► Reference

Hockenberry, M. J., Wilson, D. (2015). Wong’s

nursing care of infants and children. (10th
ed.). USA: Mosby