FAHC Burn Care Manual

Complied by:
Peter Igneri, PA-C, Jennifer Gratton, RN

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FAHC BURN CARE MANUAL – 2008

Table of Contents
INTRODUCTION................................................................................ 4  

INITIAL ASSESMENT........................................................................ 5  

INHAL ATION INJURY ....................................................................... 8  

ESTIMATING TOTAL BODY SURFACE AREA OF BURNS.......... 12  

TYPES OF BURNS AND TREATMENTS........................................ 15  

DRESSING CHANGES .................................................................... 22  

DRESSING TYPES FOR BURNS.................................................... 25  

TOPICAL S FOR BURN DRESSINGS ............................................. 29  

EXCISION AND BURN GRAFTING ................................................ 31  

MANAGEMENT OF SPECIFIC BURN AREAS ............................... 35  

CHEST...................................................................................................................... 35
AXILLA.................................................................................................................... 35
 NECK AND BREAST.............................................................................................. 36
LOWER EXTREMITIES ......................................................................................... 36
UPPER EXTREMITIES........................................................................................... 37
HANDS..................................................................................................................... 37
BACK ....................................................................................................................... 38
PHASES OF GRAFT MATURATION........................................................................ 39
LONG TERM COMPLICATIONS.............................................................................. 41 

BURN NUTRITION........................................................................... 44  

BURN NUTRITION - PEDIATRIC .................................................... 50  

BURN REHAB ILITATION ................................................................ 53  

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HYPOTHERMIA AND FROSTBITE ................................................. 58  

Frostbite protocol .......................................................................................................... 60 

PEDIATRIC BURNS: SPECIAL CONSIDERATIONS ..................... 61  

PSYCHOSOCIAL ASPECTS OF BURNS ....................................... 64  

BURN CARE REMINDERS ............................................................. 65  

WEBSITE REFERENCES................................................................ 67  

BURN (Dressing change) CART INFORMATION ......................... 68  

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INTRODUCTION

This burn care document was developed by the burn committee as a

resource for Fletcher Allen staff that may have questions in regards to
caring for the burn patient.
 Although there are advances in burn treatments most of the
documents in this binder remain the standard of care for the patient.
 As new treatment develops the manual can easily be updated.
Thanks to all of the people that researched information for the manual
for all there time and effort.

Fletcher All en Burn Commit tee

Jennifer Gratton, RN Trauma Program Supervisor
Peter Igneri, PA Trauma Service
Lori Camp, RN Trauma Case Manager
Jess Langer, RN Care Coordinator Baird 6
Pam Kupiec, RN Baird 6
Marie Zebertavage, RN Baird 6
Tracey Wagner, RN Baird 5
Carole Richards, RN Baird 5
Gail Tuscany, RN SICU
Patrick Delaney, RN SICU
Patty Crease, RN SICU
Gil Helmken, RN ED
Ray Scollins, RN FACT
Kristen Brewster Occupational Therapy
Barb Blokland Occupational Therapy
Karyann Bombardier Physical Therapy
Julie Jacob, SW Trauma Social Worker

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Burn Care

INITIAL ASSESSMENT

Primary Survey
 A – Airway.
•  Secure the airway first.

•  Get history as much as reasonably possible before intubation

•  Soot or singed nasal hairs?

B – Breathing;
•  High flow Oxygen for all.

•  Escharotomy? - Monitor chest wall excursion in presence of FT torso

burns
•  Listen: verify breath sounds
•  Assess rate & depth

C – Circulation
•  Monitor BP,

•  pulse rate,

•  skin color

•  Establish IV access,

•  Warm IV fluids

•  Monitor peripheral pulses in circumferential burns.

D - Disability;
•  Associated Injuries?

•  CO poisoning?

•  Substance abuse?

•  Hypoxia?

•  Pre-existing medical condition

E – Exposure;
•  Remove all clothing and jewelry

•  Ensure warm environment

•  Clean DRY blankets

•  It is OK to use water to stop the burning process and clean but not at the
expense of reducing body core temperature.

Secondary survey
Repeat Primary

Complete head to toe evaluation

Start after resuscitation fully established

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Complete the HPI
•  What type of burn (flame, chemical, scald)

•  Duration of exposure

•  What time did burn occur?

•  What treatment already provided.(chemical brushed off, water to cool, etc)

•  Did burn occur in house fire/enclosed space (think inhalation injury)

Order labs and x rays

•  CBC, BUN, Cr, Lytes

•  Carboxyhemoglobin

•  CXR

•  Blood gas

•  Insert Foley

•  EKG (especially in electrical injury)

Special considerations;
•  Abuse patterns
o  Children, elderly

•  Concomitant trauma
o  C-spine precautions
o  Trauma protocols if trauma is majority of injuries

Determine TBSA
•  Use Lund Browder chart.

•  Can start with patients palm = 1% of patients BSA

•  A good online program is sagediagram.com. Need patient weight and

height and age for this program. Can print out a graphic with parkland
calculations.

Initiate resusci tation str ategy  – DO NOT need on <15% TBSA  

•  Parkland formula
o  2-4 ml RL X kg X % BSA burn

o  ½ in 1st 8 hrs
o  ¼ in 2nd 8 hrs
o  ¼ in 3rd 8 hrs  

•  Pediatric parkland
o  2-4 ml RL X kg X % BSA burn
o  ½ in 1st 8 hrs
o  ¼ in 2nd 8 hrs
o  ¼ in 3rd 8 hrs  
o  add maintenance fluid – use D5LR
   100cc/kg for 10 kg of weight
   50 cc/kg next 10 kg of weight
   20cc/kg remaining 10 kg after

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Pediatric calculation example
23 Kg child with 20% deep burn
♦  Resuscitation (Ringer’s Lactate)
3 ml X 23 Kg X 20% Burn = 1380 mls
½ in 1st 8 hrs post burn = 86 cc/hr
♦  Maintenance (D5LR)
•  1st 10 Kg: 100 cc/kg/24hr = 1,000 cc/24 hr
•  2nd 10 Kg: 50 cc/kg/24hr = 500 cc/24 hr
•  Remaining 3 Kg: 20cc/kg/24hr = 60 cc/24 hr
1560 cc/24 hr = 65cc/hr

Cleaning & Debridement –

•  Whenever possible, clean using mixture of Hibiclens and sterile water (not
saline – it stings more when mixed with Hibiclens).
•  If picking patient up at OSH, remove wet dressings and place bacitracin
and fluffs or Exu-Dry for transport.
•  If transporting out to MGH or other larger Burn center, contact them and
find out what they like for dressings on transferred patients. (i.e. MGH
typically wants a dry sterile dressing)
•  Assemble team to view at same time to avoid time consuming dressing
removal and reapplication.
•  Take picture(s) if possible – print color pictures for chart.

•  Involve resident physicians to teach when possible.

•  First cleaning should take place in the ED if possible. Set a plan for the
next cleaning/shower time and let other team members know.
•  Use reverse isolation precautions to clean and débride when

•  TBSA>15%

•  Associated inhalation injury

•  Immunocompromised patient.

Dressings/Supplies:
•  There is a burn care cart in the ED that requires a key from PIXIS system.
Keep track of supplies in order to replace on cart ASAP.
•  The SICU does not stock burn dressings. If needed for the SICU order
burn cart through distribution/transport tracking.
•  Please ensure IBM card used to deal with cost center issues when getting
supplies from another unit.
•  Mepilex Ag dressing is available only in CSR as of May 2008. It may be
stocked in the patient floors in the future.

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DRESSING CHANGES

FULL THICKNESS AND DEEP PARTIAL THICKNESS (PRE-GRAFT)

For the Bedside nurse/provi der:

1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams.
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care

PREPARATION:
1) Gather all materials prior to starting burn care
2) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff
participating in care
3) Remove dressings, exposing a minimal amount of body surface area to prevent
hypothermia
4) In sterile fashion, cleanse area with equal amounts of Hibiclens and sterile saline,
using lap sponges
5) Débride areas of loose skin and eschar with sterile scissors
6) Allow to air dry
7) Apply ordered creams to affected areas, usually Silvadene to torso and limbs,
Bacitracin to face, and Sulfamylon to cartilaginous area
8) Cover wounds with Exu-Dry, contain Exu-Dry with Kerlix wraps if needed

SUPERFICIAL (FIRST DEGREE) AND HEALED DONOR SITES

For the Bedside nurse/provi der:

1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, Fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care

Procedure:
1) Wash and/or have patient help wash all affected areas with anti-bacterial soap and
water

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2) Pat dry with clean cloth

3) Apply Eucerin Cream to areas, remembering that with application, “Some is good, More
is better”
4) Cover, if ordered, with loose dressing, or with clean white shirt if on torso, or clean
white gloves (turned inside-out) if on hands
5) Reinforce dressings, and reapply creams as ordered and PRN to keep skin well-coated

NEWLY GRAFTED BURNS AND DONOR SITES

For the Bedside nurse/provi der:

1) Gather necessary supplies (order burn cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available
5) Connect with PT/OT, BST to establish time of burn care

PROCEDURE:
1) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff
involved with procedure
2) Maintain integrity of newly grafted burn sites for 5 days, or unless directed otherwise
by house staff
3) Minimize areas uncovered during burn care to maintain euthermia
4) Remove dressings from donor sites to Xeroform- remove via sterile scissors only
the areas peeling back or loose
5) Cleanse with equal amounts of Hibiclens and Sterile Saline
6) Allow to air dry
7) Apply generous amounts of Bacitracin over Xeroform, remembering that with
creams, “Some is good, More is better”
8) Cover with Telfa and Kerlix, making sure distal circulation is not constricted
9) ** Newly grafted burn dressings must be removed initially by house staff, to assess
successful take of grafted skin**

DRESSING CHANGES
PARTIAL THICKNESS AND DONOR SITES

For the Bedside nurse/provi der:

1) Gather necessary supplies (order cart via transport tracking)
2) Ensure adequate quantities of burn creams
3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix,
clean white gloves, and other items
4) Have adequate pain medicine available

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5) Connect with PT/OT, BST to establish time of burn care

PROCEDURE:
1) Have staff wear gown, gloves, and mask for burn isolation
2) Cleanse wounds with sterile Hibiclens and Saline (mixed in equal amounts), washing
with lap sponges if available
3) Note: gentle scrubbing will help with light debriding of partial thickness burns, and
remove previous creams
4) Clip any loose or pealing Xeroform from donor sites, using sterile scissors
5) Allow to air dry
6) Cover areas affected with Bacitracin, unless otherwise directed. Remember: When
applying creams, “Some is good, More is better”
7) Apply Exu-Dry dressing over partial thickness burns, Telfa pads covered by Kerlix, or
dressed as ordered ** Be sure dressings are not constrictive to peripheral/distal
circulation

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DRESSING TYPES FOR BURNS

EXU-DRY- non-adherent dressing made up

of multiple layers. It is designed to conform readily and comfortably to contoured
areas. It is highly absorbent and has an anti shear layer. It is compatible with
topical agents. Mainly used with first and second degree burns and after grafting.
It comes in gloves and jackets and pants also.

FLUFFS-these are woven gauze dressings used over third

degree burns to assist in debriding prior to grafting. These can
be used out of package or a Kerlix can be opened all the way
up to use as a fluff. It is often used as a padding layer to
protect grafts postop and to apply soft but constant pressure
onto the grafts to facilitate imbibition.

CONFORM - this is slightly elastic cotton roll gauze dressing. It

is good for use on fingers and anywhere that mobility is
important as it flexes easily. It comes in 1 inch and up sizes.

KERLEX- this is used to wrap burns and

assist in keeping underlying dressings in
place. Often used over Exu-Dry to keep in
place.

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