Burn

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 Management of Patients With
Burn Injury

Most burns occur in the home.

Young children and the elderly are at high

risk for burn injuries.

Classification of Burns (See Table 57-1)

1. Superficial partial-thickness (first degree)
2. Deep partial-thickness (second degree)
3. Full-thickness (third degree) 2
 Superficial partial-thickness:
Skin Involvement: Epidermis; possibly a portion of dermis
Symptoms: Tingling, Hyperesthesia (supersensitivity), Pain
that is soothed by cooling
Wound: appears red and dry, as in sunburn, or it may blister.
Recovery phase: Complete recovery within a week; no
scarring

A deep partial-thickness burn

Skin Involvement: Epidermis, upper dermis, portion of deeper
dermis
Symptoms: Pain, Hyperesthesia, Sensitive to cold air
Wound: Blistered, red base; broken epidermis; weeping
surface
Edema, exudes fluid
Recovery phase: Recovery in 2 to 4 weeks, Some scarring
and depigmentation
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 A full-thickness burn

Skin Involvement: Epidermis, entire dermis, and

sometimes subcutaneous tissue; may involve connective
tissue, muscle, and bone

Symptoms: Pain free, Shock, Hematuria (blood in the

urine) and possibly hemolysis (blood cell destruction

Wound: The wound appears leathery; hair follicles and

sweat glands are destroyed; Wound color ranges widely
from white to red, brown, or black; Dry; pale white,
leathery, Broken skin with fat exposed, Edema

Recovery phase: Grafting necessary, Scarring and loss of

contour and function

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 Extent of Body Surface Area Injured

Rule of Nines
The rule of nines is a quick way to estimate the extent of
burns
The system assigns percentages in multiples of nine to
major body surfaces.

Lund and Browder Method

A more precise method of estimating the extent of a burn
Recognizes that the percentage of surface area of various
anatomic parts, especially the head and legs, changes with
growth.

Palm Method
In patients with scattered burns,
The size of the patient's palm is approximately 1% of the
TBSA.
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 Classification of Burns by Extent of Injury
Minor burn
Second-degree burn of <15% total body surface
area (TBSA) in adults
Third-degree burn of <2% TBSA not involving
special care areas (eyes, ears, face, hands, feet,
perineum, joints)
Moderate, uncomplicated burn
Second-degree burns of 15–25% TBSA in adults
Third-degree burns of <10% TBSA not involving
special care areas
Major burn
Second-degree burns >25% TBSA in adults
All third-degree burns >10% TBSA
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 Pathophysiology

Burns are categorized as thermal (including electrical burns),

radiation, or chemical.

Tissue destruction results from coagulation, protein

denaturation, or ionization of cellular contents

Disruption of the skin can lead to increased fluid loss,

infection, hypothermia, scarring, compromised immunity, and
changes in function, appearance, and body image.

1 second of contact with hot tap water at 68.9°C may result

in full-thickness injury. 15 seconds of exposure to hot water
at 56.1°C results in a similar full-thickness injury.

Burns that do not exceed 25% TBSA produce a primarily

local response.
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Burns that exceed 25% TBSA may produce both a
local and a systemic response (major burn injuries).

A maximal response seen in burns covering 60% or

more TBSA.

The systemic response is caused by the release of

cytokines and other mediators into the systemic
circulation.

During the initial burn-shock period include tissue

hypoperfusion (fluid loss) and decrease O2 delivery
secondary to decreased cardiac output (decrease
systolic Bp)
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 Cardiovascular alterations

Followed by a hyperdynamic and hypermetabolic phase as a

compensating mechanism and resulting of increae HR,
peripherl vasoconstriction as aresult of releasing of
catecholamines

Myocardial contractility may be suppressed by the release of

inflammatory cytokine necrosis factor

Generally, the greatest volume of fluid leak occurs in the first

24 to 36 hours after the burn, peaking by 6 to 8 hours.

When hemodynamic state regain, urinary output increases;

Diuresis continues for several days to 2 weeks.

Some red blood cells may be destroyed and others

damaged, resulting in anemia. Despite this, the hematocrit
may be elevated due to plasma loss. 10
 Fluid and electrolytes Alterations

The initial systemic event after a major burn injury include

loss of capillary integrity and a subsequent shift of fluid,
sodium, and protein from the intravascular space into the
interstitial spaces.

In burns involving less than 25% TBSA, the loss of capillary

integrity and shift of fluid resulting in blister formation and
edema only in the area of injury.

It begins to resolve 1 to 2 days after the burn and usually is

completely resolved within 7 to 10 days

The physician may need to perform an escharotomy, a

surgical incision into the eschar (devitalized tissue resulting
from a burn), to relieve the constricting effect of the burned
tissue caused by edema

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 During burn shock, Usually, hyponatremia
Immediately after burn injury, hyperkalemia results
from massive cell destruction.
Hypokalemia (potassium depletion) may occur later
with fluid shifts and inadequate potassium
replacement.

Pulmonary Alterations
Bronchoconstriction (caused by release of
histamine, serotonin) and chest constriction
Hypoxia may be present: catecholamine alters
(decrease) peripheral blood flow
Later, hypermetabolism and continued
catecholamine release lead to increased tissue
oxygen consumption, which can lead to hypoxia.
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Renal Alterations
Renal function may be altered as a result of decreased
blood volume.

Immunologic Alterations
Serious burn injury diminishes resistance to infection.
The loss of skin integrity is compounded by the release of
abnormal inflammatory factors, and a reduction in
lymphocytes (T-helper lymphocytes)

Thermoregulatory Alterations
Loss of skin also results in an inability to regulate body
temperature.

Gastrointestinal Alterations
Paralytic ileus (absence of intestinal peristalsis).
Gastric distention, nausea, Gastric bleeding
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 Phases of Burn Injury

1. Emergent or resuscitative phase

Onset of injury to completion of fluid resuscitation

2. Acute or intermediate phase

From beginning of diuresis to wound closure

3. Rehabilitation phase
From wound closure to return to optimal physical
and psychosocial adjustment
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 Emergent or Resuscitative Phase:
On-the-Scene Care
Prevent injury to rescuer.
Stop injury: extinguish flames, cool the burn, irrigate chemical
burns.
ABCs: Establish airway, breathing, and circulation.
Monitor patient with electrical injuries for at least 24 hours
Apical pulse and blood pressure are monitored frequently.
The neurologic status is assessed quickly in the patient with
extensive burns.
Start oxygen and large-bore IVs.
Remove restrictive objects and cover the wound.
Do assessment, surveying all body systems, and obtain a
history of the incident and pertinent patient history.
Note: Treat patients with falls and electrical injuries as for
potential cervical spine injury.
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 Emergent or Resuscitative Phase

Patient is transported to emergency department.

For mild pulmonary injury, 100% humidified

oxygen is administered and the patient is
encouraged to cough so that secretions can be
removed by suctioning.

A large-bore (16- or 18-gauge) IV catheter should

be inserted in a nonburned area

Fluid resuscitation is begun.

Foley catheter is inserted.
Patients with burns exceeding 20-25% should
have an NG tube inserted and placed to suction. 16
Patient is stabilized and condition is continually
monitored.

Clean sheets are placed under and over the patient

to protect the burn wound from contamination,
maintain body temperature, and reduce pain
caused by air currents

Patients with electrical burns should have an ECG.

Address pain; only IV medication should be
administered.

Psychosocial consideration and emotional support

should be given to patient and family.
Once the patient's condition is stable, attention is
directed to the burn wound itself.
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 Management of Shock: Fluid Resuscitation

Maintain BP above 100 mm Hg systolic and urine output of 30-50

mL/hr. Maintain serum sodium at near-normal levels.

One goal is to maintain serum sodium levels in the normal range during
fluid replacement.

Formulas have been developed for estimating fluid loss based on the
estimated percentage of burned TBSA and the weight of the patient.

Consensus formula; Evans formula; Brooke Army formula

Note: Adjust formulas to reflect initiation of fluids at the time of injury.

The following example illustrates use of the consensus formula in a 70-

kg (154-lb) patient with a 50% TBSA burn:
– Consensus formula: 2 to 4 mL/kg/% TBSA
– 2 × 70 × 50 = 7000 mL/24 hours
– Plan to administer: first 8 hours = 3500 mL, or 437 mL/hour; next 16 hours =
3500 mL, or 219 mL/hour
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Fluid and Electrotype Shifts: Emergent Phase

Generalized dehydration
Reduced blood volume and
hemoconcentration
Decreased urine output
Trauma causes release of potassium into
extracellaur fluid: hyperkalemia.
Sodium traps in edema fluid and shifts into
cells as potassium is released: hyponatremia.
Metabolic acidosis
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 Nursing interventions

The nurse monitors vital signs frequently.

If all extremities are burned, A sterile dressing

applied under the blood pressure cuff protects the
wound from contamination.

Because increasing edema makes blood

pressure difficult to auscultate, a Doppler
(ultrasound) device or a noninvasive electronic
blood pressure device may be helpful.

In patients with severe burns, an arterial catheter

is used
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 Acute or Intermediate Phase

48-72 hours after injury

Continue assessment and maintain

respiratory and circulatory support.

Prevention of infection, wound care, pain

management, and nutritional support are
priorities in this stage.

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 Fluid and Electrolyte Shifts: Acute Phase

Fluid re-enters the vascular space from the

interstitial space.
Hemodilution
Increased urinary output
Sodium is lost with diuresis and due to
dilution as fluid enters vascular space:
hyponatremia.
Potassium shifts from extracellular fluid into
cells: potential hypokalemia.
Metabolic acidosis
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 Rehabilitation Phase

Rehabilitation is begun as early as possible in the

emergent phase and extends for a long period after
the injury.

Focus is upon wound healing, psychosocial support,

self-image, lifestyle, and restoring maximal
functional abilities so the patient can have the best-
quality life, both personally and socially.

The patient may need reconstructive surgery to

improve function and appearance.

Vocational counseling and support groups may

assist the patient.
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