BURNS

Major and Minor Burns

BURNS
 Burns can be caused by flame, UV radiation, hot liquids,
electricity, lightning and certain chemicals. Major burns are a
medical emergency and require urgent medical attention. In
some cases, skin graft surgery is needed.

 Statistically, males are more than twice as likely as females to

suffer a burn injury. Most of these injuries happen to men in
their 20s and are in some way work-related. The second most
likely burn victims are young children, with liquid scalds and
hot surface burns (radiators, heaters and 'potbelly' stoves) as the
most common causes.
 The most serious burns
result from flames or
scalds. About 5% of
patients hospitalized with
severe burns will die as a
result of their injury. The
majority of these are from
flame burns. At least half
of all people killed in
building fires, however,
die not from burns but
rather from asphyxiation
or carbon monoxide
poisoning caused by fire.
 Classified as first-, second-,
third-degree

 First degree (superficial)-

limited to the epidermis, most
common example is sunburn
 Second degree (partial
thickness)- damage to the
epidermis and a part of
dermis
 Third degree (full thickness)-
damage extends through
deeply charred subcutaneous
tissue to muscle bone
 Classified by amount of
body surface area (BSA)
affected (see USING THE
RULES OF NINES and
the LUND-BROWDER
CHART)
 Major – more than 10% of
an adult’s BSA; more than
20% of a child’s BSA
 Moderate- 3 % to 10% of
an adult’s BSA; 10% to
20% of a child’s BSA
 Minor- less than 3% of an
adult’s BSA; less than
10% of a child’s BSA
MINOR BURN
 Minor burns - these can
be managed on an
outpatient basis:
 <10% total body surface
area (TBSA) in an adult
 <5% TBSA in young or
elderly
 <2% full thickness bur
MODERATE BURNS
 Moderate burns - these
should be managed on an
inpatient basis:
 10-20% TBSA burn in an
adult
 5-10% TBSA in young or
elderly
 2-5% full thickness burn

 Suspected inhalation injury

 Circumferential burn

 Associated medical
problem, e.g., diabetes
MAJOR BURN
 Major burns - these require
transfer to a specialized
burn center:
 >20% TBSA burns in adult

 >10% TBSA burns in young

or elderly
 >5% full thickness burn

 Known inhalation injury

 Significant burn to face,

eyes, genitalia or joints
 Significant associated
traumatic injury
 Traditional
Nomenclature Depth Clinical findings Example
nomenclature
Erythema,
Superficial Epidermis
first degree significant pain,
thickness involvement
lack of blisters
Partial thickness – Superficial Blisters, clear fluid,
second degree
superficial (papillary) dermis and pain

Whiter appearance
or fixed red
Partial thickness – Deep (reticular)
third degree staining (no
deep dermis
blanching),
reduced sensation

Epidermis, Dermis,
and complete
Charred or
destruction to
leathery,
Full thickness fourth degree subcutaneous fat,
thrombosed blood
eschar formation
vessels, insensate
and minimal pain,
requires skin grafts
UNDERLYING PATHOPHYSIOLOGY
 The injuring agent denatures cellular proteins; some cells
die because of traumatic or ischemic necrosis
 Loss of collagen cross-linking also occurs with
denaturation, creating abnormal osmotic and hydrostatic
pressure gradients, which cause the movement of
intravascular fluid into interstitial space.
 Cellular injury triggers the release of mediators of
inflammation, contributing to local and, in major burns,
systemic increases in capillary permeability
 Specific pathophysiologic events depend on the cause
and classification of the burn
CAUSES:
 Thermal burns may result from any external heat source
(flame, hot liquids, hot solid objects, or, occasionally,
steam). Fires may also result in toxic smoke inhalation
 Radiation burns most commonly result from prolonged
exposure to solar ultraviolet radiation (sunburn) but may
result from prolonged or intense exposure to other
sources of ultraviolet radiation (eg, tanning beds) or from
exposure to sources of x-ray or other nonsolar radiation.
 Chemical burns may result from strong acids, strong
alkalis (eg, lye, cement), phenols, cresols, mustard gas,
phosphorus, and certain petroleum products (eg, gasoline,
paint thinner). Skin and deeper tissue necrosis caused by
these agents may progress over several hours.
 Electrical burns (see also
Electrical and Lightning Injuries: Electrical Injuries)
result from heat generation and electroporation of cell
membranes associated with massive current of electrons.
Electrical burns may cause extensive deep tissue damage
to electrically conductive tissues, such as muscles and
nerves, despite minimal apparent cutaneous injury.

 Events associated with a burn (eg, jumping from a

burning building, being struck by debris, motor vehicle
collision) may cause other injuries. Abuse should be
considered in young children and elderly patients with
burns.
RISK FACTORS:

 Age: less than four years

 Sex: male

 Low socioeconomic status

 Smoking

 Alcohol use

 Illegal drug use

 Absent or non-functioning smoke detectors

 Substandard or older housing

 Unsupervised or improperly supervised children

 Using tap water hotter than 120°F

COMMON SYSTEMIC COMPLICATIONS :

 Hypovolemia, causing hypoperfusion of burned tissue

and sometimes shock, can result from fluid losses due to
burns that are deep or that involve large parts of the body
surface; whole-body edema from escape of intravascular
volume into the interstitium and cells also develops.
Hypoperfusion of burned tissue also may result from
direct damage to blood vessels or from vasoconstriction
secondary to hypovolemia.
 Infection, even in small
burns, is a common cause
of sepsis and mortality, as
well as local
complications. Impaired
host defenses and
devitalized tissue enhance
bacterial invasion and
growth. The most common
pathogens are streptococci
and staphylococci during
the first few days and
gram-negative bacteria
after 5 to 7 days; however,
flora are almost always
mixed.
 Risk factors of burn wound
infection include:
 Burn > 30% TBS
 Full-thickness burn
 Extremes in age (very
young, very old)
 Preexisting disease e.g.
diabetes
 Virulence and antibiotic
resistance of colonizing
organism
 Failed skin graft
 Improper initial burn wound
care
 Prolonged open burn wound
 Metabolic abnormalities may include hypoalbuminemia
that is partly due to hemodilution (secondary to
replacement fluids) and partly due to protein loss into the
extravascular space through damaged capillaries.
Dilutional electrolyte deficiencies can develop; they
include hypomagnesemia, hypophosphatemia, and
hypokalemia. Metabolic acidosis may result from shock.
Rhabdomyolysis or hemolysis can result from deep
thermal or electrical burns of muscle or from muscle
ischemia due to constricting eschars. Rhabdomyolysis
causing myoglobinuria or hemolysis causing
hemoglobinuria can lead to acute tubular necrosis and
renal failure.
 Hypothermia may result from large volumes of cool IV
fluids and extensive exposure of body surfaces to a cool
emergency department environment, particularly in
patients with extensive burns.
 Ileus is common after extensive burns.
 Local: Eschar is stiff, dead tissue caused by deep burns.
A circumferential eschar, which completely encircles a
limb (or sometimes the torso), is constricting. A
constricting eschar limits tissue expansion in response to
edema; instead, tissue pressure increases, eventually
causing local ischemia. The ischemia threatens viability
of limbs and digits, and an eschar around the thorax can
compromise respiration.
 Scarring and contractures result from spontaneous
healing of deep burns; if the burn is located near joints or
in the hands, feet, or perineum, function can be severely
impaired. Infection can increase scarring. Keloids form
in some patients with burns, especially in patients with
darker skin.
ASSESSMENT FINDINGS

 Visual examination:  Second degree

severity and extent of - Pain
burn determined by Rule  - Oozing, fluid-filled
of Nines, Lund and vesicles
Browder chart  - Erythema
 - Shiny, wet subcutaneous
layer after vesicles
 First degree rupture
- Erythema
 - Edema
 Third degree
- Eschar
 - Pain
 - Erythema
 - Blanching
 - Little or no pain
TREATMENT

 Treatment: based on severity and extent of burn

 Secure anxiety and provide oxygen therapy

 IV therapy: hydration and electrolyte replacement

 Withhold oral food and fluids until patient is stable

 Diet high protein, high calorie, with increased

fluids(high calorie, high protein drinks
 Incubation and mechanical ventilation if patient is in
respiratory distress
 Activity: bed rest if severe

 Monitoring: vital signs, cardiac rhythm, hemodynamic

variables, I/O, and neurovascular checks
 Antibiotic: gentamycin sulfate

 Anti-infectives: silver sulfadiazine, silver nitrate

 Antitetanus: tetanus toxoid

 Wound care
NURSING MANAGEMENT

 Administer oxygen and maintain patent airway

 Administer I.V. fluids as directed; assess for signs of
hypovolemia
 Assess respiratory status and fluid balance

 Assess pain level, administer analgesics as prescribed,

and evaluate response
 Monitor and record vital signs

 Maintain the patient’s diet

 Administer medication as prescribed

 Provide skin and mouth care

POSSIBLE SURGICAL INTERVENTIONS

 Skin grafting
 Tissue debridement

 escharotomy