BURNS CARE

INTRODUCTION:
Burn injuries are among the most
devastating of all injuries and a major global
public health crisis. Burns are the fourth
most common type of trauma worldwide,
following traffic accidents, falls, and
interpersonal violence. Approximately 90
percent of burns occur in low to middle
income countries, regions that generally lack
the necessary infrastructure to reduce the
incidence and severity of burns.
DEFINITION:
 Burn is defined as tissue damage
caused by a variety of agents, such as
heat, chemicals, electricity, sunlight, or
nuclear radiation. Most common are
burns caused by scalds, building fires,
and flammable liquids and gases.”
 INCIDENCE
 WHO report suggest an annual mortality
rate of 100,000 to 140,000 in 2012-2013 in
India. This staggering incidence is largely
due to illiteracy, poor living conditions,
neglect of children, and certain social
customs that are unique to India.
 
 As per WHO report, Annually 6.2 %
rates of burns occur in Gujarat.
 Approximately 1.1 million people
require medical attention for burns
injury each year.
 Of these 50,000 require acute
hospitalization and about 4,500 people
die from the burns and related
inhalation injuries annually.
 TYPES OF BURNS
 According to the depth of tissue
destruction.
1. Superficial partial thickness burns.
 Involves epidermis.
 Skin is red without blister.
 Dry skin.
 Painful.
 Heals within 5-10 days.
2. Deep partial thickness burns(Second
degree)
 Extends to superficial papillary
dermis into deep dermis.
 Redness with clear blister.
 Skin yellow or white.
 Very painful.
 Moist.
 Heals within less than 2-3 weeks.
 Blanching with pressure.

Boling water burns

3.Full thickness burns( Third degree)
 Involves entire dermis.
 Fairly dry.
 Color variable(deep red, white, black,
brown)
 Discomfort .
 Heals within 3-8 weeks.
 No blanching.
 Insensate.
 Auto grafting is required.
4. Fourth degree burns:
 Involves entire skin, underlying fat,
muscles.
 Color variables (black).
 Charring visible in deepest
extremities.
 Extremity movement limitation.
 Insensate.
 Charred with eschar.
 Painless.
 Scarring, contractures.
 Auto grafting is required.
 Amputation is required.
 CLASSIFICATION ACCORDING
TO SEVERITY OF BURNS:

 Minor burns.
 Moderate burns.
 Severe or critical burns.
SEVERE BURNS:
MINOR
BURNS
 CAUSES:

 Contact with fire.

 Illiteracy.
 Traditional loose garments.
 Marital problems.
 Inflammable liquid or gas burns.
 Electricity burns.
 Chemical burns.
 Sunburns
 Therapeutic burns (as in operation,
laser etc)
 Burns due to contact of skin with
extreme hot materials, like frying pan,
oven's grill, etc.
 Extreme cold.
 Inhaling smoke or toxic fumes,
particularly from chemical explosions
or house fires.
 THERMAL BURNS:
 Including flame, radiation, or
excessive heat from fire, steam, and
hot liquids and hot objects.
 RADIATION BURNS:
 Such as from nuclear sources.
Ultraviolet light is also a source of
radiation burns.
 Light Burns.
 Heat burns.
 Cold temperature burns.
 Friction burns.
 
CLINICAL MANIFESTATIONS:
 Signs and symptoms of burns include:
 Red, swollen skin.
 Pain, which may be severe.
 Wet or moist-looking skin.
 Blisters.
 Waxy white, leathery skin.
 Blackened or charred skin, in severe
cases.
 Fluid and electrolyte imbalance.
 Changes in Elimination pattern.
 Decreased cardiac output.
 Decreased blood pressure.
 weak peripheral pulses.
 Altered level of consciousness.
 Alteration in respiration.
ASSESSMENT AND
DIAGNOSTIC FINDINGS:
 EXTENT OF BODY SURFACE
AREA INJURED:
 Various methods are used to estimate
the total body surface area(TBSA)
affected by burns, among them are :
 Rule of nines.
 Lund and Browder method.
 Palm method.
 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 burn is the Lund and
Browder method, which recognised the
percentage of surface area of various
anatomic parts, especially the head
and legs, changes with growth.
Because of changes in body proportion
with growth, the calculated TBSA
changes with age as well.
 Bydividing the body into very small
areas and providing an estimate of the
proportion of TBSA accounted for by
each body part.
 Palm method:
 In patient with scattered burns, the
palm method may be used to estimate
the extent of burns. The size of the
patient’s palm is approximately 1% of
TBSA
MANAGEMENT OF
BURN INJURY
PHASES DURATION PRIORITIES
Emergent From onset of injury First aid.
to completion of Prevention of shock.
fluid resuscitation. Prevention of respiratory distress.
Detection and treatment of
concomitant injuries.
Wound assessment and initial
care.
Acute/ From beginning of  Wound care and closure.
intermediate dieresis to near  Prevention or treatment of
completion of wound complications, including
closure. infections.
 Nutritional support
Rehabilitation From major wound  Prevention of scars and
closure to return to contractures.
individual’s optimal  Physical, occupational, and
level of physical and vocational rehabilitation.
psychosocial  Functional and cosmetic
adjustment. reconstruction.
 Psychosocial counselling.
Emergent/Resuscitative
Phase:
On The Scene Care.
Transfer The Patient To Burn
Centre.
FLUID REPLACEMENT
THERAPY
 The total volume and rate of iv fluid
replacement are gauged by the
patient’s response and guided by
resuscitation formula, the adequacy of
fluid resuscitation is determine
monitoring urine output total and,
index of renalpathy.
 Urine output totals of 30 to 50 ml/hr have
been used as a resuscitation goal, systemic
blood pressure existing 100 mm of hg, pulse
rate less than 110 beats/min.
 Within the first 24 hours after injury, if the
hematocrit and haemoglobin level decrease
or if the urine output exists 50 ml/hr the
rate of IV fluid administration may be
decrease.
 One goal is maintain serum sodium
levels in the normal range during the
fluid replacement.
 Minute to minute base deficient sensors
have been used to measure levels of pco2
in the tissues during fluid resuscitation
to determine cellular perfusion.
 Factors that are associated with
increase fluid requirement:
 Delayed resuscitation.
 Scald burn injuries.
 Inhalation injury.
 High voltage electrical injury.
 Hyperglycaemia.
 Alcohol intoxication.
 Chronic diuretic therapy.
FORMULAS USED IN
FLUID REPLACEMENT:
 Consensus formula.
 Evans formula.
 Brooke army formula.
 Parkland formula.
 Hypertonic saline formula.
ACUTE/ INTERMEDIATE PHASE:

 The acute or intermediate phase of

burn care follows the emergent phase
and begins 48 to 72 hours after burn
injury.
 Attention is directed towards
continued assessment and maintainace
of following:
 Circulatory status.
 Fluid and electrolyte balance.
 Gastro intestinal function.
 Infection prevention.
 Wound care.
 Pain management.
 Nutritional support.
MEDICAL MANAGEMENT
 Wound Cleaning:
 Hydrotherapy.
 The temperature of water is
maintained at 37.80C (1000 F).
 Hydrotherapy, in whatever form,
should be limited to a 20 to 30 minute
period to prevent chilling
 After the burn wound is cleaned, they
are gently patted with towels, and the
prescribed method of wound care
performed.
 In ambulatory patients, wound can be
cleaned in shower.
 The wound of non ambulatory patients
can be cleaned using shower carts-
mobile stretchers made with
removable slides, drainage holes, and
positioning capabilities.
 The wound of non ambulatory patients
can be cleaned using shower carts-
mobile stretchers made with
removable slides, drainage holes, and
positioning capabilities.
TOPICAL ANTIBACTARIAL
THERAPY
 Topical antibacterial therapy does not
sterilize the burn wound ; it simply
reduces the number of bacteria so that
the overall population can be
controlled by the body’s host defence
mechanisms.
 There is general agreement that some
form of antimicrobial therapy is
applied to burn wound is the best
method of local care in extensive burn
injury.
Bacitracina Ease of application; painless;
antimicrobial spectrum not as wide as
above agents
Neomycin Ease of application; painless;
antimicrobial spectrum not as wide
Polymyxin Ease of application; painless;
B antimicrobial spectrum not as wide
Nystatin Effective in inhibiting most fungal
Mycostatin growth; cannot be used in combination
with mafenide acetate
Mupirocin More effective staphylococcal coverage;
(Bactroban) does not inhibit epithelialization;
expensive
THERMAL BURN
MEDICATIONS:
 TOPICAL ANTIBIOTICS:
 Neosporin
 Silvadene
 ANALGESICS:
 Morphine sulphate
 Vicoding
 Demerol
 NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS :
CHEMICAL BURN
MEDICATIONS
 Topical antibiotics.
 calcium and magnesium salts.
 standard IV fluid and narcotic
therapy.
 Analgesics:
 Morphine and Acetaminophen.
 Nonsteroidal Anti-inflammatory
Agents.

 Advil, Motrin Ansaid, Naprosyn and
Anaprox.
 Antibiotics:
 Erythromycin ointment (Bacitracin).
ELECRTRICAL BURNS
MEDICATIONS:
 Fluids:
 Lactated ringers are used for fluid
revival. It is an isotonic and has
volume restorative properties. They
are administered using an IV and
should be stopped if pulmonary edema
develops.
Osmotic Diuretics:
 Mannitol.
 Scar Treatment Medications:
 Cica-Care Gel Sheets.
 Mederma.
WOUND DEBRIDEMENT:
 Debridement, another fact of burn
wound care, has two goals:
 To remove tissue contaminated by
bacteria and foreign bodies, thereby
protecting the patient from invasion of
bacteria
 To remove devitalized tissue or burn
eschar in preparation for grafting and
wound healing
 Types of wound debridement

 Natural debridement.

 Mechanical debridement.

 Surgical debridement.
WOUND DRESSING:

 When wound is clean, the burned

areas are patted dry and the
prescribed topical agent is applied;
wound is covered with several layers
of dressings. A light dressing is used
over joint areas to allow motion.
 Circumferential dressings should be
applied distally to proximally.
 If the hand or foot is burned, the
fingers and toes should be wrapped
individually to promote healing.
 Burn to face may be left open they have
been cleaned and the topical agent has
been applied. Careful attention must be
given to ensure that the topical agent
does not interference with the eyes or
mouth. A light dressing can be applied to
the face to absorb excess exudates that
might run to eyes, causing irritation.
 An occlusive dressing is thin gauze
that is impregnated with a topical
antimicrobial agent and use over areas
with new skin grafts. These dressing
remain in place for 3 to 5 days, at
which time they are removed for
examination of the graft.
 Dressings impede circulation if they
are too tightly wrapped. The
peripheral pulses must be checked
frequently and burned extremities
elevated on two pillows. If the patient
pulse is diminished, dressing should be
changed.
WOUND GRAFTING
 If the wounds are deep (full- thickness) or
extensive, spontaneous reepitheliazation is
not possible. Therefore, covering of the
wound is necessary until coverage with a
graft of the patient’s own skin (auto graft) is
possible.
 The purpose of wound coverage are:
 To decrease risk of infection.
 To prevent further loss of fluid,
protein, electrolytes through wound.
 To minimize heat loss through
evaporation.
NUTRITIONAL SUPPORT
 AIM:

 To provide optimum calories and nitrogen

through enteral route.
 To maintain premoorbid weight
 ADVANTAGES:
 Wound heals faster.
 Reduces mortality and morbidity.
 Weight gain.
 Short length of hospital stay.
 Less rate of infection.
 Cost effective.
 Improves survival.
SURGICAL MANAGEMENT:
 ESCHAROTOMY:
 Deep burns on the chest and
extremities lead to constriction.
 Escharotomies are performed in the
ward with sedation. The thick eschar is
cut in the form of a grid to relieve this
constriction.
SKIN GRAFTING:

 Graft: graft is a piece of skin which is

completely detached from the body
devoid of its blood supply and
transplanted to other raw area where
it develops a new blood supply for its
survival.
 FASCIOTOMY:
 This is very commonly performed in high voltage
electrical burns of the extremities leading to
edema and increased compartment syndrome.

 Faciotomy is performed in the ward under

sedation. The incision is made up to the fascia so
that the muscles bulge out of the tight
compartments.
 TANGENTIAL EXCISION:

 This is performed in cases where the

depth of burn is questionable. it is layer
after layer excision of the burn surface till
bleeding tissue or viable tissue is seen.
Immediate graft has to be laid over the
excised area to prevent drying of wound.
 WOUND DEBRIDEMENT:

 This is done both in the ward and

operation wound to clean the wound
for subsequent cover. Either a
Humby’s knife or 15 blades can be
used to debride the slough.wet
dressings help in early removal of
slough.
 AMPUTATION:
 In deep burn wounds, inspite of
Faciotomy, if gangrene is seen then
amputation at various levels should be
performed.
COMPLICATIONS OF BURNS IN ACUTE PHASE:
 Heart failure and pulmonary edema.
 Sepsis.
 Acute respiratory failure and acute
respiratory distress syndrome.
 Visceral damage.
REHABILITATION PHASE:
 The goals of the rehabilitation process
are to maximize function and
appearance of the scars.  This is done
by trying to counteract two main
physiologic processes, scar
hypertrophy and contracture.
 COMPLICATIONS
 Neuropathies.
 Heterotopic ossification.
 Hypertrophic scarring.
 Contractures.
 Wound breakdown.
 Gait deviation.
 Complex regional pain syndrome
(previous reflex sympathetic dystrophy)
 Joint instability.
HYPERTROPHIC SCARRING
 Hypertrophic scars are thickened, red,
and raised scars which can often be
very itchy.
 Hypertrophic scarring generally does
not develop in burns that require less
than 2 weeks to heal.  Hypertrophic
scarring develops in 33% of wounds
that take less than 3 weeks to heal, but
78% of wounds that take more than 3
weeks.  It also affects skin grafts.
CONTRACTURES:

AXILLARY
CONTRACTURE
 Joint contractures are one of the most
challenging aspects of burn
management, and are the main source
of disability from thermal burns. Scar
contracture is due to activity of the
myofibroblasts which act to contract
scars.
 When the scars are across joints,
particularly flexion joints, these can
lead to permanent flexion deformities.
In addition, flexed positions are often
positions of comfort during the acute
phase of burn management,
exacerbating the problem
 To combat joint contractures,
stretching and splinting is necessary.
Stretching and range of motion
exercises should be initiated from the
beginning. With initial edema,
movement may be a bit difficult but
should be encouraged with daily
exercises. 
 Upper thigh/lower abdominal burns
require positioning to prevent flexion
of the hips. Stretching and range of
motion exercises should be initiated
from the beginning. With initial
edema, movement may be a bit
difficult, but should be encouraged
with daily exercises.
 Contractures are the most debilitating
residual stigma of burns, and high-risk
patients (deeper burns over flexion
joint surfaces) can easily be identified.
 Splinting should be considered when
any loss of extension is noted across
elbows and knees. Hands should be
splinted from the onset. Simple plaster
slabs covered in elastic tube bandage or
“stockinet” makes excellent volar hand
splints, can be wrapped on with tensor
bandages and are re-usable till soiled.
Splints are often applied overnight,
allowing for mobilization and function
in the daytime.
 The ankle can have contractures in
both directions.  Burns and scar
contractures to the dorsum are more
common, which must be combated
with plantar flexion exercises and
splints. However, the Achilles tendon
may also become shortened with a
prolonged planter flexion. For an
ambulating patient, this is not a
concern. However, for a patient who is
bed-ridden, splinting should be
initially for dorsiflexion to prevent
Achilles tendon shortening.
HAND CONTRACTURES:
 Contractures in the hands include
flexion contractures of the fingers and
wrist, web space narrowing of the
digits, as well as hyperextension of the
MCP joints. 
 Finger contractures can sometimes be
released with z-plasties, if the burn
area is isolated to the central palmer
aspect of each finger. If z-plasties are
used, care should be taken not to cause
excess tension with closures leading to
finger ischemia.
 Release of prolonged flexion
contractures can also have ischemia
from overstretching of shortened
neurovascular bundles.  Release may
need to be staged, or stretched post-
operatively with therapy. Kirshner
wires may be beneficial for the first 1-
2 weeks until the skin graft take is
reasonable
 A 5-flap z-plasty (also known as a double
Z-plasty with V-Y advancement) allows
for more deepening, while a 4-flap
allows for much greater lengthening.
These are used primarily in the 1st web
space. Deepening of the other web
spaces is often performed using
techniques for congenital syndactyly,
with a skin flaps used to reconstruct the
base of the web space to prevent future
web creep. Skin grafts are often
necessary to fill in the gaps on the sides. 
NECK CONTRACTURES
 Neck flexion is often associated with
webbing of the neck. There is often a
severe shortage of skin, and a
significant size skin graft may be
necessary for coverage of the defect
after release.  Unless very minor, or
featuring a narrow band of scar, these
are usually not amenable to z-plasties
 Another challenge for severe neck
contractures is difficulty with
intubation. The release of the neck may
need to be done under local anaesthetic
to allow for neck extension before
initiation of general anaesthetic and
reconstruction of the defect. If the
injury is anterior only, a good
alternative for coverage of the neck is a
pedicled latissimus dorsi flap, which
would provide normal skin coverage
without risk of contracture recurrence. 
AXILARY CONTRACTION:
 Axillaries scar contractures are
also very common. These can at
times be treated with a large 4-flap
z-plasty, similar to for the first
web space, or multiple z-plasties
or V-Y plasties.  Alternatively, they
can sometimes also be managed
with release and skin grafts
FACE CONTRACTURE:
 Eyelid contractures can be released
with skin grafts. Patients with eyelid
burns must be followed to watch for
ectropion, which can lead to corneal
abrasions. These can be release with
preferably full thickness skin graft
placement. Thin full-thickness skin
can be harvested from the pre or post-
auricular region if available.
Microstomia and commissure burns
can be treated initially with splinting
and stretching exercises
HEALTH EDUCATION:
 Enclose fires and limit the height of
open flames in domestic environments.
 Promote safer cook stoves and less
hazardous fuels, and educate
regarding loose clothing.
 Apply safety regulations to housing
designs and materials, and encourage
home inspections.
 Improve the design of cook stoves,
particularly with regard to stability
and prevention of access by children.
 Lower the temperature in hot water
taps.
 Promote fire safety education and the
use of smoke detectors, fire sprinklers,
and fire-escape systems in homes.
 Promote the introduction of and
compliance with industrial safety
regulations, and the use of fire-
retardant fabrics for children’s
sleepwear
DIET PLAN
 NURSING DIAGNOSIS
 1.Hypothermia related to loss of
microcirculation and open wounds.
 2.Fluid volume deficite related to increase
capillary permeability and evaporative losses
from the burn wound.
 3.Ineffective airway clearance related to edema
and effects of smoke inhalation.
 4.Impaired gas exchange related to carbon
monoxide poisoning,smoke inhalation and upper
airway obstruction.
 5.Risk for infection related to loss of skin barrier
and impaired immune response.
 NURSING DIAGNOSIS
 6.Impaired skin integrity related to open burn
wound.
 7.Imbalanced nutrition less than body
requirement related to hyper metabolism and
wound healing needs.
 8.Pain related to tissue and nerve injury and
emotional impact.
 9.Excessive fluid voluma related to resumption
of capillary integrity and filuid shifts from the
interstials to intravascular compartment.
 10.Anxiety related to fear and emotional impact
of burn injury.
 AN K
T H
Y O U