Burn Training Assessment & Management Dr. D. N. Bid
▪ Anatomy of Integumentary System Review
▪ Determining Severity of Burn
▪ Transfer to Burn Center
Anatomy of the Integumentary System (Skin)
Skin covers ~ 1.5-2.0 square meters in the average adult
▪ Largest organ of the body
▪ Two principal layers
Contains major vesicular networks, fat, nerves,
Acts as a shock absorber and heat insulator for underlying structures of muscles, tendons, bones, and internal organs
Anatomy of the Skin
Anatomy of the Skin
Function of the Skin
Against external forces
Nerves report touch & status in environment
Blood vessel dilation/constriction
Burn wounds occur when there is contact between tissue and an energy source such as - heat (thermal) - chemicals - electrical current - radiation
Extent of burns are influenced by
intensity of the energy
duration of exposure
type of tissue injured
Zones of Burn Injury
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 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 edema—can convert this zone into an area of complete tissue loss.
Zone of hyperemia - In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.
Zones of Burn Injury
Zones of Burn Injury Clinical image of burn zones. There is central necrosis, surrounded by the zones of stasis and of hyperemia
Depth of Burns
Superficial (first-degree) burns
Involve only top skin layer
Superficial - First degree burns
Epidermis only damaged
Painful to touch
Area initially erythematous due to vasodilatation
Epidermis sloughed off in 7 days with complete scarless healing
Depth of Burns
Partial-thickness (second-degree) burns
Involve epidermis and some portion of dermis
Can be either
superficial or deep
Partial thickness – Superficial Second degree burns
Epidermis & various degrees of dermis destroyed
Are pink to cherry red and wet
May or may not have intact blisters and are very painful when touched or exposed to air
Heal in 7-14 days with topical antimicrobials or wound dressings
Partial thickness – Superficial Second degree burns
Partial thickness – Deep Second degree burns
Epidermis & deeper degrees of dermis destroyed
Are pink to cherry red, wet, shiny with serous exudate
Very painful when touched or exposed to air
Heal in 14- 28 days with scarring
May need early excision and grafting
Partial Thickness-Deep Second degree burns
Depth of Burns
Full-thickness (third-degree) burns
Extend through all layers of skin
Need better phtls
Will appear as thick, dry, leathery, waxy white to dark brown regardless of race or skin color
May have a charred appearance with visible thrombosis of blood vessels
Will have little to no sensation because nerve endings have been destroyed except in surrounding tissues with partial thickness burns
Full-thickness – Third degree burns
Full Thickness-Third degree burns
Depth of Burns
Extend through all layers of skin as well as extending to underlying fat, muscle, bone or internal organs
Need better phtls Fig 13-7
Burn Size Estimation
Critical to providing adequate resuscitation
3 common guidelines used
Rule of Nines
Rule of Nines
In the adult, most areas of the body can be divided roughly into portions of 9% or multiples of 9.
In the child, similar portions are assigned
This division is useful in estimating the percentage of body surface damage an individual has sustained in burn.
Rule of Nines
The palmer surface of the patient’s hand –from crease at wrist to tip of extended fingers- equals ~ 1% of the patient’s total body surface area
Severity of Burn Injury
Treatment of burns is directly related to the severity of injury
Severity is determined by
depth of burn
external of burn calculated in percent of total body surface (TBSA)
location of burn
patient risk factors
Full-thickness burns involving less than 2% of the total body surface area
Partial-thickness burns covering less than 15% of the total body surface area
Superficial burns covering less than 50% of the total body surface area
Full-thickness burns involving 2% to 10% of total body surface area excluding hands, feet, face, upper airway, or genitalia
Partial-thickness burns covering 15% to 30% of total body surface area
Superficial burns covering more than 50% of total body surface area
Critical Burns (1 of 2)
Full-thickness burns involving hands, feet, face, upper airway, genitalia, or circumferential burns of other areas
Full-thickness burns covering more than 10% of total body surface area
Partial-thickness burns covering more than 30% of total body surface area
Burns associated with respiratory injury
Critical Burns (2 of 2)
Burns complicated by fractures
Burns on patients younger than 5 years old or older than 55 years old that would be classified as moderate on young adults
Burns to children are considered more serious than burns to adults.
Children have more surface area relative to body mass than adults.
Minor Burns in Infants and Children
Partial-thickness burns covering less than 10% of total body surface area
Moderate Burns in Infants and Children
Partial-thickness burns covering 10% to 20% of total body surface area
Critical Burns in Infants and Children
Full-thickness burns covering more than 20% of total body surface area
Thermal burns cause a number of effects described in the ‘Zones of injury”
2 types of chemical burns
acids- can be neutralized
alkaline - adheres to tissue, causing protein hydrolyses and liquefaction
examples: industrial or agricultural sites, highways and battlefields > cleaning agents, drain cleaners, lyes, and military grade agents, etc.
With chemical burns, tissue destruction may continue for up to 72 hours afterwards.
It is important to remove the person from the burning agent or vice versa.
Chemicals, heat, and light rays can burn the eye.
Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current.
Can cause tissue anoxia and death
The severity depends on amount of voltage, tissue resistance, current pathways, and surface area in contact with the current and length of time the current flow was sustained.
External signs of an electrical burn may be deceiving. Entrance may be small, while deeper tissue damage may be massive.
Electrical injury can cause:
Fractures of long bones and vertebra
Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury
Severe metabolic acidosis--can develop in minutes
Myoglobinuria--acute renal tubular necrosis- myoglobin released from muscle tissue whenever massive muscle damage occurs--goes to kidneys--and can mechanically block the renal tubules due to the large size!
Electricity can instantaneously destroy tissue. This child has a burn that resulted from biting on an electrical cord. These burns often occur at the corners of the mouth, as seen here.
Smoke and Inhalation Injury
Can damage the tissues of the respiratory tract
Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.
The glottis (1) is the opening in the epiglottis (2). It is the dark slit in the center of the epiglottis and is evident when the tongue is pulled down toward the chest cavity.
Inhalation injury Airway edema & Carbon deposits
3 types of smoke and inhalation injuries
1. Carbon monoxide poisoning (CO poisoning and asphyxiation count for majority of deaths)
Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can occur without any burn injury to the skin
2. Inhalation injury above the glottis (caused by inhaling hot air, steam, or smoke.)
Mechanical obstruction can occur quickly-True ER! Watch for facial burns, signed nasal hair, hoarseness, painful swallowing, and darkened oral or nasal membranes
3 . Inhalation injury below glottis
(above glottis-injury is thermally produced)
below glottis-it is usually chemically produced.
Amount of damage related to length of exposure to smoke or toxic fumes
Can appear 12-24 hours after burn
The typical exposure to radiation occurs in an industrial or occupational setting
With increasing threat of global terrorism, the detonation of a nuclear device is a possibility
Detonation of a nuclear weapon would injure/kill by three mechanisms
Thermal burns from initial firestorm
Supersonic destructive blast
Mortality from a combination of thermal & radiation burns is greater than that from thermal or radiation burns of equal magnitude
Physiologic consequence signs/symptoms of whole-body radiation appear within hours of exposure
Cells of the body that are most sensitive to radiation are typically those the undergo rapid division
3 Phases of Burn Management
0 – 48 hours, can be up to days later
Acute (definitive care)
▪ day 3 until wounds heal
Begins during resuscitation and continues throughout lifespan
Emergent Phase (Resuscitative Phase)
Lasts from onset to 5 or more days but usually lasts 24-48 hours
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
Emergent Phase – Initial Management/Care
MAKE SURE YOU ARE SAFE !!!
Remove patient from area! Stop the burn!
Airway- check for patency, soot around nares, or signed nasal hair. 100% O2 via NRM @ 15L. Watch for early upper airway edema >intubate is in doubt.
Breathing - check for adequacy of ventilation, consider need for early intubation or early escharotomy if ventilation is impaired
Emergent Phase –Initial Management/Care
Circulation- check for presence and regularity of pulses, consider early escharotomy if circulation to a limb is impaired
Disability- AVPU, altered mental status in burn patient is not normal >think carbon monoxide poisoning. Check pupils. Check for movement in all extremities.
Expose- Remove clothing and jewelry. Do not pull on clothing stuck to skin > Cut away clothing or soak it off. Cover with dry sterile sheet and tuck in sides.
Emergent Phase –Initial Management/Care
Fluid Resuscitation- estimate TBSA burn percentage and weight then calculate fluids for first 24 hour period using Parkland formula
Foley catheter- to monitor urine output
Secondary survey starting with a good scene and patient history then head to toe exam
Pain Management- early and often based on patient’s hemodynamic status and pain scale
Psychosocial issues- consider need for religious intervention, legal consult for family affairs, etc for patients with life-threatening burns
Secondary Survey History
How did the burn occur? Did the burn occur outside or inside? Did the clothes catch on fire? How long did it take to extinguish the flames? How were the flames extinguished? Was gasoline or another fuel involved? Was there an explosion? Was there a building/house fire? Was the patient found in a smoke-filled room? How did the patient escape? If the patient jumped out a window, from what floor? Were others killed at the scene? Was there a motor vehicle crash? How badly was the vehicle damaged? Was there a motor vehicle fire? Are there other injuries? Are the purported circumstances of the injury consistent with the burn characteristics?
Secondary Survey History
What was the agent? How did the exposure occur? What was the duration of contact? What decontamination occurred? Was there an explosion?
Secondary Survey History
What kind of electricity was involved? What was the duration of contact? Did the patient fall? What was the estimated voltage? Was there loss of consciousness? Was cardiopulmonary resuscitation administered at the scene?
Specific burn –Treatment notes Care for Thermal Burn
For <10% TBSA burn-apply moist cool sterile dressings to small burn
For larger-cover area with dry sterile dressings or sheet
Specific burn –Treatment notes Care for Chemical Burn (1 of 2)
Remove the chemical from the patient.
If it is a powder chemical, brush off first.
Remove all contaminated clothing.
Care for Chemical Burn (2 of 2)
Flush burned area with large amounts of water for 30 minutes or more.
Transport quickly .
Chemical Burn- Eyes
Occur whenever a toxic substance contacts the body
Eyes are particularly vulnerable.
Fumes can cause burns.
To prevent exposure, wear appropriate gloves and eye protection.
Chemical Burn- Eyes
For chemicals, flush eye with saline solution or clean water.
You may have to force eye open to get enough irrigation to eye.
With an alkali or strong acid burn, irrigate eye for about 20 minutes.
Bandage eye with dry dressing.
Irrigating the Eye
Specific burn –Treatment notes Care for Electrical Burn
Fluids -Ringers Lactate or other fluids to flush kidneys if myoglobinuria is present
Assess for bone fractures and treat appropriately if found
Complications during emergent phase of burn injury may occur in 3 major organ systems
Arrhythmias, hypovolemic shock which may lead to irreversible shock
Circulation to limbs can be impaired by circumferential burns and then the edema formation
Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene
Escharotomies (incisions through eschar) done to restore circulation to compromised extremities
Vulnerable to 2 types of injury
1. Upper airway burns that cause edema formation & obstruction of the airway
2. Inhalation injury can show up 24 hrs later-watch for respiratory distress such as increased agitation or change in rate or character of respirations
preexisting problem (ex. COPD) more prone to get respiratory infection
Pneumonia is common complication of major burns
Is possible to overload with fluids--leading to pulmonary edema
Most common renal complication of burns in the emergent phase is Acute Tubular Necrosis (ATN) (muscle destruction > myoglobulin release > protein leak clogs kidney cells >ischemia) Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.
Patient management in the Emergent Phase
Airway management -early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn)
Ventilator - ABGs - Escharotomies
Bronchoscopy to assess lower respiratory tract
6-12 hours later
High Fowler’s position-cough & deep breathe every hour, turn q 1-2 hrs, chest physiotherapy, suction prn
Massive fluid shifts out of blood vessels as a result of increased capillary permeability. When capillary walls become more permeable, water, sodium, and later plasma protein (esp. albumin) moves into interstitial spaces & other tissues. The colloidal osmotic pressure decreases with loss of protein from the vascular space. This called second spacing.
Fluids goes into areas with no fluids and this is called third spacing. Examples of third spacing are exudate and blister formation
Net result is decreased volume, depletion due to fluid shifts = edema, decreased blood pressure, and increased pulse
Occurs when there is a loss of intravascular fluid volume. The volume is inadequate to fill vascular space and is unavailable for circulation
Burns have a direct loss of fluid due to evaporation
1 or 2 large bore IV replacement lines (may need jugular or subclavian)
Cutdowns are rare due to increased risk of infection & sepsis
Fluid replacement based on: size/depth of burn, age of pt., & individualized considerations--ex. Dehydration in preburn state, chronic illness
Options- RL, D5NS, dextam, albumin, etc.
Parkland formula to determine adequate amount to give
Lactated Ringers solution is recommended 3ml/kg/%TBSA burn = ml’s in first 24 hours
½ of this total given in the first 8 hours post injury
remaining ½ given in the next 16 hours.
Titrate to maintain urinary output as well.
Example - 50 kg patient with 50% TBSA burn
3 ml/kg/%TBSA burn
3 (ml) x 50 (kg) x 50 (%TBSA) = 7500 ml in first 24 hrs
give 3750 ml in first 8 hrs @ 469 ml/hr
give 3750 ml in next 16 hrs @ 234 ml/hr
In children <30kg also administer D5 ½ LR solution @ maintenance rate of:
For the first 1 to 10 kg - 100ml/kg/24 hours = 4ml/kg/hour
For the second 11 to 20 kg - 50ml/kg/24hours = 2ml/kg/hour
For any weight 21 to 30 kg - 20ml/kg/24hours = 1ml/kg/hour
Example for a 12 kg child:
100 ml/kg for first 10 kg 10 kg x 100 ml = 1000ml
50 ml/kg for each kg between 11 and 20kg 2 kg x 50 ml = 100ml
20 ml/kg for each kg between 21 and 30 kg --- none needed ----
Do not give dextrose solutions (except for maintenance fluids in children)- they may cause an osmotic diuresis and confuse adequacy of resuscitation assessment.
Assessment of adequacy of fluid replacement
Urinary output is most commonly used parameter
Adequate urine output is 30 ml/hr in adults and
1 ml/kg/hr in a child less than 30 kg
Cardiopulmonary factors- BP (systolic 90-100 mmHg), pulse less than 100, resp 16-20 breaths per min. (BP more accurate with arterial line)
Sensoruim-alert, oriented to time, place, & person
Inflammation & Healing
Burn injuries cause coagulation necrosis whereby tissues and vessels are damaged or destroyed
Wound repair begins within the first 6-12 hours after injury.
Are caused by burns
Skin barrier destroyed and all changes make the burn patient more susceptible to infection
Patient may be in shock from pain and hypovolemia
Considerations (1 of 2)
Full-thickness burns and deep partial thickness burns are initially anesthetic because nerve endings are destroyed
Superficial to moderate partial thickness burns are very painful
Considerations (2 of 2)
Severe dehydration is possible even though the patient may be edematous
May have an dynamic ileus due to body’s response to massive trauma and potassium shifts
Shivering due to chilling caused by heat loss, anxiety, and pain
Patient unable to recall events due to hypoxia associated with smoke inhalation, or head trauma or overdose of sedatives or pain meds
Wound Care for Burns
Can wait until patent airway, adequate circulation, fluid replacement is assured
Cleansing and Debridement
Can be done in tank, shower, or bed
Debridement may be done in surgery (Loose necrotic skin is removed)
Bath given with with surgical detergent, disinfectant, or cleansing agent to reduce pathogenic organisms
Infection is the most serious threat to further tissue injury and possible sepsis
SURVIVAL is related to prevention of wound contamination
Source of infection is pt’s own flora, predominantly from the skin, resp. tract, and GI tract
Prevention of cross contamination from other patients is the priority for patient care staff
Wound Management Methods
Open method - pt’s burn is covered with a topical antibiotic and has no dressing
Closed method- uses sterile gauze impregnated with or laid over a topical antibiotic. Dressings changed 2-3 times q 24 hrs.
Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed
Appropriate use of aseptic- sterile vs. nonsterile techniques
Keep room warm
Disinfect patient bathing areas before and after bathing
Coverage is the primary goal for burn wounds. There is usually not enough unburned skin for immediate skin grafting, other temporary wound closure methods are used
Allograph or homograft (same species which is usually from cadavers) is used for wound closure-- temporary--3 days to 2 wks
Porcine skin-heterograft or xenograft (different species)--temporary--3 days to 2 wks
autograft or cultured epithelial autograft- (pt’s own skin and cell culture)- permanent
Surgeons use a dermatome (left) to remove donor skin and a mesher (right) to put holes in it.
Surgeons agree that no single product or technique is right for every burn situation.
There is no true replacement for healthy, intact skin, which is the body's largest organ, and one of the most complex
Example of healing burn
Other care measures
Face is vascular and subject to increased edema- use open method if possible to decrease confusion and disorientation
Eye care-use saline rinses, artificial tears
Hands &arms-extended and elevated on pillows or in slings to minimize edema, may need splints to keep them in functional positions
Ears- keep free of pressure –use no pillows Neck burns should not use pillows in order to decrease wound contraction
Perineum- must be kept clean & dry Indwelling Foley will help in this & provide hourly outputs
Special studies as needed: arterial blood gas, carboxyhemoglobin, ECG, glucose
Physical therapy started immediately
Analgesics and Sedatives
given for patient comfort
IV pain medications initially due to
GI function is slowed or impaired because of shock or paralytic ileus
IM injections will not be absorbed well
Tetanus immunization- given routinely to all burn patients because of the likelihood of anaerobic burn-wound contamination
Antimicrobial agents- usually topical due to little or no blood supply to the burn eschar so little delivery of the antibiotic to wound
Drug of choice is: Silver sulfadiazine
Fluid replacement takes priority over nutritional needs in the initial emergent phase
NG tube is inserted and connected to low intermittent suction for decompression
When bowel sounds return (48-72 hrs) after injury, start with clear liquids and progress up to a diet high in proteins and calories
Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition
Give calorie containing liquids instead of water due to need for calories and potential for water intoxication
Enteral feedings into the duodenum (recommended) can: reduce nausea /vomiting, provide more continuous feedings, and increase wound healing
Calorie Intake Formula
(25 x wgt in kg) + (40 x TBSA burn)
Example for 50 kg patient with 50% TBSA burn:
(25 x 50) + (40 x 50) = 1250 + 2000 = 3250 Kcals
Begins with mobilization of extracellular fluid and subsequent diuresis
Is concluded when the burned area is completely covered or when wounds are healed. May take weeks or months
Patient is no longer grossly edematous due to fluid mobilization, full & partial thickness burns more evident, bowel sounds return, pt more aware of pain and condition
Healing begins when WBCs have surrounded the burn and phagocytosis begins, necrotic tissue begins to slough, fibroblasts lay down matrices of collagen precursors to form granulation tissue
Partial-thickness burns (if kept free from infections) will heal from edges and from below. (10-14 days)
Full-thickness burns must be covered by skin grafts
Sodium- Hyponatremia can occur due to: silver nitrate topical oints as a result of sodium loss through eshcar, hydrotherapy, excessive GI drainage, diarrhea, excessive water intake
S/S of hyponatremia: weakness, dizziness, muscle cramps, fatigue, HA, tachycardia, & confusion
Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, inappropriate fluid administration
S/S of hypernatremia: thirst; dried furry tongue; lethargy; confusion; and possible seizures
Potassium- hyperkalemia is note if pt is in renal failure, adrenocortical insufficiency, or massive deep muscle injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness & EKG changes are noted.
Hypokalemia is noted with silver nitrate therapy and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplementation. Constant K+ losses occur through the burn wound.
Complications of Acute Phase
Infection- due to destruction of body’s 1st line of defense. Partial thickness wds can convert to full-thickness wds with infection present. Pt may get sepsis from wound infections. Signs of sepsis are: high temp., increased pulse & resp., decreased BP, and decreased urinary output, mild confusion, chills, malaise, and loss of appetite. WBC bet. 10,000 and 20,000. Infections usually gram neg. bacteria (pseudomonas, proteus)
Obtain cultures from all possible sources:
IV, Foley, wound, oropharynx, and sputum
Cardiovascular- same as in emergent phase
Neurologic- possible from electrical injuries
Musculoskeletal- has the most potential for complications during acute phase due to healing and scar formation making skin less supple and pliant. ROM limited, contractures can occur
Gastrointestinal- adynamic ileus results from sepsis, diarrhea or constipation (due to narcotics & decreased mobility), gastric ulcers due to stress, occult blood in stools possible
Fluid replacement continues from emergent phase to acute phases-- given for: fluid losses, administer medications, & for transfusions
Physical therapy- to maintain optimal joint function
Pain management- most critical functions as a nurse.
Nutritional therapy- provide adequate proteins & calories
Wound Care- the goals are cleanse and debride the area of necrotic tissue &debris, minimize further damage to viable skin, promote patient comfort, & reepithelialization or success with skin grafting.
Care for donor site and other grafts necessary
Excision and grafting- eschar removed to subcutaneous tissue or fascia, graft applied to tissue
Cultured epithelial autograft (CEA)uses patient’s own cells to grow skin-permanent
Artificial skin -examples: Alloderm, Life-Skin, etc.
Defined as beginning when the patient’s burn wound is covered with skin or healed and patient is capable of assuming some self-care activity.
Can occur as early as 2 weeks to as long as 2-3 months after the burn injury throughout the patient’s lifespan
Goals for this time is to assist patient in resuming functional role in society & accomplish functional and cosmetic reconstruction
Burn wound either heals by primary intention or by grafting
Scars & Contractures may form
Mature healing is reached in 6 months to 2 years
Avoid direct sunlight for 1 year on burn
New skin sensitive to trauma
Most common complications of burn injury are skin and joint contractures and hypertrophic scarring
Because of pain, patients will assume flexed position. It predisposes wounds to contracture formation
Use of physical therapy, pressure garments, splints, etc. are used to prevent/treat these
Example of Contracture
Example of a pressure garment
Nursing management during Rehabilitation Phase
Must be directed to returning patient to society, address emotional concerns, spiritual and cultural needs, self-esteem, teaching of wound care management, nutrition, role of exercises and physical therapy explained. A common emotional response seen is regression.
Special Needs of the Patient Care Staff
Critical Stress Defusing/Debriefing sessions should be offered early and often
Staff of burn units are prone to higher rates of burn-out. The care of a burn patient can be a long period that stresses the patient, care giver, and significant others. The road to recovery is full of potential threats to the patient. Support services are necessary for the medical team of any long-term burn patients.