2. Contents
▪ Anatomy of Integumentary System Review
▪ Determining Severity of Burn
▪ Assessment
▪ Management
▪ Transfer to Burn Center
3. 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
-Epidermis
-Dermis
4. Subcutaneous Tissue
• Contains major vesicular networks, fat, nerves,
and lymphatics
• Acts as a shock absorber and heat insulator for
underlying structures of muscles, tendons, bones,
and internal organs
6. Function of the Skin
• Protection
– Against external forces
– Against infection
• Sensation
– Nerves report touch & status in environment
• Temperature control
- Blood vessel dilation/constriction
- Sweat evaporates
7. Burn wounds occur when there
is contact between tissue and an
energy source such as
- heat (thermal)
- chemicals
- electrical current
- radiation
8. Extent of burns are influenced by
- intensity of the energy
- duration of exposure
- type of tissue injured
9. 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.
11. Zones of Burn Injury
Clinical image of burn zones. There is central necrosis,
surrounded by the zones of stasis and of hyperemia
12. Depth of Burns
• Superficial
(first-degree)
burns
• Involve only
top skin layer
13. 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
14. Depth of Burns
• Partial-thickness
(second-degree)
burns
• Involve
epidermis and
some portion of
dermis
• Can be either
superficial or
deep
15. 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
17. 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
19. Depth of Burns
• Full-thickness
(third-degree) burns
• Extend through all
layers of skin
Need better
phtls
20. • 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
22. Depth of Burns
• Fourth-degree
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
23. Burn Size Estimation
• Critical to providing adequate resuscitation
• 3 common guidelines used
– Rule of Nines
– Lund-Browder Chart
– Palmer Method
24. 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.
27. Palmer Method
• 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
28. 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
29. Minor Burns
• 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
30. Moderate Burns
• 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
31. 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
32. 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
33. Pediatric Needs
• Burns to children are considered more
serious than burns to adults.
• Children have more surface area relative to
body mass than adults.
34. Minor Burns in Infants and Children
• Partial-thickness burns covering less than
10% of total body surface area
35. Moderate Burns in Infants
and Children
• Partial-thickness burns covering 10% to
20% of total body surface area
36. Critical Burns in Infants
and Children
• Full-thickness burns covering more than
20% of total body surface area
• Burns involving hands, feet, face, upper
airway, genitalia
37. Location of Burns
• Has a direct relationship to the severity of
the burn.
• Face, neck & chest burns may inhibit
respiratory illness RT mechanical
obstruction secondary to edema or eschar
formation
38. Patient Risk Factors
• Older adults heals slower & has more
difficulty with rehab
• common complications are:
– infection & pneumonia
– preexisting illnesses: cardiovascular,
pulmonary, or renal disease
– DM or PVD is at increased risk for gangrene &
poor healing
39. Types of Burn Injury
• Thermal Burn-can be caused by flame, flash, scald,
or contact with hot objects
• Chemical Burn-are the result of tissue injury and
destruction from necrotizing substances
• Electrical Burn-results from coagulation necrosis
that is caused by intense heat from an electrical current
• Smoke & inhalation injury-inhaling hot air or
noxious chemicals
• Radiation Burn/Exposure- burns are usually
localized & are indicative of high radiation doses to
affected area
40. Thermal Burns
• most common type
• result from residential fires, automobile
accidents, playing with matches, improperly
stored gasoline, space heaters, electrical
malfunctions, arson, terrorism
• inhaling smoke, steam, dry heat (fire), wet
heat (steam), radiation, sun, etc...
42. Chemical Burn
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.
43. Chemical Burn
• 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.
44. Electrical Burns
• 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.
45. External signs of an electrical burn may be deceiving.
Entrance may be small, while deeper tissue damage may
be massive.
46. 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!
47. 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.
48. 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.
49. 3 Phases of Burn Management
–Emergent (resuscitation)
• 0 – 48 hours, can be up to days later
–Acute (definitive care)
▪ day 3 until wounds heal
–Rehabilitation
• Begins during resuscitation and continues
throughout lifespan
50. 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
51. 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
52. 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.
53. 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
54. Secondary Survey History
• Flame
• 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?
55. Secondary Survey History
• Chemical
• What was the agent?
How did the exposure occur?
What was the duration of contact?
What decontamination occurred?
Was there an explosion?
56. Secondary Survey History
• Electrical
• 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?
57. 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
58. 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.
59. Care for Chemical Burn (2 of 2)
• Flush burned area
with large amounts
of water for 30
minutes or more.
• Transport quickly.
60. 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.
61. 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.
63. Specific burn –Treatment notes
Care for Electrical Burn
• Cardiac Monitor
• Fluids -Ringers Lactate or other fluids to
flush kidneys if myoglobinuria is present
• Assess for bone fractures and treat
appropriately if found
65. Cardiovascular System
• 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
66. Respiratory System
• 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
67. Renal System
• 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.
68. 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
69. Fluid Shifts
• Massive fluid shifts out of blood vessels as
a result of increased capillary permeability.
70. Third Spacing
• Net result is decreased volume, depletion
due to fluid shifts = edema, decreased blood
pressure, and increased pulse
71. Hypovolemic Shock
• 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
72. Fluid Therapy
• 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
73. Parkland Formula
Lactated Ringers solution is recommended
4ml/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.
74. 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
75. 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.
76. Immunologic Changes
• 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
77. 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
78. 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
79. Wound Care for Burns
• Can wait until patent airway, adequate
circulation, fluid replacement is assured
80. 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 surgical detergent,
disinfectant, or cleansing agent to reduce
pathogenic organisms
81. 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
82. 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.
83. Wound Care
• Staff should wear disposable hats, gowns, gloves,
masks when wounds are exposed
• Appropriate use of aseptic- sterile vs. nonsterile
techniques
• Keep room warm
• Careful handwashing
• Disinfect patient bathing areas before and after
bathing
84. • 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
85. Surgeons use a dermatome (left) to remove
donor skin and a mesher (right) to put
holes in it.
86. • 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
88. 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
89. • 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
• Lab tests
– Baseline studies: hematocrit, electrolytes, blood
urea nitrogen, urinalysis, chest x-ray
– Special studies as needed: arterial blood gas,
carboxyhemoglobin, ECG, glucose
• Physical therapy started immediately
90. Drug Therapy
• 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
91. Drug Therapy
• 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
92. Nutritional Therapy
• 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
93. • 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
Nutritional Therapy
94. 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
95. Acute Phase
• 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
96. • 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
97. Laboratory Values
• 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
98. • 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.
99. Rehabilitation Phase
• 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
100. Clinical Manifestations
• 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
101. Complications
• 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
104. Transfer to Burn Center
• Minimal Criteria for Transfer to a Burn Center
• Partial thickness burns > 10% Total Body Surface
Area (TBSA)
• Third degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation burns
• Burn injury in a patient with pre-existing medical
disorders that could complicate management, prolong
recovery, or affect mortality
• Any patient with burns and concomitant trauma (such
as fractures). If trauma poses more of a mortality risk,
then consider stabilization at a trauma center prior to
transfer to a burn center
105. Transfer to Burn Center
• Secondary Criteria for Transfer to a Burn Center
• Burns involving face, hands, feet, genitalia,
perineum, or major joints
• Burn injury in patients who will need special social,
emotional, and/or long-term rehab intervention
106. Transfer to Burn Center
• Preparation for Transfer
• Primary and secondary assessments complete
• Initial treatments for respiratory, circulatory, GI, burn
wounds, pain management accomplished
• Documentation complete and copied: to include Hx,
PE, lab results, flowsheet with fluid resuscitation, pain
management, all medications, nutritional therapies
recorded
• Contact with verbal report given to receiving Burn
Center, both physician-to-physician and nurse-to-
nurse; as well as nurse-to-transporting agency
EMT/PM/RN
