2. 2
Dr. Ahmad Aqel
- Age: morbidity and mortality increased with children & elderly
- Depth of the burn
- Body surface area that is burned
- Presence of inhalation injury
- Presence of other injuries
- Location of the injury in special care areas
Factors determine the severity of burn injury:
Burn
3. Cause
example
Skin
Involvement
Manifestation Wound
appearance
Treatment
▪Sunburn Epidermis ▪Tingling
▪Hyperesthesia
(hypersensitivity)
▪ Pain
▪ Peeling
▪ Itching
• Red, dry, no
edema
• Blanches
with pressure
• Recoverywithina
fewdays
• painmedication
• Coldcompresses
• Skinlubricants
• Topicalantibiotics
notindicated
3
Dr. Ahmad Aqel
First Degree Burn (Superficial)
4. Cause Skin
Involvement
Manifestations Wound
appearance
Treatment
▪ Scalds
▪ Flash flame
▪ Contact
▪ Epidermis
▪ Portion of
dermis
▪ Painful
▪ Hyperesthesia
▪ Sensitive to
air current
▪ Blisters,
▪ Mottled red
▪ Weeping
surface
▪ Edema
▪ Recovery in
2-3 weeks
▪ Scarring &
pigmentation
possible;
▪ Grafting
may
required.
Second Degree Burn (partial thickness)
4
Dr. Ahmad Aqel
5. Cause Skin
Involvement
Manifestations Wound
appearance
Treatment
▪ Flame
▪ Hot liquids
▪ Electric &
Chemical
▪ Epidermis
▪ Dermis
▪ subcutaneous
, connective
tissue,&
muscle may
involved
▪ Painless
▪ Shock
▪ Myoglobinuria
▪ Dry, Pale
white to red
▪ leathery, or
charred
▪ Edema
▪ Eschar
▪ Grafting
▪ Scarring
▪ loss of
function
Third Degree (full thickness)
5
Dr. Ahmad Aqel
escharotomy: a linear excision made through eschar to release constriction of
underlying tissue
fasciotomy: an incision made through the fascia to release constriction of underlying
muscle
6. Cause Skin
Involvement
Manifestations Wound
appearance
Treatment
▪ Prolonged
exposure
or high
voltage
electrical
injury
▪ Extend
to deep
tissue,
muscle
and bone
▪ Shock
▪ Myoglobinuri
possible
hemolysis
▪ Charred
متفحم
▪ Amputation
likely
▪ Grafting of
no benefit
Fourth Degree Burn
(Full thickness includes fat, fascia, muscle and bone)
6
Dr. Ahmad Aqel
7. Factors Determining Burn Depth
▪ How the injury occurred
▪ Causative agent
▪ Temperature of agent
▪ Duration of contact with the agent
▪ Thickness of the skin
7
Dr. Ahmad Aqel
Burn
Methods to estimate the total body
service area (TBSA) affected by
burns
1. The rule of nines
2. The palmer method.
8. Rule of Nines
▪ The system divides the body into multiples of nine.
▪ The sum total of these parts equals the total body
surface area.
Palm method
▪Used in patients with scattered burns
▪ The size of the patient hand including
fingers is approximately 1% of the
patient TBSA
Burn
8
Dr. Ahmad Aqel
9. ▪Zone of coagulation: the innermost area,
where cellular death occurs, the most
damage
▪Zone of stasis: the middle area has a
compromised blood supply, inflammation
and tissue injury
▪Zone of hyperemia: the outermost area
sustains the least damage
Zones of Burn Injury
9
Dr. Ahmad Aqel
10. 1) Fluid loss
2) Infection
3) Hypothermia
4) Scarring
5) Compromised immunity
6) Changes in function, appearance, and body image.
❖Burns <20% TBSA produce primarily a local response.
❖Burns >20% TBSA produce systemic response (hemodynamic instability)
Effects of Burn Injury
10
Dr. Ahmad Aqel
11. Effects of Burn Injury
Cardiovascular effects
➢ Loss of fluids >>> hypovolemia >>> decreased o2 to cells
➢ As fluid loss continues >>> CO decreases >>> BP decreased
➢ SNS releases catecholamine >>> peripheral vasoconstriction >>> HR increased
Edema & Electrolyte
➢ Edema increases may lead to compartment syndrome.
➢ Hyponatremia: water shifts from the interstitial space to the vascular space.
➢ Hyperkalemia: occurs immediately from massive cell destruction.
➢ Hypokalemia: may occur later with fluid shifts and inadequate k replacement
11
Dr. Ahmad Aqel
12. ➢Upper airway injury due to inhalation of heated air
➢Lower airway injury: due to inhaling noxious gases
▪ Tissue hypoxia: CO combines with hemoglobin (carboxyhemoglobin)
▪ Bronchospasm: inflammatory response causing hypersecretion and
mucosal edema
▪ Atelectasis (collapse of alveoli):due to decreased surfactant
❖The main sign of lower airway injury is carbon particles in the sputum
Effects of Burn Injury
12
Dr. Ahmad Aqel
13. Indicators of possible upper airway injury
1) Injury occurring in an enclosed space;
2) Burns of the face or neck;
3) Singed nasal hair;
4) Hoarseness, high-pitched voice change, dry cough, stridor;
5) Sooty or bloody sputum;
6) Labored breathing or tachypnea (rapid breathing), hypoxemia
7) Erythema and blistering of the oral or pharyngeal mucosa.
Effects of Burn Injury
13
Dr. Ahmad Aqel
14. ❖ Renal alterations: RF, Acute Tubular Necrosis (Myoglobin occlude the renal
tubules)
❖Immunologic alterations: high risk for infection and sepsis
❖Thermoregulation alterations: inability to regulate body temperature.
❖Gastrointestinal Alterations:
▪ Paralytic ileus, Curling’s ulcer (acute gastric erosion), vomiting, Gastric
bleeding,
Effects of Burn Injury
14
Dr. Ahmad Aqel
15. Phase Duration Priorities
Emergent /
resuscitative
phase:
From injury to completion
of fluid resuscitation
•First aid care
•Prevention of shock and resp distress
•Detect & treat associated injuries
•Initial wound assessment and care.
Acute /
intermediate
phase
From diuresis to near
completion of wound
closure
•Wound care & closure
•Prevent & treat complication (infection)
•Nutritional support
Rehabilitation
phase
From wound closure to
return to individual’s
optimal level of physical
and psychosocial
adjustment
•Prevention & Rx of scars and contractures
•Physical, occupational rehabilitations
•Psychological counseling
15
Dr. Ahmad Aqel
Phases of Burn Injury
16. On-the-Scene Care
▪ Remove from source of injury and stop the burning (The flame can be
extinguished if the person drops to the floor and rolls (stop, drop, and roll),
Discontinue electrical source
▪ Soaking the burn area intermittently in cool water
▪ Never apply ice directly to the burn, Butter is contraindicated.
▪ Assess the ABCDE
▪ Start oxygen and large-bore IVs
▪ Remove restrictive objects and cover the wound
▪ Note: treat patient with falls and electrical injuries as for potential cervical
spine injury
Management of Burn Injury
16
Dr. Ahmad Aqel
17. Emergent phase:
1) Prevention of R. distress
▪ O2, Encourage pt to cough, mechanical ventilation if needed.
2) Prevention of Shock
▪ IV lactated Ringer’s (solution of choice) to maintain a urine output (30 mL/h).
▪ Calculated total RL/24H = 2ml x wt x TBSA
- (administer ½ total in the first 8 hours and ½ over the 16 hours)
- For electrical burn 4ml x wt x TBSA
3) Correct electrolyte imbalance (hyperkalemia, hyponatremia)
Management of Burn Injury
17
Dr. Ahmad Aqel
18. Emergent phase:
▪ Frequent assessment of V/S & Respiratory status
▪ Remove clothes/jewelry, Maintain body temperature
▪ Use Aseptic management
▪ Insert NG tube & urinary catheter as ordered, IV analgesia, T.Toxoid,
▪ Check Peripheral pulses of burned extremities hourly
▪ Elevate the burned extremities to decrease edema.
▪ Monitor fluid I&O.
▪ Use Doppler ultrasound (edema makes BP difficult to auscultate).
18
Dr. Ahmad Aqel
Nursing Management
19. Acute phase: 48–72 hours post injury
▪ wound care: wound cleaning, topical antibacterial, wound dressing ,
débridement, and wound grafting
How to prevent/minimize infection?
- Use Private rooms (increase airflow, and low humidity)
- Environmental hygiene, limit use of cloth
- Use PPE (caps, masks, gowns and gloves); Gowns and gloves are worn by all
caregivers and visitors
- Hand washing and hygiene before and after leaving the patient room
- Aseptic technique & constant observation of the wound
Wound care
19
Dr. Ahmad Aqel
20. ▪ Antibiotics based on C&S
▪ Control of hyperglycemia
▪ Early culture for Methacillin-Resistance Staphylococcus Aureus (MRSA) and
vancomycin resistant enterococci
▪ Early enteral feeding help avoid increased intestinal permeability and
prevent early endotoxin translocation
• Common source of potential contamination in a burn unit include:
– hydrotherapy equipment (bath, shower)
– Direct and indirect contamination from HCP
20
Dr. Ahmad Aqel
Wound care/ prevention of infection
21. ▪ Daily dressing with Débridement to remove nonviable tissue.
▪ Apply topical agent as ordered (Silver sulphadiazine 1% cream), Cover
the burned area with several layers of dressings.
▪ Use light dressing over joint areas to allow for motion, Wrap the
fingers and toes individually (when burned) .
▪ Leave face burns open to air once they have been cleaned
Nutritional Support
Feeding begins immediately or within 24 to 72 hours post burn, Enteral
route is preferred. High-protein, high-calorie meals and supplements
Wound cleaning & dressing change
21
Dr. Ahmad Aqel
22. ➢ This phase focus on: wound healing, psychosocial support, self-
image, lifestyle, and restoring functional abilities .
▪ Plastic surgery to improve function and appearance.
▪ Vocational counseling and support groups may assist the patient.
▪ Prevention of scar: Elastic pressure garments are worn
continuously
Rehabilitation phase
22
Dr. Ahmad Aqel
