5. Resuscitative / Emergent phase
First Aid
◦ Remove patient and self from injury
source
◦ Extinguish actively burning material
◦ Assess ABC
◦ Need for cervical spine immobilization
◦ Cooling....
◦ Brief assessment
Extent and
severity of burn injury
inhalation injury
6. Cont...
◦ Cooling
Done for all flame and chemical burns
and explosions
Cooling reduces retained heat and
flushes out chemical, reducing depth
of penetration and severity of damage
7. Cont...
Cooling
◦ Done with cool running tepid water
◦ Duration- 20 min:
◦ Continue eye irrigation until all the
chemical is diluted & flush out
◦ Eye irrigation- prior to transfer,
during transfer and waiting for
assessment
8. Cont...
Avoid hypothermia.
◦ Keep the patient covered, warm and
dry.
◦ Hypothermia occurs due to depth and
severity of the injury
◦ Covering patient- prevents airplay on
the wound and reduces pain. Use a
sheet
9. Transportation of burn victims should be
done as quickly as possible, so that the
“golden period” of resuscitation is not
wasted.
During transportation , especially infants
and children should be kept well covered
to avoid excessive heat loss and
resulting hypothermia.
10. Medical management
Assess ABC
◦ 100% oxygen, encouraged to cough,
suctioning,
◦ If edema of the airway develops
ET tube Mechanical ventilation
◦ Set up IV line with a large-bore(16/18G
) & start fluids- N.saline/
11. Cont...
Assess for cervical spinal injuries or
head injury
Remove all clothing and jewelry, contact
lenses
Analgesics. IV morphine is the preferred
analgesic.
Tetanus prophylaxis
Gastric Acid suppression – Use IV H2
blockers/PPI
12. Cont...
If major burn (>20% TBSA)
◦ Insert NG tube & indwelling urinary
catheter (genital burns/electrical burns)
Assess both TBSA burned and depth of
the burn
Baseline height, weight, ABGs,
hematocrit, electrolyte values, urinalysis,
CXR, ECG
Attend to the patient’s and family’s
psychological needs
13. Rule of Nines (Wallace’s rule of nines)
The system divides the body into
multiples of nine-A common method
14. Palmer Method
The size of the patient’s palmer
surface of the hand is approximately
1% of the TBSA. This is used as a
guide to assess the extent of small or
patchy burns (all age group)
15. Management of Fluid Loss and
Shock
Goal to give sufficient fluid
◦ To allow perfusion of vital organs
without over hydrating and risking later
complications and circulatory overload
◦ Urine output - 0.5-1.0 ml/kg/h for adult
Immediate I.V. fluid resuscitation
◦ Adults burn > 18% - 20% TBSA
◦ Children – burns > 12% -15% TBSA.
◦ Electrical injury, elderly patients
16. Cont...
Resuscitation fluids
◦ 0.9% NaCl, lactated Ringer’s solution,
Hartmann’s solution.(crystalloid )
◦ 5% albumin, hetastarch, whole blood,
plasma ( colloid )
Fluids calculating formulas
◦ The Parkland formula most commonly
used.
◦ The Brooks and Evans formulas
20. Cont...
Ex:- a person weighing 75 kg with
burns to 20% of his or her body
surface area would require 4 x 75 x 20
= 6,000 mL of fluid replacement within
24 hours
◦ First 8 h – 3000ml or 375ml/h
◦ Next 16 h – 3000ml or 187.5ml/h
21. Cont...
The next 24 hours
◦ Colloids or Human albumin is given
◦ Fluids calculation- (0.5mlcolloid x
weight x TBSA) + 2000ml D5W
Maintenance Fluids
◦ After the first 24 hours the
maintenance fluid is given
22. Cont...
3rd day onwards
◦ Major burns IV fluid and nutritional
supplement may be necessary
◦ No Na containing fluids for a few
days as Na gets reabsorbed from the
ECF.
◦ Potassium needs to be
supplemented. (Oral or IV )
23. Initial wound care - major burn
Clothes are removed. Wounds are
washed using 1% Povidone iodine/
Chlorhexidine scrub with adequate
analgesia or, anaesthesia
The blisters are opened and all dead
skin is removed
Wound dress with Silver sulphadiazine
cream and covered with fresh sterile
absorbent dressings
24. Cont...
Wounds covered with crepe bandages
to minimize oedema.
Splints are applied to hands neck and
lower limbs in position of function
25. Escharotomy
An incision made through the full
thickness of burnt skin (the eschar) to
release underlying pressure
In circumferential burns of the
extremities and trunk where it can
compromise blood supply to the limb
or compromise breathing
26.
27.
28. Positioning
This is the key to preventing scar
contracture and deformity and starts at
admission and continues throughout
hospital stay. (Position of function)
Supine, elevate 20 to30 degrees in
head and neck and facial burns
No pillow is allowed under the head, if
neck face or ears are burned.
29. Cont....
Shoulders abducted 90 degrees,
Hands to be kept in functional position
(20 degrees dorsiflexion at wrist,
flexion of 90% at MP joints IP joints
fully extended and thumb in
opposition) and elevated
30. Cont...
The lower limbs are separated by 15
degrees from each other.
Use pressure relieving devices
If dorsal surface burn
◦ Use air mattress
◦ Prone position with his feet hanging
beyond the mattress, Face should be
turned frequently.
31. Nutritional Support
After burn- hypermetabolic, and
hypercatabolic- 200% above basline
Increased catabolic hormones (cortisol
and catechols)
Decreased anabolic hormones (human
growth factor, and testosterone)
High metabolic rate high energy
requirment
All burns of 20% or more TBSA will need
enteral feeding via a nasogastric tube
33. Cont…
Adult burn patient may require 3,000
to 5,000 calories or more per day.
Burn <10% usually requires minimal
supplementation.
10% - 20% burn - A high-protein, high-
calorie diet
20% - 30%, burn -enteral feedings are
generally necessary.
30% -40% TBSA burns may require
TPN However, the current trend is to
meet nutritional needs enterally, if
possible.
34. CONT...
Electrolytes requirement per day
◦ Na 60-200 meq, K 50-60 meq, Cl100-
200 meq, Ca 4-30 meq
Vitamin and mineral supplementation
◦ Multivitamin, Folic acid, Ascorbic acid
Vitamin A, Zinc sulfate
Enteral feeding better than Parenteral
feeding
35. Wound Cleansing And
Debridement
Wound cleansing, debridement or
dressing
Shower/Bath protocol
◦ A clean procedure
◦ Done only by trained personnel
◦ A clean environment reserved only
for burns
◦ Water temperature- 37.8C (100F)
◦ Prevent hypothermia
36. Cont....
Nonviable tissue (eschar) may be
removed through natural, enzymatic,
mechanical, and/or surgical
debridement
◦ Ex-Tangential excision or shaving of
the burned skin layers & skin graft
Removal of the outer layer of
devitalized tissues by shaving it off
42. Achieving Adequate Oxygenation
and Respiratory Function
Monitor respiratory rate, depth,
rhythm, and cough, signs of
hypoxemia, character and amount of
respiratory secretions
Provide humidified oxygen
Encourage coughing and deep
breathing
Administer bronchodilator treatments
as ordered.
Keep intubation equipment nearby
43. Maintaining Adequate Tidal Volume
and Unrestricted Chest Movement
Assess tidal volume; report
decreasing volume
Encourage deep breathing and
incentive spirometry
Observe rate and quality of breathing
Make sure that chest dressings are
not constricting
Prepare the patient for escharotomy
and assist as indicated
44. Supporting Cardiac Output
Position the patient to increase
venous return.
Give fluids as prescribed.
Monitor vital signs, CVP, pulmonary
artery pressures, and urine output at
least hourly.
Determine cardiac output as
requested.
Document all observations, and
particularly note trends in vital sign
changes.
45. Promoting Peripheral
Circulation
Remove all jewelry and clothing.
Elevate extremities.
Monitor peripheral pulses hourly. Use
Doppler as necessary.
Prepare the patient for escharotomy if
circulation is impaired.
Monitor tissue pressure.
46. Reducing Pain
Assess for pain periodically
Offer analgesics before wound care or
before particularly painful treatments
Change the patient's position when
possible, supporting extremities with
pillows
Teach relaxation techniques, such as
imagery, breathing exercises
47. Facilitating Fluid Balance
Administer fluid intake as ordered
Maintain accurate intake and output
records.
Weigh the patient daily.
Monitor results of serum potassium
and other electrolytes.
Be alert to signs of fluid overload and
heart failure
Administer diuretics as ordered.
48. Protecting and Reestablishing Skin
Integrity
Cleanse wounds and change
dressings- hydrotherapy tank, bathtub,
shower, or at the bedside
Apply topical bacteriostatic agents as
directed
Careful handling skin graft and donor
site area as directed
49. Promoting Stable Body
Temperature
Do not expose wounds unnecessarily.
Maintain warm ambient temperatures.
Keep patient warm - Use warming
blankets
Obtain urine, sputum, and blood cultures
if fever
Warm wound cleansing and dressing
solutions to body temperature.
Use blankets in transporting patient to
other areas of the hospital.
Administer antipyretics as prescribed
50. Avoiding Wound and Systemic
Infection
Use isolation technique
Assess wounds daily for local signs of
infection
Be alert for early signs of septicemia
Promote optimal personal hygiene for
the patient
Administer antibiotics, as prescribed
Maintain aseptic technique
Provide nutritional diet
51. Promoting Mobility
Encourage patient to be as active as
possible
Perform active ROM exercises throughout
the day
Position the patient to decrease edema and
avoid flexion of burned joints
Maintain splints in proper position as
prescribed
Maintain adequate pain management
strategies
Use pressure garments and scar
52.
53.
54. Ensuring Adequate Nutrition
Weigh the patient daily
Provide recommended nutrition
through Oral/NG/IV
Administer vitamins and mineral
supplements as prescribed
Minimize metabolic stress by allaying
fears, pain, and anxiety
Keep record of caloric intake
55. Preserving Positive Body
Image
Encourage patient to express
concerns regarding changes in self-
image or lifestyle
Positively reinforce appropriate
Arrange for the patient to talk with
other patients who have had a similar
injury
Encourage participation in counseling
secession, supportive groups
