Burns are one of the most common household injuries, especially among children. The term “burn” means more than the burning sensation associated with this injury. Burns are characterized by severe skin damage that causes the affected skin cells to die. Most people can recover from burns without serious health consequences, depending on the cause and degree of injury. More serious burns require immediate emergency medical care to prevent complications and death.

1. BURNS AND ITS
MANAGEMENT
Mr. MAHESH S
M.Sc. Nursing
Nurse Educator
MGMCRI

2. Introduction
• Epidermis
• Dermis
• Subcutaneous (Fat layer )

4. Cause of Burn:
Injuries to skin tissues ca
used by:
I. Thermal
II. Electricity
III.Radiation
IV.Chemicals
V. Frostbite
VI.Inhalation

5. I. Thermal burns
• Flames
• Hot liquids / objects
• Gases
• Flash
5

6. II. Electrical burns
Accidental electrical contact
Depend on:
• strength of electrical volt
• duration of contact

7. III. Radiation burns
• UV light
• X-rays
• Radiation therapy
• Radiant energy
• Skin effects from ionizing radiation depend
on the amount of exposure to the area,
with hair loss seen after 3 Gy, redness seen
after 10 Gy, wet skin peeling after 20 Gy,
and necrosis after 30 Gy.
7

8. IV.Chemical burns
• Strong acids (sulfuric acid)
• Strong bases (sodium hydroxide)
• Detergents
• Solvents ( acetone)
• sulfuric acid as found in toilet cleaners,
sodium hypochlorite as found in
bleach, and halogenated hydrocarbons
as found in paint remover
• Tissue destruction may continue
for up to 72 hours after a chemical
injury

9. V. Frostbite
Cold Injury (Frostbite)
• Numbness, pallor, severe pain, swelling, ede
ma
• Sensory loss, Handle the tissue carefully!
• Skin appear mottled blue, yellowish-white or
waxy
Interventions – Frostbite
• Warm rapidly and continuously for 15-20
minutes
• AVOID slow thawing
• Do not debrided blisters

12. VI. Inhalation
• Carbon monoxide poisoning (CO)
• Inhalation of hot air or noxious chemical
Signs include
• singed nares,
• facial burns,
• charred lips,
• posterior pharynx edema,
• hoarseness,
• cough, or wheezing

13. Degree of Burn
Every aspect of burn treatment depends on a
ssessment of the depth and extent of burn
.
i. First degree burn (superficial)
ii. Second degree burn (superficial partial
thickness)
iii.Third degree burn( deep partial thickness)
iv. Fourth degree burn (Full thickness ,
subcutaneous tissue, muscles, bone
s)
13

15. First-degree of burns ( Superficial )
• example – sunburn ,UV light
• Epidermis a portion of the dermis may be injured
• symptoms
Redness
Mild pain
Dry skin
No blisters
Mild swelling
Involves minimal tissue damage
Minimal fluid lose (can dehydration in
young child.)
Not serious unless large areas involve
Generally heals on its own without scarring in
3–5days

16. Second-degree of burns (Superficial partial thickness)
• Example – contact with hot objects or flame,
tar burn
• Involves epidermis and part of dermis
• decreased blood flow in tissue can convert to
a full- thickness burn
• symptoms
Blisters
Redness, shiny, wet
deep redness
very painful
Spontaneous re-epithelialization in 2–3 weeks

17. Third-degree of Burn
(deep partial thickness)
• Example – electrical or chemical sources, flames …
• Epidermis and entire dermis
• Symptoms
Dry skin ,Swelling
White, black, brown
or yellow skin
Little to no pain
Requires removal of eschars
Can result in disruption of nails, hair, sebaceous gland
May cause scarring: skin grafting usually required

18. Fourth-degree of burns (full thick
ness)
• Injury involve all layers of the skin and underlying
tissue
(tendons and bone).
• Need immediately hospitalization
• Symptoms
Black, white skin
No sensation
Dry, or hard skin
Pain may be intense or absent depending on
nerve ending involvement
Causes scarring; skin grafting required
• Example -flames , electrical or chemical sources…etc

19. Percentage of Burn
Various methods are used to estimate the TBSA (total
body surface area) affected by burns; among them
are:
• The rule of nines,
• The Lund and Browder method, and
• The palm method.

20. RULE OF NINES
20
An estimation of the TBSA involved in a burn
is simplified by using the rule of nines.
The rule of nines is a quick way to calculate
the extent of burns.
The system assigns percentages in multiple
of nine to major body surfaces.
Note that the ‘ rule of 9s ’ cannot be applied to
a child who is less than 14 years old .

23. LUND AND BROWDER METHOD
• A more precise method of estimating the extent of a
burn is the Lund and Browder method,
• It recognizes that the percentage of TBSA of various
anatomic parts, especially the head and legs, and
changes with growth.
• By dividing the body into very small areas and provid
ing an estimate of the proportion of TBSA accounted
for by such body parts, one can obtain a reliable
estimate of the TBSA burned.

25. PALM METHOD
25
• In patients with scattered burns, a meth
od to estimate the percentage of
burn is the palm method.
• The size of the patient’s palm is
approximately 1% of TBSA. (from crease
of wrist to the top of extended fingers is
approximately 1% of TBSA.

26. PATHOPHYSILOGY
Heat causes coagulation necrosis of skin and subcutaneous tissue
Release of vasoactive peptides
Altered capillary permeability
Loss of fluid
Severe hypovolaemia
Decreased cardiac output
Decreased myocardial function
Decreased renal blood
Oliguria flow (Renal failure)

27. Altered pulmonary resistance causing pulmonary
edema
Infection
Systemic Inflammatory Response Syndrome
(SIRS)
Multiorgan Dysfunction Syndrome
(MODS).

28. First Aid For BURNS

29.  Immediately cool the effect area with cool /runny
water for at least 10 minute for all burns except
electricity.
 Immerse the site in cold water to reduce pain and
oedema and to minimize tissue damage.
 Water temp no less than 8 Celsius.
 Do not use ice, because it may further damage the
injured skin.
 If the area of the burn is large, after it has been
doused with cool water, apply clean wraps about the
burned area (or the whole patient) to prevent
systemic heat loss and hypothermia.
INITIAL PHASE

30. Initial assessment of burn
30
Initial assessment include :
A: Airway with cervical spine
stabilization
B: Breathing
C: Circulation
D: Disability
E: Exposure

31. Secure the airway first
Assess for signs of inhalation injury and oral scalds o
because of severe burns to the face or oropharynx :
(Hoarseness / stridor / dysphasia / drooling)
History fire in an enclose space or fall.
Consider intubation for >20%TBSA of burn
 e.g. House fire, Car fire, Toxic fumes (Industrial)
Airway with cervical spine
stabilization

32. Airway with cervical spine
stabilization

33. Breathing
• Assess for airway support.
• Assess rate and deep of breathing
• History of inhalation injury
• Listen: verify breath sounds
• Signs of cyanosis (late sign)
• If there are signs of breathing problems
consider for intubation.

35. Circulation
• Sign of hypovolaemic shock
• If shock appear look elsewhere for a
cause
• Color of skin
• Depth of burn (degree)
• Capillary refill
• Monitor Blood Pressure, Pulse, and
Skin color.

37. • LOC?
• AVPU
Alert
Respond to voice stimuli
Respond to pain stimuli
Unresponsive
• Pupil
• GCS
Disability / Neurological

39. • Stop burning process.
• Expose the patient (remove clothes and jewelry)
• Children with burn easy to lose heat so keep the
child in warm environment and cover with clean
dry blankets when no being examined.
• It is OK to use water to stop the burning process
.
Exposure

41. Fluid Management
 Fluid resuscitation is required for burns covering:
 > 15% for adults
 > 10% for children
 Use Ringer’s lactate or normal saline with 5% glucose
 For maintenance fluid use Ringer’s lactate with 5% glucose
or half-normal saline with 5% glucose
 Parkland’s formula is suitable starting
 The goal of fluid resuscitation is to anticipate prevent
hypovolaemic shock.

42. Parkland’s formula
For adult:
• fluid given in the first 24h= Weight(kg) x TB
SA % x 4ml
• Rate:
½ in the first 8h
¼ in the second 8 hrs
¼ in the third 8 hrs

43. Parkland’s formula
For children:
fluid given in the first 24h= Weight(kg) x TBSA % x 4ml
• Rate:
½ in the first 8h
¼ in the second 8 hrs
¼ in the third 8 hrs
• Add maintenance fluid as follows:
100ml /kg for first 10 kg of weight
50ml / kg for next 10kg of weight
20ml /kg for remaining 10kg after
Keep urine out put
2ml /kg/h or more

44. Ringer's Lactate : 1.5 ml/kg/%
Colloids : 0.5 ml/kg/%
Dextrose 5% : 2000ml
Brooke formula

45. Evans formula
Crystalloid : 1 ml/kg/%
Colloid : 1 ml/kg/%
Dextrose 5% : 2000ml

46. MEDICAL MANAGEMENT OF BURNS
• Chlorhexidine gluconate (Hibiclens, Hibistat,
Tegaderm CHG Dressing)-Active against gram-
positive and gram-negative organisms, facultative
anaerobes, aerobes, and yeast.
• Silver sulfadiazine (Silvadene, SSD, Thermazen
e)- It has bactericidal activity against many gram-
positive and gram-negative bacteria, including ye
ast. It has poor eschar penetration.

47. MEDICAL MANAGEMENT OF BURNS
• Silver nitrate- It exhibits activity against
gram-positive bacteria, gram-negative
bacteria and candida species. The major
drawbacks are that it has poor penetration
of eschar.
• Mafenide is a topical sulfonamide. It
diffuses freely into the eschar and is highly
effective against gram- negative organisms,
including pseudomonal species.

48. • Tetanus toxoid
Tetanus immune globulin (TIG) is used for passive
immunization of any person with a wound that may
be contaminated with tetanus spores. Tetanus
toxoid is used to induce active immunity against
tetanus in selected patients.
• Tetanus immune globulin (HyperTET S/D)
Used for passive immunization of any person with a
wound that may be contaminated with tetanus
spores.
Vaccines:

50. Dailytreatment
• Changethe dressing daily
• On each dressing change,
remove any loose tissue.
• Inspect the wounds for
discoloration or haemorrhage,
which indicate developing in
fection.

51. SURGICAL MANAGEMENT OF BURNS
Debridement

52. Excision
Escharotomy
Debridement

53. EarlyExcision
• Within the first 3-5days
• After 5 days chances of Sepsishigher and bleeding
more
• 15%of BSAis excised at atime
• Spacedapart (every 2 or 3days)
• Byone estimate excision of 1%burn area can
result in 100 ccsblood loss
• The goal of early excision is toremove all de- vitali
zed tissue and prepare the wound for skin
grafting

54. Humby Skin Grafting
Handle

55. Goulian- type Weck
Knife

56. involves repeated
removing of very
thin slices (0.5 mm
thick) of burned
tissue from the
zones of stasis and
coagulation.
TangentialExcision

57. •Applies to deep dermal burn
& 3rd degree burns
•Full-thickness burns extending
into the subcutaneous tissue -
burned fat excised in a similar
manner until aplane of healthy
, yellow, bleeding fat is found.
TangentialExcision

58. Advantages
Disadvantages
Goodcosmesis
More wound
coverage methods
High blood loss
Difficult burn
methods depth
evaluation
TangentialExcision

59. FascialExcision
• Removes all layers of eschar
and underlying tissue to
the level of fascia.
• Excision to this plane
minimizes bleeding and
provides a reliable, clean,
vascular bed.
• Recommended
-subcutaneous fat is burned
-selected large burns with
>60% BSA full-thickness who
have high risks for infection,
blood loss, or skin graft
slough

60. Advantages
Disadvantages
Easyburndepth
evaluation
Lowblood loss
Fewergrafting
possibilities
Injury to nerve&
joints
FascialExcision

62. •An escharotomy is a surgical procedure
used to treat full thickness (third-
degree) circumferential burns.
•Full-thickness circumferential burn of an
extremity orTrunk can result in vascular
compromise.
Escharotomy

63. Indications
1.Pain Pallor
2.Paresthesia
3.Poikilothermia
4.Paresis
5.Pulselessness

64. Indicated when the
circulation is
compromised due to
increased pressure in
the burned limb
and can not be
relieved by simple
elevation.
LimbEscharotomy

65. Chest Escharotomy
• Considered when a circumf
erential burn of the chest
wall results in respiratory
compromise by restricting
normal chest wall
movement.
• Circumferential burns of the
abdomen may also cause
respiratory compromise by
restricting diaphragmatic
movement. E.g. Infants
under 12 months

66. Plan the Incision

67. Incision using
Diathermy

68. CheckIncision
Adequacy

69. Separation of
Eschar

70. Dressing

71. Fasciotomy
• Fasciotomy or fasciectomy
is a surgical procedure
where the fascia is cut to
relieve tension or pressure
commonly to treat the
resulting loss
of circulation to anarea
of tissue or muscle.
• Done in Patients with
Electrical Burns

73. • After excision the wound, there is wound
closure.
• Goals:
• Reestablish barrier (epidermis) to prevent
bacterial invasionand evaporative water loss
• Reconstitute the dermis to provide durability
pliabilityand acceptable cosmetics.
WoundClosure

74. SkinGrafting

75. According tothickness
• Full thickness skin graft
• Partial thickness skingraft
also called split thickness
skin graft
• Composite graft –skin
along with underlying
tissue is grafted
Classificationofskingrafting

76. Aims of skingraft
• To facilitate optimal and rapid heal
ing of the wound, minimizing dele
terious consequences such as scar
contracture
• Maximizing the best function
aland cosmetic outcomes.
• Ameliorate the body’s systemic
responses, especially the immune
and metabolic systems.

77. Types of skingraft
• An autograft is a patient’s own skin, taken
from an unburned area and transplanted to
cover aburned area.
• An allograft (or homograft) is skin taken from
an individual of the same species, usually
cadaver skin.
• Xenograft (or heterograft), is skin from an
other species, usually a pig. Allografts or
xenografts are used until there is sufficient
normal skin available for anautograft.

78. Autograft
1. Pinch grafts
– Small pieces of skin
are placed on the i
njured site to grow
and cover it.
– Grow even in areas of
poor blood supplyand
resist infection.

79. Autograft
2. Split-thickness grafts
• The surface layer of the skin (epider
mis) is removed along with a portio
n of the deeper layer of the dermis.
• Oncethe graft is in place,the area
may be covered or left exposed.
• Most commonly used and can cover
large areasespecially when meshed.
• Used for non-weight-bearing parts
of thebody.

80. Autograft
3. Full-thickness grafts
– Theentire dermis and its overlying
epidermis is removed which conta
ins all of the layers ofthe skin incl
uding blood vessels.
– Within 36 hours new blood vessels
will begin to grow into the transp
lanted skin.
– Are used for weight-bearing por
tions and friction proneareas of
the body suchas,feet and joints
.

81. Autograft
4. Skin Flap
–Portion of the skin used from the donor site
will remain attached to the donor area and the
remainder is attached to the recipientsite.
–The blood supply remains intact at the donor
location and removed after new blood supply
hascompletely developed.
–Usedfor hands, face or neck areasof thebody.

82. Allograft
• It is askin graft that hasbeen takenfrom
one individual and transplanted into an
other.
• Done when no enough skin for anautograft
is available (e.g. Casefor serious burn victi
ms).
• It is treated much the samewayasany
other organtransplant.

83. xenograft
• Xenografts are skin grafts that areobtained
from another species.
• Most xenografts come from pig tissue, andin
many cases,are cultured or mixed with
growth factors and proteins to enhancetheir
ability to be integrated withhuman skin.
• Usedastemporary in the treatment oflarge
wounds.
• Quick implantation may prevent bacterial
infection and excessiveblood loss.

84. Dermatome withblade

85. Dermatome-harvesting Graft

86. Pre-Op wound
Application ofHomograft
Day 3
Complete healing
Day 21
Earlyexcisionandgrafting

87. Acellular skin substitutes
Cellular Allogenic Skin Substitutes
Cellular Autologous Skin Substitutes
Biobrane
Integra
Alloderm
Transcyte
Apligraf
Dermagraft
Cultured Epidermal
Autograft Cultured
Skin Substitutes
Skin Substitutes

91. Rehabilitation
Splinting and
Positioning
Scar
Management

92. • Positioning splints need not alwaysbeapplied
prophylactically.
– If apatient is unable tomaintain proper position, and
start losing ROM,splinting should be initiated.
• Positioning and splinting is an essential part of
acute burn treatment regime and usedfor:
– Protecting joints at risk of developing contractureor
deformity.
– Preservingfunction.
• When splinting
– the burn OTmust be aware of the anatomyand
kinesiology of the body surface to besplinted.
Splinting

93. • Indications for Splints
– Prevention or Correction of deformity.
– Positioning - post grafting.
– Protection of exposed tendons andjoints.
– Aiding in controlling edema, inflammation, or
infection.
• Warning signals of badsplinting:
– Pain.
– Sensory impairment.
– Wound maceration.
Splinting

94. TypesOfSplinting
Primary Splints
• acute phaseand pre
grafting period
Postural Splints
• Immediate post graft
phase
• usedto position the invol
ved joints during sleep, in
activity, or periods of unre
sponsiveness.
• Worn continuously for 5to
14 daysuntil the graft is
secure.

95. • Proper fit and Secureapplication
– Must be secured with straps or bandage.
– too loose and without adequate contour
willnot maintain proper position.
– Asplint too tight causes pressure necrosi
s or nerve compression.
• Avoidance of pressure over
abony prominence
• Periodic removal and performing exercise
• Daily checking and re-evaluation.
• Cleansing with each re-application.
RequirementsforAllSplints

99. BodyArea Contracture Predisposition Preventive Positioning
*Neck Flexion Extension /Hyper ext.
* AnteriorAxilla ShoulderAdduction ShoulderAdduction
* Antecubital space Elbow flexion Elbow Extension
* Forearm Pronation Supination
* Wrist Flexion Extension- 30o
Dorsal/hand/finger
MCP Hyper extension IP Flex
ion,thumb adduction
MCP Flexion-80o, IF Extension, thu
mb palmar abduction
*
Palmar hand/finger Finger flexion, thumb opposition Finger extension thumb radial abdu
ction
Hip Flexion, adduction external rotatio
n
Extension, abduction neutral rotatio
n
* Knee Flexion Extension
*Ankle Planter flexion Dorsiflexion
* Dorsal toes Hyperextension Flexion
* Planter toes Flexion Extension
Burn PatientPositioning

100. RangeofMotionExercise
• Performed twice aday.
• Exercises should be started on the
first day after admission.
• Joint ranges of movement and mu
scle power must be documented
on achart on day one.
• Assessedand recorded on a daily b
asis until full active range of mov
ement is achieved.

101. Intermediate Phase Rehabilitation
• Transferred from intensive or high
dependency care to award setting
• Apatient is medically stable and the am
ount of therapy depending onseverity of
the injury
• continue respiratory, circulatory, positioni
ng and splinting until the child has regain
ed full active range ofmovement and mobil
ity.

102. Nursing Care Plan
Acute pain r/t destruction of skin /tissue as evidenced p
ain, numeric pain scale
Goal
Expect outcome
Intervention Evaluation
-Decrease pain
-Pt participate in
activity, sleep, rest
appropriate
-Access pain scale
-Give pain killer as order
-Encourage express feeling
about pain
-Encourage use of stress
management techniques
progressive relaxation, d
eep breathing,
guided imagery, and
visualization .
-Re-access pain
-apprise to Dr. if pain not
relieved …..
-Pain relieved
-Vital sign in normal
57

103. Risk for fluid volume deficient r/t increase capillary
permeability and evaporate from burn wound.
Goal Intervention Evaluation
Expect outcome
-No sign of dehydration
-Individual adequate
urinary output with n
ormal , stable vital si
gns, moist mucous
membranes.
-Assess sign of
dehydration
-Monitor vital sign
-Monitor I & O
-Estimate wound drain
age and insensible los
ses.
-Observe for gastric
distension, hematemesis
-Pt no sign no
dehydration
-Normal I & O

104. Risk for infection r/t skin intact / destruction of skin
barrier / traumatic tissue.
Goal Exp
ect outcome
Intervention Evaluation
-wound healing free of p
urulent exudates and be
afebrile.
-No sign of infection
-Assess sign of infection
-Implement appropriate
isolation techniques.
-good hand washing
technique for all ind
ividuals coming in c
ontact with patient.
-Use gowns, gloves, ma
sks, and strict aseptic te
chnique during direct w
ound care.
-Monitor and/or limit
visitors, if necessary.
-Monitor vital signs for
fever,…..
-Wound heal with no
sign of infection.
-Pt no sign of fever.