This document provides information on burns, including causes, types, assessment, management, and treatment. It discusses: - The different causes of burns, including thermal, electrical, chemical, and radiation burns. - How to assess burn severity based on depth and extent of damage. Burns are typically classified as superficial, partial thickness, full thickness, or fourth degree. - The signs and symptoms associated with different burn depths. More severe burns involve deeper tissue damage and have a poorer prognosis. - The three phases of burn management: emergent/resuscitative, intermediate, and rehabilitative. The emergent phase focuses on initial first aid, ABCDE assessment, pain management and fluid resuscitation

1. Prepared by
Ms Shiwani Sah
Lecturer

2. Review Anatomy and Physiology
• The skin is the largest organ of the body.
• The skin is composed of three layers:
epidermis,
dermis,
subcutaneous
• The thickness of these layers varies considerably,0.5
mm to 6mm depending on location.
• The PH of skin is 4-5.5.
• The renewal of skin takes place in 28-50

3. Types of skin
There are two types of skin
• Hirsute- Thin, hairy skin which covers greater part of
the body.
• Glabrous –Which covers the surface of plams, soles,
and flexor surfaces of the digits.
Fig: Hirsute Fig: Glabrous

4. Structure of the skin
The skin has three layers with different thickness,
strength and function:
• Epidermis: Thin outer layer
• Dermis: Thick inner layer
• Hypodermis or subcutis: A fatty layer of
subcutaneous tissue

5. Functions of skin
• Protecting the body against trauma
• Regulating body temperature
• Maintaining water and electrolyte balance
• Sensing painful and pleasant stimuli
• Participating in vitamin D synthesis

6. Definition:
• A burn is a injury to the skin or other tissue
primarily caused by heat or due to radiation,
radioactivity, electricity, friction or contact
with chemicals, friction or radiation.

7. Causes
1. Thermal burn: Majority of burns results from contact
with thermal agents such as flames, hot surfaces, or hot
liquids.
a)Scald burn: This type of burn is caused by contact with
moist heat (water or oil) and steam. The most common
hot liquids are liquid foods such as hot water, tea,
coffee, milk. It is common in toddlers, because of
curiosity they pull hot water, spills hot cup of tea or
may enter into a tub of hot water.

8. a)Flame burns: This type of burn is the 2nd common
cause of burn and a leading cause of mortality among
children. During playing with lighter, candles, matches
or open fire in winter seasons or from fireworks during
festivals.
b)Contact with hot objects: This type of burn occurs due
to direct contact with stove, heater, cylinder of
motorbike, cigarettes smoking in bed and
unextinguished cigarettes etc.

9. c) Cold exposure (frostbite): Frostbite is a severe,
localized cold-induced injury due to freezing of
tissue. Immersion foot (also referred to as trench foot)
is a nonfreezing cold injury (NFCI) that may also
cause tissue loss and long-term squeal.

10. 2. Electrical burns: These burn injuries are common in
toddler and adolescent, specially associated with risk
taking behavior of the boys, i.e., when sticking fingers
or objects in electrical out let, biting of extension cords,
touching high tension wires and using electrical
appliance. Young children may poke objects in electrical
outlets, bite or suck connected electrical cord leading to:
 cardiac arrhythmias,
 cardiac arrest and
 unexpected falls with resultant factures

11. 3. Chemical burn: Chemical burn is caused by
chemicals mostly acid and alkali ,because of the curious
nature, children are exposed with the different kinds of
household chemical products, especially cleaning
products contains noxious agents which may cause
localized damage as well as systemic toxicity. Contact
burns may occur due to heated liquids as Tars.

12. 4.Radiation burn: This type of burn occurs due to
prolonged exposure to ultraviolet rays (UV) of the sun
or to other sources of radiation, such as x-ray or gamma
radiation therapy for cancer. Damage may occur due to
exposure to ionizing radiation

13. Others causes:
 Inhalation burn : Results from inhalation of smoke,
gases, vapors etc.
 Therapeutic burn: Resulting from an operation or
laser treatment
 Friction burn: Burns from direct damage to the cells
and from the heat generated by the friction that may
occur in children falling on or touching a treadmill in
motion or a rope burn from a rope sliding through
hands.

14. Risk factors
• Gender-female have higher death rates than males in
all age groups.
• Age-Children are at high risk
Other risk factors:
 underlying medical conditions, including epilepsy,
peripheral neuropathy, and physical and cognitive
disabilities;

15. Pathophysiology of Burn

16. Type Layers involved Appearance Texture
Sensat
ion
Healing
Time
Prognosis
Superficial (1st-
degree)
Epidermis
Red without
blisters
Dry Painful5–10 days
Heals well Repeated sunburns
increase the risk of skin cancer la
in life
Superficial partial
thickness (2nd-
degree)
Extends into
superficial
(papillary)
dermis
Redness with clea
rblister Blanches
with pressure.
Moist
Very
painful
< 2–3 weeks
Local infection/cellulites but no
scarring typically
Deep partial
thickness (2nd-
degree)
Extends into
deep (reticular)
dermis
Yellow or white.
Less blanching.
May be blistering.
Fairly dry
Pressur
e &
discom
fort
3–8 week
Scarring, contractures (may requ
excision and skin grafting)
Full thickness (3rd-
degree)
Extends through
entire dermis to
subcutaneous
layer
Stiff and
white/brown No
blanching
Leathery
Painles
s
Prolonged
(months) and
incomplete
Scarring, contractures, amputatio
(early excision recommended)
4th-degree
Extends through
entire skin, and into
underlying fat, muscle
and bone
Black; charred with
eschar
Dry Painless
Requires
excision
Amputation, significant functional impairme
and, in some cases, death.

17. Effects of Burn
The effect of burn injury on the patients can be considered as
• Local
• Regional
• systemic
a. Local effects of burn:
• Burn wounds will almost be colonized by microorganisms
within 24-48 hours and may remain as a local wound or
regional infection.
• Local response experimental work by Jackson has shown
that a burn wound consists of 3 zones

19. Contd..
Zone of coagulation
• This occurs at the point of maximum cellular damage from
the heat source.
• Destruction of blood vessels, resulting in ischemia to the
area. (coagulative necrosis & gangrene).
• Irreversible tissue loss.

20. Contd..
Zone of stasis
• Damage in microcirculation resulting in compromised
circulation, untreated it will lead to necrosis.
• The main aim of burns resuscitation is to increase tissue
perfusion here and prevent any damage becoming
irreversible.
• This is the main areas of focus when treating burn
injuries.

21. Contd..
Zone of hyperemia
• It is the area surrounding the zone of stasis but it is
red due to inflammation.
• Perfusion is adequate due to patent blood vessels
• Erythema occurs due to increased vascular
permeability.
• Not at risk for further necrosis

22. Classification of Burn Injury
1. According to depth/degree of burn injury
1. Superficial (1st degree) Burn
2. Partial thickness (2nd degree) burn
• Superficial partial-thickness
• Deep partial-thickness burns
3. Full-thickness (3rd degree) burn
4. Fourth degree burn

24. 1. Superficial Burn Injuries (1st degree Burn)
• Usually involves epidermal layer
• Minor in nature.
• There is minimal tissue damage with no blistering.
• Protective function of skin remains intact and systemic
effects are rare.
• Pain is a predominant symptom.
• Burn injury heals within 5 to 10 days without scarring.
• Eg Mild sunburn

25. 2. Partial-thickness (Second degree Burn)
• This type of injuries involves epidermis and varying
degree of the dermis.
• Wounds are painful, moist, red and blistered.
• Some portion of the skin appendages remains viable
• Epithelial repair of the burn wound without skin grafting.

26. a. Superficial partial-thickness
• Burn involves the epidermis and superficial (papillary)
dermis, dermal elements are intact.
• Pink, moist, and soft and presence of blister and very
painful.
• Very sensitive to temperature change, exposure to air
and even to light touch.
• Wound heals within 14 to 21 days with varying degree
of scarring

27. b. Deep partial-thickness burns
• Full thickness injuries in many respects except that sweat
glands and hair follicles remains intact
• Burn may appear mottled, pink, red or waxy white area
exhibiting blisters and edema formation.
• Less painful than superficial partial thickness burns.
• Systemic effect may present as in full thickness burn.
• Many wounds may heals spontaneously and may extend
beyond 21 days with extensive scarring.

28. 3. Full-thickness (Third degree) burn
• It involve the entire epidermis, dermis and extend into
subcutaneous tissue.
• Capillary network of the dermis is completely destroyed.
• The nerve endings, hair follicles and sweat glands, are
destroyed.
• Color varies from red to tan, waxy white, brown, or black
and is distinguished by dry leathery appearance.
• Full thickness injuries are not capable of re-epithelialization
so requires surgical excision and grafting to close the wound

29. 4. Fourth degree burn
• Destruction of the skin and subcutaneous tissue and also
involve the underlying structures as fascia, muscle, bone.
• The wound appears dull and dry, and ligaments, tendons,
and bone may be exposed.
• It results from prolonged exposure to the usual causes of
third-degree burns.
• These injuries require extensive debridement and
complex reconstruction of specialized tissues.

31. 2. According to extent of burn Injury
• The extent of burn is expressed as a percentage of the
total Body Surface Area (TBSA).Various methods are
used to estimate the TBSA affected by burn. Among
them are
– Rule of nine
– Lund and Browder
– Palm method

32. a. Modified Rule of Nine

33. b. Lund-Browder Chart
• Lund-Brower charts with age-appropriate diagrams can
be used to better estimate the area of burn injury in
children.
• It gives the exact percentage at different age groups in
different parts of the body.
• It subdivides body areas into segments and assigns a
proportionate percentage of body surface to each area
based on age.

36. C. Rule of hand/Palm method
Child’s own one hand surface with closed finger,
amounts to 1% (approximately) of body surface area
and this can be used for calculation the extent of burn
injury.

38. 3. According to the severity of burn injury
• Major Burn Injury
• Moderate Burn Injury
• Minor Burn Injuries

39. a. Major Burn Injury
Major burn injury includes:
• Partial-thickness burns ( 2nd degree) involving
• >25% of TBSA in >10 years
• >20% of TBSA in children < 10 years or
• Full-thickness burns ( 3rd degree) involving >10% of
TBSA.

40. Contd..
• All burns involving the face, eyes, ears, hands, feet,
or perineum that may result in functional or cosmetic
impairment.
• Burns caused by caustic chemical agents, high-
voltage electrical injury, complicated by inhalation
injury or major trauma etc.

41. b. Moderate Burn Injury
• Moderate burn injury includes:
• Partial-thickness (2nd degree) burns of
• 15-25% of TBSA in >10 years
• or 10-20% of TBSA in children < 10 years or
• Full-thickness (3rd degree) burns involving < 10% of
TBSA that do not present serious threat of functional or
cosmetic impairment of the eyes, ears, face, hands, feet,
or perineum.

42. c. Minor Burn Injuries:
 Minor burn injury includes:
• Partial thickness ( 2nd degree) burns involving
• < 10% of TBSA in <10 years
• and <15% of TBSA in >10 years and
• Full-thickness (3rd degree) burns involving less than 2%
of TBSA that do not present a serious threat of functional
or cosmetic risk to eyes, ears, face, hands, feet, or
perineum.

43. Signs and symptoms
Type Layers involved Appearance Texture
Sensat
ion
Healing
Time
Prognosis
Superficial (1st-
degree)
Epidermis
Red without
blisters
Dry Painful5–10 days
Heals well Repeated sunburns
increase the risk of skin cancer la
in life
Superficial partial
thickness (2nd-
degree)
Extends into
superficial
(papillary)
dermis
Redness with clea
rblister Blanches
with pressure.
Moist
Very
painful
< 2–3 weeks
Local infection/cellulites but no
scarring typically
Deep partial
thickness (2nd-
degree)
Extends into
deep (reticular)
dermis
Yellow or white.
Less blanching.
May be blistering.
Fairly dry
Pressur
e &
discom
fort
3–8 week
Scarring, contractures (may requ
excision and skin grafting)
Full thickness (3rd-
degree)
Extends through
entire dermis to
subcutaneous
layer
Stiff and
white/brown No
blanching
Leathery
Painles
s
Prolonged
(months) and
incomplete
Scarring, contractures, amputatio
(early excision recommended)
4th-degree
Extends through
entire skin, and
into underlying
Black; charred
Dry Painless
Requires Amputation, significant functional

44. Indications for Hospitalization for Burns
• Burns affecting >10% of BSA
• Burns >10–20% of BSA in adolescent/adult
• 3rd-degree burns
• Electrical burns caused by high-tension wires or
lightning
• Chemical burns
• Inhalation injury, regardless of the amount of BSA
burned

45. Contd..
• Suspected child abuse or neglect
• Burns to the face, hands, feet, perineum, genitals, or
major joints
• Burns in patients with preexisting medical conditions
that may complicate the acute recovery phase
• Associated injuries (fractures)
• Pregnancy

46. Laboratory and diagnostic tests
• Complete blood count—decreased
• Arterial blood gas values—metabolic acidosis
(decreased pH, increased partial pressure of carbon
dioxide [Pco2], and decreased partial pressure of
oxygen [Po2])
• Serum electrolyte levels—decreased because of loss to
traumatized areas and interstitial spaces
• Serum glucose level—increased because of stress-
invoked glycogen breakdown or glyconeogenesis

47. Contd.
• Blood urea nitrogen level—increased because of
tissue breakdown and oliguria
• Creatinine clearance—increased because of tissue
breakdown and oliguria
• Serum protein levels—decreased because of protein
breakdown for massive energy needs
• Chest radiographic study

48. Management of Burn Injury
Three phases of burn management are:
a. Emergent/Resuscitative Phase
b. Intermediate Phase
c. Rehabilitative Phase

49. A. Emergent/ Resuscitative Phase
• This phase begins from the onset of injury to the
completion of fluid resuscitation.
• It includes:
- First Aid
- Initial management: ADCDEF
- Pain management
- Supportive measures

50. First Aid
• Ensure own safety
• Stop the process of burning
• Remove the child from the area of accident
• Reassure the child and parents
• Extinguish flames with a blanket or by pouring water
• "stop, drop, cover and roll" the child in case of open
flame burn
• Remove the victim’s wet clothes, rings, shoes etc.
carefully

51. • Cover the burned areas with clean clothes or dressing if
available
• Remove the secretion if present in the nose and mouth
and turn the head of the child to side to prevent
aspiration
• In thermal burn: put burned areas under running water,
if running water is not available, immerse the burned
areas in cool water for 20 minutes
• In case of chemical burn: brush off any remaining
chemical, if powdered or solid, then irrigate or wash the
affected areas with water

52. • If the burn is caused by hot tar, use mineral oil to
remove the tar
• In electrical burn: turn off or switch off the main
source
• Seek medical help as soon as possible (The first 6
hour of injuries is critical)

53. Initial Management/Primary Survey
A: Airway with cervical spine control
B: Breathing and ventilation
C: Circulation
D: Disability
E: Exposure (Includes burn assessment)
F: Fluid Resuscitation

54. Airway with cervical spine Control
• Stabilize cervical spine: maintain alignment,
prevent movement
• Manage the airway:
• Insert oral airway tube, if airway is still not
secured
• Administer oxygen
• Intubate, if sign of impending obstruction

55. Breathing and Ventilation
• Inspect for respiratory movement, rate, colour,
burn area
• Extensive burn to the chest and abdomen can
restrict ventilation: escharotomy is needed

56. Circulation
• Inspect for hemorrhage, pallor and capillary
refill time
• Palpate for presence of pulse, pulse rate ,
peripheral temperature
• Check for BP, conscious level

57. Disability
Check level of consciousness using AVPU
A: Alertness (Ask questions such as name and
address)
V: Voice (Response to vocal stimuli)
P: Pain (Response to painful stimuli)
U: Unresponsive
Check pupillary response to light

58. Exposure
• Expose the patient completely to assess burned
surface area as well as type and depth of burn
• Keep the patient warm to prevent hypothermia
• Remove clothing and jewellery

59. Fluid Resuscitation
• It is done if the patient has burn more than 10% of TBSA.
• The objectives of fluid therapy are to:
- Compensate for water and sodium losses
- Correct electrolyte abnormalities
- Restore adequate intravascular volume
- Provide adequate perfusion
- Improve renal function
- Correct acidosis

60. Types of fluid given
Crystalloids: Ringer lactate, Hartmann’s solution,
Normal saline are given during the initial 1st 24 hour
after burn
Colloids: Albumin, blood, electrolytes are given during
the 2nd 24 hour and thereafter

61. The Parkland formula estimates the amount of fluid to be
replaced over 24 hours as follows:
• Volume of Ringer lactate (ml) = 4ml x weight (kg) x %
TBSA burn
• Half of the resuscitation volume should be given in the
initial 8 hours
• And, the remaining half in the following 16 hours
• Subsequent fluid management (after 24 hours)
comprises of maintenance therapy and ongoing fluid
losses. Hourly ongoing fluid loss is calculated as:

62. • The adequacy of fluid resuscitation should be
constantly assessed and is based on different parameters
like vital signs, urine output, capillary refill time, blood
gas analysis, hematocrit, serum protein and mental state.
• Albumin (5%) infusions may be used to maintain the
serum albumin levels at a desired level of 2 g/dL and is
infused over 24 hours as:

63. • Packed red blood cells infusion is recommended if the
hematocrit falls below 24% (hemoglobin ≤8 g/dL).
• Fresh frozen plasma (FFP) is indicated if clinical and
laboratory assessment shows deficiency of clotting
factors or are scheduled for an invasive procedure or a
grafting procedure that could result in an estimated blood
loss of more than half of blood volume.
• Sodium supplementation may be required for children
having burns greater than 20% BSA if 0.5% silver nitrate
solution is used as the topical antibacterial burn dressing.

64. - Oral sodium chloride supplement of 4 g/m2 burn area
• Intravenous potassium supplementation is supplied
to maintain serum potassium level over 3 mEq/dL.
• Potassium losses may be significantly increased when
0.5% silver nitrate solution is used as the topical
antibacterial agent

65. Pain Management

66. Pharmacological method
Analgesics: (according to WHO)
Mild: paracetamol, Ibuprofen
Moderate: Codomol, Codeine, Tramadol
Strong: Morphine, Diamorphine

67. Non-pharmacological methods
Non-pharmacological methods include:
Positioning: comfortable positioning reduces pain
Elevation: elevation of limbs and head reduces pain and
swelling
Dressings: open wounds are more painful than dressed
wound
Communication : reassurance and explanation reduce
anxiety
Distraction: play materials, telling a story, TV, music therapy
etc
Timing: carrying out the dressing and other procedure after
feeding
Education: understanding of the condition

68. Supportive Measures
• Assess vital sign
• Initial wound care
• Tetanus prophylaxis
• Catheterization if needed
• Maintain intake and output
• Reassurance to patient and visitors
• Inform concerned authority (police case)

69. B. Intermediate Phase
• The acute or intermediate phase of burn care
follows the emergent/resuscitative phase and begins
48 to 72 hours after the burn injury and ends to near
completion of wound closure. It includes;
- Infection prevention and hygiene
- Burn wound care
- Pain management
- Nutritional management

70. Measures to prevent infection are as follows:
• maintaining good general hygiene, keeping hands,
wound and dressing clean and using aseptic
technique.
• aware of the sign and symptoms of infection, send
culture swab.
• local application of antimicrobials, cleaning of the
wound and surgical debridement
• provide a nutrient-rich diet

71. Burn Wound Care
It comprises:
a. Wound cleaning
b. Topical antimicrobial therapy
c. Wound dressing
d. Wound debridement
e. Wound grafting

72. Wound Cleaning
- Done by antibacterial wash (iodine or
chlorhexidine), saline or water (hydrotherapy).
- Hydrotherapy involves the soaking in tub or
shower at least once a day for no more than 20
minutes as water acts to loosen and remove
sloughing tissue, exudates and topical medications.

73. Topical Antimicrobial Therapy
- Topical antimicrobial agents are applied directly to
burn areas as ointments, creams whereas some are
packaged and prepared on a fine meshed gauze.
- The commonly used topical antibiotics are:
• Silver nitrate 0.5%
• Silver sulfadiazine1 %
• Mafenide acetate

74. • Bacitracin/Polysporin
• Placentrix
• Mupirocin
Wound Dressing
The overall aims of burn dressing are:
• Preventing infection
• Promoting wound healing
• Reducing pain and swelling
• Allowing for movement and function

75. Wound debridement
- Process of removing
non-viable tissues in
the upper layer of burn
wound.
- Usually, deep partial
thickness and full
thickness wounds
require debridement.

76. Wound Grafting
- If wounds are deep (full thickness) or extensive,
spontaneous epithelialization is not possible.
Therefore, covering of the burn wound is necessary
until coverage with a graft of the patient’s own skin
(autograft) is possible.

77. Types of wound coverings
a. Temporary skin coverings
b. Permanent skin coverings
Temporary Skin Coverings
i. Allograft (Homograft)
- Skin is obtained from living or recently deceased
human (human cadavers) and even the amniotic
membrane can be used.
- Particularly, useful when available donor site are
limited.

78. ii. Xenograft (Heterograft)
- Skin is obtained from variety of species, most commonly
pigs
- Particularly effective in children with partial thickness scald
burns of hands and face.
iii. Synthetic Skin Coverings
- Biobrane is widely used synthetic dressing that remains in
place for 3 – 4 weeks.
- Used in superficial partial thickness burns and donor site

79. Nutritional Management
- Burn injury produces a hypermetabolic response
characterized by both protein and fat catabolism.
- Therefore, high calorie and high protein diet are
provided for survival and recovery.
- Calories are provided at approximately 1.5 times the
basal metabolic rate.

80. - Protein requirement: 2-3 gm/kg body weight
- Multivitamins, particularly the vitamin A, B, C and
zinc are also necessary
- Oral feeding is encouraged unless the child is intubated
or paralytic ileus persists.
- Parenteral nutrition is considered in children with
extensive burns, inhalation injury or prolonged
paralytic ileus.

81. Rehabilitative Phase
- The principles of rehabilitation programmes are:
1. Minimizing swelling and oedema
2. Preventing deformity
3. Mobilizing/Maintaining function
4. Treating long-term scarring problems
5. Psychosocial care

82. Plastic and re-constructive surgery

83. Complications of Burn
Early Complications:
• Respiratory distress
• Shock (Hypovolemic, Neurogenic,
septic)
• Fluid and electrolytes disturbances
• Increase metabolic rate leading to
weight loss
• Curling GI Ulcer
• Gangrene
Late complications:
• Disfigurement
• Contracture
• Severe disability
• Psychological upset
• Chronic ulcer leading to
malignancy

84. Nursing Diagnosis of Burn
• Impaired gas exchange related to inhalation injury as
evidenced by dyspnea, tachypnea.
• Ineffective airway clearance related to mucosal edema
and loss of ciliary action / circumferential full-thickness
burns of the neck/ thorax/ chest as evidenced by dyspnea,
cough.
• Deficit fluid volume related to intravascular fluid loss as
evidenced by edema, dry mucus membrane

85. Nsg contd…
• Acute pain related to destruction of skin/tissues and nerve
injury as evidenced by crying, irritability
• Impaired skin integrity related to burn injury as evidenced by
disruption of skin surface/layers.
• Imbalance nutrition : less than body requirements related to
hyper-metabolic state as evidenced by weight loss
• Parental anxiety related to threat of death and/or
disfigurement as evidenced by expressed concern regarding
changes in life, fear of unspecified consequences

86. Nsg contd…
• Disturbed body image related to disfigurement as
evidenced by negative feelings about body/self, fear of
rejection/reaction by others.
• Risk of infection related to destruction of skin barrier and
decreased immunity.
• Risk of development of contractures related to scarring of
tissue and immobility.