Burns 1

DEFINITION
“A burn occurs when there is injury to the tissues of the body caused by heat,
chemicals, electric current, or radiation.”
The resulting effects are influenced by the temperature of the
• Burning agent
• Duration of contact time,
• Type of tissue that is injured.

TYPES OF BURN INJURY
• Thermal Burns
Thermal burns, which can be caused by flame, flash, scald, or contact with hot
objects, are the most common type of burn

Chemical Burns
• Chemical burns result from tissue injury and destruction from acids, alkalis, and
organic compounds.
• Acids are found in many household cleaners and include hydrochloric, oxalic, and
hydrofluoric acid.
•

• Alkali burns can be more difficult to manage than acid burns since alkaline
substances are not neutralized by tissue fluids as readily as acid substances.
• Alkalis adhere to tissue, causing protein hydrolysis and liquefaction.
• This damage continues even when the alkali is neutralized.
• Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial
cleansers.

• Organic compounds, including phenols and petroleum products, produce contact
burns and systemic toxicity.

SMOKE AND INHALATION INJURY
• Smoke and inhalation injuries result from the inhalation of hot air or noxious
chemicals and can cause damage to the tissues of the respiratory tract.
• Fortunately, gases are cooled to body temperature before they reach the lung
tissue.
• Although damage to the respiratory mucosa can occur, it seldom happens because
the vocal cords and glottis close as a protective mechanism.
• Redness and airway swelling (edema) may result when damage occurs.
• Smoke inhalation injuries are a major predictor of mortality in burn patients.

There are three types of smoke and inhalation injuries
Carbon monoxide poisoning ( Metabolic Asphyxiation):
• Carbon monoxide (CO) poisoning and asphyxiation account for the majority of deaths at
a fire scene.
• CO is produced by the incomplete combustion of burning materials.
• It is subsequently inhaled and displaces oxygen (O2) on the hemoglobin molecule,
causing hypoxia, carboxyhemoglobinemia, and ultimately death when the CO levels are
high.
• Often the victims of fires, especially those who have been trapped in a closed space, will
have elevated carboxyhemoglobin levels.

• If CO intoxication is suspected, the patient should be quickly treated with 100%
humidified O2 and the carboxyhemoglobin level should be measured when feasible.
• Skin color is often described as “cherry red” in appearance with CO poisoning.
• CO poisoning may occur in the absence of burn injury to the skin.

Inhalation injury above the glottis (Upper Airway Injury)
• A general principle to remember is that inhalation injury above the glottis is
thermally produced, and injury below the glottis is usually chemically produced.
• Injury above the glottis may be caused by the inhalation of hot air, steam, or
smoke.
• Mucosal burns of the oropharynx and larynx are manifested by redness, blistering,
and edema.

Inhalation injury below the glottis ( Lower Airway Injury)
• Tissue injury to the lower respiratory tract is related to the duration of exposure to
smoke or toxic fumes.
• Clinical manifestations such as pulmonary edema may not appear until 12 to 24
hours after the burn, and then they may manifest as acute respiratory distress
syndrome (ARDS)

ELECTRICAL BURNS
• Electrical burns are the result of intense heat generated from an electric current.
• Direct damage to nerves and vessels, causing tissue anoxia and death, can also
occur.
• The severity of the electrical injury depends on the amount of voltage, tissue
resistance, current pathways, surface area in contact with the current, and length of
time that the current flow was sustained.

Cold Thermal Injury OR Frostbite
• Frostbite can be described as “true tissue freezing,” which results in the formation
of ice crystals in the tissues and cells.
• Peripheral vasoconstriction is the initial response to cold stress and results in a
decrease in blood flow and vascular stasis.
Superficial frostbite
• It involves skin and subcutaneous tissue.
• The skin appearance will range from pale yellow to blue to mottled, and the skin will
feel crunchy and frozen.

Deep frostbite
• It involves muscle, bone, and tendon.
• The skin is white, hard, and insensitive to touch.
• The area has the appearance of deep thermal injury with mottling gradually
progressing to gangrene.

CLASSIFICATION OF BURN INJURY
• The treatment of burns is related to the severity of the injury.
• Severity is determined by
(1) Depth of burn,
(2) Extent of burn calculated in percent of total body surface area (TBSA),
(3) Location of burn
(4) Patient risk factors

DEPTH OF BURN
• Burn injury involves the destruction of the integumentary system. The skin is divided
into three layers: the
1. Epidermis
2. Dermis
3. Subcutaneous tissue
1. The epidermis, or nonvascular outer layer of the skin, is approximately as thick as a
sheet of paper.
• It is composed of many layers of nonliving epithelial cells that provide a protective
barrier to the skin, hold in fluids and electrolytes, help to regulate body temperature,
and keep harmful agents in the external environment from injuring or invading the body.

2. The dermis, which lies below the epidermis, is approximately 30 to 45 times thicker
than the epidermis.
• The dermis contains connective tissues with blood vessels and highly specialized
structures consisting of hair follicles, nerve endings, sweat glands, and sebaceous
glands.
• Under the dermis lies the subcutaneous tissue, which contains major vascular
networks, fat, nerves, and lymphatics.
3. The subcutaneous tissue acts as a heat insulator for underlying structures, which
include the muscles, tendons, bones, and internal organs.

• In the past, burns were defined by degrees: first degree, second degree, and third
degree. The ABA now recommends a more precise definition of second- and third-
degree burns, categorizing them according to depth of skin destruction:
• Partial-Thickness Skin Destruction
A. Superficial (first-degree):
Erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters (although
after 24 hr skin may blister and peel.
B. Deep (second-degree):
• Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured); severe pain
caused by nerve injury; mild to moderate edema

Full-Thickness Skin Destruction (Third- and fourth-degree)
• Dry, leathery or hard skin, visible thrombosed vessels; insensitivity to pain because
of nerve destruction; possible involvement of muscles, tendons, and bones
• All skin elements and local nerve endings destroyed.
• Coagulation necrosis present.
“Coagulative necrosis is a type of accidental cell death typically caused by ischemia or
infarction”
• Surgical intervention required for healing.

EXTENT OF BURN
• Two commonly used guides for determining the total body surface area affected or the extent of a burn
wound are the
1. Lund-Browder chart
2. The rule of nines
• The Lund-Browder chart is considered more accurate because the patient's age, in proportion to relative
body-area size, is taken into account.
• The rule of nines, which is easy to remember, is considered adequate for initial assessment of an adult
burn patient.
• For irregular- or odd-shaped burns, the palmar surface of the patient's hand is considered to be
approximately 1% of the total body surface area (TBSA).
• The extent of a burn is often revised after edema has subsided and a demarcation of the zones of injury
has occurred.

• A, Lund-Browder chart.
• B, Rule of nines chart.

Location of Burn
• The severity of the burn injury is related to the location of the burn wound.
• Burns to the face and neck and burns to the chest/back may inhibit respiratory function due to
mechanical obstruction secondary to edema or leathery and eschar formation.
• These injuries also may signal the possibility of inhalation injury and respiratory mucosal damage.
• Burns of the hands, feet, joints, and eyes are of concern because they make self-care very difficult.
• Burns of the hands and feet are challenging to manage because of superficial vascular and nerve
supply systems.
• Burns to the ears and the nose are susceptible to infection because of poor blood supply to the
cartilage.
• Burns to the buttocks or genitalia are highly susceptible to infection.
•

•Patient Risk Factors
• The older adult heals more slowly and usually experiences more difficulty with
rehabilitation than a younger adult.
• Any patient with preexisting cardiovascular, respiratory, or renal disease has a poorer
prognosis for recovery because of the tremendous demands placed on the body by a
burn injury.
• The patient with diabetes mellitus or peripheral vascular disease is at high risk for poor
healing and gangrene, especially with foot and leg burns.
• General physical debilitation from any chronic disease, including alcoholism, drug
abuse, or malnutrition, renders the patient less physiologically able to recover from a
burn injury.
• In addition, the burn patient who has concurrently sustained fractures, head injuries, or
other trauma has a poorer prognosis for recovery.

PHASES OF BURN MANAGEMENT
• Burn management has been organized chronologically into three phases that
correspond to the key priority of each particular phase:
• Emergent (resuscitative)
• Acute (wound healing)
• Rehabilitative (restorative).
• An overlap in care exists from one phase to another.
• Rehabilitation begins on the first day after the burn has occurred, with the formal
rehabilitative phase beginning in earnest when the burn wounds have almost healed.

EMERGENT PHASE
• The emergent (resuscitative) phase is the period of time required to resolve the
immediate, life-threatening problems resulting from the burn injury.
• This phase may last from the time of the burn to 3 or more days, but it usually lasts
24 to 48 hours.
• The primary concern is the onset of hypovolemic shock and edema formation. The
phase ends when fluid mobilization and diuresis begin.

PATHOPHYSIOLOGY
• Fluid and Electrolyte Shifts
• The greatest initial threat to a patient with a major burn is hypovolemic shock.
• It is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary
permeability and can begin as early as 20 minutes postburn.
• As the capillary walls become more permeable, water, sodium, and later plasma proteins (especially
albumin) move into interstitial spaces and other surrounding tissue.
• The colloidal osmotic pressure decreases with progressive loss of protein from the vascular space.
“Oncotic pressure, or colloid osmotic pressure, is a form of osmotic pressure exerted by proteins,
notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the
circulatory system.”

• This results in more fluid shifting out of the vascular space into the interstitial spaces.
(Fluid accumulation in the interstitium is termed second spacing.)
• Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed
third spacing.
• Examples of third spacing in burn injury are exudate and blister formation, as well as
edema in nonburned areas.
• The net result of the fluid shift is intravascular volume depletion.
• Decreased blood pressure (BP), increased pulse rate, and other manifestations of
hypovolemic shock

• The circulatory status is also impaired because of hemolysis of RBCs.
• The RBCs are hemolyzed by a circulating factor released at the time of the burn as well
as by the direct insult of the burn injury.
• Thrombosis in the capillaries of burned tissue causes an additional loss of circulating
RBCs.
• An elevated hematocrit is commonly caused by hemoconcentration resulting from fluid
loss.
• After fluid balance has been restored, lowered hematocrit levels are found secondary to
dilution.

• Sodium and potassium are involved in electrolyte shifts.
• Sodium rapidly shifts to the interstitial spaces and remains there until edema formation
ceases.
• A potassium shift develops initially because injured cells and hemolyzed RBCs release
potassium into the circulation.
• Toward the end of the emergent phase, capillary membrane permeability will be
restored if fluid replacement is adequate.
• Fluid loss and edema formation cease.
• Interstitial fluid gradually returns to the vascular space

• At the time of major burn injury, there is increased capillary permeability.
• All fluid components of the blood begin to leak into the interstitium, causing edema and
a decreased blood volume.
• The red blood cells and white blood cells do not leak.
• Therefore the hematocrit increases and the blood becomes more viscous.
• The combination of decreased blood volume and increased viscosity produces
increased peripheral resistance.
• Burn shock, a type of hypovolemic shock, rapidly ensues and continues for about 24 to
48 hr.

INFLAMMATION AND HEALING
• Burn injury causes coagulation necrosis, whereby tissues and vessels are damaged
or destroyed.
• Neutrophils and monocytes accumulate at the site of injury.
• Fibroblasts and newly formed collagen fibrils appear and begin wound repair within
the first 6 to 12 hours after injury.

IMMUNOLOGIC CHANGES
• Burn injury causes widespread impairment of the immune system.
• The skin barrier to invading organisms is destroyed, resulting in bone marrow
depression and decreased circulating levels of immunoglobulins.
• Defects occur in the function of white blood cells (WBCs).
• The inflammatory cytokine cascade triggered by tissue damage impairs the function
of lymphocytes, monocytes, and neutrophils, which puts the patient at greater risk
for infection.

CLINICAL MANIFESTATION
• The burn patient is likely to be in shock from pain and hypovolemia.
• Frequently, areas of full-thickness and deep partial-thickness burns are initially
anesthetic because the nerve endings are destroyed.
• Superficial to moderate partial-thickness burns are painful.
• Blisters filled with fluid and protein may occur in partial-thickness burns.
• Fluid is not actually lost from the body as much as it is sequestered in the
interstitial spaces and third spaces.

• The patient may have signs of adynamic ileus, such as absent or decreased bowel
sounds, as a result of the body's response to massive trauma and potassium shifts.
• Shivering may occur as a result of chilling that is caused by heat loss, anxiety, or
pain.
• Most burn patients are quite alert and can provide answers to questions shortly after
the injury or until they are intubated.

MANAGEMENT FOR EMERGENT PHASE
• In the emergent phase, patient survival depends on rapid and thorough assessment and
intervention
Airway Management
• Airway management frequently involves early endotracheal (preferably orotracheal)
intubation.
• Early intubation eliminates the necessity for emergency tracheostomy after respiratory
problems have become apparent.
• In general, the patient with major injuries involving burns to the face and neck requires
intubation within 1 to 2 hours after burn injury.

• Within 6 to 12 hours after injury in which smoke inhalation is suspected, a fiberoptic
bronchoscopy should be performed to assess the lower respiratory tract.
• The patient should also be encouraged to cough and deep breathe every hour.
• If respiratory failure is impending, intubation should be performed and the patient should
be supported with mechanical ventilation.
• Positive end-expiratory pressure (PEEP) may be used to prevent collapse of the alveoli
and progressive respiratory failure.
• Bronchodilators may be administered to treat severe bronchospasm.
• CO poisoning is treated by administering 100% O2 until carboxyhemoglobin levels
return to normal.

FLUID THERAPY
• As soon as the patient (usually with a >15% TBSA burn) arrives at a health care
facility, at least one (and usually two) large-bore intravenous (IV) access routes
must be obtained.
• It is critical to establish IV access that can accommodate large volumes of fluid.
• For burns >30% TBSA, central lines and an arterial line for fluid/medication/blood
access should be considered.
• The extent of an adult's burn wound should be assessed using the rule of nines or
Lund-Browder charts.

• The type of fluid replacement is determined by size and depth of burn, age of the
patient, and individual considerations, such as dehydration in the preburn state or
preexisting chronic illness.
• Fluid replacement is accomplished with crystalloid solutions (usually lactated Ringer's),
colloids (albumin), or a combination of the two.
• The Brooke and Parkland (Baxter) formulas are the most commonly used.
Parkland (Baxter)
• Crystalloid : Lactated Ringer's solution: 4 ml/kg/% TBSA burn; ½ given first 8 hr; ¼
given each next 8 hr
• Colloids: 20%-60% of calculated plasma volume
• Glucose in water: Amount to replace estimated evaporative losses

Brooke (modified)
• Crystalloid: Lactated Ringer's solution: 2.0 ml/kg/% TBSA burn; ½ given during first
8 hr; ½ given during next 16 hr
• Colloids: 0.3-0.5 ml/kg/% TBSA burn
• Glucose in water : Amount to replace estimated evaporative losses

FLUID RESUSCITATION WITH THE PARKLAND (BAXTER)
FORMULA
• Formula
• 4 ml lactated Ringer's solution per kg body weight per% TBSA burn
• Total fluid requirements for first 24 hr after burn
• Application
• ½ of total in first 8 hr
• ¼ of total in second 8 hr
• ¼ of total in third 8 hr

Example
• For a 70-kg patient with a 50% TBSA burn:
• 4 ml × 70 kg × 50% TBSA burn = 14,000 ml
• 14 L in 24 hr
• ½ of total in first 8 hr = 7000 ml (875 ml/hr)
• ¼ of total in second 8 hr = 3500 ml (436 ml/hr)
• ¼ of total in third 8 hr = 3500 ml (436 ml/hr)

Example for students
• For a 50-kg patient with a 80% TBSA burn: ?
• ½ of total in first 8 hr = ?
• ¼ of total in second 8 hr = ?
• ¼ of total in third 8 hr = ?

ANSWER
• For a 50-kg patient with a 80% TBSA burn:
• 4 ml × 50 kg × 80% TBSA burn = 16,000 ml
• 16 L in 24 hr
• ½ of total in first 8 hr = 8000 ml (1000 ml/hr)
• ¼ of total in second 8 hr = 4000 ml (500 ml/hr)
• ¼ of total in third 8 hr = 4000 ml (500 ml/hr)

• Assessment of the adequacy of fluid replacement is best made by the use of more
than one parameter.
• Urine output is the most commonly used parameter.
• Assessment parameters include the following:
1.Urine output: 30 to 50 ml/hr in an adult;
2.Cardiopulmonary factors: BP (systolic >90 mm Hg), pulse rate (<120 beats/minute).
BP is most appropriately measured by an arterial line.
Peripheral measurement is often invalid, because of vasoconstriction and edema.

WOUND CARE
• Wound care should be delayed until a patent airway, adequate circulation, and
adequate fluid replacement have been established.
• Full-thickness wounds will be dry and waxy white to dark brown/black and will have
only minor, localized sensation because nerve endings have been destroyed.
• Partial-thickness wounds are pink to cherry red and wet and shiny with serous
exudate.
• These wounds may or may not have intact blisters and are painful when touched or
exposed to air.

• Cleansing and gentle debridement, using scissors and forceps, can occur in a
hydrotherapy tub, cart shower, shower, or patient bed/stretcher.
• Extensive, surgical debridement should be performed in the operating room.
• Releasing escharotomies and fasciotomies can be carried out in the emergent
phase, usually in burn units by burn physicians.
• Care should be taken to accomplish these procedures as quickly and effectively as
possible

HYDROTHERAPY CART SHOWER. SHOWERING
PRESENTS AN OPPORTUNITY FOR PHYSICAL THERAPY
AS WELL AS WOUND CARE.

OPERATIVE DEBRIDEMENT OF FULL-THICKNESS
BURNS IS NECESSARY TO PREPARE THE WOUND
FOR GRAFTING.

• Patients find the initial wound care to be both physically and psychologically
demanding.
• Immersion in a tank for longer than 20 to 30 minutes can cause electrolyte loss
from open burned areas.
• Prolonged immersion can lead to chilling after the bath and cross-contamination of
wounds from one area of the body to another.
• The water does not need to be sterile; tap water, not exceeding 104°F (40°C), is
acceptable.
• Because pathogenic organisms are present on the burn wound, a surgical
detergent, disinfectant, or cleansing agent may be used.
• A once-daily shower and dressing change in the morning, followed by a dressing
change in the patient's room in the evening, is a common routine in many burn
units.

• Infection is the most serious threat to further tissue injury and possible sepsis.
• Survival is directly related to prevention of wound contamination.
• The source of infection in burn wounds is the patient's own flora, predominantly
from the skin, respiratory tract, and gastrointestinal (GI) tract.
• The prevention of cross-contamination from one patient to another is a priority for
nursing care.

• Two types of wound treatment used to control infection are the open method and the
use of multiple dressing changes.
• In the open method, the patient's burn is covered with a topical antimicrobial and has
no dressing over the wound.
• In the multiple dressing change method, sterile gauze dressings are impregnated
with or laid over a topical antimicrobial.
• These dressings are changed anywhere from every 12 to 24 hours to once every 3
days, depending upon the topical agent and the dressings used.
• Most burn units support the concept of moist wound healing and use dressings to
cover the burned areas, with the exception of the burned face.

• When the patient's open burn wounds are exposed, staff must wear disposable hats,
masks, gowns, and gloves.
• When removing contaminated dressings and washing the dirty wound, the nurse may
use nonsterile, disposable gloves.
• Sterile gloves are used when applying ointments and sterile dressings.
• Careful hand washing and the use of an alcohol hand rinse outside each patient room
is also required to prevent cross-contamination.
•

DRUG THERAPY
• Analgesics and Sedatives
• Analgesics are ordered to promote patient comfort.
• Early in the post burn period, IV pain medications should be given because
• Intramuscular (IM) injections will not be absorbed adequately in burned or
edematous areas, causing pooling of medications in the tissues.
• When fluid mobilization begins, the patient could be inadvertently overdosed from
the interstitial accumulation of previous IM medications.

•Analgesia
• Morphine
• Fentanyl (Sublimaze)
• Nonsteroidal antiinflammatory (e.g., ketoprofen [Orudis])

•Sedation
• Haloperidol (Haldol): Produces antipsychotic and sedative effects, promotes sleep
• Lorazepam (Ativan): Diminishes anxiety
• Midazolam (Versed): Has short-acting amnestic properties

•Gastrointestinal Support
• Ranitidine (Zantac): Decreases incidence of Curling's ulcer (It is an acute gastric
erosion resulting as a complication from severe burns when reduced plasma volume
leads to ischemia and cell necrosis of the gastric mucosa).
• Nystatin (Mycostatin): Prevents overgrowth of Candida albicans in oral mucosa
• Antacid: Neutralizes stomach acid

TETANUS IMMUNIZATION
• Tetanus toxoid is given routinely to all burn patients because of the likelihood of
anaerobic burn wound contamination.
• If the patient has not received an active immunization within 10 years before the
burn injury, tetanus immunoglobulin should be considered.

ANTIMICROBIAL AGENTS
• After the wound is cleansed, topical agents are applied and covered with a light
dressing.
• Systemic antibiotics are not usually used in controlling burn wound flora because there
is little or no blood supply to the burn eschar, and consequently, there is little delivery of
the antibiotic to the wound.
• Some topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of
the wound.
• Silver sulfadiazine (Silvadene, Flamazine) and Mafenide acetate (Sulfamylon) are
commonly used.
• Silver-impregnated dressings (Acticoat, Silverlon, Aquacel Ag) that can be left on for up
to 3 days and in some cases longer, are used in some burn units.
• They are effective against many organisms.

APPLICATION OF SILVER SULFADIAZINE
CREAM TO SALINE-MOISTENED GAUZE

• Frequently, fungal infections develop in the patient's mucous membranes (mouth
and genitalia) as a result of antibiotic therapy and low resistance in the host.
• The offending organism is usually Candida albicans.
• Oral infection is treated with nystatin (Mycostatin) mouthwash.
• When a normal diet is resumed, yogurt or Lactobacillus (Lactinex) may be given by
mouth to reintroduce the normal intestinal flora that have been destroyed by
antibiotic therapy.

NUTRITIONAL THERAPY
• Fluid replacement takes priority over nutritional needs in the initial emergent phase.
• However, early and aggressive nutritional support within several hours of the burn
injury can decrease mortality and complications, optimize healing of the burn wound.
• Nonintubated patients with a <20% TBSA burn will generally be able to eat enough to
meet their nutritional requirements.
• Intubated patients and/or those with larger burns require additional support.
• Enteral feedings (gastric or intestinal) have almost entirely replaced the need for
parenteral feeding.
• Early enteral feeding preserves GI function, increases intestinal blood flow, and
promotes optimal conditions for wound healing.

• The patient with large (>20% TBSA) burns frequently develops paralytic ileus within
a few hours as a result of the body's response to major trauma.
• If a large nasogastric tube is inserted on admission, gastric residuals should be
checked frequently to rule out a paralytic ileus and delayed gastric emptying.
• In general, feedings can be commenced slowly at 20 to 40 ml/hr and be increased to
the goal rate within 24 to 48 hours.
• A hypermetabolic state proportional to the size of the wound occurs after a major
burn injury.
• Resting metabolic expenditure may be increased by 50% to 100% above normal in
patients with major burns.

• Calorie-containing nutritional supplements and milkshakes are often given because
of the great need for calories.
• Protein powder can also be added to food and liquids.
• Supplemental vitamins may be given as early as the emergent phase, with iron
supplements often started in the acute phase

• The acute phase begins with the mobilization of extracellular fluid and subsequent
diuresis.
• This phase is concluded when the burned area is completely covered by skin grafts
or when the wounds are healed. This may take weeks or many months.

PATHOPHYSIOLOGIC CHANGES
• Burn injury involves pathophysiologic changes in many body systems.
• Diuresis from fluid mobilization occurs, and the patient is less edematous.
• Areas that are full- or partial-thickness burns are more evident than in the emergent
phase.
• Bowel sounds return.
• The patient may now become aware of the enormity of the situation.
• Some healing begins as WBCs surround the burn wound and phagocytosis occurs.

CLINICAL MANIFESTATIONS
• Partial-thickness wounds form eschar, which begins separating fairly soon after
injury.
• Once the eschar is removed, re-epithelialization begins at the wound margins and
appears as red or pink scar tissue.
• Epithelial buds from the dermal bed eventually close in the wound, which then heals
spontaneously without surgical intervention, usually within 10 to 14 days.
• Margins of full-thickness eschar take longer to separate than partial-thickness
eschar. As a result, full-thickness wounds require surgical debridement and skin
grafting for healing.

LABORATORY VALUES
• Because the body is attempting to reestablish fluid and electrolyte homeostasis in
the initial acute phase, it is important to follow serum electrolyte levels closely.
• Sodium: Hyponatremia can occur if hydrotherapy is too lengthy because the
hypotonicity of the bath water pulls sodium from open burn areas. Other causes of
hyponatremia include excessive GI suction, diarrhea, and excessive water intake.
• Potassium: Hyperkalemia is noted if the patient has renal failure or massive deep
muscle injury with large amounts of potassium released from damaged cells.

COMPLICATIONS
• Infection:
• The body's first line of defense, the skin, has been destroyed by burn injury.
• The burn wound is get colonized with organisms.
• If the bacterial density at the junction of the eschar with underlying viable tissue
rises, the patient has a burn wound infection.

Musculoskeletal System
• The musculoskeletal system is particularly prone to complications during the acute
phase.
• ROM may be limited, and contractures can occur.
• Because of pain, the patient will prefer to assume a flexed position for comfort.
• Splinting can be beneficial to prevent/reduce contracture formation.

Gastrointestinal System
• The GI system may also exhibit complications during this phase.
• Paralytic ileus results from sepsis.
• Diarrhea may be caused by the use of supplemental feedings or antibiotics.
• Constipation can occur as a side effect of opioid analgesics, decreased mobility, and
a low-fiber diet.
• Curling's ulcer, a type of gastroduodenal ulcer characterized by diffuse superficial
lesions (including mucosal erosion).

Endocrine System
• An increase in blood glucose levels may be seen transiently because of stress-
mediated cortisol and catecholamine release, resulting in the increased mobilization
of glycogen stores, gluconeogenesis, and the subsequent production of glucose.
• Later, hyperglycemia can be caused by the increased caloric intake necessary to
meet some patients’ metabolic requirements.
• When this occurs, the treatment is supplemental IV insulin, not decreased feeding.
• Serum glucose levels are checked frequently, and an appropriate amount of insulin is
given if hyperglycemia is present.

COLLABORATIVE MANAGEMENT
ACUTE PHASE
• The predominant therapeutic interventions in the acute phase are
(1) Wound care
(2) Excision and grafting
(3) Pain management
(4) Physical and occupational therapy
(5) Nutritional therapy
(6) Psychosocial care

1. WOUND CARE
• The goals of wound care are to
• (1) Cleanse and debride the area of necrotic tissue and debris that would
promote bacterial growth
• (2) Promote wound re-epithelialization and/or successful skin grafting.
• Wound care consists of daily observation, assessment, cleansing,
debridement, and dressing reapplication.
• Nonsurgical debridement, dressing changes, topical antibiotic therapy, graft
care, and donor site care may be performed from 2 times daily to once every
few days.

• Enzymatic debriders made of natural ingredients, such as papain ( Protien-digestive
enzyme made from unripe papayafruit), may be used for the enzymatic
debridement of burn wounds, which speeds up the removal of dead tissue from the
healthy wound bed.
• When partial-thickness burn wounds have been debrided, a protective, coarse or
fine-meshed, greasy gauze dressing is applied to protect the re-epithelializing cells
as they resurface and close the open wound bed.

• These meshed gauze dressings have a greasy base (paraffin or petroleum) that
prevents adherence of the graft to the middle/outer, cotton gauze dressings.
• Dressings often are not applied, so it is possible for blebs (serosanguineous
exudates) to form between the graft and the recipient bed.
• The evacuation of blebs is best performed by aspiration with a tuberculin syringe.
• Burn unit nurses have the option of pricking the bleb and rolling the skin graft if they
have received instruction in this specialized skill.
• It should not be performed by non–burn unit staff.

2. EXCISION AND GRAFTING
• Current therapeutic management of burn wounds involves early removal of the
necrotic tissue followed by application of split-thickness autograft skin.
• During the procedure of excision and grafting, eschar is removed down to the
subcutaneous tissue, depending on the degree of injury.
• A graft is then placed on clean, viable tissue to achieve good adherence.
• Hemostasis is achieved by pressure and the application of topical thrombin or
epinephrine, after which the wound is covered with autograft (person's own) skin.

• With early excision, function is restored and scar tissue formation is minimized.
• Because the dead tissue is planed off until viable tissue is reached, extensive bleeding is
expected to occur, which may pose a problem when grafting is performed.
• Donor skin is taken from the patient for grafting by means of a dermatome, removes a
thin (split-thickness) layer of skin from an unburned site.
• The donor skin can be meshed to allow for greater wound coverage, or it may be applied
as a sheet graft for a better cosmetic result when grafting the face, neck, and hands.
• The donor site now becomes a new open wound.
• For the thin-skinned elderly patient, healing of the donor site may be a difficult task and
requires vigilant care by the health care team.

• A, The skin harvests from a patient's thigh using a dermatome.
• B, Appearance of donor site after harvesting split-thickness skin graft. Donor site is
covered with a transparent occlusive dressing.
• C, Healed donor sites.
• D, Healed split-thickness
sheet skin graft to the hand.

CULTURED EPITHELIAL AUTOGRAFTS
• In the patient with large body surface area burns, only a limited amount of unburned
skin may be available as donor sites for grafting, and some of that skin may be
unsuitable for harvesting.
• Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a
person with limited available skin for harvesting.
• CEA is grown from biopsy specimens obtained from the patient's own unburned skin.
• This procedure is performed in burn units as soon as possible after admission on
patients who have been identified as suitable candidates.

• The specimens are sent to a commercial laboratory, where the biopsied keratinocytes
are grown in a culture medium containing epidermal growth factor.
• After approximately 18 to 25 days, the keratinocytes have expanded up to 10,000 times
and form confluent sheets that can be used as skin grafts.
• The cultured skin is returned to the burn unit, where it is placed on the patient's excised
burn wounds.
• Because CEA grafts are made only of epidermal cells, meticulous care is required to
prevent shearing injury or infection.
• CEA grafts generally form a seamless, smooth replacement skin tissue.
• Problems related to CEA include a poor graft take due to thin epidermal skin graft loss,
and contracture development.

Patient with cultured epithelial autograft (CEA).
• A, Intraoperative application of cultured epithelial autograft.
• B, Appearance of healed cultured epithelial autograft.

ARTIFICIAL SKIN
• It is now recognized that any successful artificial skin must replace all functions of
the skin and consist of both dermal and epidermal elements.
• The Integra artificial skin dermal regeneration template is an example of one of the
newest and most successful skin replacement systems available in burn care today.
• Its application requires a high degree of skill.
• As with CEA, it is indicated for use in the treatment of life-threatening, full-thickness
or deep partial-thickness burn wounds when conventional autograft is not available
or advisable, as in elderly or high-anesthetic-risk patients.

• Integra artificial skin has a bilayer membrane composed of a cellular dermis and
silicone.
• In the operating room, the wound is debrided, the bilayer membrane is placed
dermal layer down, and the wound is wrapped with dressings.
• The dermal layer functions as a biodegradable template that induces organized
regeneration of new dermis by the body.
• The silicone layer remains intact for 3 weeks as the dermal layer degrades.
• At this point, the silicone is removed during a second surgical procedure and
replaced by the patient's own epidermal autografts. In some situations, burn units
use CEA as the source of epidermis.

PAIN MANAGEMENT
• Burn patients experience two kinds of pain:
1) continuous, background pain that exists throughout the day and night.
(2) treatment-induced pain associated with dressing changes, ambulation, and
rehabilitation activities.

• The first line of treatment is pharmacologic.
• With background pain, if the patient has a continuous IV infusion of morphine or
hydromorphone, this will allow for a steady, therapeutic level of medication.
• Breakthrough doses should also be available.
• If an IV infusion is not present, slow-release twice-a-day opioid medications are
indicated.
• Around-the-clock oral morphine/hydromorphone can also be used.
• Again, breakthrough medication needs to be available.
• Anxiolytics, which frequently potentiate analgesics, are also indicated and include
lorazepam (Ativan) or midazolam (Versed).
• Pain can also be managed using nonpharmacologic strategies, such as relaxation
tapes, visualization, hypnosis, etc.

PHYSICAL AND OCCUPATIONAL THERAPY
• Physical therapy throughout burn recovery is imperative to maintain optimal joint
function.
• A good time for exercise is during and after wound cleansing, when the skin is softer
and bulky dressings are removed.
• Passive and active ROM should be performed on all joints.
• The patient with neck burns must sleep without pillows or with the head hanging
slightly over the top of the mattress to encourage hyperextension.
• Custom-fitted splints are designed to keep the joints in functional position and must
be reexamined frequently to ensure an optimal fit.

NUTRITIONAL THERAPY
• The goal of nutritional therapy during the acute burn phase is to provide adequate
calories and protein to promote healing.
• Meeting daily caloric requirements is crucial and should begin within the first 1 to 2
days postburn.
• The daily estimated caloric needs must be regularly calculated by a dietitian and
readjusted as the patient's condition changes (e.g., wound healing, sepsis).
• If the patient is on a mechanized ventilator or unable to consume adequate calories
by mouth, a feeding tube can be placed and a complete liquid diet administered.
• If caloric requirements cannot be met by enteral feeding alone, parenteral nutrition
may be given temporarily while continuing to deliver enteral feedings.

• Appetite is usually diminished, and constant encouragement may be necessary to
achieve adequate intake. Ideally, weight loss should not be more than 10% of
preburn weight.
• Calorie intake needs to be monitored by the dietitian on a regular basis.

PSYCHOSOCIAL CARE
• The patient and family have many needs for psychosocial support during the often
lengthy, unpredictable, and complex course of care.
• The social worker and nursing staff have important support and counseling roles to
play.

• The formal rehabilitation phase begins when the patient's burn wounds have healed
and the patient is able to resume a level of self-care activity.
• This can occur as early as 2 weeks or as long as 7 to 8 months after the burn injury.
• Goals for this period are to assist the patient in resuming a functional role in society
and to accomplish functional and cosmetic reconstructive surgery.
• Rehabilitation-focused activities that have been taking place during the earlier
emergent and acute phases now begin in earnest once the patient's wounds have
healed.

PATHOPHYSIOLOGIC CHANGES
• Burn wounds heal either by primary intention or by grafting.
• Layers of epithelialization begin rebuilding the tissue structure destroyed by the
burn injury.
• Collagen fibers, present in the new scar tissue, assist with healing and add strength
to weakened areas.
• The new skin appears flat and pink.
• In approximately 4 to 6 weeks, the area becomes raised and hyperemic.
• If adequate ROM is not instituted, the new tissue will shorten, causing a contracture.

• Mature healing is reached in 6 months to 2 years when suppleness has returned,
and the pink or red color has faded to a slightly lighter than the surrounding
unburned tissue.
• It takes longer for more heavily pigmented skin to regain its dark color because
many of the melanocytes are destroyed.
• Often, skin never completely regains its original color.
• Cosmetics can help even out unequal skin tones and improve the patient's overall
appearance and self-image.

• Scarring has two components: discoloration and contour.
• The discoloration of scars will fade somewhat with time.
• However, scar tissue tends to develop altered contours; that is, it is no longer flat or
slightly raised but becomes elevated and enlarged above the original burned area.
• It is believed that pressure can help keep a scar flat.
• Gentle pressure can be maintained on the healed burn with custom-fitted pressure
garments.
• These garments are worn up to 24 hours a day for as long as 12 to 18 months.
• They are removed only for short periods while bathing.

CLINICAL MANIFESTATION
• The patient typically experiences discomfort from itching where healing is occurring.
• Frequent applications of water-based moisturizers and diphenhydramine (Benadryl)
help reduce the itching.
• As “old” epithelium is replaced by new cells, flaking will occur.
• The newly formed skin is extremely sensitive to trauma.
• Blisters and skin tears are likely to develop from slight pressure or friction.
• Additionally, these newly healed areas can be hypersensitive or hyposensitive to cold,
heat, and touch.
• Grafted areas are more likely to be hyposensitive until peripheral nerve regeneration
occurs.
• Healed burn areas must be protected from direct sunlight for 6 to 9 months to prevent
hyperpigmentation and sunburn injury.

COMPLICATIONS
• The most common complications during the rehabilitative phase are skin and joint contractures
and hypertrophic scarring.
• A contracture (an abnormal condition of a joint characterized by flexion and fixation) develops
as a result of the shortening of scar tissue in the flexor tissues of a joint.
• Areas that are most susceptible to contracture formation include the anterior and lateral neck
areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and ankles.
• These areas encompass major joints.
• Not only does the skin over these areas develop contractures, but the underlying tissues, such
as the ligaments and tendons, also have a tendency to shorten during the healing process.

• Positioning, splinting, and exercise should be instituted to minimize this complication.
• These procedures should be continued until the skin matures.
• Therapy is aimed at the extension of body parts because the flexors are stronger
than the extensors.
• Burned legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist with
circulation to leg graft and donor sites before ambulation.
• This additional pressure prevents blister formation, promotes venous return, and
decreases pain and itchiness.
• Once the skin is completely healed and less fragile, custom-fitted pressure garments
replace the elastic bandages.

COLLABORATIVE MANAGEMENT
• During the rehabilitation phase, both the patient and family are actively encouraged
to participate in care.
• Since the patient may go home with small, unhealed wounds, education and “hands-
on” instruction will be needed in dressing changes and wound care.
• If needed, home care nursing services can be arranged to assist with care for the
first few weeks postdischarge.
• An emollient water-based cream (e.g., Vaseline Intensive Care Extra Strength) that
penetrates the dermis should be used routinely on healed areas to keep the skin
supple and well moisturized, which will decrease itching and flaking.

• Oral diphenhydramine (Benadryl) may be used if itching persists.
• Postburn reconstructive surgery is frequently required following a major burn. It is
important for the patient to understand the need for or possibility of further surgery
before leaving the hospital.
• The continuous role of exercise and physical/occupational therapy cannot be
overemphasized.
• Constant encouragement and reassurance are necessary to maintain a patient's
morale, particularly once the patient realizes that recovery can be slow and
rehabilitation may need to be a primary focus for at least the next 6 to 12 months.

• Because of the tremendous psychologic impact of a burn injury, health care providers
should be particularly sensitive to the patient's emotions and concerns.
• It is essential that patients be encouraged to discuss their fears regarding loss of
their life as they once knew it, loss of function, temporary/permanent deformity and
disfigurement, return to work and home life, and financial burdens resulting from a
long and costly hospitalization.
• Care should also be taken to address individual spiritual and cultural needs, as both
these facets of a patient's life play a role in recovery.

• Earlier discussions with family members in the emergent and acute phases have
likely identified the different meanings a burn injury can have in different cultures
and for their loved one, in particular.
• Hospital chaplains and cultural community groups may be helpful resources to the
patient, family, and health care team.
• Patients can then be assisted toward a realistic and positive appraisal of their
particular situation, emphasizing what they can do instead of what cannot be done.

• A person's self-esteem is usually adversely affected by a burn injury.
• In some individuals, an overwhelming fear may be the loss of relationships because of
perceived or actual physical disfigurement.
• In a society that values physical beauty, alterations in body image can result in
psychologic distress.
• Encouraging appropriate independence, an eventual return to preburn activities, and
interactions with other burn survivors will involve the patient in familiar activities that may
bring comfort and help to restore self-esteem.
• Counseling should be made available after the patient goes home.
• Patients need reassurance that their feelings during this period of adjustment are
normal, and that their frustration is to be expected as they attempt to resume a normal
lifestyle.

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