Burns can be caused by heat, chemicals, electricity or radiation. The severity depends on temperature, duration of contact and type of tissue injured. Common causes include kitchen accidents, fires, chemicals and electricity. Burns are classified by depth and extent. First degree burns affect the epidermis only, second degree involve the dermis and third degree destroy all skin layers. Burn management involves fluid resuscitation, wound care, infection prevention and rehabilitation. Care includes wound cleaning, debridement, skin grafting and splinting to prevent contractures. Pain management and nutrition are also important aspects of collaborative burn care.

1. BURNS
PRESENTED BY : MRS PALLAVIPARBHAT CHAUHAN

2. Definition
A burn occurs when there is an injury to the tissues of
the body caused by heat, chemicals, electric current or
radiation.
The resulting effects are influenced by:
 Temperature of the burning agent
 Duration of contact time
 Type of tissue that is injured

3. Common Places & Causes of Burn Injury
Occupational Hazards Kitchen/Bathroom General Home
Tar
Chemicals
Hot Metals
Steam Pipes
Combustible fuels
Fertilizers/ Pesticides
Electricity from power lines
Sparks from live electric sources
Pressure Cookers
Micro-waved Food
Hot water heaters set higher than 60°C
Hot grease or liquids from cooking
Gas fireplaces
Open space heaters
Frayed or defective wiring
Radiators (home/automobile)
Improper use of outdoor grills
Multiple extension cords per outlet
Carelessness with cigarettes or matches
Improper use or storage of flammables

4. Types of Burn Injury
Type of Burns
`
Causative Factors
Thermal Burns Caused by flame, flash, scald or contact with hot objects.
Chemical Burns Results from tissue injury and destruction from acids,
alkalis and organic compounds.
Electrical Burns Occurs as a result of intense heat generated from an
electric current.
Radiation Injury Exposure to high doses of radiation or radioactive
material.
Smoke/Inhalational Injury Results from inhalation of hot air or noxious chemicals.

5. Burn Injury: Classification
Based on Depth & Extent

6. • Superficial Burn
• Partial Thickness Burn
• Full Thickness Burn

7. First-Degree
(Superficial)
• Redness
• Mild swelling
• Tenderness
• Pain
Effects the epidermis

8. Second-Degree
(Partial-Thickness)
• Blisters
• Swelling
• Weeping of Fluids
• Intense Pain

9. Third-Degree
(Full-Thickness)
No pain — nerve endings are
dead

10. Assessment of Burn Injury
RULE OF NINE RULE OF PALM

11. RULE OF NINE

12. Patient’s palm
equals 1% of his
body surface area

13. Burns
Cell Lysis Increased Capillary
permeability
Possible Inhalation
Injury
Loss of Skin barrier
Hypoxia
•Hemolysis,
•Hyperkalemia,
•Hemoglobin &
Myoglobin in urine
•Loss of sodium, water & protein shift
to interstitial space
•Increased Blood viscosity
•Electrolyte disturbances
•Burn Shock
•Thermo-regulation
problems
•Inflammatory response
•Impaired immune response

14. Burn Shock
Massive Stress Response
Release of Corticoid hormone & Catecholamine release
 Peripheral vaso-constriction
 Tachycardia
 Hyperglycemia
 Increased Catabolism
 Risk of Curling Ulcer
 Increased metabolism (After shock resolves
Decreased Tissue Perfusion

15. Decreased Tissue Perfusion
Decreased Renal Flow Risk of ARF
Decreased GI Flow Risk of paralytic ileus
Anaerobic Metabolism Metabolic Acidosis
Tissue Damage Potential Tissue necrosis
Cellular Dysfunction Cell Swelling

16. MANAGEMENT

17. FLUID REPLACEMENT
FORMULAS
Parkland/ Baxter formula
Lactated ringer’s solution: 4ml*kg body weight*%TBSA burned
Day 1: half to be given in first 8 h; half to be given over next 16 h.
Day 2: varies. Colloid is added.
Evans formula
Colloids: 1ml*kg body weight*%TBSA burned
Electrolytes(saline): 1ml*body weight* %TBSA burned
Glucose(5% in water): 2000ml for insensible loss
Day 1: half to be given in 1st 8 h; remaining half over next 16 h.
Day 2: half of previous day’s colloids and electrolytes; all of insensible fluid replacement.

18. PHASES OF BURN CARE

19. Emergent or immediate
resuscitative
From onset of injury to completion of fluid
resuscitation
 First aid
 Prevention of shock
 Prevention of respiratory distress.
Acute From beginning of diuresis to near
completion of wound closure
Detection & Rx of concomitant injuries.
 Wound assessment & initial care.
 Wound care & closure
Rehabilitation From major wound closure to return to
individual’s optimal level of physical &
psychological adjustment
Prevention or Rx of complications,
including infection.
 Nutritional support.
 Prevention of scars & contractures.
 Physical,occupational & vocational
reconstruction.
 Psychosocial counseling.

20. Emergency Management: Thermal Burns
Initial
 Ensure patent airway
• Assess for inhalational injury
 Monitor vital signs, level of consciousness, respiratory status, oxygen saturation, cardiac rhythm
 Assess airway, breathing and circulation
 Remove non-adherent clothes, shoes, watch, jewellary, glasses or contact lenses, if face was exposed
 Establish IV access with 2-large bore catheters for > 15% TBSA burn
 Begin fluid replacement and Insert urinary catheter

21. • Ongoing monitoring
 Monitor Airway
 Monitor vital signs, cardiac rhythm, LOC, respiratory status and oxygen saturation
 Monitor urinary output

22. Emergency Management: Chemical Burns
Initial
 Ensure patent airway
 Anticipate intubation with significant inhalational injury, circumferential full-thickness burns to the
neck/chest and/or large TBSA burn.
 Assess airway, breathing and circulation before decontamination procedures.
 Brush dry chemical from skin before irrigation.

23.  Administer IV analgesia & assess effectiveness frequently
 Cover burned areas with dry dressing or clean sheet
 Contact poison control center for assistance.
 Caregiver should protect self from potential exposure.
Ongoing monitoring
 Monitor Airway if exposed to chemicals and urinary output.
 Consider possibility of systemic effect of chemical & treat accordingly

24. Emergency Management: Electrical Burns
Initial
 Removal from current source with special equipment to prevent injury to rescuer.
 Assess & treat patients after removal from current source.
 Ensure patent airway
 Monitor vital signs, LOC, respiratory status, oxygen saturation & cardiac rhythm
 Assess airway, breathing and circulation
 Remove non-adherent clothes, shoes, watch, jewellary, glasses or contact lenses, if face was exposed
 Establish IV access with 2-large bore catheters for > 15% TBSA burn
 Begin fluid replacement and Insert urinary catheter.
 Elevate burn limbs above heart to reduce edema.

25. Ongoing monitoring
 Monitor Airway and urinary output to ensure adequate volume replacement.
 Monitor vital signs, LOC, respiratory status, oxygen saturation & neuro-vascular status of
injured limbs.
 Monitor urinary output for development of myoglobinuria to muscle breakdown.

26. Collaborative Care
Wound Care
 Cleansing & Gentle debridement using scissors and forceps
 Surgical debridement in operating room
 Prevention of Wound Infection:
 Open Method: Wound is covered with topical anti-microbial dressing and no other dressing over the wound
 Multiple dressing change method: Sterile, gauze dressings are impregnated with or laid over a topical anti-microbial
 Dressing changes can be done every 12-24 hours or once every 3 days.
 hand-washing and use of gown, gloves, masks etc. by care-provider.
 Use of aseptic technique during dressing changes.
 Aggressive nursing care

27.  Administer Tetanus toxoid or tetanus anti-toxin
 Assess and manage pain and anxiety
 Provide support to patient and family during initial crisis phase
 Place patient in position that prevents contracture formation and assess need for splints.
 Eye Care, Ear Care, Skin Care
 Assess nutritional needs and begin feeding by most appropriate route as possible

28. Drugs
Drugs
Purpose
Vitamin A, C, E & multi-vitamins Promotes wound healing
Minerals: Zinc, Iron Promotes cell integrity & Hemoglobin formation
Oxandrolone Promotes weight gain and preservation of lean body
mass
Morphine, Hydromorphine, Fentanyl, Oxycodone,
Methadone, NSAIDs, Adjuvant
All Analgesic drugs

29. Haloperidol Produces anti-psychotic & sedative effects, induces
sleep
Lorazepam Diminishes anxiety
Midazolam Has short-acting amnesic properties
Ranitidine Decreases incidence of Curling ulcer

30. Excision and Grafting
 Excision: Removal of the eschar down to the subcutaneous tissue or fascia
depending on the degree of the injury.
 Achievement of the homeostasis by pressure and application of topical thrombin or
epinephrine
 Grafting of the wound with auto graft (patient’s own skin)

31. Sources of Grafts
Source Graft Name Coverage
Patient's own skin Auto graft Permanent
Porcine Skin Heterograft or xenograft (diff. sps.) Temporary
(2 days-2 weeks)
Patient’s own skin & cell-cultures Cultured epithelial auto graft (CEA) Permanent
Bovine collagen & glycosaminoglycan
bonded to silicon membrane
Integra Permanent
Human, dermal fibroblast-derived matrix
with growth factors
TransCyte Temporary
(10-21 days)

33. Care After Grafting
Care of the patient with an Autograft
 Use of occlusive dressings
 Use of splints to immobilize the graft
 First dressing change after 3-5 days, earlier if foul odor or purulent drainage
 Minimal dressing changes
 Gentle positioning and handling the patient to prevent disturbing the graft
 Elevating the extremity, if grafted to reduce edema.
 If dislodgement of graft occurs, prevent drying of the graft by saline compresses till reinforcement.
Care of the Donor Site
 Application of mist dressing, thombostatic agents (epinephrine etc) to stop bleeding/oozing
 Application of dressings: Gauze impregnated with petrolactum/ Biobrane
Heals within 7-14 days with proper care

34. Harvesting donor skin
Once the skin has been harvested it is laid flat with the moist side facing upwards ready for application onto the graft site. If the area to cover is large the donor skin is meshed using a meshing tool or blade. This involves tiny slits
being made throughout the skin so that when stretched the skin can cover a larger surface area
Debriding graft site
Prior to grafting, the wound bed is cleaned and dead tissue or ‘eschar’ is removed. The area is debrided to a bleeding wound bed to encourage optimum graft survival. Debridement may be carried out
Skin application
The donor skin is applied to the graft site, making sure that all areas are suitable covered.
Applying donor skin
The graft skin is attached using staples, sutures, surgical glue or an adhesive dressing such as Hypafix, depending on graft site requirements and the surgeon’s preference.

35. Other Collaborative Care…
Physical & Occupational Therapy
 Begin early physical therapy program for maintenance of range of motion.
 Assess need for splints & anti-contracture positioning
 Counsel and teach patient and family about physical and psycho-social aspects of care
 Encourage and assist patient with self-care as possible
Nutritional Therapy
 Continue to assess diet to support wound healing
 Meet nutritional requirements using Cureri’s Formula
Psycho-social Care
 Assessing psychosocial & emotional needs of patient and family members
 Offer pastoral care, if needed
 Refer to psychologist for counseling

36. Nursing Diagnosis
 Fluid-volume excess r/t resumption of capillary integrity & fluid shift from interstitial to
intravascular compartment
 Risk for infection r/t loss of skin barrier & impaired immune response
 Altered nutrition, less than body requirements r/t hyper metabolism & wound healing
 Impaired skin integrity r/t open wounds
 Pain r/t exposed nerves, wound healing and treatments
 Impaired physical mobility r/t burn wound edema, pain, joint contractures
 Ineffective individual coping r/t fear, anxiety, grieving, and forced dependence on health-
care providers
 Altered family process r/t burn injury
 Potential complications: CHF, Pulmonary edema, sepsis, ARDS, visceral damage