Burn injuries are a major health issue that can cause significant tissue damage and systemic effects. A burn occurs when skin is damaged by heat, electricity, chemicals, friction or radiation. First degree burns involve only the epidermis, while second degree burns extend deeper into the dermis. Third degree burns destroy both the epidermis and dermis. Burn depth, size, and location impact severity and treatment approach. The emergency management of burns focuses on the ABCs - airway, breathing, circulation, disability, exposure and fluid resuscitation based on burn size. Definitive burn care then focuses on wound management and rehabilitation.

1. Dr Rahul Gorka
M.S, M.Ch
Lecturer (Plastic Surgery)

2. Definition of a Burn
 “Tissue injury caused by thermal,
radiation, chemical, or electrical
contact resulting in protein
denaturation, burn wound edema,
and loss of intravascular fluid
volume due to increased vascular
permeability.”

3. Burn Statistics
 At least 50% of all burn accidents can
be prevented
 children playing with fire account for
more than one-third of preschool
deaths by fire
 In the US, approximately 2.4 million
burn injuries are reported each year.
 Burn injuries are second to motor
vehicle accidents as leading cause of
accidental death in the US

4. TYPES OF BURNS
 Flame (Thermal)
 Electrical
 AC & DC
 Lightning
 Chemical
 Steam
 Radiation
 Scald
COURTESY DAVID
EFFRON, M.D.
THIRD DEGREE BURNS
WITH ESCHAROTOMIES

5. Types of Burns
 Thermal Injuries (most common)
 Contact
Direct contact with hot object (i.e. pan or iron)
Anything that sticks to skin (i.e. tar, grease or
foods)
 Scalding
Direct contact with hot liquid / vapors (moist
heat)
i.e. cooking, bathing or car radiator
overheating
Single most common injury in the pediatric client
 Flame
Direct contact with flame (dry heat)
i.e. structural fires / clothing catching on fire

6. Types of Burns
 Chemical
 Caused by strong acids, alkalis, phenols,
cresols, phosphorus or mustard gas
 Results in necrosis
 Electrical
 Caused by electric current which may
generate heat up to 5000ºC
 May result in necrosis, respiratory paralysis, or
ventricular fibrillation

7. Types of Burn Injury
 Smoke & inhalation injury-inhaling hot
air or noxious chemicals
 Cold thermal injury-frostbite.
 Radiation
 Caused by prolonged or intense exposure to
ultraviolet radiation
 Examples: Sunburn, tanning beds

8. Classification of Burn Injury
 Treatment of burns is directly related to
the severity of injury!
 Severity is determined by:
 depth of burn
 external of burn calculated in percent of total
body surface (TBSA)
 location of burn
 patient risk factors

9. Location of Burns
 Has a direct relationship to the severity of
the burn.
 Face, neck & chest burns may cause
respiratory illness mechanical obstruction
secondary to edema or eschar formation

10. Burn Patient Severity
 Patient age
 Less than 2 or greater than 55
 Have increased incidence of complication
 Burn configuration
 Circumferential burns can cause total occlusion of
circulation to an area due to edema
 Restrict ventilation if encircle the chest
 Burns on joint area can cause disability due to scar
formation

11. Anatomy and Physiology of
Skin

12. Skin
 Largest body organ. Much more than a
passive organ.
 Protects underlying tissues from injury
 Temperature regulation
 Acts as water tight seal, keeping body fluids
in
 Sensory organ

13. Skin
 Injuries to skin which result in loss, have
problems with:
 Infection
 Inability to maintain normal water balance
 Inability to maintain body temperature

14. Skin
 Two layers
 Epidermis
 Dermis
 Epidermis
 Outer cells are dead
 Act as protection and
form water tight seal

15. Skin
 Epidermis
 Deeper layers divide to produce the stratum
corneum and also contain pigment to protect
against UV radiation
 Dermis
 Consists of tough, elastic connective tissue
which contains specialized structures

16. Skin
 Dermis - Specialized Structures
 Nerve endings
 Blood vessels
 Sweat glands
 Oil glands - keep skin waterproof, usually
discharges around hair shafts
 Hair follicles - produce hair from hair root or
papilla
 Each follicle has a small muscle (arrectus pillorum)
which can pull the hair upright and cause goose
flesh

17. First-Degree Burns
 Does not go below
basal layer of the
epidermis
 Dry and painful
 Appears red due to
increased blood
flow
 Heals in a few days

18. Second-Degree Burns
 Extends below basal
layer, but not
completely through
dermis
 Superficial
 Blister, very painful,
contains skin parts
(adnexa) which assist
in epithelialization
 Deep Partial-thickness
 Deeper in dermis,
fewer adnexa, longer
healing time, less
painful

19. Third-Degree Burns
 Extends completely
through dermis
 Adnexa destroyed so
can’t heal by
epithelialization
 Dermal plexus of
nerves destroyed-
less painful
 Burns can be yellow,
red, black, brown

20. Burn Depth
 Fourth-degree
 Full-thickness
destruction of
skin/subcutaneous
tissue
 Involves underlying
fascia, muscle, bone or
other structures
 Prolonged disability

22. FIRST AND SECOND DEGREE
BURNS
FIRST DEGREE BURN SECOND DEGREE BURN

23. THIRD DEGREE BURNS
COURTESY DAVID EFFRON,M.D.
COURTESY BONNIE
MENEELY, R.N.

24. CHEMICAL BURN
COURTESY ROY ALSON,
M.D.

25. SCALD BURN
COURTESY DAVID
EFFRON, M.D.

26. Initial Estimate of : “Rule of Nines”
Adult anatomical areas = 9% BSA (or multiple)
Extent of Burn
• Not accurate for
infants / children due
to larger BSA of head
& smaller BSA of legs.
Burn diagrams
illustrate adult and
child differences.

27. Rule of Nines
 In the adult, most areas of the body can
be divided roughly into portions of 9%, or
multiples of 9. This division, called the rule
of nines, is useful in estimating the
percentage of body surface damage an
individual has sustained in burn.

28. Burn Assessment Lund & Browder Chart

29. Thermal Burn Injury
Pathophysiology
 Emergent phase
 Response to pain  catecholamine release
 Fluid shift phase
 massive shift of fluid - intravascular 
extravascular
 Hypermetabolic phase
  demand for nutrients  repair tissue
damage
 Resolution phase
 scar tissue and remodeling of tissue

30. Zones of Burn Injury
 Zone of Coagulation
 Inner Zone
 Area of cellular death (necrosis)
 Zone of Stasis
 Area surrounding zone of coagulation
 Cellular injury: decreased blood flow & inflammation
 Potentially salvable; susceptible to additional injury
 Zone of Hyperemia
 Peripheral area of burn
 Area of least cellular injury & increased blood flow
 Complete recovery of this tissue likely.

31. ESCHAR
 The necrotic tissue resulting from a burn
is known as eschar.
 It is a good substrate for microorganisms.
If left untreated it becomes colonized,
contaminated and eventually infected.
 Topical antimicrobial agents increase the
time to eschar separation.

32.  systemic changes

33. Burn
Pathophysiology:inflammation&
Edema
 Injured tissue: capillary permeability es
 Protein leakage: resultant
hypoproteinemia, and ed osmotic
pressure in burned tissue
 Decreased cell membrane potential with
inward shift of Na+ and H2O, resulting in
cellular swelling
 Edema maximal at 24 hrs, usually resolved
by 3-5 days; capillary leak normal at 24
hrs

34. Burn Pathophysiology: Metabolic
 Hypermetabolic response  BSA affected;
may approach 200% of basal metabolic
rate
 catabolic response
 acute phase response
 Mediators implicated:
 stress hormones: catecholamines, steroids
 cytokines: TNF, IL-1, IL-6
 lipids: prostaglandins, thromboxane B2, PAF

35. Burn Pathophysiology: Metabolic
 Prostaglandins, IL-1, IL-6 implicated in:
 increase in core temperature of 1-2oC
 initiating acceleration of nitrogen catabolism
 ? inversion of T4/T8 ratios from 2:1 to 1:2
 Early enteral feeding associated with
attenuation of the hypermetabolic
response

36. Burn Pathophysiology:
Cardiac
 Cardiac output initially decreases
 loss of intravascular volume
 CVP and PCWP typically low-normal, even
after adequate volume resuscitation
 Cardiac output usually normalizes before
intravascular volume completely restored
  iCa++ may present as hypotension/EMD
 out of proportion to hypoalbuminemia

37. Burn Pathophysiology: Renal
it can result from:
 prolonged hypotension due to hypovolemia
 myoglobin release from damaged
muscle/tissue
 hemoglobinuria from heat-induced hemolysis
 Renal blood flow initially es, followed by
dramatic  in GFR, coinciding with onset
of the postburn hypermetabolic state, and
hyperdynamic circulation

38. Burn Pathophysiology: Renal
 Early in the postburn period, decreased
urinary Na+ and Cl-
 K+ wasting in the urine is common (up to
200 mEq/liter), secondary to the intense
adrenal response to burn injury/stress

39. Burn Pathophysiology: Hypertension
 May be common in pediatric patients
 up to 57% in one study
 7-10 year old boys with >20% BSA affected
 Hypertensive encephalopathy may result
 7% of hypertensive pediatric burn patients
 Mechanism may involve hypervolemia with
concomitant activation of RA SYSTEM
 ?elevated “stress” plasma renin and
aldosterone

40. Burn Physiology: Pulmonary
 Pulmonary dysfunction etiologies in this
setting:
 shock, inhalational injury, aspiration, sepsis,
CHF, trauma
 Upper airway injury/edema may contribute
 airway occlusion impairs flow of tidal breaths
• resolution of occlusion can cause reexpansion

41. Burn Physiology: Pulmonary
 Circumferential thoracic eschar or edema
may contribute to restrictive lung disease
 Hypovolemia may cause V/Q mismatch
 Inflammatory mediators released in burn
injury linked to evolution of ARDS
 therefore, expect some degree of pulmonary
capillary leak, on a continuum from mild
pulmonary edema, to frank ARDS

42. Burn Pathophysiology: CNS
 CNS dysfunction in up to 14% of burn pts
 most had >50% BSA involvement
 Hypoxia most common etiology
 smoke inhalation, pulm edema, pneumonia
 Hypovolemia, hyponatremia, cortical vein
thrombosis, sepsis, and gliosis due to
watershed infarct also implicated
 ? Role of neurotoxic factors

43. Burn Pathophysiology: GI
 Stress (curling’s) ulcer
 prophylaxis: antacids, H2 blockers, or
sucralfate
 Increased gut permeability in first 24
hours
 Acalculous cholecystitis
 fever, abdominal distention, jaundice
 bacterial seeding (ascending cholangitis)
 sterile, in patients with dehydration, ileus, or
pancreatitis

44. Burn Pathophysiology: GI
 Acute pseudo-obstruction of the colon
 massive colonic dilation without organic cause
Narcotic ileus
 oral narcotic antagonists may be efficacious
 hypovolemia shunt blood from the splanchnic
bed and promote mucosal atrophy and failure
of the gut barrier

45. Burn Pathophysiology:
Hepatic
 Modest hepatic dysfunction common early
 Persisting, or severe hepatic dysfunction,
associated with negative outcome
 larger BSA involvement (58% vs 30%)
 greater mortality (74% vs 9%)
 clinical jaundice associated with 90%
mortality
 Late onset of conjugated
hyperbilirubinemia usually related to
occult, or overt, sepsis

46. Burn Pathophysiology: Blood
 Initially, shortened RBC survival with intra-
vascular hemolysis/possible
hemoglobinuria
 typically resolves after the 1st week
 Anemia is common, and to be expected;
 may be masked initially by hemoconcentration
 may be exacerbated by fluid management,
occult blood loss
 typically persists until wound healing occur
 depressed erythropoietin levels documented

47. Burn Physiology:
Immunologic
 Skin as an organ of host defense:
 keratin layers as physical barrier to
penetration
 cycles of desquamation (“debulking” of
skin bacterial burden)
 stratum corneum: unsaturated free fatty
acid film which is bacteriostatic and
fungistatic
 colonization resistance due to normal flora
 antigen presentation to Langerhans’ cells

48. Burn Physiology:
Immunologic
 Cellular Immune Function
 markedly delayed allograft rejection
 ed antigen responses
 total lymphocyte count typically normal, but
T4 (helper T-cell) count , while T8
(suppressor T-cell) count  (T4/T8 ratio
inverts)
 several circulating mediators in burn patient
sera suppress normal lymphocyte function

49. Burn Physiology:
Immunologic
 “Immunologic Dissonance” resulting
from activation of inflammatory
cascades/SIRS
 Systemic immunosupression may therefore
occur very early in the post-burn period;
magnitude of immunocompromise  BSA

50. Increased gut
mucosal Permeability
Immunosuppression
Decreased Renal blood flow
Severe Burn
Vascular Permeability &
oedema
Altered haemodynamics
Hypermetabolism

51. Phases of Burn Care
 Emergency assessment and care (ABCs)
 Resuscitation (hours 0-48)
 Definitive care (day 3 until wounds are
closed)
 Rehabilitation (begins during resuscitation
and lasts entire lifespan)

52. Rescue
 A-B-C-D-E-F
 Stop the burning
 Decontaminate casualty at the scene
 Avoid injury to the rescuer
 Careful with high voltage electrical wires
 Assess for other injuries

53. ABCs of Emergency Burn Care
(Advanced Burn Life Support)
 A = Airway (with cervical spine assessment)
 B = Breathing
 C = Circulation
 D = Disability
 E = Exposure and Environmental Control
 F = Fluid Resuscitation based on Burn Size and
Weight Measurement
 Secondary Survey

54. A: Airway
 Assess the patient’s airway
 Upper airway edema due to inhalation injury
 Rapid or delayed progression
 Decision to intubate: individualized
 Mild symptoms: observe in ICU
 Pre-transport: prophylactic intubation
 When in doubt, intubate

55. B: Breathing
 Look, listen, feel for breath sounds and
chest movement
 Give 100% oxygen to all victims of major
burn beginning in the field
 Pulse oximetry
 Arterial blood gases
 Required for definitive diagnosis of CO
 Baseline chest x-ray

56. C: Circulation
 Who needs fluid resuscitation?
 All >20% total body surface area burned (TBSA)
 Young and old with >10% TBSA
 2 large bore peripheral IVs
 Unburned skin
 Burned skin
 Central access
 Cutdown
 Interosseous

57. D: Disability
 Assess level of consciousness: AVPU
 Alert
 Responds to verbal stimuli
 Responds to painful stimuli
 Unresponsive
 Alteration in mental status is not normal
 Pupils
 Moves extremities

58. E: Exposure and Environment
 Remove clothing, jewelry
 Keep warm
 blankets
 warm I.V. fluids
 heating lamps
 heat the room
 Keep Patient Dry

59. F: Fluid Resuscitation
(based on burn size and weight)
 Determine fluid needs based on burn size and
weight
 Burn size: include second and third degree only
 Rule of Nines
 One hand = one percent
 Lund-Browder chart
 Overestimation by referring hospitals is common
 Weight: pre-burn weight

60. Fluid Therapy
 1 or 2 large bore IV replacement lines (may
need jugular or subclavian)
 Cutdown if no option , increased risk of
infection & sepsis
 Fluid replacement based on: size/depth of
burn, age of pt., & individualized
considerations--ex. Dehydration in preburn
state, chronic illness
 options- RL, D5NS, dextam, albumin, etc.
 there are formula’s for replacement: Parkland
formula and Brooke formula

61.  Total Body Surface Area (TBSA) Burned
 Palmar Method
 A quick method to evaluate scattered or
localized burns
 Client’s palm = 1 % TBSA
 Rule of Nines
 A quick method to evaluate the extent of burns
 Major body surface areas divided into multiples
of nine
 Modified version for children and infants
 Lund-Browder Method
 Most Accurate; based on age (growth)
 Can be used for the adult, children & infants

62. Burns
 Parkland/Baxter Formula
 4 ml RL/kg body wt X % TBSA=ml RL for 24
hours
 eg. Pt. wt=75 kg and burned 25%
4/75/25=7500 ml/24 hours
50% 1st 8 hours=3750ml
25% 2nd 8 hours=1875 ml
25% 3rd 8 hours=1875

63. Formulas for Fluid Replacement
Evans Formula.
􀂋 Colloids 1 ml./kg. of body wt/%/burn.
􀂋 Saline 1 ml/kg. of b. wt./% of burn.
􀂋 free water: dependent on age &
insensible loss.
􀂋 1/2 of total is given the 1st 8 hrs. and
the remainder given the next 16 hrs.

64. Brooke Formula
􀂋.
􀂋 Colloids .5 ml/kg/% of body surface
burned.
􀂋 Lactated Ringers 1.5 ml/% of body wt/%
burn.
􀂋 H20 Again dependent.
􀂋 1/2 total amount given 1st 8 hrs.
􀂋 1/4 of total the 2nd 8 hrs. 1/4 the third 8
hrs.

65. Galveston formula
Resuscitation Formula
 1. Fluid administration-Ringers lactate
First 24 h:
 a. 5000 ml/M2 burn + 2000 ml/TBSA m2
 b. administer 1/2 in first 8 h postinjury and the 2nd half
in the next 16 h.
 Example: 15 kg child with an 87% TBSB, height 96 cm.
 Body Surface (m2) =.60
 Total Burn (m2)=.52
 2000 ml x .6 TBSAm2 = 1200 ml
 5000 ml x .52 TBSABm2 =2600 ml
 Total fluids first 24 h = 3800 ml
 Total fluids first 8 h = 1900 ml = 237 ml/h
 Total fluids next 16 h = 1900 ml = 118 ml/h

66. Assessment of adequacy of
fluid replacement
 Urinary output is most commonly used
parameter
 urine OP-30-50 cc/hr in an adult
 cardiopulmonary factors- BP (systolic 90-100
mmHg, pulse less than 100, resp 16-20 breaths
per min. (BP more accurate with arterial line)
 sensoruim-alert, oriented to time, place, &
person

67. FIRST AID
cooling the burn wound soon after the injury
(within 30minutes) is beneficial in removing heat
from the wound and limiting tissue damage.
It can also reduce early edema and protein
extravasation.
Care must be taken, as prolonged or excessive
cooling can be detrimental.

68. Other precautions...
 Burn too large--don’t immerse in water
due to extensive heat loss
 Never pack in ice
 Pt. should be wrapped in dry clean
material to decrease contamination of
wound and increase warmth

69. CRITERIA FOR ADMISSION
 Both 2nd & 3rd
degree burns
 >20% BSA any age
 >10% BSA <10 or
>50 years of age
 3rd degree only
 >5% BSA
 Burns of face,
hands, feet,
genitals, or joints

70. CRITERIA FOR ADMISSION
 Specialized burn
types
 Electrical &
lightning
 Chemical
 Inhalation injury
 Circumferential
chest or extremity
burns
 Significant medical
illness
 Significant other
injuries

71. Critical Burn Criteria
 30 > 10% BSA
 20 > 30% BSA
 >20% pediatric
 Burns with respiratory injury
 Hands, face, feet, or genitalia
 Burns complicated by other trauma
 Underlying health problems
 Electrical and deep chemical burns

72. Moderate Burn Criteria
 30 2-10% BSA
 20 15-30% BSA
 10-20% pediatric
 Excluding hands, face, feet, or genitalia
 Without complicating factors

73. Minor Burn Criteria
 30 < 2% BSA
 20 < 15% BSA
 <10% pediatric
 10 < 20% BSA

74. Escharotomies
—required if circumferential full thickness burns
of chest,limbs or digits are present.
 can impair circulation and cause distal
ischemia. Circumferential full-thickness chest
burns can restrict chestwall excursion and impair
ventilation.
mid-axial escharotomies performed either at
bedside or in the operating room..
An escharotomy incision will only improve
outcome without risk of harm in that situation.

76. INHALATION INJURIES
 Carbon monoxide poisoning
 Toxic gas inhalation
 Smoke inhalation
 Heat inhalation
 Steam inhalation
 Asphyxiation

77. 3 types of smoke and
inhalation injuries
 1. Carbon monoxide poisoning (CO
poisoning and asphyxiation count for
majority of deaths)
 Treatment- 100% humidified oxygen-draw
carboxyhemoglobin level- can occur without
any burn injury to the skin

78.  2. Inhalation injury above the
glottis (caused by inhaling hot air,
steam, or smoke.)
 Mechanical obstruction can occur quickly-
True ER! Watch for facial burns, signed
nasal hair, hoarseness, painful swallowing,
and darkened oral or nasal membranes

79.  3. Inhalation injury below glottis
 (above glottis-injury is thermally produced)
 below glottis-it is usually chemically
produced.
 Amount of damage related to length of
exposure to smoke or toxic fumes
 Can appear 12-24 hours after burn

80. SIGNS OF SMOKE INHALATION
 Exposed to smoke in enclosed
space
 Unconscious while exposed to
smoke
 After exposure to smoke
 Develops cough
 Develops dyspnea
 Develops chest pain

81. SIGNS OF UPPER AIRWAY BURNS
 Burns of the face
 Singed eyebrows or
nasal hairs
 Burns in the mouth
 Sooty sputum
 History of being burned
while confined to an
enclosed space
COURTESY ROY ALSON, M.D.
LIP BURNS & SOOT IN
MOUTH

82. Inhalation Injury Management
 Airway, Oxygenation and Ventilation
 Assess for airway edema early and often
 Consider early intubation
 When in doubt oxygenate and ventilate
 High flow oxygen
 Bronchodilators may be considered if
bronchospasm present
 Diuretics not appropriate for pulmonary
edema

83. Inhalation Injury Management
 Circulation
 Treat for Shock (rare)
 IV Access
 LR/NS large bore, multiple IVs
 Titrate fluids to maintain systolic BP and perfusion

84. Inhalation Injury Management
 Other Considerations
 Assess for other Burns and Injuries
 Treat associated inhalation injury/poisoning
 Cyanide poisoning antidote kit
 Positive pressure ventilation
 Hyperbaric chamber (carbon monoxide poisoning)

85. Wound Care Principals
Goals
 􀂄 close wound
 􀂄 prevent infection
 􀂄 reduce scarring and contractures
 􀂄 provide for comfort
Wound cleaning
Debridement
 􀂄 mechanical
 􀂄 surgical
Topical antibacterial therapy

86. Cleansing and Debridement
 Can be done in tank, shower, or bed
 Debridement may be done in surgery.
(Loose necrotic skin is removed)
 bath given with with surgical detergent,
disinfectant, or cleansing agent to reduce
pathogenic organisms

87. Infection is the most serious
threat to further tissue injury
and possible sepsis.
 SURVIVAL is related to prevention of
wound contamination.
 Source of infection is pt’s own flora,
predominantly from the skin, resp. tract, and
GI tract.
 Prevention of cross contamination from other
patients is the priority for nurses!

88. 2 methods used to control
infections in burn wounds...
 Open method- pt’s burn is covered with
topical antibiotic and has no dressing
 Closed method-uses sterile gauze
impregnated with or laid over a topical
antibiotic. Dressings changed 2-3 times q
24 hrs.

89. Wound Care continued...
 Staff should wear disposable caps, gowns,
gloves, masks when wounds are exposed
 use of sterile techniques
 keep room warm
 careful handwashing
 any bathing areas disinfected before and
after bathing

90.  Coverage is the primary goal for burn
wounds. Since usually not enough unburned
skin for immediate skin grafting, other
temporary wound closure methods are used
 Allograph or homograft (same species which is
usually from cadavers) is used for wound
closure-- temporary--3 days to 2 wks
 Porcine skin-heterograft or xenograft (different
species)--temporary--3 days to 2 wks
 autograft or cultured epithelial autograft- (pt’s
own skin and cell culture)- permanent

91. Burn Wound Closure
 Permanent Skin Grafts
 Two types:
Autografts and Cultured Epithelial Autografts
(CEA)
 Autograft
Harvested from client
Non-antigenic
Less expensive
Decreased risk of infection
Can utilize meshing to cover large area
Negatives: lack of sites and painful

92. Permanent Burn
Wound Closure Cont.,
 Permanent Skin Grafts Cont.,
 Cultured Epithelial Autografts (CEA)
A small piece of client’s skin is harvested and
grown in a culture medium
Takes 3 weeks to grow enough for the first
graft
Very fragile; immobile for 10 days post grafting
Great for limited donor sites
Negatives: very expensive; poor long term
cosmetic results and skin remains fragile for
years

93. Temporary Burn Wound Closure
 Biosynthetic Temporary Skin Grafts
 Homograft
 AKA Allograft
 Live or cadaver human donors
 Fairly expensive
 Best infection control of all biologic coverings
 Negatives:
 Risk of disease transmission (i.e. HBV & HIV)
 Antigenic: body rejects in 2 weeks
 Not always available
 Storage problems

94. Temporary Burn Wound Closure
 Biosynthetic Temporary Skin Grafts Cont.,
 Heterograft
AKA Xenograft
Graft between 2 different species
i.e. Porcine (pig) most common
Fresh, frozen or freeze-dried (longer shelf life)
Amendable to meshing & antimicrobial impregnation
Antigenic: body rejects 3-4 days
Fairly inexpensive
Negatives: Higher risk of infection

95. Temporary Burn Wound Closure
 Temporary Skin Grafting Cont.,
 Artificial Skins
Transcyte:
A collagen based dressing impregnated with
newborn fibroblasts.
Integra:
A collagen based product that helps form a
“neodermis” on which to skin graft.
 Synthetic
Any non-biologic dressing that will help
prevent fluid & heat loss
Biobrane, Xeroform or Beta Glucan collagen
matrix

96. Donor Site:
Wound Considerations
 The donor site is often the most painful
aspect for the post-operative client.
 We have created a brand new wound !!
 Variety of products are used for donor sites.
Most are left place for 24 hours and then left
open to air.
 Donor sites usually heal in 7-10 days

97. using a dermatome (left) to remove
donor skin and a mesher (right) to put
holes in it.

98. Example of healing burn

99. Other care measures include
 Face is vascular and subject to increased
edema- use open method
 eye care-use saline rinses, artificial tears
 hands &arms-extended and elevated on
pillows or in slings to minimize edema,
may need splints to keep them in
functional positions

100.  Ears- keep free of pressure. Ear burns-
no pillows! Neck burns should not use
pillows in order to decrease wound
contraction.
 Perineum-must be kept clean & dry.
Indwelling foley will help in this & also
to provide hourly outputs.
 Lab tests ; to monitor electrolyte
imbalance and ABGs
 Physio therapy stared immediately

101. Drug Therapy
 Analgesics and Sedatives
 given for pt comfort
 IV pain meds initialy due to:
 GI function is slowed or impaired because of
shock or paralytic ileus
 IM injections will not be absorbed well

102. Drug Therapy
 Tetanus immunization- given routinely
to all burn patients because of the
likelihood of anaerobic burn-wound
contamination
 Antimicrobial agents-usually topical
due to little or no blood supply to the burn
eschar so little delivery of the antibiotic to
wound
 Drug of choice is: Silver sulfadiazine

103.  Curlings ulcer prophylaxis
(Peptic Ulcer)
 An H2 blocker (cimetidine,
ranitidine,famotidine) start first 6 hours
 antacids are no longer recommended - the
patient should be kept NPO
 with burns > 15% of BSA, an NG (OG) tube
and bladder catheter should be placed

104. Burns (medications)
 Silver nitrate 0.5% (rarely used)
 wet dressing effectively prevents cross infection
 >0.5% injures the tissue and not effective<0.5%
 danger of electrolyte imbalance (especially Na and K)
since the electrolytes are withdrawn from the body
fluids and also from the dressing.
 Turns black in sunlight and stains clothes and hands
black

105. Burns (medications)
 Silvadene
 wide-spectrum antimicrobial that is
nonstaining and relatively painless
 no systemic metabolic abnormalities however
is contraindicated in pregnant women near
term and premature infants
 does not penetrate the eschar as well as
sulfamylon

106. Burns (medications)
 Sulfamyalon acetate
 interferes with bacterial cellular metabolism
 diffuses rapidly through burned skin and eschar
 used for gram-negative organism
 burning sensation after applied topically
 may cause metabolic acidosis and is a carbonic
andryrase inhibitor
 may cause a rash

107. Burns (medications)
 Furacin-nitrofurazone (gauze or cream)
 a synthetic broad-spectrum antibacterial
 inhibits enzymes required for carbohydrate
metabolism in bacteria
 Xeroform-a fine mesh gauze with
antimicrobial action

108. Topical antimicrobials
Advantages and Disadvantages
 Silver Sulfadiazine –Painless but Lack of
penetration
 Mafenide Acetate –Penetrates but Painful,
Carbonic anhydrase inhibitor
 Silver Nitrate- Broad spectrum but Limited
penetration
 Sodium Hypochlorite -Broad spectrum but
Impairs wound healing in high doses

109.  Table 7.2. Other topical agents
 Bacitracin: Gram-positive Minimal coverage
Often combined with polymyxin and neomycin
into triple ointment
 Polymyxin B :Petroleum-based Keeps grafts
moist, Often combined with mycostatin into
“Polymyco”
 Bactroban: Staphylococcal coverage ,Very
expensive
Useful for ghosted grafts
 Silvamyco:(Silvadene and mycostatin) Extended
coverage

110. SYSTEMIC ANTIMICROBIAL
THERAPY IN BURNS
 only after clinical suspicion of an infection
exists
 appropriate in patients with massive burns
 based on culture and sensitivities

111. Complications of Acute Phase
 Infection- due to destruction of body’s 1st line
of defense. Partial thickness wds can convert to
full-thickness wds with infection present.
 Signs of sepsis are: high temp., increased
pulse & resp., decreased BP, and decreased
urinary output, mild confusion, chills, malaise,
and loss of appetite. WBC bet. 10,000 and
20,000. Infections usually gram neg. bacteria
(pseudomonas, proteus)
 Obtain cultures from all possible sources: IV,
foley, wound, oropharynx, and sputum

112. Neurologic-possible from electrical injuries
 Musculoskeletal-has the most potential f
complications during acute phase due to
healing and scar formation making skin less
supple and pliant. contractures can occur
 Gastrointestinal-adynamic ileus results from
sepsis, diarrhea or constipation ( narcotics &
decreased mobility), gastric ulcers , stress,
occult blood in stools possible
 Endocrine-stress DM might occur-assess
glucose

113. Complications Cont.,
 Electrolytes Imbalances
 Hyperkalemia
 A result of cellular destruction
 Hyponatremia
 A result of fluid shifts into interstitial space
 Acid-Base Imbalances
 Metabolic Acidosis
 Failure to conserve bicarbonate
 Also, a result of fluid shifts into interstitial space
See Smeltzer & Bare pp. 1713; Table 57-3

114. Burn Shock
 Shock is a state of inadequate cellular perfusion
 Burn Injuries involving > 35 % TBSA
 Clinical manifestations:
 Hypotension & tachycardia
 Decreased Cardiac Output:
 Decreased preload, stroke volume & contractility
 Increased afterload
 Monitoring: PCWP & CVP values decreased
 Prevention: Early & full fluid resuscitation !!
Smeltzer & Bare pp. 1708 (Figure 57-3)

115.  NUTRITION

116. Nutritional Therapy
 Fluid replacement takes priority over
nutritional needs in the initial emergent
phase.
 NG tube is inserted and connected to
low intermittent suction for
decompression. When bowel sounds
return (48-72 hrs) after injury, start
with clear liquids and progress up to a
diet high in proteins and calories

117. Adult Energy Requirements
 Curreri formula
 Daily energy requirement = (25W + 40B)
 Long formula
 BEE x activity factor x injury factor
 Male BEE = 66.6 + 13.8W + 5H – 6.8A
 Female BEE = 655 + 9.6W + 1.9H – 4.7A
 Activity factors:
 1.2 if confined to bed
 1.3 if out of bed
 Injury factor:
 2.1 for severe thermal burn
 W=weight in kg, B=total burn area as % of
total body mass, H=height in cm, A=age in
years

118. Child Energy Requirements
 Wolfe Formula
 Energy = BMR x 2
 BMR Calculations
Age Boys Girls
0-3 years 60.9W – 54 61W – 51
4-10 years 22.7W + 459 22.5W +
499
11-18 years 17.5W + 651 12.2W + 746
 W= weight in kg

119. Child Energy Requirements
 Modified Galveston formula
 < 1 year: (2100 x BSA) + (1000 x burn area)
 < 12 years: (1800 x BSA) + (1300 x burn
area)
 12-18 years: (1500 x BSA) + (1500 x burn
area)
 BSA = body surface area in m2
 Burn area = surface area burned in m2

120. Carbohydrate Requirements
 Glucose reduces extent of hypermetabolic
response and protein breakdown
 High rates of glucose delivery:
 Causes hyperglycaemia needing insulin
 Stimulates hepatic lipogenesis & altered liver function
 Increased CO2 production
 Prevents & slow weaning from ventilator
 Adults: 5 mg/kg/min avoids complications
 Children: 5-7 mg/kg/min
 Infants: D5W 5 mg/kg/min initially then
increased to a max of 15 mg/kg/min over first few
days

121. Fat Requirements
 Normal diet leads to muscle wasting
with central obesity due to hepatic
steatosis
 Fat reduction prevents problems when
protein replaces lipid energy
 Adults: Minimum of 4% total energy
 15% meets essential fatty acid requirements and
provides for fat-soluble vitamins
 Vary composition of fats
 Children: Minimum of 2-3% total energy
 Infants: Maximum of 4g/kg of IBW

122. Protein Requirements
 Intact protein rather than amino acids
 Improved weight maintenance and survival
 Frequent estimations of nitrogen loss to
ensure adequate replacement
 TNL = TUN + 4g
 TNL = (UUN x 1.25) + 4g
 NB = TNL – NS
 6.25 g protein = 1 g nitrogen
 Adults: 2-3 g protein/kg IBW
 Children:
 < 1 year old: 3-4 g protein/kg IBW
 1-3 years old: 2.5-3 g protein/kg IBW
 >3 years old: 1.5-2.5 g protein/kg IBW
 25% energy as protein

123. Vitamin Requirements
 Specific requirements not established for
most
 Multivitamin supplementation
 Vitamin A
 Immune function & epithelialization
 10,000 IU/day
 < 3 years old: 5,000 IU/day

124. Vitamin Requirements
 Vitamin C
 Immune function
 Wound Healing
 Collagen synthesis
 Free radical scavenging properties limits tissue damage
 Ascorbic acid study
 High doses reduced resuscitation fluid volume, body
weight gain, wound edema, & severity of respiratory
dysfunction
 Adults: 500 mg twice a day
 Children up to age 10: 250 mg twice a day

125. Enteral vs. Parenteral Feeding
 Enteral preferred over parenteral
 Maintains integrity of GI tract
 Parenteral more expensive & increases
complications
 Hospital-made vs. commercial diets
 Hospital made diets as good as commercial
 Weight gain & protein increase similar
 Patient tolerance similar

126. SPECIAL CONSIDERATIONS

127. ELECTRICAL BURNS
 Extent of injury
depends upon
 Type of current
 Amount of current
 Path of current
 Duration of current

128. ELECTRICAL BURNS
 Injury from electrical
burns results from
coagulation necrosis
that is caused by
intense heat
generated from an
electric current.

129. Electrical injury can cause:
 Fractures of long bones and vertebra
 Cardiac arrest or arrhythmias--can be
delayed 24-48 hours after injury
 Severe metabolic acidosis--can develop in
minutes
 Myoglobinuria--acute renal tubular
necrosis- myoglobin released from muscle
tissue whenever massive muscle damage
occurs--goes to kidneys--and can
mechanically block the renal tubules due
to the large size!

130. ELECTRICAL INJURY
 Cardiac arrhythmias
are the most serious
immediate injury that
occurs with electrical
contact
 V-Fib
 V-Tach

131. ELECTRICAL BURNS
COURTESY DAVID EFFRON,
M.D.
COURTESY BONNIE
MENEELY, R.N.

132. Treatment of electrical
burns…
 Fluids--Ringers lactate or other fluids-
flushes out kidneys--you want 75-100
cc/hr until urine sample clear
 an osmotic diuretic (Mannitol) may be
given to maintain urine output

133. Electricity can instantaneously destroy tissue. This child has a
burn that resulted from biting on an electrical cord. These
burns often occur at the corners of the mouth, as seen here.

134. ADDITIONAL INJURIES
 Skin burns
 Entrance and
exit wounds
 Fractures
 cannot
determine the
extent of the
injury from the
surface burn
DA
Y
ON
E
DA
Y
3

135. LIGHTNING STRIKE
 Usually superficial
injury
 Victims die from
cardiac arrest
 Resuscitate the
“dead”
 Patients who are
breathing will usually
survive

136. Chemical Burn
2 types of chemical burns
 acids-can be neutralized
 alkaline- adheres to tissue, causing
protein hydrolyses and
liquefaction
 examples: cleaning agents, drain cleaners,
and lyes, etc...

137. Chemical Burns
 Acids
 Immediate coagulation-type ,necrosis creating
an eschar though self-limiting injury
 coagulation of protein results in necrosis in which
affected cells or tissue are converted into a dry,
dull, homogeneous eosinophilic mass without
nuclei

138. Chemical Burns
 Bases (Alkali)
 Liquefactive necrosis with continued
penetration into deeper tissue resulting in
extensive injury
 characterized by dull, opaque, partly or completely
fluid remains of tissue
 Dry Chemicals
 Exothermic reaction with water

139. CHEMICAL BURNS
 Injure the skin
 May be absorbed into the body and
damage internal organs
 May be inhaled into the lungs and cause
lung tissue damage
 May have minimal skin injury and yet
cause severe systemic injury

140. FACTORS CAUSING TISSUE
DAMAGE IN CHEMICAL
BURNS
 Type of chemical
 Concentration of
chemical
 Amount of chemical
 Duration of contact
 Manner of contact
 Mechanism of
action
ACID BURN

141. TREATMENT OF CHEMICAL EXPOSURE
 Remove and bag all contaminated
clothing
 Brush off dry chemical
 Flush with copious amounts of water
or any drinkable liquid
 Wipe or scrape any retained chemical
and irrigate again
“THE SOLUTION TO POLLUTION IS
DILUTION”

142. Chemical Burn to Eye
Management
 Flood the eye with copious amounts of
water only
 Never place chemical antidote in eyes
 Flush using LR/NS/H2O from medial to
lateral for at least 15 minutes
 Nasal Cannula
 IV Ad Set
 Remove contact lenses
 May trap irritants

143. Rehabilitation Phase
 Defined as beginning when the patient’s
burn wound is covered with skin or healed
and patient is capable of assuming some
self-care activity.
 Can occur as early as 2 weeks to as long as
2-3 months after the burn injury
 Goals for this time is to assist patient in
resuming functional role in society &
accomplish functional and cosmetic
reconstruction.

144. Clinical Manifestations
 Burn wd either heals by primary intention
or by grafting.
 Scars may form & contractures.
 Mature healing is reached in 6 months to
2 years
 new skin sensitive to trauma

145. Complications
 Most common complications of burn injury
are skin and joint contractures and
hypertrophic scarring
 Because of pain, pts will assume flexed
position. It predisposes wds to contracture
formation
 Use of physical therapy, pressure
garments, splints, etc. are used

146. Hypertrophic Scar Formation
 Excessive scar formation, which rises above
the level of the skin
 Management: Pressure Garments
 Elasticized garments that are custom fitted
 Maintains constant pressure on the wound
 Result: smoother skin & minimized scar appearance
 Client Considerations:
 Must be worn 23 hours a day
 Need to be worn for up to 1-2 years
 Are very hot and tight !!

147. Example of a pressure
garment

148. Contracture Formation
 Shrinkage and shortening of burned tissue
 Results in disfigurement
 Especially if burn injury involves joints
 Management is opposing force:
 Splints, proper positioning and ROM
Must begin at day one !!
Multidisciplinary approach
is essential !!

149. Example of Contracture

150. Psychosocial Considerations
 Alterations in Body Image
 Loss of Self-Esteem
 Returning to community, work or school
 Sexuality
 Supports Services
 Psychologist, social work & vocational counselors
 Local or national burn injury support organizations
 Nursing Considerations
 Encourage client & family to express feelings
 Assist in developing positive coping strategies

151. Prevention of Burn Injuries
 Proper education and supervision
 childproof items in electrical sockets
 keep dangerous items (matches) out of reach
 Safety measures for the elderly
 teach small children 911
 smoke detectors in house
 STOP, DROP, AND ROLL

152. Position of comfort after burn trauma (to be
avoided)
 1. Neck flexion
 2. Shoulder protraction
 3. Elbow flexion
 4. Metacarpal extension
 5. Interphalangeal flexion
 6. Wrist flexion
 7. Hip flexion
 8. Knee flexion
 9. Ankle plantar flexion

153.  Techniques available for burn
reconstruction
 1. Without deficiency of tissue
 • Excision and primary closure
 • Z-plasty
 2. With deficiency of tissue
 • Simple reconstruction
 - Skin graft
 - Transposition flaps (Z-plasty and modifications)
 • Reconstruction of skin and underlying tissues
 - Axial and random flaps
 - Myocutaneous flaps
 - Tissue expansion
 - Free flaps

154. Pediatric Burns
 Thin skin
 increases severity of burning relative to adults
 Large surface/volume ratio
 rapid fluid loss
 increased heat loss  hypothermia
 Delicate balance between dehydration and
overhydration
 Immature immunological response  sepsis
 Always consider possibility of child abuse

155. Geriatric Burns
 Decreased myocardial reserve
 fluid resuscitation difficulty
 Peripheral vascular disease, diabetes
 slow healing
 COPD
 increases complications of airway injury
 Poor immunological response - Sepsis
 % mortality ~= age + % BSA burned

156. Recent advances
 IV or nebulised Heparin shown to reduce
tracheobronchial cast formation in
inhalation burns
 Early near total excision and grafting
 Anabolic agents like oxandrlone
,GH,testoesterone as a nutritional
adjuvants

157. SUMMARY
 Protect yourself and your patient
 Maintain c-spine immobilization
 Treat burn patients as trauma patients
 Properly cool the burn
 Be alert for inhalation injuries
 Flush chemical burns adequately
 Monitor heart in electrical burn patients

158. BURNS
B - breathing
body image
U - urine output
R - rule of nines
resuscitation of
fluid
N - nutrition
S - shock
silvadene