Burns can cause devastating physical and emotional effects. Classification is based on depth of skin damage from 1st to 4th degree. Severe burns increase risks of infections, loss of mobility, and multi-organ damage. Treatment involves stabilizing fluid and electrolyte shifts, administering IV fluids based on burn size, and preventing complications like shock, hypothermia, and infections. Patients with severe or complex burns may require referral to a specialized burn center.

1. BURNS
Linda H. Warren
EdD RN MSN CCRN
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2. OBJECTIVES:
• Review anatomy (elderly)
• Causes of burns
• Burn classification & severity
• Extent of Injury
v TBSA*
v Categories and Zones
Physiological Responses
v Hypovolemic stage
• Relative hypovolemia r/t fluid shifts.
v Diuretic stage
• r/t IVF resuscitation & overhydration.
Treatment
v Emergent
v Acute (hospitalization)
v Rehabilitation

3. EFFECTS OF BURNS:
A severe burn can be a devastating injury (physically & emotionally).
• Affect not only the burn victim, but the entire family.
• Burns can also cause emotional problems such as depression, nightmares, or PTSD.
• Loss of a friend, family member, or possessions may add grief to the emotional
impact of a burn.
SEVERE BURNS: may leave pt with a loss of certain physical abilities, including:
vLoss of limbs, disfigurement, loss of mobility, scarring.
vRECURRENT INFECTIONS: burned skin has ↓ ability to fight infection.
vSevere burns can penetrate deep skin layers, causing muscle or tissue
damage that may affect every system of the body.

4. INTEGUMENTARY SYSTEM:
Epidermis:
• Outermost
• Thinnest layer
Dermis:
• Collagen / elastic fibers
• Blood & lymph vessels
• Sweat & sebaceous glands
• Hair follicles (will not regenerate if scar tissue forms).
• Sensory nerve fibers (temperature, pain, touch receptors).
SubQ fat tissue layer:
• Binds dermis to body organs and tissue
• Connective tissue & fat deposits

5. EFFECTS OF AGING ON SKIN:
• Less resilience to mechanical trauma.
• Atrophy of dermal & subQ tissues
• ↓ microcirculation
• ↓ immunological response
• ↓ physiological reserve
• Co-morbidities
• ↑ morbidity and mortality
v Tissue changes predispose elderly pts to
deeper wounds & slower healing.
v Massive amts of IVF can effect renal and
cardiac fx in pts with CHF or renal disease.

6. SKIN FUNCTIONS:
• Protection
• Temperature regulation
• Regulates fluid loss
• Vitamin D synthesis
• Sensory perception
• Person’s identity
• Body image
• Cosmetic appearance

7. CAUSES OF BURNS:
• Thermal
• Chemical
• Radiation
• Electrical (alternating vs direct current)
• Friction (road rash)
• Cold (frostbite)
• Medications (S.J. syndrome)

8. CLASSIFICATION OF BURNS:
1st: Superficial skin (into epidermis)
2nd: Partial-thickness burn
• Superficial or deep
• Partially into dermis (partial)
• Fully into dermis (deep)
3rd: Full-thickness burn
• Into SUBQ tissue
4th: Muscle & bone involved

9. CLASSIFICATION OF BURNS:

12. 1st Degree
• Superficial
• Classic sunburn
• Scald injury
• Localized to epidermis
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13. 2nd Degree (Superficial)
• Extends into upper dermis.
• Blisters, blanching, painful (ex: severe sunburn)
• Weepy “wet” appearance
• Regeneration of hair follicles / sweat glands within 7-14 days
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14. 2nd Degree (Deep)
• Partial-thickness, extends deep into dermis.
• Nerves & blood vessels damaged.
• Pale, mottled, dry skin.
• ↓ sensation
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18. 3rd Degree (Full-Thickness)
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• Destroys epidermis, dermis, & accessory structures
• Extends into SUBQ tissue
• Dry, brown, yellow, or black in color
• Non-pliable à feels leathery
• May need skin graft
• ↓ sensation

20. 3 ZONES OF BURNS:
Zone of coagulation necrosis
• Irreversible tissue damage
• Direct burn site
Zone of stasis
• Immediate surrounding area
• ↓ perfusion
• Tissue may regenerate
• GOAL: inc. perfusion
Zone of hyperemia
• Tissue perfusion is inc.
• Vasodilation & edema
• Inc. risk for sepsis and prolonged hypoperfusion

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3 ZONES OF BURNS:

23. Extent of Injury (TBSA)
**RULE OF NINES: The picture can't be displayed.

25. LUND-BROWDER
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26. RULE OF PALMS:
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• Used for scattered burns.
• Not measured with nurse’s
palm, but with pt’s palm.
• Entire hand up to the wrist
= 1% TBSA

27. • Lung Injury can occur with…
- Smoke
- Chemical Toxins
- Byproducts of incomplete combustion (treated wood, sutt)
• Exposure to Toxic Gases:
- Carbon monoxide poisoning
- Cyanide poisoning
• Supraglottic Injury:
- Thermal injuries most common cause.
- Injury to pharynx & larynx à airway obstruction
• Subglottic Injury:
- Chemical injury most common cause.
- Damages ciliary function
- Erythema & edema à bronchospasms
- Mucosal ulceration
INHALATION INJURIES:

28. INHALATION INJURIES:
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29. • Exposure to smoke in a confined area.
• Facial burns / singed nasal hair
• Soot around mouth / nose
• Carbonaceous sputum (black)
• Hypoxemia (agitation, tachycardia, restless, dysrhythmias, confusion)
• Abnormal breath sounds
• Respiratory distress (↑ WOB, sternal retractions, dysphagia)
• ↑ carboxyHgb levels
• Abnormal ABGs (↑ RR à alkalosis, ↓ RR à acidosis)
• Inactivation of surfactant results in:
- Alveolar collapse
- Pneumonia
- Pulmonary edema
INHALATION INJURIES:
CLINICAL MANIFESTATIONS

31. TOXIC GASES:
Carbon Monoxide (CO) Poisoning:
• Binds to Hgb more rapidly than oxygen.
• Cells starved of O2 even with supp. oxygen
• Tissue Hypoxia
Cyanide Poisoning:
• Binds to respiratory enzymes in the mitochondria
• Inhibits cell metabolism
• Impaired oxygen utilization

33. Carbon Monoxide Poisoning
• Carboxyhemoglobin Levels (COHgb)
• Pulse ox unable to differentiate between oxyHgb/ COHgb à INACCURATE PULSE OX READING
COHgb <10-15%
• No Symptoms
• Headache or visual acuity
COHgb 15-40%
• CNS dysfunction
• Restless, confused, dizzy
• Impaired dexterity
• N/V
COHgb 40-60%
• Loss of consciousness
• Tachycardia / Tachypnea
• Seizures
• Cherry red or cyanotic skin.
COHgb >60%
• Coma / death

34. • Falsely elevated SpO2 readings
in pt’s with CO poisoning.
• Need to put pts on
supplemental oxygen.
If pt given 100% O2 or placed in
hyperbaric chamber… half-life of
COHgb is cut substantially.

35. PATHO. OF BURNS:
• Initial Hemostatic response
-Coagulation & microvascular constriction
• Resuscitative Phase
-Vasodilation & capillary leaking (weeping)
• Epithelization
-Restoration of fluid balance, temp. regulation,
& microbial barrier FX (skin integrity).
• Fibrogenesis
-Associated with wound appearance & tissue strength.

36. • Capillaries leak à Third spacing
• F&E Imbalances: Na+, K+, Ca+, lactate
- Hypovolemia
- pH: acidosis (r/t muscle breakdown)
- Hyperkalemia**
- Hyponatremia
• Hemoconcentration:
- ↑ blood viscosity
- ↓ perfusion
- May show high H+H prior to IVF resuscitation.
- After starting IVF… H+H will ↓ drastically.
- Tissue hypoxia
PATHO. OF BURNS:

39. Multi-Organ Effects of Burns
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Curling’s ulcer
Rhabdomyolysis à AKI

40. Electrolyte Disturbances:
Initial Resuscitation (0-36 hrs after injury):
• Begins at time of injury (not EMS arrival).
• Depends on burn severity.
• Hyperkalemia à cells damaged à release of K+ from cells à dysrhythmias
• Hyponatremia à capillary leakage à edema
• Pts will require serial bloodwork: BMP (q2-4h)
- CENTRAL ACCESS for frequent lab tests.
- IO access may be required.
Post-Resuscitation:
• Hypernatremia
• Hypokalemia
• Hypocalcemia
• Hypomagnesemia
• Hypophosphatemia

41. Electrolyte Disturbances: Post-Resuscitation
• Hypernatremia: Fluid shifts intravascularly
- Change IVF to isotonic or hypotonic (shifts fluid into cells)
- Isotonic: NS, LRs, D5W
- Hypotonic: 0.45% NS, 0.33% NS, 2.5 D5W
• Hypokalemia: K+ shifts back into cells & urinary losses of K+
- Monitor EKG for dysrhythmias
• Hypocalcemia: Ca+ shift back into cells & urinary losses of Ca+
• Hypomagnesemia: Coexistent with hypokalemia & hypocalcemia
• Hypophosphatemia: Mobilization of fluid & nutritional status
- Phosphorus always shows us pt’s NUTRITIONAL STATUS***
- Low phosphorus = poor nutrition

42. vIVF Resuscitation: Based on burn size (TBSA)
vFluid of choice: Lactated Ringer’s
Formula is used for…
• Burns covering >20% TBSA
• 2nd degree burns
• 3rd degree burns
Adult Formula: 4ml x weight (kg) x TBSA burned
• Initial 24-hr fluid requirement:
- Half of the volume to be infused given in the first 8 hrs.
- Remaining half given over next 16 hrs.
- Based on initial time of burn event (NOT arrival to ED).
- Titrate infusion rate to urinary output.
- Want ↑ u/o to prevent AKI (100-150 mL/hr)
PARKLAND FORMULA:

43. Children with burns >20%:
• 2ml x weight (kg) x TBSA burned
• Add calculated maintenance fluid:
0–10 kg à 100cc/kg
11–20 kg à 50 cc/kg (+1000)
>21 kg à 20 cc/kg (+1500)
• Divide total by 24 à hourly maintenance rate (cc/hr)
Lactated Ringer’s (LRs)***
- First half given over 8 hrs.
- Second half given over 16 hrs.
- Titrate infusion rate to urinary output.
- Contains buffers that help with metabolic acidosis & ↑ lactic acid levels.
2
PARKLAND FORMULA:

45. RESUSCITATIVE PHASE: (pre-hospital)
• Extricate the patient safely
• STOP the burning process!!!
ü Cool with tepid water
ü Never apply ice! (vasoconstriction à further tissue damage)
ü Remove all jewelry
ü Clothing adhering to skin is NOT removed.
ü If clothing is not adhering, remove it.
• Electrical Injuries
ü Remove patient from source.
ü Protect rescuer (wood), use PPE
• Chemical Injuries:
ü Brush powdered chemicals off prior to removing clothes & lavaging.
ü Remove all clothing
ü Lavage with clean water prior to & during transport.
ü Remove contact lenses.
ü Irrigate eyes: inner à outer canthus (prevent cross-contamination)
ü Neutralizing agents not recommended

46. vIdentify life-threatening injuries (secondary injuries: internal organs, frx)
vRapid transport to hospital – Minimize time on scene.
PRIMARY SURVERY:
Airway with c-spine precautions:
• Assess for inhalation injuries
• Facial burns
• Stridor
Breathing:
• NRB 100%
• Intubation
Circulation:
• Remove clothing and jewelry
• Two large bore IVs through non-burned skin.
• Administer LRs.
• Monitor for signs of hypovolemia.
• Prevent heat loss à cover with clean sheets & blankets
RESUSCITATIVE PHASE: (pre-hospital)

47. 1. Administer High Flow 100% Oxygen at 15 L/min (NRB or ETT)
2. Assess Breathing: Look for signs and symptoms of inhalation injury & deterioration.
3. Assess for Deep Circumferential Chest Burns
• Burns can restrict chest expansion à altered respirations.
• Burnt skin loses elasticity quickly à tourniquet effect when combined with rapidly accumulating edema.
• Respiratory insufficiency or ischemia of an extremity are a risk.
• Escharotomy may be required.
4. Assess for COHb Poisoning:
• Consider CO poisoning in pts who sustain burns in an enclosed area.
• CO has a 280x greater affinity for Hgb than oxygen does.
• O2 administration is pivotal to help O2 bind to Hgb & unbound CO can be exhaled.
• SpO2 is unreliable indicator of CO poisoning.
• Pulse-ox interprets CO as oxygen à pt can be hypoxic with high SpO2 readings
-Supplemental O2 should be given regardless of SpO2
Assess for symptoms of high COHb levels:
• Hx of altered LOC
• Cherry pink skin
• Anxiety, restlessness

48. • HR
• BP à arterial line
• Urine output:
- Insert a Foley
- Monitor hourly u/o
- Simple way to assess fluid balance
• Distal pulses
• Capillary refill
• Color and turgor of unburned skin
• ABGs
• Serum lactate
ASSESS FLUID STATUS:

49. PREVENT HYPOTHERMIA:
1. Cover the burn ASAP
2. Stop cooling the wound if core temperature <35oC
3. Cover the patient with blankets:
• Warm blankets
• Space blankets
• Forced air warming blanket (Bair Hugger)
4. Warm IV fluids
5. Keep the room warm
6. Check temp. regularly
7. Remove any wet dressings, sheets etc. (evaporative heat loss)

50. q Exposure in confined area
q Facial burns / singed nasal hair
q Soot around mouth / nose
q Carbonaceous sputum (black)
• Massive edema develops rapidly à requires ETT
• Longer they wait, the narrower the airway gets.
• If airway is completely closed off…need to trach pt.
Electrical injuries:
• HIGH RISK of ATN r/t myoglobin release à
rhabdomyolysis à AKI
• Require LARGE VOLUMES of IVF replacement.

52. BURN SHOCK:
• Shock from intravascular volume loss r/t sudden F&E shifts
immediately following a burn injury.
• Combination of distributive & hypovolemic shock.
• ↑ capillary permeability, third-spacing à relative hypovolemia
• ↓ oncotic pressure:
- Leaking of proteins (fluid follows protein)
- Draws intravascular fluid into interstitium (tissues).
- Relative hypovolemia (fluids moves intravascularly à interstitially)
• Edema formation
- Due to ↓ oncotic pressure
- Natural inflammatory response
- Risk of compartment-like syndrome à escharotomy or fasciotomy

54. • ↑ K+
• ↓ Na+
• Hemoconcentration
• ↑ Hgb, ↑ Hct
• ↑ lactic acid
• Metabolic acidosis

55. COMPLICATIONS OF
FLUID RESUSCITATION:
OVER-RESUSCITATION: ↓ tissue perfusion
• Compartment syndrome
• Pulmonary edema (fluid in lungs)
• Pleural effusion (fluid surrounding lungs)
• Electrolyte abnormalities
UNDER-RESUSCITATION: ↓ tissue perfusion
• A.T.N. à AKI
• Conversion from partial-thickness à full-thickness wounds
-Damage continues if IVF resuscitation is not efficient.
• Curling’s stress ulcer (r/t reduced GI blood flow and damaged mucosa).

56. PHASES of BURN PROGRESSION:
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57. REFERRAL TO BURN CENTER:
• Partial-thickness burns >20% TBSA
• Full-thickness burns
• Burns of the face, hands, feet,
genitalia, perineum, or major joints.
• Chemical & electrical burns
• Inhalation injuries
• Elderly & pediatric pts
• Comorbidities
• Associated trauma w/ burn injury
• Pts requiring special interventions:
- Social
- Emotional
- Rehabilitation

58. v Stabilize fluid & protein shifts within 48-72 hrs.
Respiratory:
• Respiratory compromise
• Pneumonia
• VAP
Cardiovascular:
• Maintenance IVF to match u/o.
• I&Os
• Daily weights
Neurological:
• Ongoing assessment for changes:
-Hypoxemia, hypoperfusion, or sepsis
Renal:
• Post-burn diuresis
• I&Os
• Glycosuria
GI:
• Monitor for stress ulcers (Curling’s)
• Nutrition, enteral feedings
• High calorie, protein, carb diet.
ACUTE CARE PHASE:

60. Integumentary:
• Burn wound healing: major focus of burn recovery
• Burn wound depth conversion
• Infection
Blood & Electrolytes:
• Hemodilution (after IVFs start)
• Hyponatremia (pre-resus) à Hypernatremia (post-resus)
• Hypokalemia*
• Metabolic acidosis
• Hypoproteinemia
• Hyperglycemia
• Leukopenia (↓ WBCs)
• Leukocytosis (↑ WBCs)…indicate infection
• Thrombocytopenia (↓ platelets)
• Prolonged coagulation time
ACUTE CARE PHASE:

62. SPECIAL BURN CONSIDERATIONS:
Facial Burns:
• Potential for inhalation injuries
• Edema à compromised airway à ETT
• Elevate HOB
• Prevent excessive bleeding & damage to new tissue growth.
• Topical antimicrobial agent
Ear Burns:
• Chondritis (r/t poor vascular supply of ear)
• Prevent pressure on area
• Sulfamylon (mafenide acetate): antimicrobial of choice
Eye Burns:
• Remove contact lenses
• Exam by ophthalmologist
• Irrigate / Irrigate / Irrigate
• Protect cornea & conjunctive from exposure / drying out (eyelid retraction)
• Ophthalmic ointments and artificial tears.
All will go to burn centers!

63. Hands, Feet, or Major Joints:
• May cause permanent disability
• GOAL: Preservation of FX!!
• Active ROM
• Splinting & anti-deformity positioning
• Prevent webbing (scar tissue): Wrap digits individually
• Elevation to prevent edema
• Prevent venous stasis / pooling (elastic bandages, thromboguards)
Genitalia & Perineum
• Monitor for urinary tract obstruction.
-Indwelling Foley until wounds healed or grafted.
• High risk of urine or fecal contamination.
• Elevation of scrotum to relieve edema.
SPECIAL BURN CONSIDERATIONS:

65. High voltage (>1000 volts):
• Requires trauma evaluation
• Cardiac dysrhythmias / cardiac arrest
• Hypoxia
• Deep tissue necrosis
• Compartment Syndrome (esp. extremities)
• Long bone or vertebral frx (rigidity), SCI, TBI
• Rhabdomyolysis à AKI
• Acute cataract formation
• Neurological deficits
• Motor or sensory deficits
• Neuropathy
Low voltage:
• Local Injury
• Common in children (cords, outlets)

66. • Voltage takes the shortest path to the ground.
ENTERANCE & EXIT BURNS:
• Extensive tissue damage occurs btwn.
entrance and exit wounds.
• Tissue necrosis
• Upon exiting, the electricity can cause
tissues to explode.
• Exit wounds may be larger.

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68. SCARS & CONTRACTURES:
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• Wrap digits individually
• Splints to prevent contractures
• ROM exercises
• Want to maintain joints in the
most functional position.
Webbing occurs r/t scar tissue formation.

69. • Stop burning process!!!
• Protective equipment (PPE)
• Decontamination required:
• Brush off powder substance
• Continuous water irrigation
• ALKALIS: require longer irrigation
• Determine specific chemical agent
• Control pain
• Minimize heat loss à cover with dry blankets
• Monitor for signs of chemical absorption
• Chemicals can be absorbed thru. skin à systemic complications

70. PAIN CONTROL:
MAJOR FOCUS OF BURN MANAGEMENT:
• Background pain
• Procedural pain
• Meds often exceed normal dosing guidelines
• Hypermetabolism à require higher doses of pain meds.
Assess pain levels frequently:
• Pain meds: ALWAYS given IV***
• SUBQ & IM injections ineffective: impaired circulation à altered absorption rates
• Cannot determine rate of absorption if given IM or SUBQ…always given IV.
Tx of anxiety:
• Anxiolytics
• Relaxation, hypnosis, guided imagery, distraction
Pt’s with HX of alcohol or substance abuse:
• Compound pain management
• Opiates: drug of choice

71. • Combo of opioids + sedatives
• Anxiolytics

72. Susceptibility to infection in burn pts:
• Loss of skin (first line of defense)
• Extended hospital stays
• Invasive procedures
• IVs, central lines
• Foley catheters
• Immuno-compromised
INFECTION CONTROL MEASURES:

73. INFECTION CONTROL MEASURES:
• Aseptic management of wound & environment
• Topical antibacterial agents
• Care of invasive catheters (central lines, A-line, Foley)
• Aggressive wound management
• Prevention of MDROs: identification of infectious organism
• Use of appropriate ABX
• Monitor lab values / signs of sepsis
• Early wound closure / restore skin barrier
• Adequate nutrition
• Interventions to improve patient outcomes
• Staff education

74. STEVENS-JOHNSON SYNDROME (SJS):
Reaction caused by certain meds: OTC drugs, ABX, sulfa drugs
• Nikolsky sign: epidermis separates from dermis with even slight rubbing.
• Mucosal sloughing: assess oral cavity
• >20% TBSA à Toxic epidermal necrolysis (TENS)
• Stop the drug
• Resuscitate (IVF)
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76. ASSESS FOR CHILD ABUSE:
• Donut pattern on buttocks
• Stocking pattern
• Glove pattern
• Sparing: soles of feet, back of knees
• Line of demarcation
• Waterlines
• Scalds

78. DIFFUSE ROAD-RASH:
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• Very painful
• Bacitracin
• Debridement of dirt & stones
• Topical agents
• Heal fairly quickly

79. WOUND MANAGEMENT & GOALS:
• Cleansing & debridement
• Topical ABX: delay wound colonization & infection
• Escharotomy or fasciotomy:
- For circumferential burns, deep burns, compartment syndrome.
• Elevate extremities
• Surgical excision & grafting
GOALS:
• Close wound quickly
• Prevent infection
• Reduce scarring & contractures
• Provide comfort

80. TOPICAL ABX:
• Silvadene (sulfadiazine) cream:
- Broad-spectrum, covers pseudomonas
- Does not penetrate eschar
- Cooling affect
- Side effects: neutropenia, thrombocytopenia
• Silver nitrate cream:
- Blackens skin
- Side effects: electrolyte abnormalities
• Sulfamylon cream or solution (mafenide acetate):
- Penetrates eschar & deep into burn wounds.
- PAINFUL!!
- Face & neck edema
- Side effects: Metabolic acidosis à via carbonic anhydrase inhibition

81. NEW WOUND CARE:
• Bacitracin
• Adaptic
• Vaseline gauze
• Xeroform gauze
• Medi-Honey

82. SURGICAL INT:
Escharotomy:
• Prevent circumferential constriction
• Removal of eschar
• Facilitates healing
Surgical Debridement:
• Removes burn wound to level of viable tissue
• Should bleed briskly before coagulation.
• Know tissue is viable if it bleeds.
• Early excision & grafting improves function & ↓ mortality
Autografting – permanent skin coverage:
• Homograft / allograft – human skin
• Heterograft / xenograft – animal (usually pig)
• Dermal substitute dressings – Biobrane, Intregra
• Full-thickness skin grafts
• Split-thickness skin grafts

83. Cultured Epithelial Autografts
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84. ESCHAROTOMY:
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• Longitudinal incision thru eschar itself.
• Only down to SUBQ tissue (not thru!!)
• Relieves stiff eschar that forms (thru epidermis & dermis)

86. Excision & Debridement
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SKIN GRAFTING:

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• Need to debride wound FIRST.
• Viable tissue: bleeds
• Mesh graft placed onto wound bed
• Stapled to skin
• Keep it moist à covered w.
metahoney, xeroform dressing
SKIN GRAFTING:

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SKIN GRAFTING:

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SKIN GRAFTING:

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SKIN GRAFTING:

92. SKIN GRAFTING:
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• Harvest skin from larger areas
• Typically the thigh

93. NUTRITIONAL
CONSIDERATIONS:
• Stress-induced hypermetabolic / catabolic response
• Post-burn hypermetabolism:
- Skeletal muscle breakdown
- Delayed wound healing / skin graft loss
- Impaired immunological response
• Muscle weakness & atrophy:
- r/t prolonged mechanical ventilation
- Extended rehabilitation time
• Oral Diet
- High-calorie, high-protein diet w. protein supplements
- Protein: 1.5-2 g/kg/day
• Enteral feedings
• Beta-blockers: propranolol (lowers metabolic rate & release of
cytokines / stress hormones)
• Anabolic hormones: oxandrolone
- These meds help ↓ length of stay by ↓ metabolism