Burns Guide

burns
Burns are injuries to tissues caused by
heat, friction, electricity, radiation or
chemicals

 Burn injuries do not bleed in the acute phase,
and therefore evidence of blood indicates an
associated injury.

The problem/ disease burden
 Burns
* Several causes and associated factors
* Tip of ice berg ( deaths and ‘minor’ burns)
* Permanent or severe injury
* Lifelong disability ( children)
* Requires committed multidisciplinary care

Types of burn Injuries
 Thermal
 Electrical
 Chemical
 Radiation
 Cold Injuries
 Complications( Inhalation )

 Types of Burns
• Thermal injury
- Scald - spillage of hot liquids. Toddlers are at risk
of such burns by hot liquids in kitchen accidents
and un guarded fires are a threat to children
- Flash burns due to exposure of natural gas,
alcohol, combustible liquids
- Contact burns - contact with hot metals/
objects /hot materials

- Flame burns
 these burns are due to flames of fire. Such
burns are common in house fires.
 Burns sustained in house fires are commonly
accompanied by smoke inhalation with injury to
the lungs

• Electrical injury: the extent of injury caused
electricity is normally underestimated as surface
damage may be small despite extensive deep
injury
• Chemical burns - acid / alkali
• Cold injury - frost bite.
- intracellular crystals causing cell lysis
- Microvascular occlusions and peripheral vasoconstriction leading
to ischaemia.
- Superficial frost bite: only skin and subcutaneous tissue involved
- Mgt:

1. Rewarm rapidly in water bath (40-42) degrees celicius
2. After rewarming tissue bmes, purple, edematous, painful
blisters may appear, resolving after several wks
3. Leave injured region open to air
4. Leave blisters intact
5. Surgery may be needed to release eschars
6. Wait unitl complete demarcation before amputation
Ionising radiation
• Sun burns:

Who’s at risk
 Alcaholics. Alcohol is the comonest contributing
factor in burn injury
 Diminished awareness of pain
 Associated conditions in adults, such as mental
disease (attempted suicide or assault),
 Epilepsy
 Disability
 Populations at highest risk: pediatric and elderly
(ameriburn.org, November 12, 2005)

Prevention of burns
 A significant proportion of burns can be
prevented by:
■ Implementing good health and safety
regulations
■ Educating the public
 ■ Introducing of effective legislation

Burns: the numbers* (severe cases only)
 Mulago Hospital : 350 severe burn admissions per year
 All Kampala Hospitals: Over 1000 severe cases per year
 Uganda in general: Scanty data. yet, but significant numbers as seen from rate of
burns complications country wide
 IDP camps Increased Recently , High death rate
 Highway fuel tanker accidents: increasing, high death rates
 Acid burns : increased, severe disfigurement, blindness, stigma
* Areas of Research and Intervention.

Burns : Sex Distribution
More boys (Male) than girls (Female) get burnt in the ratio of 6:4
42.2%
57.8%
Female Male

Effects of burns
 Destruction of tissue (depth depends on heat of
causative agent and time of contact)
 Loss of barrier to infection: removal of
epidermis opens way for bacterial invasion
 Fluid loss from surface or trapped in blisters-
magnitude of loss depends on extent of injury.
- Loss is greately increased by leakage of fluid
from the circulation.

EFFECTS OF BURNS
With deeper burns, damaged capillaries become
permeable to protein and an exudate forms with
electrolyte/protein content only slightly less
than that of plasma.
Lymphatic drainage fails to keep pace. Edema
reduces circulating volume
 Exudation is maximum in the first 12 hrs,
capillary permeability returning to normal within
48 hrs

cntnd
 Red cell destruction. Common in full thickness
burns . Many more are damaged bt not
destroyed immediately. However red cell loss is
less than fluid loss, a high hemoconcentration is
reflected in rising hematocrit
 Large burns increase metabolic rate due to
increased
 Hypovolaemic shock

Burns: Age group distribution (Over half of burns are
seen in children 5 years or younger, and 2/3 of all burns occur in children 15 years or younger!)
51.7
11.1
3.7
7.2 6.6
7.4
3.3 3.9 5.1
0
10
20
30
40
50
60
Percentage
(%)
1-5 11-15 21-25 31-35 40
and
above
Age group

Burns : Causative agents
Scald: hot water, liquid foods, etc/ Flame: fire/ Contact: touching hot solids/ Chemicals: acid mainly.
63.4
24.5
2.5
1.4
3.9 4.3
Scald Flame Contact Other Chemical Electrical

Classification of Burn Injuries Cont.,
Burns can be classified according to:
- Depth
- Size of area burnt
- Degree of burns

Depth of Burn Injury
A. Partial Thickness skin loss/ partial thickness burns
B. Full thickness burns
PARTIAL THICKNNES BURNS
Two types: superficial partial thickenss and deep partial
thickness burns
superficial partial thickness
-It is either first or second degree burn .
-Superficial partial thickness burns: (First Degree) - Here the
epidermis looks red and painful, no blisters, heals rapidly in 5-7
days by epithelialization without scarring

Superficial partial thickness burns
( Second Degree)
 involve only the epidermis and the superficial dermis.
Pain, swelling, blistering and fluid loss may be marked.
New epidermal cover is provided by undamaged cells of
the epidermal appendages (hair follicles, nails and
sebaceous glands that are pushed deep into the epidermis)
-Burn heals in less than 3 wks c agd cosmetic

Degree of burns
Superficial-1st Degree Burns
 Involves the epidermis
 Wound Appearance:
 Red to pink (light skin)
 Mild edema
 Dry and no blistering
 Pain / hypersensitivity to touch
 i.e. Classic sunburn
 Desquamation occurs 2-3 days
 Wound Healing spontaneous
 Duration 3 to 5 days
 No scarring / other complications

Deep partial thicknes burns
(Second Degree)
 In dp partial thickness burns, the epidermis and much of the
dermis are destroyed. Restoration of the epidermis depends
on intact epitherial cells within the remaining appendages.
 Pain, swelling, fluid loss are marked and healing takes longer
than three wks due to fewer epithelial appendages tht survived.
The colour does not blanch with pressure under the examiner’s
finger. Sensation is reduced, and the patient is unable to
distinguish sharp from blunt pressure when examined with a
needle. Often heals with prdn of an ugly hypertrophic scar
 Infection may delay healing and can coz further tissue
distraction and convert the injury to full thickness burn

Burns at Ten Days
Deep 2nd Degree

Full thickness skin loss
 Full Thickness skin loss ( Third Degree)
 : It is third degree burns which is charred, insensitive,
deep involving all layers of the skin including the
epidermal appandages.
 The destroyed tissues undergo coagulation
necrosis and forms an eschar wch begins to lift
in 2-3 wks
 white/brown leathery skin, sensation absent.
Scar badly, heal slowly, skin grafting is usually
required.

Full-Thickness Burns
 Involves the entire epidermis and dermis
 Dry, leathery and rigid
 + Eschar (hard and in-elastic)
 Red, white, yellow, brown or black
 Severe edema ( ? Escharotomy in limbs, chest)
 Painless & insensitive to palpation
 Wound Healing:
 No spontaneous healing;
weeks to months with graft
 Wound Management:
 Surgical excision & skin grafting

Flame Burns : About 25% Burns are severe fire burns that occur
in homes, & more recently on highways (fuel tanker related) & rebel activities
3rd Degree
4th Degree

Deep, Full-Thickness Burns 4TH
DEGREE
 Extends beyond the skin to include muscle, tendons
& possibly bone.
 Black (dry, dull and charred)
 Eschar tissue: hard, in-elastic
 No edema
 Painless & insensitive to palpation
 Wound Healing:
 No spontaneous healing; weeks to months with graft
 Surgical excision & skin grafting
 Frequently requires amputation if extremity involved

Determination of burn depth
 there is no fullproof method for determination
of burn depth.
 Burn depth is proportional to the temperature
of the causal agent and to the length of contact
time
-Scalds from liquids below boiling point usually
produce partial thickness burns
-boiling liquids, long contact with hot soilids-full
thickness burns

 Erythema denotes epidermal damage
 Blanching on pressure indicates capillaries are
intact and that injury is partial thickness. A dead
white appearance indicates full thickness injury
 Intact cutaneous sensation implies that the
epidermal appendages have survived as they lie
at the same level with cutaneous nerve endings
 Blisters are accumulation of fluids superficial to
the basal layer of the epidermis and suggests
partial thickness injury. May be broken by the

Deep 2nd Degree Burns
 Involves larger portion of dermis (not complete)
 Mottled: Red, pink, to white surface
 Moist
 No blisters
 Moderate edema
 Painful; usually less severe than superficial 2nd Degree
 Wound Healing:
 May heal spontaneously 2-6 weeks
 If so Hypertrophic scarring / formation of contractures
 Treatment of choice: surgical excision & skin grafting

Classification of Burn Injuries Cont.,
Size of a Burn Injury
Total Body Surface Area (TBSA)
Burned
 Palmar Method
 A quick method to evaluate scattered or localized
burns
 Client’s palm = 1 % TBSA.
 In the case of smaller burns or patches of burn, the best measurement is to
cut a piece of clean paper the size of the patient’s whole hand (digits and
palm), which represents 1% TBSA, and match this to the area. Fingers
close together.

Rule of Nines (Wallace's rule of
"9")
 A quick method to evaluate the extent of burns
 Wallace's rule of nine is used for early
assessment –The rule of nines, which states that
each upper limb is 9% TBSA, each lower limb
18%, the torso 18% each side and the head and
neck 9%, can be used as a rough guide to TBSA
outside the hospital environment.
 Modified version for children and infants (Rule of
Sevens )

Lund-Browder Method
 Most Accurate; based on age (growth)
 This a tool used in the management of burns for
estimating the TBSA. Unlike the wallace rule of
nine, this chart considers the age of person c
decreasing % of BSA for the head and
increasing body surface area for the legs as child
ages, making it more useful in paed
 Using the Lund and Browder chart is better method for assessing the
burns wound. Here each part of the body is individually assessed
for involvement of burns. Its more useful in large burns
 Can be used for the adult, children & infants

cnd
 The assessor draws on the illustration the actual
burn ignoring simple erythematus areas on the
patient and compares the various parts of their
drawing with the BSAP of the actual burn of
that particular part of the body wc is then
recorded in the table on the LB. the total body
surface area burnt is got by adding the different
parts of the body.

Pathophysiology of burns.
 Burns cause damage in a number of different
ways, but by far the most common organ
affected is the skin.
 However, burns can also damage the airway and
lungs, circulatory ,git, immunity etc
42

INJURY TO THE AIRWAY AND
LUNGS
 Physical burn injury to the airway above the
larynx.
 The hot gases can physically burn the nose,
mouth, tongue, palate and larynx. Once burned,
the linings of these structures will start to swell.
After a few hours, they may start to interfere
with the larynx and may completely block the
airway if action is not taken to secure an airway.
43

 Physical burn injury to the airway below the
larynx.
 In such injuries, the respiratory epithelium
rapidly swells and detaches from the bronchial
tree. This creates casts, which can block the
main upper airway.
 Others include:
 Metabolic poisoning, inhalational injury and
mechanical block to rib movement.
44

Metabolic poisoning
 There are many poisonous gases that can be
given off in a fire, the most common being
carbon monoxide, a product of incomplete
combustion that is often produced by fires in
enclosed spaces. This is the usual cause of a
person being found with altered consciousness
at the scene of a fire. Carbonmonoxide binds to
haemoglobin with an affinity 240 times greater
than that of oxygen and therefore blocks the
transport of oxygen.
45

Inhalational injury
 Inhalational injury is caused by the minute
particles within thick smoke, which, because of
their small size, are not filtered by the upper
airway, but are carried down to the lung
parenchyma.
 They stick to the moist lining, causing an intense
reaction in the alveoli. This chemical
pneumonitis causes oedema within the alveolar
sacs and decreasing gaseous exchange over the
ensuing 24 hours .
46

The swelling that occurs with
inflammation due to burns
47

Mechanical block on rib movement
 Burned skin is very thick and stiff, and this can
physically stop the ribs moving if there is a large
full-thickness burn across the chest.
48

INFLAMMATION AND
CIRCULATORY
CHANGES
 The changes occur because burned skin activates
a web of inflammatory cascades.
 These inflammatory factors alter the
permeability of blood vessels such that
intravascular fluid escapes from the intravascular
to the extravascular space.
 This flow occurs over the first 36 hours
 after the injury, but does not include red blood
cells.
49

The immune system and
infection
 The inflammatory changes caused by the burn have an
effect on
 the patient’s immune system. Cell-mediated immunity
is significantly
 reduced in large burns, leaving them more susceptible
to bacterial and fungal infections.
50

Changes to the intestine
 The inflammatory stimulus and shock can cause
microvasculardamage and ischaemia to the gut
mucosa. This reduces gut motility and can prevent the
absorption of food.
 This process also increases the translocation of gut
 bacteria, which can become an important source of
infection in large burns.
 abdominal compartment syndrome. which splints the
diaphragm and increases the airway pressures needed
for respiration.
51

Danger to peripheral circulation
 In full-thickness burns, the collagen fibres are
coagulated. The normal elasticity of the skin is lost.
A circumferential fullthickness
 burn to a limb acts as a tourniquet as the limb
swells. If untreated, this will progress to limb-
threatening ischaemia
52

Severity of Burn Injuries
 Treatment of burns is directly related to the severity
of injury!
 Severity is determined by:
 Depth of burn injury
 Total body surface (TBSA) burned
 Location of burn( face, hands, feet and perineum are considered severe !! )
 Patients Age
 Presences of other preexisting medical conditions or
trauma
 Complications ( Inhalation , Hypothermia , Shock )
Ref:- Smeltzer & Bare: Table 57-4 pp. 1712

Fluid shifts in burns
 A. hpovolaemoc stage
- Begins at onset burns & lasts for 48-72 hr
• Rapid fluid shifts from vascular compartment to
interstitial spaces (third spacing)
• Capillary permeability invreases with
vasodilation
• Fluid loss deep in wounds
• Initially sodium & water
• Protein loss-hypoproteinemia

cnt
 Hemoconcentration-hematocrit increases, water
loss
 Low bld volume/ oliguria
 Hyponatremia
 Hyperkalemia-damaged cells release k
 Metabolic acidosis

Diuretic stage
begins 48-72 hr
 Capillary membrane integrity returns
 Edema fluid returns to vessels-bld volm
increases
 Bld flow increases-renal bld flow increases and
so does diuresis
 Hemodilution-low hct, decreased k as it goes
back into cells or excreted
 Fluid overload may occur due to increased
intravascular volume

Pathophysiology
 Heat causes coagulation necrosis of skin and subcutaneous tissue
 Release of vasoactive peptides
Altered capillary permeability
 Loss of fluid ~ Severe hypovolaemia
 Decreased cardiac out put

cnt
 Decreased myocardial function
Decreased renal blood flow~ Oliguria (Renal failure)
Altered pulmonary resistance causing pulmonary oedema
 Infection
 Systemic Inflammatory Response Syndrome (SIRS) (sepsis)
 Multi Organ Dysfunction Syndrome (MODS).

Effects of burns on body organs
 HEART
 Cardiac dysfunction is due to:
 Hypovolaemia.
 Release of cardiac depressants.
 Hormonal causes like catecholamines,
vasopressin, angiotensins

kidneys
 Renal changes are due to:
 Release of ADH from posterior pituitary to cause maximum
water reabsorption.
 Release of aldosterone from adrenals to cause maximum sodium
reabsorption.
 Toxins released from the wound along with sepsis causes acute
tubular necrosis. Myoglobin released from muscles (in case of
electric injury or often from eschar) is most injurious to kidneys

Respiratory-lungs
 Pulmonary changes are due to:
 Altered ventilation-perfusion ratio.
 Pulmonary oedema due to burn injury, fluid
overload, inhalation injury.
 ARDS.
 Aspiration.
 Septicaemia

Assessment of airway injury is
important in burns
 Airway injury Occurs in burns around face and neck, or trapped
in burning room. Presents with hoarseness or stridor
 Inhaled burning gases can cause upper airway burns and
laryngeal oedema
 Smoke inhalation can cause chemical alveolitis, pulmonary
oedema, ARDS and respiratory failure
 Steam inhalation can cause damage to respiratory epithelium and
subglottic oedema
 Carbon monoxide inhalation more than 10% is dangerous as it
forms carboxyhaemoglobin (CO has got 240 times more affinity
to haemoglobin than oxygen) which blocks oxygen transport
completely causing respiratory arrest, hypoxia and metabolic
acidosis.

GIT
 GIT changes are due to:
 Acute gastric dilatation which occurs in 2-4 days.
 Paralytic ileus.
 Curling's ulcer.
 Cholestasis and hepatic damage.
 Infections are commonly due to:
 • Streptococci - (Beta haemolytic - commonest)
 • Pseudomonas
 • Staphylococci
 • Other gram-negative organisms
 • Candida albicans
 Fig.

Metabolic Changes
 Hypermetabolic rate (BMR). Due to elevated plasma
catecholamines, cortisol & inflammatory cells that lead to whole
body catabolism. The response isxrised by muscle protein
degradation, blunted growth, insulin resistance, increased risk for
infection.
 Effects mitigated by: early skin grafting, thermoregulation, ngt
feeding with high-carbohydrate and protein diet
 Negative nitrogen balance. Nitrogen balance is a measure of
nitrogen input-nitrogen output. In a –ve state, output is higher
than input due to high rate of protein catabolism to mit bodies
needs eg enzyme synthesis, antibody prdn etc
 Electrolyte imbalance.
 Deficiencies of vitamins and essential elements.

Management of burned patient
 NB
 The area of burn determines the volume of fluid
lost and vol. pt requires in first few hrs to
prevent shock
 Depth determines how you shd treat the burn
especially if you need to graft it
 Its position determines how you shd nurse him
and especially how u shd prevent contractures

FIRST AID
 Key principles of f/a mgt
 Arrest the burning process
 Ensure an adequate airway
 Avoid wound contamination
 Arrest the burning process
-extinguish burning clothes-
- stop, drop, cover face and role if on fire
Lay the pt flat avoid rising to the neck and face
with inhalation of smoke and fumes

 Cool the burn wound. This provides
analgesia and slows the microvascular damage
that can occur after a burn injury. Cooling
should occur for a minimum of 10 minutes and
is effective up to 1 hour after the burn injury. It
is a particularly important first aid step in partial-
thickness burns, especially scalds. In temperate
climates, cooling should be at about 15°C, and
hypothermia must be avoided
69

cnt
 Remove clothes
 Keep the patient warm to avoid hypothermia
 Apply C-spine collar if appropriate
 Elctrical burns, swicth off the source of power.
Do not pull the pt. if this not possible , push the
away the pt c a non conductor

Adquate air way
 Ensure an adequate air way: pt must be moved
as fast as possible into a smoke free area

Ensure an adequate air way
 Move pt quickly to a smoke free area
 If necessary start mouth to mouth resuscitation
Avoid wound contamination
-Cover wounds with a clean sheet. Tradional
house hold remedies shd be avoided

 Give oxygen. Anyone involved in a fire in an
enclosed space should receive oxygen,
especially if there is an altered consciousness
level.
 • Elevate. Sitting a patient up with a burned
airway may prove life-saving in the event of a
delay in transfer to hospital care.
 Elevation of burned limbs will reduce swelling
and discomfort.
73

Management and Referral of burn
patients
 Minor Burns--- Discharge
 Severe Burns--- Transfer to Burn Center
 Moderate Burns--- Hospitalize
 Admission criteria for severe burns
 Severe burns should be transferred to a burn center
if available.
 Moderate burns should be admitted to a local
hospital. Minor burns may be treated as an
outpatient.

.
 Minor burns are: Second degree <15% in adults
or <10% in children, third degree <2%, no
involvement of face, hands, feet, or genitalia, no
smoke inhalation, no complicating factors.

 Moderate burns are: Second degree of 15 to
25% TBSA in adults, or 10 to 20% in children,
third degree of 2 to 10% (not involving hands,
feet, face, or genitalia), circumferencial limb
burns, smoke inhalation with minor (<2%)
burns, possible child abuse, and if the patient is
not able to care for the burns as an outpatient.

 Severe burns are: Second degree >25% in
adults, second degree >20% in children, third
degree >10%, high voltage electrical burns, deep
second or third degree burns of face, hands,
feet, or genitalia, smoke inhalation with >2%
burn, burns with major trunk, head or
orthopedic injury, and burns in poor risk
patients (elderly, diabetic, COPD, etc.).

Outpatient burn care
 Carefully instruct the patient and family in the dressing change
procedure.
 Change the ointment and dressing at least once a day
(preferably twice a day). See the patient for a recheck in 2 to 3
days if he is reliable.
 Patient instructions are to remove the bandage and dressing,
wash off the old Silvadene ointment with warm soapy water
(may soak the area first), peel off any loose or broken blisters
and pat the area dry, reapply new Silvadene ointment 2 to 4
mm thick, and reapply a new bandage.
 The patient may take pain medicine 30 minutes before
changing the ointment and bandage.

 On recheck visits, look for redness and tenderness
outside the original burned area. Thick drainage from the
burn is usually just exudate and not a sign of infection.
See if the patient is maintaining satisfactory range of
motion of the affected area.
 Advice to the patient after the burn heals is to keep the
area moist with cold cream. Keep the area out of the sun
for 6 months (to prevent unpredictable lightening or
darkening of the affected skin).
 Treatment of hypertrophic scarring if it occurs involves
intensive physical therapy and active range of motion
exercises.

HOSPITAL CARE
 The principles of managing an acute burn injury
are the same as in any acute trauma case:
 A, Airway control
 B, Breathing and ventilation
 C, Circulation
 D, Disability – neurological status
 E, Exposure with environmental control
 F, Fluid resuscitation.
80

Resuscitation
 Airway:
 Intubate immed if impending airway
obstruction, hypoxia on 100% O2,
hypoventilation
 Intubate urgently if ↓SaO2 on 60-100% , voice
change, oral erythema/blistering
BREATHING: Give humidified oxygyen

Circulation:
 2 x IVC if major burn. Try to avoid burnt tissue
if possible. Aim for urine output of 0.5-
1ml/kg/hr in adults, 1-2ml/kg/hr in children.
Fluids: No evidence for colloid over crystalloid. If
TBSA>15% (Child: 10%) use
Hartmann’s init rate (Parklands): Total 2º/3º BSA
(%) x Wt (kg) x 4mL.
 Give 1/2 in 1st 8h, rest over 16h. Add
maintenance fluids for child<30kg..

FLUID RESUSCITATION
 The principle of fluid resuscitation is that the
intravascular volume must be maintained
following a burn in order to provide sufficient
circulation to perfuse not only the essential
visceral organs such as the brain, kidneys and
gut, but also the peripheral tissues, especially the
damaged skin
83

types of fluid used
Crystalloid resuscitation.
 Ringer’s lactate is the most commonly used
crystalloid.Crystalloids are said to be as effective
as colloids for maintaining intravascular volume.
 They are also significantly less expensive.
84

 In children, maintenance fluid must also be given.
 4 mls/kg for the first 10kg of body weight plus
 2ml/kg for the second 10 kg of body weight plus
 1ml/kg of body weight
85

 Modified Brooke formulafirst 24 hours-
 RL: 4 ml/ kg/% burns in 24 hours
 (first half in first 8 hours)
 Colloid- none.
 Second 24 hours-
 Crystalloids- to maintain urine output
 Colloids- 0.3 ml to O.5 ml/kg/burns in 24 hours.
(Albumin in RL solution) (Albumin alone should be
 given with care if really indicated only).
86

Hypertonic saline
 Human albumin solution (HAS) is a commonly used
colloid.
 Hypertonic saline has been effective in treating burns
shock for many years. It produces hyperosmolarity
and hypernatraemia.
 This reduces the shift of intracellular water to the
extracellular space. Advantages include less tissue
oedema and a resultant decrease in escharotomies and
intubations.
87

Colloid resuscitation
 Plasma proteins are responsible for the inward
oncotic pressure that counteracts the outward
capillary hydrostatic pressure.
 Without proteins, plasma volumes would not be
maintained as there would be oedema.
 Proteins should be given after the first 12 hours of
burn because, before this time, the massive fluid
shifts cause proteins to leak out of the cells.
88

 The most common colloid-based formula is the
Muir and Barclay formula:
 Muir and Burclay regime:
 % Burns x Body weight in kg/2 = 1 Ration
 3 Rations given in first 12 hours at 4 hr intervals.
 2 Rations in second 12 hours.
 1 Ration in third 12 hours
89

 o If low urine output, & not responsive to
↑fluids, can use mannitol + frusemide.

Initial assessment of burns & mgt
 Once air patency is assured, take h/o burns,
note:
-time of injury, type of burn, previous rx, burn
extent and depth.
 If burn > 15% in adults and >10% in children
establishment of an IV line takes priority over
history & examination
 Withdraw bld for cross matching, determination
of hematocrit, urea & electrolyte concentrations.

cntd
 Arterial Bld gas analysis
 Pulse rate, bp, core & peripheral temperature
difference
 Catheter
 Analgesia: Cooling, wrapping to air currents. PO
paracetamol/codeine if minor, opioids e.g.
morphine 0.1mg/kg IV (not IM – variable
absorption) if larger
 TT

 NB: the pin prck test.
 This is a test of pin prick not pin pressure.
The pt must be conscious bt cooperative
and understands the difference bt pain and
pressure
 Take a sterile hypodermic needle and
practice first on a normal skin and ask e pt if
he can feel its sharp and blunt ends. Then
test the burn
 If he mostly says blunt, these cd be deep

Caring for severe burns
30-40% in adults
20-25% in children
 Aims
-prevent infection turning a partial thickness
burn to full thickness. Means correct and early
rx
-minimize severity of all contractures and
prevent them. Graft full thickness burns early,
usually btn the 10th & 18th day
-release & graft some contractures you have not
been able to prevent
-prevent all death from shock

The first 24 hrs after burn
 Indications for admission:
a) All patients liable to shock
b) Any pt who has burnt his face, eyes, hands, ft
or perinium wahtever e size of his burn
c) All pt who has inhaled smoke
 secure the pts airway -first priority
especially if face or inhaled smoke

 -only do tracheostomy if absolutely necessary &
intubation fails.
 If his breathing is noisy, his air is obstructed.
Hoarseness & stridor occur late in e shock stage
& are important signs in airway obstruction
 If face swollen, suspect edema of nasopharynx
 Set up a gd drip for all burns >15% in adults &
10% in children. As you put a canulla, get bld
for hematoclit & gping & crossmatching

 Pain relief: Use opiods eg morphin if pt hs not inhaled smoke. If
any sign that pt inhaled smoke or bnt his lungs, don’t give
morphin or any opiods
 If restless, bt not in severe pain , he needs fluids, not morphine
 Catheterisation- measure urine after every one hr.
 Calculate and give e right amt of fluids
 TT injection
 Antibiotics-peniccillin to prevent streptococcal infection

Nursing care
 Place pt on a clean sht with polithen under to
stop soiling of mattress. Don’t let him lie on
the burn
 Use bed cradle to get off beddings off him
 If conscious, lie him supine, raise legs or foot
of his bed. Don’t allow him sit up until shock is
over
 If unconscious, put him in recovery posn

 NGT if burn severe, or he is nauseated or
vomits or abdomen is distended with scanty
bowel sounds or if unconscius
 Monitor pt every one hr

Next day (48hrs)
 Monitor for complications of burns
 Anuria & oliguria
 Haemoglobinuria
 Pulmonary oedema-due to fluid overload or lung damage, reduce
the infusion rate, give frusemide and steroids
 Anaemia
 Contractures and joint stiffness

How much fluid does a burns pt
require
 The proportions of parts of the body differ in adults and
children, estimate them using the lund and browder burns chart.
Use the rule of nines for inititial assessment and if burns are
scattered use palmar method.
 Don’t include areas of erythema in yo estimate, blisters may not
appear for 24 hrs, bt if they appear late revist e estimate
 There is an upper limit to the severity of the burn above which
the pt is almost sure to die and if he does live his life will be a
burden to him. Any pt with burns of 60% or more may not
make. Morphine and a drip to prevent him suffering from thirst
will surely give him a comfortable death

Shd you let a burns pt drink?
 Well, if a pt can and his burns are not extensive,
you can let him drink, bt it can cause problems.
He may drink too little or too much.
 Nausea, vomiting paralytic illeus may occur in
severe burns.
 Shock may make him feel so thirst and he may
drink too much.
 Even if the pt is on drip and wants to drink let
him

 If burns are less than 15% in adults and 10% in
children, let him receive fluids orally as
bicarbonate saline. (I teaspoon of salt + one tea
spoon sodium bicarbonate)
 If 15 % adults & 10% children, he is on
borderline give oral fluids bt supervise him

Does a burn pt need blood
 If a deep burn is more than 10% in a child or 20% in adult, and
is full thickness, give blood
 Give bld on the second day after the shock phase and repeat as
necessary
 At rate of 25mls/kg
 Indications for bld
 Evidence of bld loss such as hematemesis, melena, a falling
hematocrit when infusions are not excessive

 Assignment : how much fluid does a burns pt
need when shock is over
 Use a normogram to calculate the burn patients
fluids

Note
 If urine out put falls below 30mls/hr in an adult or 10mls/ hr in
a child after the first 12 hrs, this is likely to be serious. During
the first 12 hrs, this is not significant, but after, its an indication
that the pt’s kidneys are not being perfused well or the kidneys
are failing.
 If its less than this for the next consecutive hrs, give a test dose
of 1 litre saline in ½ an hr. if this increases out put, it means
transfusion was inadequate
 If out put is not increased, give 1g/kg of mannitol or frusemide,
if this does not increase out put, his kidneys are failing, refer for
dialysis

Treatment of burn wounds
 Various methods are use to rx burn wounds
a) The open (exposure) method w/c leaves the burn open to the
air & encourages it to form a crust
b) The closed method- burn isolated from the environment by the
quick dressings
c) A saline method in w/c e burn is kept continuously moist with
saline
d) The plastic bag method for hands and feet
e) Early excision and grafting.
 Each method has its own advantages & disadvantages. There is
no best method. Mix all of them depending on the pts situation

Open method
 In a superficial burn, the crust separates like the
skin of a snake to leave a pink, well healed skin
underneath
 In deep burns : the dead tissues form a tough
eschar or may remain as a wet slough.
 The best way to rx these eschars is to cover
them with saline soaks. Dry or moist, the
eschar has to be removed and the area
grafted.

 Common modification is to cover the whole burn c vaseline
gauze and expose the wound to the environment. Exudate flows
thro the pours within the gauze
Indications:
- Small burns
- Smaller burns of the hands
- A larger burn for w/c e pt has to be transported else where

The closed (occlusive) method
 At the moment of burning, a burn is sterile, the aim is to keep it
so as far as possible by sealling it off from the environment with
an effective dressing, before it has bme infected. To be effective,
the dressing shd be abt two cms thick, so that it absorbs the
exudate and prevents from reaching the surface where it can
bme infected. Good practice to put some antibiotic over the
burn (silver sulphadiazine or o.5% silver nitrate
 This method:
a) Demands more & better nursing care
b) Needs abundant dressings
c) More dependent on local antiseptic than open method
d) Can coz hyperpyrexia with large burns in hot climate
Dressings are left on for 10 days.

 This technique demands extreme aseptic
mesures. Use a no touch technique . No human
hand shd touch the burn. Dressings shd be thick
enough (2.5 cm)
 Changing dressings
 If the burn is partial thickness, dressings shd be
left on for 10 days
 if full thickness, limit is 4 days w/c corresponds
to end of effectiveness of the local antibiotic

 This is the usual interval for changing dressings
for minor burns in out patients
 Indications for removing the dressings earlier
a) Extreme smell
b) Pain
c) Fever
d) If exudate soaks through the dressings
e) Regional lymphadenitis
Nb: if dressings get stuck into the wound bt do not smell leave
them. Removing the may disturb, the most desired granulation
tissue

The saline method
 Aim: keep burn wet with half strength saline
until it heals-full strength physiological saline
may be painful. This method requires that the
burnt part be dipped into a bath of saline.
Alternative is to pour saline on a burn from a
jar and catch the excess on a macknitosh
 Advantages
1. Reduces time in hospital
2. Minimal equipment & materials used

3. Painless & allows pt move joints early
4. Partial thickness burns heal promptly and
eschars separate early, leaving healthy
granulation tissue.
Best method for deep burns in resource
constrained hospitals. Best method for full
thickness burns while using the exposure
method for superficial burns.
Important to use half strength by putting one
teaspoonful of salt into one liter of water

 With minor burns start at 48hrs and as soon as
shock is over for major burns
 If pt is to deep the wound, let him dip it atleast
twice a day for 20 minutes every time. Sloughs
will usually separate on the 12th day, and be
ready for grafting on the 15th day

Tangential excision of burn
wound with skin grafting
 can be done within 48 hours in patients with less than 25 %
burns. It is usually done in deep dermal burn wherein dead
dermis is removed layer by layer until fresh bleeding occurs.
 Later skin grafting is done.
 • In burns of head and neck region, exposure treatment is
advised.

Sloughs and escars
 Dead tissues over surface of the burn have to separate. If burn is
superficial, they peel off as pierces of dry membrane
 If deep, they form:
a) An eschar. An eschar is dry, hard and dark. It may be so brittle
that it cracks
b) Slough: its soft, moist, grey and stinking
No sharp distinction btn eschars and slough. Eschar is dry, slough
is moist. Exposure method tends to form eschars while
occlusive /saline methods form sloughs

Dangers of sloughs/ eschars
 Eshars may restrict circulation. A thick, dry and tough eschar can
act as a tourniquet and may constrict a patients neck, chest or
circulation in his limbs or fingers
 Infection. Not easy to identify infection, high temperature, pain
may indicate infection. If pus is too much, you may feel a dry
eschar floating over pus
 Severe bleeding when removed especially if removed from a
large area
 Bacteremia: manipulating any infected tissue may cause
bactereamia & removing an extensive slough or eschar may
shower so many bacteria intp a pts circulation that it causes
septic shock. Dislough under antibiotic cover. Sloughs or
eschars really bld, remove them in stages separated by a day or

Sloughectomy & esharatomy for
deep burns
 Antibiotic cover is essential if pts slough or eschar is infected
 Indications for esharatomy or sloughectomy in full thickness
burns
- A constricting eschar-emergency
- Fever which is not malaria or toxaemi

Grafting burns
 All dead tissue on a burn must be removed before grafting
 Grafting can be done in two occasions
- In small deep burns remove the ,excize the wound and graft it
either immediately or in the first three days
- Allow dead tissue to demarcate, remove it and graft within 10-18
days. Never delay graftinfg for more than 18 days.
NB:
Never graft pts burns if there signs of skin regenerating-look for
black greyish patches
Graft any areas of theburn you think it can help

 If you wait for a burn to heal from edges, you
may need to wait for a long time, and when skin
finally covers the burnt area, ti will be thin, pale,
and more likely to become a cancerous or
breakdown later

Prevention of contractures
 Prevent partial thickness burns from vonverting into full
thickness burns by preventing infection
 Graft deep burns around the joints if skin for grafting is scarce
 Scrap off too much granulation tissue so that only a thin layer
remains, this will reduce fibrosis. The scar tissue that forms a
contracture was initially, a granulation tissue. The deeper a
patients burn, and the longer you leave it un grafted the more
granulation will form, the worse his scar & the greater the risk of
contractures-t graft early
 Splint joints in extention in p. o.p plasters casts for not more
than three weeks. The danger is joint stiffness bt it does not
develop for less than three wks
 The greater danger of a scar is that as it contracts, it will pull part

 Contactures can be managed by doing a Z-
PLASTY. Read about Z-plaster

Definitive Rx for burns
 Admit the patient.
 Maintain Airway, Breathing, Circulation.
 Assess the percentage, degree, and type of bum.
 Keep the patient in a clean environment.
 Sedation and proper analgesia.
 Patient should be in burns unit (ideally airconditioned) with barrier nursing,
sterile clothes, bed
 sheets with all aseptic methods.
 Urinary catheterization to monitor output; 30-5O ml/ hour should be the
urine output.
 Tetanus toxoid.
 Monitoring the patient: Hourly pulse, BP, electrolyte analysis, blood urea,
nasal oxygen, often intubation is required.

 IV Ranitidine 5O mg 8th hourly.
 Ryle's tube insertion initially for aspiration purpose later for
feeding (Enteral feeding).
 Antibiotics: Penicillins, aminoglycosides, cephalosporins;
Metronidazole.
 Culture of the discharge; total white cell count and platelet
count at regular intervals are essential to identify the sepsis along
with fever, tachycardia and tachypnoea.
 In burns of oral cavity tracheostomy may be required to maintain the airway.
 Tracheostomy / intubation tube may be required in impending respiratory
failure or upper airway block.

Burn Wounds
 Risk for Infection
 Skin is your first line of defense against infection
 Necrotic tissue excellent medium for bacterial
 Management
 Burn wounds are frequently monitored for bacteria
 Wound swab cultures and invasive biopsies
 Dressing
 Skin grafting

Burn Wound Care
 Cleanse the wound
 Pain medications, 20-30 minutes prior to procedures
Hydrotherapy
 Shower, bed baths or clear water spray
 Maintain proper water and room temperature
 Limit duration to 20-30 minute
 Blister care
 Trim hair around wound; expect eyebrows
 Dry with towel; pat dry don’t rub
 Don’t forget about cleansing unburned skin and hair

Burn Wound Care Cont.,
 Apply an Antimicrobial Agent
 Silverex
 Broad spectrum , Ideal choice.
 Silvadene
 Broad spectrum; the most common agent used
 Sulfamylon
 Penetrates eschar for invasive wound infections
 Painful burns for approximately 20 minutes after applied
 Acticoat (antimicrobal occlusive dressing)
 A silver impregnated gauze that can be left in place for 5 days
 Moist with sterile water only; remoisten every 3-4 hours

 Sterile Dressing
 Several layers dressings.
 Special Considerations:
 Joint area lightly wrapped to allow mobility
 Facial wounds maybe left open to air, kept moist
 Circumferential burns: wrap distal to proximal
 All fingers and toes should be wrapped separately
 Splints applied over dressings
 Functional positions maintained; not always comfortable

 Debridement of the wound
 Types :
 Natural
 Body & bacterial enzymes dissolve eschar; takes a longtime
 Mechanical
 Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
 Surgical
 Operating room / general anesthesia

Surgical Management
 Skin Grafting
 Closure of burn wound
 Spontaneous wound healing would take months for even a
small full-thickness burn
 Wound needs to be covered to prevent infection, the loss
of heat, fluid and electrolytes
 Therefore, skin grafting is done for most full-thickness burns.
 Can be permanent or temporary

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

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

Temporary Burn
 Temporary Skin Grafts
 Why temporary ??
 Clients with large amounts of TBSA burned do not have enough
donor sites.
 Available donor sites are used first, but in large burns not
enough to cover all burn wounds.
 While waiting for donor site to heal so it can be reused a
temporary covering is needed.
 Types of temporary Skin Grafts
 Biosynthetic
 Artificial Skins
 Synthetic

Temporary Burn
 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

Temporary Burn
 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

Temporary Burn
 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

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

complications
 Burn shock
 ARDS
 Renal failure
 Infections and sepsis
 Curlings ulcers for extensive burns
 Scars
 Disfigurment
 Psychological harm

 Marjolins ulcers
 Prevention of complications???

Burns Guide

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