- The document discusses methods for estimating burn size and calculating fluid resuscitation needs, including the Lund & Browder chart for children and the palmar method. It also addresses indications for burn center referral and complications of fluid resuscitation like burn shock and compartment syndrome. Key aspects of wound care are outlined, such as dressing changes, autografting, and management of itching during healing.

2. • Total Body Surface Area
TBSA
Size of Burn Injury

3. Rule of “Nines”
Modified for Age
5 years
1 year
9 9
36
14
16 16
36
18
9
9
14 14
9 9
18 18
1
36
9
Adult

4. • The Lund & Browder Chart takes into account the
proportional differences of a child at different ages so is
more accurate in determining the percentage of body
burned at different ages. This chart should be used in
patients <15 years.
• The Palmar Method – where the palm and fingers
represent approximately 1% of TBSA – is useful in
estimating the extent of irregularly scattered small
burns.
Calculation of
Total Burn Surface Area

6. Lund Browder Charts
Courtesy of Nationwide Childrens Hospital

7. Lund Browder Chart
Courtesy of Nationwide Childrens Hospital

8. Patient’s palm including
fingers
is equal to 1% of their
Total Body Surface Area
(TBSA)
Estimation of Small Scattered Burns
Palmar Method

9. Burn Shock
Burn damage increases capillary permeability.
This increase and the inflammatory process causes
leakage into the interstitial space = edema /third
spacing
Level of edema peaks at 24-36 hours
Burns larger than 25% TBSA will have generalized
systemic edema, including areas not burned.
Adequate Fluid Resuscitation

10. Maintain vital organ function while
avoiding complications of too little or
too many fluids
Fluids: The Goal

11. • > 15% burn in adults
• > 10% burn in children
• Age >65 y/o or < 2 y/o any size burn
Indications for Fluid Resuscitation

12. • 1-2 Large Bore IV(s)
• Isotonic Crystalloid Solution
– Lactated Ringers (LR)
• Begin as soon as possible
Fluid Resuscitatiaon

13. Formula for Fluid Resuscitation
(At Treating Hospital)
Adult: (2ml x kg x % burn) = mls / first 24 hours
Child (13 years and under): (3ml x kg x % burn)
High voltage electrical: (4ml x kg x % burn)
ABLS Provider Manual 2015

14. Formula for Fluid Resuscitation
(At Treating Hospital)
• Parkland Formula
• (4ml x kg x % burn) = ml / 24 hours
(4ml may ↑ to 4.5-5 in electrical injuries)
Regardless of formula used, you should give:
• 50% in first 8 hours from the time of the burn
• 25% in second 8 hours
• 25% in third 8 hours
• Maintenance fluids also given with all formulas used

15. Resuscitation Calculations
Calculated Resuscitation requirement
• (In this example our patient is 20 kg, 60% TBSA burn.)
• (4ml x __ kg x __ % burn) = ml/24 hours
____ ml/24hrs
Resuscitation Fluid per 8 hours
• 1st 8 hours ____ ml or ___ ml/hr
• 2nd 8 hours ____ ml or ___ ml/hr
• 3rd 8 hours ____ ml or ___ ml/hr

16. Resuscitation Calculations
Calculated Resuscitation requirement
• (In this example our patient is 20 kg, 60% TBSA burn.)
• (4ml x 20 kg x 60 % burn) = ml/24 hours
4800 ml/24hrs
Resuscitation Fluid per 8 hours
• 1st 8 hours 2400 ml or 300 ml/hr
• 2nd 8 hours 1200 ml or 150 ml/hr
• 3rd 8 hours 1200 ml or 150 ml/hr

17. • In general, all patients with >20% burn should have a urinary
catheter inserted
• Children (1-14 yrs): 1 ml/kg/hr
• Adults (>14 yrs): 30 to 50 ml/hr
• Electrical: Child 1.5-2ml/kg/hr; Adult: 75-100 ml/hr
NOTE: Fluids are calculated and given using the formula but the
volume of fluid actually given is adjusted according to the patient’s
urinary output and clinical response.
Adequate Fluid Resuscitation
Urine Output

18. NO BOLUS THERAPY
NO DIURETICS
Increase total fluids by
one third /hr
(Decrease by 1/3 if too much urine/hr)
Urine Output Inadequate

19. Complications from Edema
• Burn patients will have edema. It is normal!
• Compartment Syndrome
• Assess for the need for Escharotomies /
Fasciotomies

20. • Assess for:
Pain
Coolness
Discoloration (Paleness)
Poor capillary refill
Numbness/Tingling
-Elevate the extremity
and assess pulse
hourly by palpation or doppler
Nursing Considerations in Circumferential
Injuries with Edema

21. • Physicians will check
compartment pressures
• Pressures equal to or >30
mmHg need
escharotomies or
fasciotomies
Compartment Pressures

22. • Generally not needed until several hours
into burn resuscitation
• Incision made into the eschar
to relieve pressure in compartment
• Laterally & medially - across
involved joints, from 1 unburned
area of skin to another
• Incision to depth to allow release of
pressure (30 mmHg)
Escharotomy & Fasciotomy

23. 23
Chest Escharotomy

24. Fasciotomy
• If pulses do not return after an escharotomy then a
deeper incision is made down through the fascia.
• If pulses do not return after the fasciotomy then
tissue necrosis will occur and amputation is
probable.

25. ABA Burn Center Referral Criteria
• Partial thickness - 2nd degree burn > 10% TBSA
• Burns involving face, hands, feet, genitalia,
perineum, or major joints
• 3rd degree burns any age group

26. ABA Burn Center Referral Criteria
• Electrical burns including lightning
• Chemical burns
• Inhalation Injuries
• Burns with pre-existing medical conditions that
could complicate management, prolong recovery, or
affect mortality

27. ABA Burn Center Referral Criteria
• Burns with concomitant trauma in which the burn
poses the greatest risk of morbidity or mortality
• Hospitals without qualified personnel or
equipment for the care of children
• Burn injury in patients who will require special
social, emotional, or long term rehabilitative
intervention

28. Wound Care

29. Management of Burn Wounds
• Starts with debridement- removal
of cellular debris and eschar
• Wounds cleaned 1-2 times per
day
• Dead tissue is removed
• Burn areas are washed with
soap and water

30. Dressing change – partial thickness
Dressing change 1-2 times daily
• Remove old dressing, soak off with soapy water as needed so
healing skin is not traumatized.
• Wash with a clean wash cloth and mild
non-perfumed soap and water removing any
old medicine and drainage.
• The wound may bleed (and bleed more if the child is crying), so
apply firm pressure with washcloth.
• Rinse the area and pat or air dry.
• Provide distraction for child during dressing change

31. Dressing Change con’t
• Apply a thin layer of an OTC antibiotic ointment - e.g.
Bacitracin, Polysporin, Neosporin - to a non-adherent
dressing (such as Adaptic)
• NO Silver Sulfadiazine (Silvadene) on small partial thickness
• Place dressing on open areas only – do not overlap onto
unburned or healed areas – irritating.
• Secure the non-adherent dressing with a gauze dressing or
similar device.
• When healed (dry & shiny) stop the OTC ointment and
massage with a non-alcohol, non-perfumed moisturizing
cream.

32. Dressing Types
• Standard Dressings
• Application of topical antibiotics to prevent
infection
• Silvadene, sulfamylon cream, bacitracin
• Multiple layers of gauze to contain drainage
• Rolled gauze or ace wrap applied in distal to
proximal direction
• Silver impregnated dressings
• Acticoat, Aquacel Ag, Mepilex Ag
• Releases silver ions when moistened
with water or exudate from the wound
• Use on partial thickness wounds
and donor site
• Can stay on for 7 days

33. Biologic Dressings
• Used for temporary wound coverage
• Promotes healing or prepares the wound for
autografting
• Allograft
• Human skin obtained from a cadaver
• Cost is high and there is a risk of transmitting a
bloodborne infection
• Xenograft
• Skin obtained from an animal; Pigskin is most common

34. Integra
• Two layered substance
• Silastic (plastic) epidermis and a
porous dermis made from beef
collagen and shark cartilage
• Over time, the artificial
dermis slowly dissolves,
leaving blood vessels and
connective tissue that
supports an autograft
after the silastic portion is
removed

35. Surgical Management
• Autografting is used when:
• Full thickness injuries
• Natural wound healing would result in loss of joint function
• Natural wound healing would result in an unacceptable cosmetic
appearance

36. Excision
• Surgical excision of the wound is performed early in
the postburn period
• Leaving dead tissue on the wound for too long
causes sepsis
• Removal of very thin layers of necrotic burn tissue
until bleeding tissue is encountered

37. Autografting
Permanent skin coverage for full thickness
burns
• Epidermis and part of the dermis is taken om from an
unburned area of the patient’s body (donor site) and
transplanted to cover the burn wound (graft site).
Graft secured in place with staples
• Leaves a partial thickness injury at the donor site
• Patient with large full thickness wounds will require
repeated removal of skin from the same donor site or
meshing of the grafts prior to application

38. Sheet Autograft
• Ideal permanent wound coverage
• Better cosmetic appearance
• Used for hands and face
38

39. Mesh Autograft
• Split thickness autograft
• Sheet graft passed through
a mesher to expand and
cover a larger area
39

40. Mesh Autograft cont…
• The graft retains the meshed pattern
• Fades slightly over time with pressure garments
40

41. Graft Care
• After initial application the graft, sites are
immobilized for 3-5 days to allow
vascularization of the grafted skin
• Allows blood vessels in the tissue to
connect with the newly transplanted
graft
• Any activity that might cause separation
of the graft from the tissue is prohibited
• Often requires increased sedation

42. Itching
• As healing occurs, skin is often dry and itchy due to
damage to the sweat & oil glands.
• Massaging healed areas 3-4x a day with an alcohol-
free, non-perfumed moisturizing cream / lotion can
help relieve this. Massage until lotion disappears.
• For overnight itching, moisturize before bedtime.

43. Itching
• If moisturizing is not helping or the child is waking
up from sleep due to itching, an antihistamine like
Benadryl (Diphenhydramine) may be used.
• Use as instructed on package directions
• Remind pt/family that Benadryl can also cause
drowsiness in some children or hyperactivity in
others.

44. Face Grafts
• Vascularize quickly
• Bleeding is often an issue; roll graft with sterile Q-tip
hourly until signs of graft healing are noted
• No dressing, only topical e.g. bacitracin
POD 0 POD 2
44

45. Epicel (Cultured Epidermal Autograft)
• CEA is pure epithelium, also called Keratinocytes
• 2 full thickness postage stamp size biopsies taken from
undamaged skin then live skin cells are extracted to get a
cell yield. Grafts grown in petri dishes.
• Pt has a dermal regeneration template (e.g. Integra)
placed on the wound to help prepare the bed for grafting
• Skin graft will be ready for use approximately 21 days
after skin biopsy is received.
• Initially, the skin grafts are very thin and immature, only
2-8 cell layers thick. Placed on a piece of Vaseline gauze
for transfer

46. Epicel (CEA)• During the first post-op week, the skin grafts will migrate to
the wound bed.
• During dressing change, area left open to air 2 hrs, 2x/day
• POD 7-10 – layer of Vaseline gauze slowly peeled back and
areas covered with adaptic & topical antibiotic (based on
cultures) during twice daily dressing change
• POD 21 – daily dressings with 2-4 hr air outs followed by
adaptic & topical antibiotic
• After POD 21 – not a sterile dressing, limited exposure to
water; grafts susceptible to maceration & blistering
• If no skin is seen by POD 21, it is unlikely to re-epithelialize

47. Pain Management – Severe Injury
“Burns hurt and patients should not have to demonstrate
their pain tolerance”.
Richard Kagan, MD
Retired Chief of Staff
SHC-C

48. Children who are in pain will:
Cry / Scream
Kick / Bite
Try to escape
Throw up
Spit / Punch / Curse
Patients will also have changes in their HR, RR, BP, and
oxygen saturation.

49. Children who are not in pain will:
Suck their thumb
Sleep
Play
Cooperate
Laugh

50. • With the numerous advances in burn care, many
seriously injured patients will survive their injury, thus
making adequate pain management throughout all
phases of care paramount for successful physical and
psychological recovery.

51. Factors which may Influence Pediatric Burn
Patients’ Pain
• Patients have developed a physical tolerance
• Prior hospitalization
• Presence/absence of parent
• Traumatic experience of the burn injury (abuse,
death of loved one, etc.)
• Anticipatory fear
• Separation / Stranger anxiety

52. Pediatric Pain Scales

53. FLACC Scale
• The Face, Legs, Activity, Cry, Consolability scale or FLACC scale is a
measurement used to assess pain for children between the ages of 2
months and 7 years or individuals who are unable to tell you about
their pain.
• The scale is scored in a range of 0–10 with 0 representing no pain.
• The scale has five criteria, which are each assigned a score of 0, 1 or
2.

54. Criteria[ Score 0 Score 1 Score 2
Face
No particular
expression or smile
Occasional grimace or
frown, withdrawn,
uninterested
Frequent to
constant
quivering chin,
clenched jaw
Legs
Normal position or
relaxed
Uneasy, restless,
tense
Kicking, or legs
drawn up
Activity
Lying quietly,
normal position,
moves easily
Squirming, shifting,
back and forth, tense
Arched, rigid or
jerking
Cry
No cry (awake or
asleep)
Moans or whimpers;
occasional complaint
Crying steadily,
screams or sobs,
frequent
complaints
Able to be
consoled
Content, relaxed
Reassured by
occasional touching,
hugging or being
talked to, distractible
Difficult to
console or
comfort

55. Pain Rating Scale
• Designed for children aged 3 years and older.
• It gives a visual description for those who don't have
the verbal skills to explain how they feel.
• To use this scale, you should explain that each face
shows how a person in pain is feeling. The patient
chooses the face that best fits how they feel.
From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301.
Copyrighted by Mosby, Inc.

56. Numerical Pain Scales
• For the older child, a numerical pain scale allows
the child to describe the intensity of his
discomfort in numbers ranging from 0 (no pain) to
10 (worst possible pain).
• Numerical pain scales may include words or
descriptions to better explain symptoms, from
feeling no pain to experiencing excruciating pain.

57. Non-Pharmacological Interventions
• Frequent pain assessment
• Distraction, music
• Giving the patient choices when able
• Reduction of waiting time as much as possible
• Honesty / development of a trust relationship
• Maintaining calm environment when able

58. Non-Pharmacological Interventions
• Use of blankets or other comfort items (pacifier,
favorite toy)
• Guided Imagery
• Healing touch
• Relaxation
• Avoidance of “over-stimulation”
• Massage
• Parental involvement

59. Pharmacological Pain Interventions
• Administration of opioid analgesics
• Morphine, Fentanyl, Dilaudid
• Given IV in the resuscitation phase
• IM or SC meds remain in the tissue spaces and don’t
relieve the pain d/t edema
• Once the fluid shift occurs and edema decreases, all
of the medication is absorbed at once resulting in
lethal blood levels of opioids
• Assess for respiratory depression
• After that, oxycodone/APAP, regular Tylenol, or similar
analgesics, are usually effective.

60. Pain Interventions
• Ketamine and nitrous oxide can also
be used for painful procedures
• There are often strict guidelines
involving the use of these
medications
• Assess the effectiveness of pain
medication

61. Nutritional Support
• Nutritional Support is of primary importance following thermal injury
• Hypermetabolic state induced by the injury
• Adequate nutrition is necessary to promote healing and survival

62. • The patient will maintain adequate nutrition for
meeting caloric needs
• Stable weight will be maintained.
• Caloric intake will meet metabolic demand.
Nutrition

63. Nutrition
• Nutrition is started within first 6-12 hrs via a
nasoduodenal feeding tube inserted under
fluoroscopy
• Monitored by direct calorimetry (measurement of
energy expenditure)
• Administer nasoduodenal feedings until patient is able
to eat on his/her own
• Early enteral feeding helps to reduce weight loss,
atrophy of the stomach and intestines, and
prevent sepsis

64. • Document strict intake and output
• Coordinate care with the nutritionist to meet caloric
and protein needs
• Meet with the interdisciplinary team and patient
to identify food preferences and for each team
member to understand the importance of
nutrition
Nutrition

65. Scar Management & Rehabilitation
Long term rehabilitation is
critical to achieving the
best outcome and quality
of life.

66. Complications
• 12-18 months for scar tissue to mature
• Immature scar: red, raised and rigid.
• Hypertrophic scar: overgrowth of dermal
components that remain within the boundary of
the wound.
• Hypertrophic scarring can hinder the mobility of
the area/joint

67. Treatment
OT/PT
•Every burned joint must be exercised at least
2x/day – lotion and stretching exercises
•Done by patient &/or family members at home
daily for 12-18 months

68. Pressure Garments & Effects of Pressure
• Pressure decreases inflammation - so there is not
excess blood flowing to the healed area and there
is a decreased rate of collagen synthesis
(hypertrophic scarring)
• Realignment of collagen bundles in a parallel
pattern
• Flattening of the scar
• Increased pliability
•Should be worn 22-23 hours per day, every day until
scar tissue is mature (12-18 months)
Treatment

69. Non-Compliance
• Scars are red, raised and firm.
• Scars are usually sensitive to touch and itchy
because patient or caregiver has not massaged
them with lotion
• Mobility is typically limited

70. • School re-entry
• Discharge outings
• Burn camps
• Phoenix Society
Psychological Support & Support Services for
Burn Survivors

71. • Topics to discuss:
-what happens when you get a burn
-certain details about the hospitalization
-exercises & appliances
-functional abilities
Faculty/staff meetings are suggested so more
detailed questions can be answered.
School Re-entry

72. • A photo of the patient ends the talk
• Establish empathy.
• Have children practice what they want to say to their burned
classmate.
• The burned child does not usually attend the re-entry because
classmates may not ask questions or pay close attention.
School re-entry continued...

73. • To reintegrate the burn survivor into the community.
• An outing can tell the patient and healthcare team what psychosocial
or physical tasks need to be improved upon.
Discharge Outings

74. • The patient should be able to:
• Establish eye contact and speak to others
• Practice how to handle someone who stares or asks
questions.
• Physically be able to handle various situations such as
stairs, paying for food etc.
Discharge Outings continued...

75. STEPS: Self talk: what we say & believe
Tone of voice: friendly &
enthusiastic
Eye Contact
Posture: up/shoulders back
Smile: warm & kind
Beyond Surviving: Tools for Thriving

76. RYR: Rehearse Your Response
Write and memorize a 3 sentence response that works
for you.
1. How you were burned
2. How you are doing now
3. Ending the conversation.
If person keep asking more than you want to talk
about: “That’s all I care to discuss today. I’m sure you
understand.” Smile and walk away.
Beyond Surviving: Tools for Thriving

77. Staring is a fact of life for many burn survivors.
It produces uncomfortable moments for both people.
Stand up straight, look the person in the eye, smile and confidently say any
friendly small talk that feels natural: “Hi, nice day isn’t it?”
This can change the energy of the moment and the person sees the survivor
as a person, rather than focusing on the burn injury.
Beyond Surviving: Tools for Thriving

78. The Art of Changing the Subject removes the
attention away from the burn injury to another
subject.
“That is a really nice _____. Did you buy it around
here?
Prepare and Practice how to handle the situations
Beyond Surviving: Tools for Thriving

79. • Goals:
-to adapt physically challenging activities
to the individual needs of the child.
-to improve self-confidence by successfully
completing new activities.
-to share common experiences and problems with
other burn survivors.
Burn Camps

80. “When you look at us you may see something
that’s backwards and different, but when we
look in the mirror we see our strength and
ABILITY!”
Camp Ytiliba…a reflection of strength

81. • International support group for burn survivors of all ages.
• Website: www.phoenix-society.org
• Excellent resource for reading materials, on-line chat groups, peer
support (SOAR), Beyond Surviving Tools
• and up-to-date information on burns and burn technology.
• Phoenix SOAR® (Survivors Offering Assistance in Recovery®) programs
provide peer support to burn survivors. The purpose of the program is to
make sure no one recovers from a burn injury alone.
• Annual national conference – Phoenix World Burn Conference
Phoenix Society for Burn Survivors

82. I’M O.K.
Treat me like a kid
Just ‘cause I got burned
Doesn’t mean I’m Something Else.
A Creature - A Monster - Poor Thing.
It doesn’t mean I need protection.
It doesn’t mean I should be hid.
It doesn’t mean you need to pity me,
Doesn’t mean I’m not a kid.
If you can’t see what’s inside
I might as well have died.