Art & science tissue viability supplement

Management of burns in
intensive and acute care
Rowley-Conwy G (2013) Management of burns in intensive and acute care.
Nursing Standard. 27, 45, 63-68. Date of submission: January 11 2013; date of acceptance: February 8 2013.

Abstract
Patients with major burns require specialist care in burn centres,
taking into account the complex systemic response to a burn injury,
avoidance of complications, specialist wound care and supportive
multidisciplinary management. Occasionally, these patients may
be managed in other settings, such as emergency departments or
general intensive care units and ward areas, for example after an
explosion or major disaster. Therefore, general nurses require an
understanding of patients complex needs, and should be aware of the
latest developments in burn care and up-to-date evidence to ensure
best practice.

Author
Gabby Rowley-Conwy
Staff nurse, Burn Unit, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
Correspondence to: rowleyconwyga@ngha.med.sa

Keywords
Burns, intensive care, systemic response, trauma, wound care

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Major burn injuries are a devastating,

life-changing trauma, causing a significant
inflammatory response and life-threatening
complications such as burn shock, acute respiratory
distress syndrome, sepsis and pulmonary embolism.
Care of patients with burn injuries is complex,
but effective specialist input can make a significant
difference to outcomes. There is limited research
into many aspects of major burn care, because
improvements in intensive care management
have only recently resulted in patients surviving
severe injuries. Most patients with a major burn
will require management in an intensive care

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unit, usually in a specialist burn centre. The

goal of treatment should be to reduce systemic
complications and ensure prompt surgical
management of burn wounds (Ansermino and
Hemsley 2004).

Respiratory care
Lung injury may be caused by inhalation injury
or systemic response to a burn (Ansermino
and Hemsley 2004). If the patient was not
intubated before transfer to the burn centre,
close observation is necessary to identify any
risk to the airway as a result of oedema, and
prompt intubation may be needed (British Burn
Association (BBA) 2004). Inhalation injury
causes an inflammatory cascade and, as with
the external burn wound, causes oedema and
increased blood supply to the lungs (Mosier
and Pham 2009). Combined with capillary
leakage, plasma moves into the interstitial
space and forms exudate, which necessitates
careful airway management and aggressive
removal of secretions. This may include:
chest physiotherapy, for example percussion
and vibration (Mlcak et al 2007); regular
position changes to loosen secretions (Mlcak
et al 2007); and aggressive bronchial toilet
using nebulisers and suctioning (Ansermino
and Hemsley 2004).
Nebuliser therapy with bronchodilators, for
example salbutamol, and cholinergic antagonists,
such as ipratropium, may be beneficial.
Nebulised heparin and acetylcysteine have also
been recommended (Ansermino and Hemsley
2004). Repeated therapeutic bronchoscopies
may be required to remove secretions (Mlcak
et al 2007). There is no consensus regarding
ideal ventilation strategies for patients with
burn injuries, however several authors suggest
various possibilities, including low tidal volume
delivery, high frequency oscillation ventilation,
permissive hypercapnia and use of nitric oxide
or extracorporeal membrane oxygenation
(Ansermino and Hemsley 2004, Mlcak et al
2007, Mosier and Pham 2009).
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Cardiovascular care
Adequate, timely fluid resuscitation is vital to
avoid burn shock caused by hypovolaemia and
resulting from capillary leakage of plasma from
the intravascular system (Williams 2008a). In the
absence of adequate fluid resuscitation, the body
compensates by reducing blood supply to the
abdomen, skin and kidneys, causing hypoperfusion
and deepening of the burn wound. Paradoxically,
excessive fluid resuscitation causes oedema, which can
contribute to tissue hypoxia and potentially overload
the cardiorespiratory system, resulting in myocardial
dysfunction (Hettiaratchy and Papini 2004).
Most authors agree that titrating fluid
resuscitation to maintain the minimal acceptable
urinary output of 0.5mL/kg in adults and 1mL/kg
in paediatric patients, along with monitoring vital
signs and laboratory results, is the best way to ensure
adequate perfusion without overloading the patient
(Ansermino and Hemsley 2004, Hettiaratchy and
Papini 2004, Williams 2008b). Inotropic support
using cardioactive or vasoactive medications to
improve heart contractility or vasoconstriction may
be necessary to maintain perfusion. However,
inotropes with a vasoconstrictive action may
cause peripheral shutdown and worsen the
burn, therefore Ansermino and Hemsley (2004)
recommended ensuring the patient is adequately
hydrated before selecting an inotrope with less of
a vasoconstrictive effect.

Renal care
Acute renal failure may be the result of inadequate
fluid resuscitation and subsequent renal
hypoperfusion, or may occur later as a result of
sepsis (Ansermino and Hemsley 2004). Patients
who have sustained a high-voltage electrical injury
are also at risk of acute tubular necrosis, as the
large myoglobin molecules released after such
an injury can damage the delicate renal tubules
(Williams 2008b). Haemodialysis or continuous
renal replacement therapy may be required and
early nephrology input is helpful.

Analgesia
Pain as a result of an acute burn can be classified
as procedural pain and background pain
(Connor-Ballard 2009a). Procedural pain is usually
short-term severe pain caused by any manipulation
of the burn wound, such as dressing changes,
debridement and skin grafting, and occupational
therapy or physiotherapy (Summer et al 2007).
Background pain is a constant, long-term,
mild-to-moderate intensity pain, which is present
when the patient is at rest (Summer et al 2007).
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Burn injuries cause pain as a result of direct

tissue destruction and the inflammatory response
following injury, which can contribute to extreme
sensitivity of the burn (Connor-Ballard 2009a).
Studies from the United States during the 1980s,
found significant variation in perception of pain by
burn care practitioners and lack of standardised
pain management (Perry and Heidrich 1982, Iafrati
1986). Subsequent advances in pain medicine appear
to have had little effect, with patients consistently
reporting poorly controlled pain following a burn
injury (Summer et al 2007, Connor-Ballard 2009a,
Yuxiang et al 2012). Poor pain management
causes patient anxiety and reluctance to participate
in wound care and rehabilitation, erodes the
therapeutic relationship between the patient and
healthcare provider, increases the metabolic response
and is thought to contribute to the development of
complex chronic pain (Yuxiang et al 2012). Patients
pain changes over time and with their condition,
therefore reassessment of pain is necessary.
A patient with a major burn will usually be
intubated and ventilated for some time, and
continuous sedation is generally required. This
should be combined with continuous infusion of
opioids to control background pain (Connor-Ballard
2009a). Various combinations of sedation and
analgesia are discussed in the literature, and therapy
should be guided by local protocols and individual
patient response, as effects can vary widely (Abdi
and Zhou 2002). Procedural pain in a patient who is
sedated may necessitate bolus doses of opioids to be
administered before the start of the procedure. Use
of an appropriate pain scale for critically ill patients
is vital to assess effectiveness of the medication
(Connor-Ballard 2009a, 2009b). Summer et al
(2007) suggested use of adjunctive anxiolytics during
procedures or even regularly, as anxiety heightens
patients perception of pain.
Patients who are conscious also need
effective pain control. Use of an intravenous
patient-controlled analgesia (PCA) system
containing morphine or hydromorphone has been
suggested (Abdi and Zhou 2002, Summer et al
2007, Connor-Ballard 2009b). Continuous infusion
of opioids may be suitable if PCA is contraindicated,
or regular opioid bolus administration is suggested
to achieve a constant serum blood level of opioids
(Summer et al 2007). Simple oral analgesics (such
as paracetamol) or long-acting oral opioids can be
given concurrently to promote analgesic effect, and
may reduce the requirement for intravenous bolus
analgesics (Connor-Ballard 2009b).
Extra prophylactic measures, or conscious
sedation with concurrent analgesics titrated to
individual response, should be combined with
non-pharmacological techniques such as

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distraction, massage, relaxation and repositioning
during wound care and rehabilitation to manage
pain and encourage compliance with treatment
(Connor-Ballard 2009b). Anxiolytics and
promotion of adequate rest is thought to contribute
to reducing patients perception of pain (Summer
et al 2007). Patients should receive individualised
pain management, and early involvement of the
acute pain team, if available, may be beneficial.

Patients with extensive erythema may

occasionally be admitted to the burn centre,
either with concurrent inhalation injury, but
minimal cutaneous burns, or for short-term pain
management. Erythema does not require dressings
as the skin is not broken, but regular application
of non-perfumed emollient creams or ointments
may help to reduce pain (Honari 2004).

Wound care

Partial-thickness burn management

Accurate assessment of wound depth on

admission is vital to guide wound management,
and reassessment is needed to ensure appropriate
wound care (Papini 2004). Burn injuries can be
classified according to the depth of the wound
(Box 1), and management will vary accordingly.
Jackson (1953) identified different zones of a
burn wound, which illustrates how such wounds
develop and can deepen over the first 48 hours
following injury.
Elevation of the patients head and limbs in the
initial phase of treatment can limit swelling, tissue
destruction and pain caused by capillary leakage
of fluid into the tissues, and is recommended for
all patients (Kavanagh and de Jong 2004). Early
input from the physiotherapy and occupational
therapy teams is essential to provide passive
movements, chest physiotherapy, positioning
and splinting to prevent contracture formation,
and promote early rehabilitation and discharge
planning (Edgar and Brereton 2004).

Partial-thickness burns usually do not require

surgical intervention, however a deep
partial-thickness burn that has not healed within
21 days should be reassessed and may require
surgery to avoid significant scarring (Papini 2004).
Blister management remains a contentious issue
in burn care, however blister deroofing ensures the
wound bed can be assessed properly and allows
contact of the dressing, and any antimicrobials,
with the wound surface (Rowley-Conwy 2012).
Although blister deroofing is recommended by
the BBA (2004), this should be considered on an
individual patient basis, taking into account the
likelihood of pain and bacterial contamination,
planned wound care and movement required at the
wound area (Kavanagh and de Jong 2004).
Dressings should fulfil the criteria of an ideal
burn dressing (Box 2), and be changed according
to the manufacturers guidelines. Topical
antimicrobials are supported by consensus in the
literature (Kavanagh and de Jong 2004, Papini
2004, Rowley-Conwy 2010, Gallagher et al 2012),
although dressings and preparations used still vary
widely. Hydrocolloids, alginates and hydrofibre
dressings with an inherent or manually added
antimicrobial, such as silver, iodine or honey, are
often recommended for partial-thickness burns,
as well as silicon mesh contact layers with a
secondary dressing or an absorbent foam dressing
(Kavanagh and de Jong 2004). Temporary
skin substitutes and biologic dressings such as
xenograft (pig skin) and allograft (cadaver skin)
have a use in burn care (Kowalske 2011).
Paraffin gauze, because of its adherence
and damage to the fragile wound bed, and
conventional layers of gauze, pads and bandages
are not recommended in the literature. However,
some burn centres still use these in preference to
more modern, evidence-based burn dressings (BBA
2004). This may be because of the lack of definitive
evidence, as well as limited available sizes of some
modern wound care products, which may restrict
their use for patients with major burn injuries.
Wound cleansing for a patient with an extensive
burn injury depends on many factors, including

BOX 1
Classification of burn depth
Erythema the skin will be bright red or pink, but is not broken. The skin
is painful to touch, but will heal spontaneously in three to five days.
Superficial partial-thickness burns the skin is broken, with a wet,
red or pink wound bed. Blisters are usually present and the wound is
extremely painful to touch. The wound will blanch easily and capillary
refill time is brisk. This type of burn should heal in 7-14 days with
appropriate management.
Deep partial-thickness burns the wound bed may appear mottled
white or deep red, with a waxy dry surface. Sensation is diminished and
there will be less exudate and blisters than in superficial partial-thickness
burns. The wound will blanch, but capillary refill time will be slow. This
type of burn should heal in 14-21 days, but may require skin grafting if
not healed at 21 days.
Full-thickness burns the wound bed may be black, brown or white, with
a dry leathery surface. Sensation will be absent and there may be visible
thrombosed veins on the wound bed. The surface of the wound will be
non-blanching and capillary refill will be absent. All the elements of the
skin that initiate healing have been destroyed, therefore a full-thickness
burn can only heal from the edges, producing significant contraction.
Skin grafting is required to ensure optimal outcomes.
(Rowley-Conwy 2012)

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Erythema management

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the patients clinical condition, facilities and staff

available, and time pressures, as well as the wound
itself. Irrigation of wounds is now suggested as
an appropriate cleansing method, as it removes
bacteria-collecting debris from the wound bed
without the trauma caused to fragile epithelial
cells by scrubbing (Kowalske 2011). In patients
with a major burn, showering is the most practical
method of irrigation (Rowley-Conwy 2010),
because no higher incidence of wound infection
has been found with the use of tap water in burn
wound care. Some centres even have facilities
to shower patients while they are sedated and
ventilated to ensure optimal wound care during the
acute phase of management.
It is important to avoid systemic hypothermia
and overcooling the wound surface during
wound care. This may be achieved by using
warmed cleansing solutions, avoiding exposure
of large wound surfaces simultaneously,
ensuring warm ambient temperature and
minimising length of dressing changes
(Kavanagh and de Jong 2004). Bathing patients
is no longer recommended because of the
risk of autocontamination, hypothermia and
hyponatraemia (Kowalske 2011).

Full-thickness burn management

Early surgical excision of eschar from
a full-thickness burn, followed by application
of split or sheet skin grafts, is recommended
(Papini 2004, Kowalske 2011). Early excision
and skin grafting has been shown to reduce
mortality and infection rates, and improve
functional and cosmetic outcomes (Ong et al
2006). Dressing management of skin grafts and
donor sites lacks consensus in the literature, but
basic principles of wound care apply. For new
skin grafts, topical antimicrobials are indicated,
and topical negative pressure therapy may
be useful for some wounds (Kowalske 2011).
Donor sites are surgical wounds and should be
superficial and sterile, and should heal within
14 days with appropriate management (Honari
2004). Adherent dressings may be applied and left
to separate as the wound heals (Honari 2004).
Alginate and biosynthetic dressings may be used
in a similar way (Kowalske 2011).
For some patients, early excision and skin
grafting may not be possible, for example after late
presentation or referral, or because of pre-existing
comorbidities that require management and
stabilisation before a surgical procedure. For these
patients, antimicrobial ointments are often used
with absorbent secondary dressings. Enzymatic
debridement of eschar is being trialled at present,

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and may present an alternative to surgical

debridement by removing devitalised tissue from
the wound bed (Honari 2004). Products used
include collegenase and manuka honey dressings,
but so far results vary (Kowalske 2011).
Burns with exposed bone or tendons will need
specialist wound covering techniques and wound
care. Topical negative pressure therapy is often
used, as well as burr holes surgical drilling of
holes into the bone to increase blood flow to the
wound, and skin flap techniques a full-thickness
skin graft that is transplanted with its own blood
supply (Kowalske 2011).

Nutrition
Burn injuries have been described as the most
severe metabolic stress a patient can experience
because of the complex inflammatory response
that occurs soon after injury, leading rapidly to a
hypermetabolic state (Flynn 2004). The level of
hypermetabolism increases as total body surface
area (TBSA) affected by the burn increases, and
also as a result of lengthy dressing or surgical
procedures, pain, infection and thermoregulatory
dysfunction (Flynn 2004). Early enteral feeding
has been shown to decrease the hypermetabolic
response, improve wound healing, decrease
infection risk and help prevent development of
stress ulcers (Lee et al 2005). Parenteral nutrition
is not recommended, as it has been associated
with significantly increased mortality in patients
with burn injuries (Lee et al 2005). Nasojejunal
or nasoduodenal tubes are suggested, as feeding
is better tolerated and absorbed by these patients
(Lee et al 2005). McCahill (2006) identified three
main criteria that indicate an individual will need
nutritional support during treatment:
If
 the burn extends over more than 30% TBSA.
If
 the patient journey involves numerous
operations, ventilatory support or compromised
mental health.
If
 the patients pre-burn nutritional status
was poor.

BOX 2
Criteria of an ideal burn dressing
The ideal burn dressing should:
Protect the wound from physical damage and microorganisms.
Be comfortable, compliant and durable.
Be non-toxic, non-adherent and non-irritant.
Allow gaseous exchange.
Promote high humidity in the wound bed.
Be compatible with topical antimicrobials.
Allow maximum activity for the wound to heal.
(Adapted from Pankhurst and Pochkhanawala 2003, Rowley-Conwy 2012)

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Ansermino and Hemsley (2004) stated, however,
that all patients with burns of more than
20% TBSA should receive nutritional support.
It is essential that an accurate weight
measurement is obtained as soon as possible, and
early specialist review by the dietitian is essential.
The dietitian will calculate energy, protein,
carbohydrate and vitamin requirements, and
develop a feeding regimen (McCahill 2006). High
protein commercial feeds are commonly used for
patients with burn injuries, and many burn centres
supplement vitamins, minerals and essential trace
elements according to local policy (Flynn 2004).
Nurses are best placed to monitor tolerance and
effects of the feeding regimen using laboratory
results, blood glucose levels and signs of
gastrointestinal irritation, and should, therefore,
be familiar with the type of feed and identify any
problems quickly (McCahill 2006).
A high-calorie, high-protein diet should be used
for patients who can tolerate oral nutrition, and
supplementation with nutritional drinks, vitamins
and minerals may be required (Lee et al 2005).

Psychosocial care
Complex psychological intervention is not
necessary during the acute phase of management,
as the patients survival is the priority. However,
clear explanations should be used by caregivers to
orientate the patient and explain any procedures
(Wiechman and Patterson 2004). Intensive
psychological and psychiatric assessment and
treatment may be needed once the patient is able to
communicate and understands the implications of
the burn injury, and timely referral to these services
is vital (Wiechman and Patterson 2004).

Conclusion
Survival rates of patients with a major burn have
improved in recent years as a result of better
intensive care management and developments in
surgical techniques. Burn care is complex and there
are many areas where evidence seems conflicting
or requires further study. However, this constantly
changing area provides opportunities for practice
development and role enhancement NS

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