Burn Injuries

Andrew D. Beluso, RN
 BURN INJURIES
 Cell destruction of the layers of the skin and the
resultant depletion of fluid and electrolytes.
 Burn size
1. Small burns: body’s response is localized to the
injured area
2. Large or extensive burns:
a. consist of 25% or more of the total body surface area
(TBSA)
b. body’s response to injury is systemic
c. affect all of the major systems of the body
 Characteristics
1. Minor Burns
a. Partial thickness burns are no greater than 15% of the
TBSA in the adult
b. Full thickness burns are < 2% of the TBSA in the adult
c. Burn areas do not involve the eyes, ears, hands, face,
feet, or perineum
d. There are no electrical burns or inhalation injuries
e. The client is an adult younger than 60 y.o.
f. The client has no preexisting medical condition at the
time of the burn injury
g. No other injury occurred with the burn
 Characteristics
2. Moderate Burns
a. Partial thickness burns are deep and are 15% to 25% of
the TBSA in the adult
b. Full thickness burns are 2% to 10% of the TBSA in the
adult
c. Burn areas do not involve the eyes, ears, hands, face,
feet, or perineum
d. There are no electrical burns or inhalation injuries
e. The client is an adult younger than 60 y.o.
f. The client has no chronic cardiac, pulmonary, or
endocrine disorder at the time of the burn injury
g. No other complicated injury occurred with the burn
 Characteristics
3. Major Burns
a. Partial thickness burns are > 25% of the TBSA in the
adult
b. Full thickness burns are > 10% of the TBSA
c. Burn areas involve the eyes, ears, hands, face, feet, or
perineum
d. The burn injury was an electrical or inhalation injury
e. The client is older than 60 y.o.
f. The client has a chronic cardiac, pulmonary, or
metabolic disorder at the time of the burn injury
g. Burns are accompanied by other injuries
 Estimating the extent of injury
Rule of nine Lund and Browder Method
- Modifies percentages for body segments acc. to age
9 - Provides a more accurate estimate of the burn size
- Uses a diagram of the body divided into sections,

9 9
with the representative % of the TBSA for ages
18
throughout the lifespan
- Should be reevaluated after initial wound
debridement
1

18 18
 Assessment of Burn Injury
Extent / Degree Assessment of Extent Reparative Process
First Degree Pink to red: slight edema, which In about 5 days, epidermis peels, heals
subsides quickly. spontaneously.
Pain may last up to 48 hours. Itching and pink skin persist for about a
Relieved by cooling. week.
Sunburn is a typical example. No scarring.
Heals spont. If it does not become
infected w/in 10 days - 2 weeks.
Second degree Superficial:
Pink or red; blisters form (vesicles); Takes several weeks to heal.
weeping, edematous, elastic. Scarring may occur.
Superficial layers of skin are
destroyed; wound moist and painful.
Deep dermal:
Mottled white and red: edematous Takes several weeks to heal.
reddened areas blanch on pressure.
Scarring may occur.
May be yellowish but soft and elastic
– may or may not be sensitive to
touch; sensitive to cold air.
Hair does not pull out easily
 Assessment of Burn Injury
Extent / Degree Assessment of Extent
Third degree Destruction of epithelial cells –
epidermis and dermis destroyed
Reddened areas do not blanch with
pressure.
Not painful; inelastic; coloration
varies from waxy white to brown;
leathery devitalized tissue is called
eschar.
Destruction of epithelium, fat,
muscles, and bone.
Reparative Process
Eschar must be removed. Granulation
tissue forms to nearest epithelium
from wound margins or support graft.
For areas larger than 3-5 cm, grafting
is required.
Expect scarring and loss of skin
function.
Area requires debridement, formation
of granulation tissue, and grafting.

AGE AND GENERAL HEALTH

• Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o.,
and for clients over the age of 60 years.
• Debilitating disorders, such as cardiac, respiratory, endocrine, and renal
d/o, negatively influence the client’s response to injury and treatment.
1. Mortality rate is higher when the client has a preexisting disorder at the
time of the burn injury
TYPES OF BURNS
• Thermal Burns: caused by exposure to flames, hot liquids, steam or
hot objects
A. Chemical Burns:
a. Caused by tissue contact with strong alkali, or organic
compounds
b. Systemic toxicity from cutaneous absorption can occur
B. Electrical Burns:
a. Caused by heat generated by electrical energy as it passes
through the body
b. Results in internal tissue damage
c. Cutaneous burns cause muscle and soft tissue damage that may
be extensive, particularly in high voltage electrical injuries
d. Alternating current is more dangerous than direct current because
it is associated with CP arrest, ventricular fibrillation, tetanic
muscle contractions, and long bone or vertebral fractures
• Radiation Burns: caused by exposure to UV light, x-rays, or
radioactive source
INHALATION INJURIES
A. Smoke inhalation injury
: results from inhalation of superheated air, steam, toxic
fumes, or smoke
: Assessment
- facial burns - erythema
- swelling of oro / nasopharynx - singed nasal hair
- stridor, wheezing and dyspnea - flaring nostrils
- sooty sputum and cough - hoarse voice
- agitation and anxiety - tachycardia
B. Carbon Monoxide Poisoning
: CO is colorless, odorless and tasteless gas that has an
affinity for Hgb 200 times greater than that of oxygen
: O2 molecules are displaced and carbon monoxide
reversibly binds to Hgb to form carboxyhemoglobin
: can lead to coma and death
C. Smoke Poisoning
: Caused by inhalation of by-products of combustion
: A localized inflammatory reaction occurs, causing a decrease in
bronchial ciliary action and a decrease in surfactant
: Assessment
- mucosal edema in the airways
- wheezing on auscultation
- after several hours, sloughing of the tracheobronchial epithelium
may occur, and hemorrhagic bronchitis may develop
- ARDS can result
D. Direct Thermal Heat Injury
: Can occur to the lower airways by the inhalation of steam or
explosive gases or the aspiration of scalding liquids
: Can occur to the upper airways, w/c appear erythematous and
edematous, with mucosal blisters and ulcerations
: Mucosal edema can lead to upper airway obstruction, esp. during the
first 24 to 48 hours
: Monitored for airway obstruction, ET intubation if obstruction occurs
PATHOPHYSIOLOGY OF BURNS

BURN

↑ Vascular permeability

Edema ↑ Hematocrit

↓ IV volume ↑ Viscosity

↑ Peripheral resistance

↓ Cardiac output
HEMODYNAMIC / SYSTEMIC CHANGES
A. Initially hyponatremia and hyperkalemia occur. Followed by
hypokalemia as fluid shifts occur and K+ is not replaced.
• The hematocrit level increases as a result of plasma loss; this initial
increase falls to below normal at the 3rd to 4th day postburn as a result
of the RBC damage and loss at the time of injury.
A. Initially, the body shunts blood from the kidneys, causing oliguria; then
the body begins to reabsorb fluid, and diuresis of the excess fluid
occurs over the next days to weeks.
B. Blood flow to the GIT is diminished, leading to intestinal ileus and GI
dysfunction.
C. Immune system function is depressed, resulting in
immunosuppression and thus increasing the risk of infection and
sepsis.
D. Pulmonary hypertension can develop, resulting in a decrease in the
arterial O2 tension and a decrease in lung compliance.
E. Evaporative fluid losses through the burn wound are greater than
normal, and the losses continue until complete wound closure occurs
F. If the intravascular space is not replenished with IV fluids,
hypovolemic shock and ultimately death will occur.
 BURN INTERVENTIONS
MAINTAIN AIRWAY
 FLUID RESUSCITATION
 RELIEVE PAIN
 PREVENT INFECTION
 PROVIDE NUTRITION
 PREVENT STRESS ULCERATION
 PROVIDE PSYCHOLOGIC SUPPORT
 PREVENT CONTRACTURES
 MANAGEMENT OF THE BURN INJURY
Phases of Management of the Burn Injury
Emergent phase
- begins at the time of injury and ends with the restoration of capillary
permeability, usually at 48-72 hours after the injury
- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ
functioning
- includes prehospital care and emergency room care
Resuscitative phase
- begins w/ the initiation of fluids and ends when capillary integrity returns
to near normal levels and the large fluid shifts have decreased
- the amount of fluid administered is based on the client’s weight and extent
of injury
- most fluid replacement formulas are calculated from the time of injury and
not from the time of arrival at the hospital
- the goal is to prevent shock by maintaining adequate circulating blood
volume and maintaining vital organ perfusion
Acute phase
- begins when the client is hemodynamically stable, capillary
permeability is restored, and diuresis has begun
- usually begins 48 - 72 hours after the time of injury
- emphasis during this phase is placed on restorative therapy, and the
phase continues until wound closure is achieved
- the focus is on infection control, wound care, wound closure,
nutritional support, pain management, and physical therapy
Rehabilitative phase
- final phase of burn care
- overlaps the acute care phase and goes well beyond hospitalization
- goals of this phase are designed so that the client can gain
independence and achieve maximal function
 FLUID SHIFTING IN BURNS

OLIGURIC PHASE – Intravascular to Interstitial

Hct increased, renal output decreased, hyper K,
hypo Na, hypo CHON, metabolic acidosis

DIURETIC PHASE – Interstitial to Intravascular

Hct decreased, renal output increased, hypo K,
hypo Na, hypo CHON, metabolic acidosis
FLUID RESUSCITATION
 Indications:
- Adults with burns involving more than 15% - 20% TBSA
- Children with burns involving more than 10-15% TBSA
- Patients with electrical injury, the elderly, or those with cardiac or pulmonary
disease and compromised response to burn injury
 The amount of fluid administered depends on how much intravenous
fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr
 Successful fluid resuscitation is evidenced by:
- Stable vital signs - Palpable peripheral pulse
- Adequate urine output - Clear sensorium
 Urinary output is the most common and most sensitive assessment
parameter for cardiac output and tissue perfusion
 If the Hgb and Hct levels decrease or if the urinary output exceeds
50ml/hr, the rate of IV fluid administration may be decreased
 Generally, a crystalloid (Ringer’s lactate) solution is used initially.
Colloid is used during the 2nd day (5% albumin, plasmate or
hetastarch)
Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st
24hrs after a Burn Injury

Formula Solution Infusion Rate

BROOKE ¾ crystalloid, ¼ colloid ½ in 1st 8 hours

2ml/kg/% BSA + D5W maintenance ½ in next 16 hours
2000ml/24hr
(maintenance)
PARKLAND (Baxter) crystalloid only ½ in 1st 8 hours
4ml/kg/% BSA for 24hr (lactated Ringer’s) ½ in next 16 hours
period
PARKLAND FORMULA
Example: Patient’s weight: 70 kg; % TBSA burn: 80%
1st 24 hours:
4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer’s
 1st 8 hours = 11,200 ml or 1,400 ml/hour
 2nd 16 hours = 11,200 ml or 700 ml/hour

2nd 24 hours:
0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently
over the 24 hour period
0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W
= 117 ml colloid/hour + 84 ml D5W/hour
PAIN MANAGEMENT
 Administer morphine sulfate or meperidine (Demerol), as
prescribed, by the IV route
 Avoid IM or SC routes because absorption through the soft tissue is
unreliable when hypovolemia and large fluid shifts are occurring
 Avoid administering medication by the oral route, because of the
possibility of GI dysfunction
 Medicate the client prior to painful procedures

NUTRITION
 Essential to promote wound healing and prevent infection
 Maintain nothing by mouth (NPO) status until the bowel sounds are
heard; then advance to clear liquids as prescribed
 Nutrition may be provided via enteral tube feeding, peripheral
parenteral nutrition, or total parenteral nutrition
 Provide a diet high in protein, carbohydrates, fats and vitamins
ESCHAROTOMY
 A lengthwise incision is made through the burn eschar to relieve
constriction and pressure and to improve circulation
 Performed for circulatory compromise resulting from circumferential
burns
 After escharotomy, assess pulses, color, movement, and sensation
of affected extremity and control any bleeding with pressure
 Pack incision gently with fine mesh gauze for 24 hours after
escharotomy, as prescribed
 Apply topical antimicrobial agents as prescribed

FASCIOTOMY
 An incision is made, extending through the SQ tissue and fascia
 Performed if adequate tissue perfusion does not return after an
escharotomy
 Performed in OR under GA, after procedure assess same as above
WOUND CARE
1. The cleansing, debridement and dressing of the burn wounds
2. Hydrotherapy
a. Wounds are cleansed by immersion, showering or spraying
b. Occurs for 30 minutes or less, to prevent increased sodium loss
through the burn wound, heat loss, pain and stress
c. Client should be premedicated prior to the procedure
d. Not used for hemodynamically unstable or those with new skin grafts
3. Debridement
a. Removal of eschar to prevent bacterial proliferation under the eschar
and to promote wound healing
b. May be mechanical, enzymatic or surgical
c. Deep partial- or full-thickness burns: Wound is cleansed and debrided
and topical antimicrobial agents are applied once or twice daily
Open Method Versus Closed Method of Wound Care
Method Advantages Disadvantages
OPEN
 Antimicrobial cream  Visualization of the  Increase chance of
applied, and wound is left wound hypothermia from
open to the air w/o a dressing  Easier mobility and joint exposure
 Antimicrobial cream is ROM
applied every 12 hrs  Simplicity in wound care
CLOSED
 Gauze dressings are  Decreases evaporative  Mobility limitations
carefully wrapped from the fluid and heat loss  Prevents effective
distal to the proximal area of  Aids in debridement ROM exercises
the extremity to ensure  Wound assessment
circulation is not compromised is limited
 No 2 burn surfaces should
be allowed to touch; can
promote webbing of digits,
contractures, and poor
cosmetic outcome
 Dressings are changed
every 8 – 12 hours
TOPICAL ANTIMICROBIAL AGENTS FOR BURNS
Silver sulfadiazine
 Most widely used agent and least common incidence of side effects
 May cause transient leukopenia that disappears 2-3 days of treatment
 Use with either open treatment, light or occlusive dressings
 Applied once or twice daily after thorough wound cleansing
Mafenide acetate 10% cream or 5% solution (Sulfamylon)
 Painful during and for a while after application
 May cause metabolic acidosis, not used if >20% TBSA
 Cream must be reapplied 12 hours to maintain therapeutic effectiveness
 Solution concentration is maintained with bulky wet dressings, rewet every
2-4 hours
Silver nitrate (0.5% solution)
 Stains everything including normal skin brown or black
 Monitor electrolyte balance carefully
Other topical dressings
 Cerium nitrate
 Povidone iodine
 Gentamycin
 Polymixin B – Bacitracin ointment
WOUND CLOSURE
 Prevents infection and loss of fluid
 Promotes healing
 Prevents contractures
 Performed on the 5th to 21st day, depending on the extent of the burn

AUTOGRAFTING
 Permanent wound coverage
 Surgical removal of a thin layer of the client’s own unburned skin, which is
then applied to the excised burn wound
 Monitor for bleeding following the graft because bleeding beneath an
autograft can prevent adherence
 Immobilized after the surgery for 3-7 days to allow time to adhere and attach
to the wound bed
 Care of the graft site
 Care of the donor site
TEMPORARY WOUND COVERINGS
Biological
Amnion
 Amniotic membranes from human placenta
 Dressing is changed every 48 hours
Allograft (Homograft)
 Donated human cadaver skin is harvested w/in 24 hrs after death
 Monitor for wound exudate and signs of infection
 Rejection can occur w/in 24 hours
Xenograft (Heterograft)
 Porcine skin is harvested after slaughter and preserved
 Rejection can occur w/in 24 – 72 hours
 Replaced every 2-5 days until the wound heals naturally or until closure with
autograft is complete

Biosynthetic and synthetic

 Visual inspection of wound is possible, as dressings are transparent or
translucent
 Monitor for wound exudate and signs of infection
Thank You!