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Burns and Patient Management

Burns and Patient Management


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Burns and Patient Management
Doctor Mohamed El Rouby :: Consultant of Plastic Surgery :: Faculty of Medicine :: Ain Shams University :: Cairo :: Egypt
د. محمد أحمد الروبي :: مدرس جراحات التجميل والاصلاح بجامعة عين شمس :: القاهرة :: مصر
Burns and Patient Management
Doctor Mohamed El Rouby :: Consultant of Plastic Surgery :: Faculty of Medicine :: Ain Shams University :: Cairo :: Egypt
د. محمد أحمد الروبي :: مدرس جراحات التجميل والاصلاح بجامعة عين شمس :: القاهرة :: مصر

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Published by: Dr Mohamed A. El Rouby on Apr 22, 2008
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Burns and Patient Management

Burn wounds occur when there is contact between tissue and an energy source, such as heat, chemicals, electrical current, or radiation.

The resulting effects of the burn are influenced by the:
• intensity of the energy • duration of exposure • type of tissue injured


Burn Statistics
• At least 50% of all burn accidents can be prevented • children playing with fire account for more than one-third of preschool deaths by fire • In the US, approximately 2.4 million burn injuries are reported each year. • Burn injuries are second to motor vehicle accidents as leading cause of accidental death in the US

What 2 types of clients account for 2/3 of all burn fatalities? • Older adults • Children (especially preschool aged children)

Where do most burns occur?
• Children, newborn to 4 y.o, from kitchen and then the bathroom • ages 5-74, most burn injuries occur outdoors with next area-kitchen • ages 75 and above, kitchen and then outdoors


Major cause of fires in the home
• Carelessness with cigarettes!! • Hot water from water heaters set at high levels above 140 degrees F (60 degrees C) • cooking accidents • space heaters • combustibles - gasoline, lighter fluids, etc. • chemicals

Types of Burn Injury
• Thermal burns-can be caused by flame, flash, scald, or contact with hot objects • Chemical burns-are the result of tissue injury and destruction from necrotizing substances. • Electrical burns-results from coagulation necrosis that is caused by intense heat from an electrical current • Smoke & inhalation injury-inhaling hot air or noxious chemicals • Cold thermal injury-frostbite.

Referral Criteria
• 2nd or 3rd Degree Burns >10% BSA • Burns to Face, Hands , Feet, Genitailia, Perineum, or major Joints. ESPECIALY CIRCUMFRENTIAL BURNS • Electrical Burns • Chemical Burns • Inhalation Injury

Referral Criteria
• Burns with pre-existing PMHX that could complicate recovery • Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit) • When in doubt , consult with a burn center


Thermal Burns
• most common type • result from residential fires, automobile accidents, playing with matches, improperly stored gasoline, space heaters, electrical malfunctions, or arson • inhaling smoke, steam, dry heat (fire), wet heat (steam), radiation, sun, etc...

Chemical Burn
2 types of chemical burns • acids-can be neutralized • alkaline- adheres to tissue, causing protein hydrolyses and liquefaction
– examples: cleaning agents, drain cleaners, and lyes, etc...


Chemical Burn
• Different types of burns 1 Outer skin layer 2 Middle skin layer 3 Deep skin layer 4 First degree burn 5 Second degree burn 6 Third degree burn

• With chemical burns, tissue destruction may continue for up to 72 hours afterwards. • It is important to remove the person from the burning agent or vice versa. • The latter is accomplished by lavaging the affected area with copious amounts of water.

Smoke and Inhalation Injury
• Can damage the tissues of the respiratory tract • Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.

3 types of smoke and inhalation injuries
• 1. Carbon monoxide poisoning (CO poisoning and asphyxiation count for majority of deaths)
– Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can occur without any burn injury to the skin


• 2. Inhalation injury above the glottis (caused by inhaling hot air, steam, or smoke.)
– Mechanical obstruction can occur quickly-True ER! Watch for facial burns, signed nasal hair, hoarseness, painful swallowing, and darkened oral or nasal membranes


• 3. Inhalation injury below glottis
– (above glottis-injury is thermally produced) – below glottis-it is usually chemically produced. – Amount of damage related to length of exposure to smoke or toxic fumes – Can appear 12-24 hours after burn


• Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current.


Electrical Burns
• Can cause tissue anoxia and death • The severity depends on amount of voltage, tissue resistance, current pathways, and surface area in contact with the current and length of time the current flow was sustained.


Electrical injury can cause:
• Fractures of long bones and vertebra • Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury • Severe metabolic acidosis--can develop in minutes • Myoglobinuria--acute renal tubular necrosismyoglobin released from muscle tissue whenever massive muscle damage occurs-goes to kidneys--and can mechanically block the renal tubules due to the large size!

Electrical injury can cause:
• Fractures of long bones and vertebra • Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury • Severe metabolic acidosis--can develop in minutes • Myoglobinuria--acute renal tubular necrosismyoglobin released from muscle tissue whenever massive muscle damage occurs-goes to kidneys--and can mechanically block the renal tubules due to the large size!

Electrical injury can cause:
• Fractures of long bones and vertebra • Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury • Severe metabolic acidosis--can develop in minutes • Myoglobinuria--acute renal tubular necrosismyoglobin released from muscle tissue whenever massive muscle damage occurs-goes to kidneys--and can mechanically block the renal tubules due to the large size!

Treatment of electrical burns…
• Fluids--Ringers lactate or other fluidsflushes out kidneys--you want 75-100 cc/hr until urine sample clear • an osmotic diuretic (Mannitol) may be given to maintain urine output


Cold Thermal Injury (Frostbite)
• Can be localized such as frostbite • systemic (hypothermia)


Classification of Burn Injury
• Treatment of burns is directly related to the severity of injury! • Severity is determined by:
– depth of burn – external of burn calculated in percent of total body surface (TBSA) – location of burn – patient risk factors


• Burn injury involves the destruction of the integumentary system. • What is the function of the integumentary system?
– – – – Protective holds in fluids and electrolyes regulates heat keeps harmful agents from injuring or invading the body

Burns are defined by...
• Were defined by degrees in the past! First, second, and third degree • 2 common guidelines now used are the:
– Lund-Browder Chart – Rule of Nines


Rule of Nines
• In the adult, most areas of the body can be divided roughly into portions of 9%, or multiples of 9. This division, called the rule of nines, is useful in estimating the percentage of body surface damage an individual has sustained in burn. • In small children, relatively more area is taken up by the head and less by the lower extremities. Accordingly, the rule of nines is modified. In each case, the rule gives a useful approximation of body surface.

Rules of Nines


Location of Burns
• Has a direct relationship to the severity of the burn. • Face, neck & chest burns may inhibit respiratory illness RT mechanical obstruction secondary to edema or eschar formation


Complicating or Co-Morbid Factors
• • • • • • • Associated Trauma Inhalation Injuries Circumferential Burns Electricity Age (Young or Old) Pre-Existing Disease Abuse

3 Phases of Burn Management

–emergent (resuscitative) –acute –rehabilitative

Pre-hospital Care
• Remove from area! Stop the burn! • If thermal burn is large--FOCUS on the ABC’s
– A=airway-check for patency, soot around nares, or signed nasal hair – B=breathing- check for adequacy of ventilation – C=circulation-check for presence and regularity of pulses

Other precautions...
• Burn too large--don’t immerse in water due to extensive heat loss • Never pack in ice • Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth


Emergent Phase (Resuscitative Phase)
• Lasts from onset to 5 or more days but usually lasts 24-48 hours • begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins • Greatest initial threat is hypovolemic shock to a major burn patient!

Complications during emergent phase of burn injury are 3 major organ systems...

–Cardiovascular –Respiratory –Renal systems

Cardiovascular Systems
• Arrhythmias, hypovolemic shock which may lead to irreversible shock • circulation to limbs can be impaired by circumferential burns and then the edema formation • Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene. • Escharotomies (incisions through eschar) done to restore circulation to compromised extremities.


Respiratory System
• Vulnerable to 2 types of injury
– 1. Upper airway burns that cause edema formation & obstruction of the airway – 2. Inhalation injury can show up 24 hrs later-watch for resp. distress such as increased agitation or change in rate or character of resp. – preexisting problem (ex. COPD) more prone to get resp. infection
• Pneumonia is common complication of major burns • Is possible to overload with fluids--leading to pulmonary edema

Renal System
• Most common renal complication of burns in the emergent phase is ATN. Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.


Nursing management in the emergent phase is...
• Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn) • ventilator? ABGs? Escharotomies? • 6-12 hours later-Bronchoscopy to assess lower resp. tact • high fowler’s position-cough & deep breathe every hour, turn q 1-2 hrs, chest physiotherapy, suction prn

Fluid Shifts
• Massive fluid shifts out of blood vessels as a result of increased capillary permeability. When capillary walls become more permeable, water, sodium, and later plasma protein (esp. albumin) moves into interstitial spaces & other tissues. The colloidal osmotic pressure decreases with loss of protein from the vascular space. This called second spacing.

Third Spacing
• Fluids goes into areas with no fluids and this is called third spacing. Examples of third spacing are exudate and blister formation. • Net result is decreased volume, depletion due to fluid shifts = edema, decreased blood pressure, and increased pulse

Hypovolemic Shock
• Occurs when there is a loss of intravascular fluid volume. The volume is inadequate to fill vascular space and is unavailable for circulation. • Also, burns have a direct loss of fluid due to evaporation.


Inflammation & Healing
• Burn injuries casue coagulation necrosis whereby tissues and vessels are damaged or destroyed • Wound repair begins within the first 6-12 hours after injury.


Immunologic Changes
• Are caused by burns. • Skin barrier destroyed and all changes make the burn patient more susceptible to infection • Pt may be in shock from pain and hypovolemia.


Other factors to consider...
• Full-thickness burns and deep partial thickness burns are initially anesthetic because nerve endings are destroyed. • Superficial to moderate partial thickness burns are very painful. Why?


Still more factors to consider...
• Severe dehydration is possible even though the patient maybe edematous--Why? • May have an dynamic ileus RT body’s response to massive trauma and potassium shifts--Why? • Shivering due to chilling caused by heat loss, anxiety, and pain • unable to recall events RT hypoxia associated with smoke inhalation, or head trauma or overdose of sedatives or pain meds

Fluid Therapy
• 1 or 2 large bore IV replacement lines (may need jugular or subclavian) • Cutdown rare RT increased risk of infection & sepsis • Fluid replacement based on: size/depth of burn, age of pt., & individualized considerations--ex. Dehydration in preburn state, chronic illness • options- RL, D5NS, dextam, albumin, etc. • there are formula’s for replacement: Parkland formula and Brooke formula

Assessment of adequacy of fluid replacement
• Urinary output is most commonly used parameter • urine OP-30-50 cc/hr in an adult • cardiopulmonary factors- BP (systolic 90-100 mmHg, pulse less than 100, resp 16-20 breaths per min. (BP more accurate with arterial line) • sensoruim-alert, oriented to time, place, & person


Wound Care for Burns
• Can wait until patent airway, adequate circulation, fluid replacement is in place!


Full-thickness burns are
• Will be dry and waxy white to dark brown • will have little to no sensation because nerve endings have been destroyed


Partial thickness burns
• Are pink to cherry red, wet, shiny with serous exudate • May or may not have intact blisters and are very painful when touched or exposed to air


Cleansing and Debridement
• Can be done in tank, shower, or bed • Debridement may be done in surgery. (Loose necrotic skin is removed) • bath given with with surgical detergent, disinfectant, or cleansing agent to reduce pathogenic organisms


Infection is the most serious threat to further tissue injury and possible sepsis.
• SURVIVAL is related to prevention of wound contamination.
– Source of infection is pt’s own flora, predominantly from the skin, resp. tract, and GI tract. – Prevention of cross contamination from other patients is the priority for nurses!

2 methods used to control infections in burn wounds...
• Open method- pt’s burn is covered wit ha topical antibiotic and has no dressing • Closed method-uses sterile gauze impregnated with or laid over a topical antibiotic. Dressings changed 2-3 times q 24 hrs.


Wound Care continued...
• Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed • appropriate use of sterile vs. nonsterile techniques • keep room warm • careful handwashing • any bathing areas disinfected before and after bathing

• Coverage is the primary goal for burn wounds. Since usually not enough unburned skin for immediate skin grafting, other temporary wound closure methods are used
– Allograph or homograft (same species which is usually from cadavers) is used for wound closure-- temporary--3 days to 2 wks – Porcine skin-heterograft or xenograft (different species)--temporary--3 days to 2 wks – autograft or cultured epithelial autograft- (pt’s own skin and cell culture)- permanent

Surgeons use a dermatome (left) to remove donor skin and a mesher (right) to put holes in it.


• Surgeons agree that no single product or technique is right for every burn situation. And so far, there's no true replacement for healthy, intact skin, which is the body's largest organ, and one of the most complex. It's the first line of defense against infection and dehydration, but it's more than just a physical barrier. Skin also helps control temperature, through adjustments of blood flow and evaporation of sweat. It's an important sensory organ, too.

Other care measures include
• Face is vascular and subject to increased edema- use open method if possible to decrease confusion and disorientation • eye care-use saline rinses, artificial tears • hands &arms-extended and elevated on pillows or in slings to minimize edema, may need splints to keep them in functional positions

• Ears- keep free of pressure. Ear burns-no pillows! Neck burns should not use pillows in order to decrease wound contraction. • Perineum-must be kept clean & dry. Indwelling foley will help in this & also to provide hourly outputs. • Lab tests prn to monitor electrolyte imbalance and ABGs • Physical therapy stared immediately


Drug Therapy
• Analgesics and Sedatives • given for pt comfort • IV pain meds initialy due to:
– GI function is slowed or impaired because of shock or paralytic ileus – IM injections will not be absorbed well


Drug Therapy
• Tetanus immunization- given routinely to all burn patients because of the likelihood of anaerobic burn-wound contamination • Antimicrobial agents-usually topical due to little or no blood supply to the burn eschar so little delivery of the antibiotic to wound • Drug of choice is: Silver sulfadiazine

• Fluid replacement takes priority over nutritional needs in the initial emergent phase. Why? • NG tube is inserted and connected to low intermittent suction for decompression. When bowel sounds return (48-72 hrs) after injury, start with clear liquids and progress up to a diet high in proteins and calories

Nutritional Therapy


• Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition. • Give calorie containing liquids instead of water due to need for calories and potential for water intoxication • Enteral feedings into the duodenum (recommended) can: reduce n&v, more continuous feedings, and increase wd healing!


Acute Phase
• Begins with mobilization of extracellular fluid and subsequent diuresis. • Is concluded when the burned area is completely covered or when wounds are healed. May take weeks or months. • Pt is no longer grossly edematous due to fluid mobilization, full & partial thickness burns more evident, bowel sounds return, pt more aware of pain and condition.

• Healing begins when WBCs have surrounded the burn and phagocytosis begins, necrotic tissue begins to slough, fibroblasts lay down matrices of collagen precursors to form granulation tissue. • Partial-thickness burns (if kept free from infections) will heal from edges and from below. (10-14 days) • Full-thickness burns must be covered by skin grafts.

Laboratory Values
• Sodium- Hyponatremia can occur due to: silver nitrate topical oints as a result of sodium loss through eshcar, hydrotherapy, excessive GI drainage, diarrhea, excessive water intake
– S/S of hyponatremia: weakness, dizziness, muscle cramps, fatigue, HA, tachycardia, & confusion

• Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, inappropriate fluid administration
– S/S of hypernatremia: thirst; dried furry tongue; lethargy; confusion; and possible seizures

• Potassium- hyperkalemia is note if pt is in renal failure, adrenocortical insufficiency, or massive deep muscle injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness & EKG changes are noted.
– Hypokalemia is noted with silver nitrate therapy and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplementation. Constant K+ losses occur through the burn wound.

Complications of Acute Phase
• Infection- due to destruction of body’s 1st line of defense. Partial thickness wds can convert to fullthickness wds with infection present. Pt may get sepsis from wound infections. Signs of sepsis are: high temp., increased pulse & resp., decreased BP, and decreased urinary output, mild confusion, chills, malaise, and loss of appetite. WBC bet. 10,000 and 20,000. Infections usually gram neg. bacteria (pseudomonas, proteus) • Obtain cultures from all possible sources: IV, foley, wound, oropharynx, and sputum

• Cardiovascular- same as in emergent phase • Neurologic-possible from electrical injuries • Musculoskeletal-has the most potential for complications during acute phase due to healing and scar formation making skin less supple and pliant. ROM limited, contractures can occur • Gastrointestinal-adynamic ileus results from sepsis, diarrhea or constipation (RT narcotics & decreased mobility), gastric ulcers RT stress, occult blood in stools possible • Endocrine-stress DM might occur-assess glucose prn


• Predominant therapeutic interventions are:

Nursing management-acute phase
– fluid replacement, physical therapy, wd care, early excision and grafting, and pain management

• Fluid replacement continues from emergent phase to acute phases--given for: fluid losses, administer medications, & for transfusions. • Physical therapy- to maintain optimal joint function • Pain management- most critical functions as a nurse. • Nutritional therapy-provide adequate proteins 73 & calories

• Wound Care- the goals are cleanse and debride the area of necrotic tissue &debris, minimize further damage to viable skin, promote patient comfort, & reepithelialization or success with skin grafting. • Care for donor site and other grafts necessary • Excision and grafting-eschar removed to subcutaneous tissue or fascia, graft applied to tissue
– Cultured epithelial autograft (CEA)uses patient’s own cells to grow skin-permanent – artificial skin is the latest trend. Examples: Alloderm, Life-Skin, etc.


Rehabilitation Phase
• Defined as beginning when the patient’s burn wound is covered with skin or healed and patient is capable of assuming some self-care activity. • Can occur as early as 2 weeks to as long as 2-3 months after the burn injury • Goals for this time is to assist patient in resuming functional role in society & accomplish functional and cosmetic reconstruction.


Clinical Manifestations
• Burn wd either heals by primary intention or by grafting. • Scars may form & contractures. • Mature healing is reached in 6 months to 2 years • Avoid direct sunlight for 1 year on burn • new skin sensitive to trauma

• Most common complications of burn injury are skin and joint contractures and hypertrophic scarring • Because of pain, pts will assume flexed position. It predisposes wds to contracture formation • Use of physical therapy, pressure garments, splints, etc. are used

Nursing management during rehabilitation phase
• Must be directed to returning patient to society, address emotional concerns, spiritual and cultural needs, self-esteem, teaching of wound care management, nutrition, role of exercises and physical therapy explained. A common emotional response seen is regression.

Special needs of the nursing staff
• The staff of burn units are prone to higher rates of burn-out. The care of a burn patient is a long journey that the patient, nurse, and significant others must travel. The road to recovery is full of potential threats to the patient. Support services are necessary for the medical team of any long-term burn patients.

Care of

B - breathing body image U - urine output R - rule of nines resuscitation of fluid N - nutrition S - shock silvadene



B- Breathing- keep airway open. Facial burns, singed nasal hair, hoarseness, sooty sputum, bloody sputum and labored respiration indicate TROUBLE! TROUBLE Body Image- assist Bernie in coping by encouraging expression of thoughts and feelings.

U- URINE OUTPUT- in an adult, urine output should be 30-70 cc per hour, in the child 20-50 cc per hour, and in the infant, 10-20 cc per hour. Watch the K+ to keep it between 3.5-5.0 mEq/L. Keep the CVP around 12 cm water pressure!

R- RESUSCITATION OF FLUID- Salt & electrolyte solutions are essential over the 1st 24 hours. Maintain B/P at 90-100 systolic. ½ of the fluid for the first 24 hrs should be administered over the first 8 hour period, then the remainder is administered over the next 16 hours. First 24 hour calculation starts at the time of injury. RULE OF NINE’S- used for adults to determine burn surface area!

N-NUTRITION- protein & calories are components of the diet! Supplemental gastric tube feedings or hyperalimentation may be used in pts with large burned areas. Daily weights will assist in evaluating the nutritional needs!

S-SHOCK- Watch the B/P, CVP, and renal function. Silvadene-for infection.


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