Critical Care for Burn Injuries

N’ Dirty Nursing: Burns
The 60-Second Summary
5 Types of burns: Chemical, thermal, electrical, ionizing radiation, inhalation injury
Classification Systems: Rule of 9's (used in transport), Lund-Browder (more detailed, used in hospital
Hypovolemia: Vasodilation and inflammation causes increased vasculature permeability and fluid leaks out of neighboring cells
Airway obstruction: Potential for any burn that affects the chest up. Inflammation results from tissue damage, which can to lead to edema and
obstruct the airway. Greatest risk for death within the first 24 hours
Circulatory impairment: Eschar/necrotic tissue formation creates increased pressure and obstructs the vasculature. Most common with inhalation
injuries and circumferential burns. Evidenced by pulselessness

Understanding Burns
Initial Considerations for Burn Injury
Consider the source of the burn, the injuring agent, severity, depth, exposure, and baseline vitals/status. The Rule of 9’s is usually used pre-hospital
(in transport by paramedics/EMTs) while Lund-Browder is used in hospital. In the Lund-Browder, the areas are divided more precisely than the Rule
of 9’s. For instance, the Rule of 9’s divides the arm as 9% (or 4.5% for posterior and anterior side), whereas the Lund Browder divides the arm into
the right upper arm, left upper arm, left lower arm, and hand.

The healthcare team members must take special considerations in cases of potential contamination to protect themselves first. After all, no patients
can be saved if everyone dies!

Special Airway Needs for Burn Injury
Any burn that affects the chest up is considered an airway problem. Damage causes inflammation, which can to lead to edema and obstruct the
airway. This is the highest risk of death within the first 24 hours. Proactive pain management is crucial, especially when mechanical “scrubbing” is
used. ABA consensus formula: 2-4 mL or crystalloid solution x body weight in Kg x TBSA to provide the total 24 hour fluid to be administered. This
amount is dived in half. The first amount is administered over the first 8 hours and the second half over the next 18 hours.

Why the Patient is at Risk for Hypovolemia
Vessels dilate and become more permeable to the membrane. Inflammatory mediators such as cytokines rush to the area of injury, causing
vasodilation and increasing the permeability. This causes fluid to leak out of the cells. Fluid administration is central to burn management as
it promotes tissue perfusion and reduces the risk of complications associated with dehydration.

Why the Patient is at Risk for Circulatory Impairment
In addition to fluid loss, circulatory impairment can result from necrotic tissue formation. Eschar complications are most serious in the lungs
(inhalation injuries) and in circumferential (all around burn) burns. In the circumferential burn causes bands of eschar, which creates pressure and
obstructs the vasculature, (evidenced by pulselessness).

Road Rash
Road rash can develop into burns. Entrapped debri embedded into the tissue can cause burns long after initial contact. They’re treated the same
way as other burns, via hydrotherapy

Types of Burn Injuries
5 Major Types of Burns
Chemical, Thermal, Electrical, Ionizing radiation, Inhalation injury

Chemical Burns
Chemical burns are caused by exposure to acidic or alkaline compound or another noxious chemical. It’s usually related to home or work exposure.
They are treated with hydrotherapy as soon as possible (rather than a neutralizer, as was the standard before). If exposure to the eyes occur, they
are continuously flushed until a specialist comes.

Thermal Burns
Thermal burns are caused by exposure to steam, smoke, flames, or a hot object
Common sources of thermal burns occur from scales secondary to exposure with hot food or beverages, or hot tap water from bathtubs or
showers
The severity of a thermal burn depends upon the temperature of the injuring agent, duration of contact, and to some extent, the actions taken
immediately afterwards (such as if someone follows the old wives tale of placing butter on the wound, which actually serves to trap in heat)
Moat beverages such as coffee, are served at a temperature of 160 to 180 degrees Fahrenheit (71-82 degrees Celsius), which can cause a
serious burn almost instantaneously upon contact
It can also increase the patients’ risk for dehydration, especially if they reside in a hot climate like Phoenix, Arizona in July

Thermodynamic regulation impairment is another major issue. Burn therapy is a highly advanced specialty. lighting Inhalation Injury The Effects of an Inhalation Injury Inhalation injuries are less obvious that external burns but can potentially cause damage that is even more of an immediate threat to survival.Electrical Burns Electrical burns are caused by exposure to voltage. The size of the burn is initially estimated by the percent of the body affected by the burn. third. Once the patient is stable. Phosgene. determined by the Rule of Nines or the Lund and Brower method Burn evaluation is crucial for several reasons. a combination of hypovolemic. resulting in hypovolemic shock. this is one of the most common events that can threaten survival in the patient with a burn injury Classifying Burns Burn Severity The severity of the burn is classified by the depth. Ammonia. Immediate Complications Associated with Burns Circulation: hypovolemic shock Circulation: hyperkalemia (can affect the heart) Exposure: hypothermia is common complication that poses immediate risks to survival (from coagulopathies and cardiac arrhythmias) Delayed and Secondary Complications Metabolic acidosis may not present until later on. Even a small injury to the hand may require an amputation if severe enough. causing additional propagation of the immune response Immune reactions disrupt sodium-ATPase activity. resulting in the loss of ciliary action. tar. cardiogenic. and oxygenation status predispose the patient to metabolic acidosis Infection is a common secondary complication of burn injuries. patients with serious burns are transferred to the local burn center for specialized treatment Burn Zones Necrotic zone Zone of stasis: triggers the release of inflammatory mediators such as histamine. and extensive mucosal sloughing Common Sources of Inhalation Injury Aldehydes. circulation impairment is a common complication associated with burn injury. In order to increase survival and minimize the effects of long-term consequences. phenol. Hydrogen chloride. and size. Inhalation of these particles can inflict damage to the tracheobronchial tree. They may occur alone or in conjunction to external burns. thromboxane. the evaporative forces that affect exposed blood and fluid can rapidly lead to hypothermia. hydrocarbons. Additionally. such as the hands. Initially. white phosphorus Electric: electrical cord. which serve to increase capillary permeability and result in localized burn wound edema.000 volts (V) or less and travels through the path of least resistance. Certain burns are automatically promoted in severity if they affect sensitive anatomical locations. The Only Warm Part of the Hospital??? Most students notice that the trauma rooms are much warmer than any other area. depending upon the affected tissue. and other facets Chemical: formic acid (cement. prostaglandins. can serve as a mechanical restrictive force in the airways. Voltage can travel to other deep areas. second. and distributive shock (usually just known as hypovolemic shock) . nitrates. Low voltage is defined as 1. This is followed by production of highly reactive oxygen species (ROS). which is necrotic tissue that is thick and leathery. as ruptured cells release potassium into the vascular spaces. it guides fluid administration for resuscitative purposes. One of the major risks is cardiac issues. anatomical location. Sulfur oxides Complications Promoting Survival in the Burned Patient In addition to airway and breathing impediments. nitric oxide. and diminished production of surfactant production. bathtubs. airway edema. utility box. anhydrous ammonia). This is not a coincidence. Extensive cellular damage is often associated with hyperkalemia. or forth degree. occupational (especially construction workers). Major dysfunction of metabolic processes impair the body’s ability to retain heat. Burn depth of the burn is categorized as first. or genitalia. Furthermore. Hydrogen cyanide. electrolyte. Common Sources of Burns Thermal: hot beverages and foods. it determines if the patient requires specialized treatment by a burn center. Trauma rooms are purposely maintained at a higher temperatures due to the patient’s risk of hypothermia. Secondary consequences can result from pulmonary edema. chemical pneumonitis. Dramatic alterations in fluid. face. which may contribute to burn shock. Noxious gases produced by hot soot particles result as a byproduct of combustion. Dramatic losses of can easily induce hypovolemia. Eschar.

the modified Lund-Browder chart is used. Degree of Severity First-degree burns: only involve the epidermis Second-degree burns: classified as superficial or deep and involve all of the epidermis and some to all of the dermis Third-degree burns: also known as full thickness. leather-like texture with variable color. with a blister Heal 10-14 days with no to minimal scarring Presentation of the Deep Second-Degree Burn Less red and not as painful Heals within 2-4 weeks. Muscle. Amputation or a complex reconstructive process may be required Parkland Formula: 4 mL x Body Weight in Kg x TBSA % = Fluid Amount in mL Burn Centers What are Burn Centers? Burn centers are specialized facilities that maintain a team of healthcare professionals that highly trained and qualified to manage the care of patients with serious burns. . often with significant scarring Third-Degree Burns Presentation of the Third-Degree Burn Dry. First-Degree Burns Presentation of the First-Degree Burn Red. branching. pain may be absent as the nerve endings are gone (pain will still be present in the area around the burn) Interventions required for healing to occur. moist. Scattered burns are estimated by the size of the patient’s palm. and muscles. affect all of the epidermis and dermis Forth-degree burns: affect all of the skin layers and varying degrees of adipose tissue. bone. and adipose layers. painful. The final 1% is represented by the perineum and genitalia. as it affects the entire span of the epidermal. as it’s especially calculated for pediatric body ratios. and bone may be missing A high level of interventions are required for healing to occur. tendon. The Rules of Nines Each arm: 9% Anterior torso: 18% (add 5% for a pregnant woman in the third trimester) Posterior torso: 18% Each leg: 18% Genitals: 1% The Lund-Browder Chart The Lund-Browder chart is a more complex and comprehensive method to measure the burn severity. which is generally proportionate to 9% of the total body surface area (TBSA). which often takes months to years.Burn Size The Rule of Nines divides the body into sections. as it’s more time consuming. as the body surface area to mass ratio in children is higher than adults. tender. with each area representing 9% (or multiple of 9%) of the total body surface area (TBSA). A complex reconstructive process may be needed and recovery may take several months to years Forth-Degree Burns Presentation of the Forth-Degree Burn Variable in presentation. tendon. Calculating the TBSA is essential for fluid volume delivery and determining if the patient needs to be treated in a burn center. For children less than 12 years of age. dermal. It’s usually utilized following the primary survey. dry. and painful The heal within a week with no scarring Damaged tissue sloughs off within a few days Second-Degree Burns Presentation of the Superficial Second-Degree Burn Red.

Maintain in-line cervical immobilization for patients at-risk (until cleared for C-Spine) during placement to the best of ability (airway management is the priority). scalds. and preexisting medical conditions. Monitor the chest wall excursion for the presence of deep torso burns C: Circulation. Remove all clothing and jewelry. Assess for neurological deficit by the patient’s monitoring level of consciousness. many of them occur spontaneously. blood pressure. and wrap the head to maintain the patient’s body temperature. A chest x-ray should be obtained (this is very important if there’s a suspicion of inhalation injury). the patient was peeing all night long prior to getting burned. Concomitant injuries also indicate the need for X-ray/CT scans. Cover the burn with a clean. warm blankets (Mylar blankets). This may indicate the need for more aggressive fluid replacement Although Prioritized… Although these actions are prioritized. Determine if alcohol or drug use was involved in the injury (not to be judgmental. and abdominal injuries. chemical burns. Establish two intravenous access sites with a large bore catheter wherever possible (through burned skin. A pregnancy test must be performed for all females of childbearing age High-Risk Patients. especially rings. linens. This is performed through conversation during resuscitative efforts. Use collected data to consider potential sources of injury. or joints Partial thickness burns that affect more than 10% TBSA Electrical burns. although drawing blood for the CBC is not nearly as crucial as airway access. 12-Lead Electrocardiogram. and wet dressings. inhalation injury. Special considerations are given for pediatric. . electrical. and with extreme caution if a crush injury is suspected B: Breathing. in order to provide information on the most appropriate collaborative interventions. and diabetic patient populations Toxicology. it’s not as important of a priority as fluid administration) Pregnancy Test. Most patients with burn injuries are typically alert and oriented. geriatric. Succinylcholine may be used only within the first 8 hours for incubation. or inhalation injury Pediatric patients with a serious burn injury Burn injuries that occur with concomitant trauma Any burn injury that requires a special form of treatment that extends beyond the expertise of the facility Trauma Management ABCDE: Primary Survey and Actions for the Patient with a Burn A: Airway. Assess circulatory status of circumferentially burned extremities. one nurse may be obtaining the blood sample as the other one assists the trauma surgeon with airway placement. Use a moisture retainer on the endotracheal tube. Monitor pulse rate and strength. hypoxia. Assess need for endotracheal intubation. such as witnesses and/or family members. which can be thought of as a “well-oiled machine. take special notes of cardiac disorders. if necessary). Assess respiratory rate. A urine drug screen and a serum alcohol level is performed. If not conscious. a patient who is intoxicated with alcohol is more likely to be dehydrated. Simultaneously perform an initial estimate the burn area. and contact. arterial blood gases. genitals. Initiate infusion of warm lactated ringers. Use a chin lift or jaw thrust to position the patient’s head while assisting the trauma surgeon in placement of an oropharyngeal or nasopharyngeal tube to maintain airway patency. Auscultate the lungs and verify breath sounds (both for the purpose of listening to the lungs and to perform the initial confirmation of the airway tube). The Level I trauma team acts as a highly organized and efficient unit. however. Collect information from the patient (if possible) and from other sources. and continue to administer warmed fluids intravenously. and pregnancy Chest X-Ray and CT Scan. diabetes. Remove wet clothing. and quality. consider the potential for associated injuries. depth. flash. When inquiring about preexisting medical conditions. but to guide treatment). or the possibility of a pre-existing medical conditions E: Exposure/Environment. Keep the patient covered with dry sheets. dry sheet or blanket when it’s not being assessed Secondary Survey and Actions for the Patient with a Burn Data Collection. Keep the room warm. assuming the patient is conscious.Referral Criteria for a Burn Center All third-degree and forth-degree burns Burns to the hands. thoracic.” For instance. Apply electrodes for an EKG D: Disability. substance abuse. the possibility of concomitant trauma (especially head. An ECG specially if an electrical injury is suspected or for patients with a cardiac history Blood Work. as these may not be readily observable). Apply covered heat packs as appropriate. Do this while administering humidified 100% oxygen. In other words. including: carbon monoxide (CO2) poisoning. as antidiuretic hormone (ADH) secretion is suppressed. radiation. Draw blood for the CBC. Additionally. and other tests (this is typically performed when IV access is being initiated. prescription medication use. Alcohol levels can influence coagulation significantly. explosion. Maintain the patient’s body temperature. and assess the skin color. face. chemical. The first questions involve the situation surrounding the event. eliminate drafts from the treatment area. including flame.

electrical burns may require additional fluid. hematocrit. including blood urea nitrogen (BUN). usually for the entire duration of day two. However. Boyle. ventricular tachycardia. Once a significant diuresis occurs. It maintains tissue perfusion by correcting blood loss. especially hemoglobin. are administered. with a special emphasis on potassium. osmolality. and albumin Intake and output Indications That We Are Giving Too Much Fluid Excessive swelling and weight gain more than 15% of pre-injury weight Dilutional hemoglobin and hematocrit Pulmonary edema: evidenced by lung crackles Abdominal compartment syndrome Acute lung injury Acute respiratory distress syndrome Increased lactate levels (Fahlstrom. which is a perimeter of cardiopulmonary arrest Lab Values Complete blood count (CBC). and renal function tests. serum electrolytes. & Flynn Makic. Patients with altered renal function that preexisted the injury may warrant alterations to the standard fluid replacement algorithm. which are hypertonic and contain large molecules that don’t diffuse through the semipermeable membrane of the cell. blood pH. 2013) hematocrit. especially blood CO2. Doppler ultrasound: used to assess pulses. May be used during the primary survey. Lactated ringers. are administered for the first 24 hours. The amount of fluid is calculated through a formula such as the Parkland. Following the initial 24 hours. 2013) Dialysis may be indicated for fluid overload associated with acute kidney injury . especially in cases of circumferential burns CT scan: concomitant injuries also indicate the need for a CT scan ECG are usually routine. The patient must be weighed daily. sodium. Fluids are administered at room temperature in order to reduce risks associated with hypothermia. colloid fluids. fluid administration is a delicate balancing act that requires careful titration. & Flynn Makic. and chloride. Fluid volume replacement is then reduced by half. The end point of fluid resuscitation isn’t clearly established and consequently requires the need to examine the entire clinical picture. and BUN/creatinine ratio Urinalysis Lactate Arterial blood gases (ABGs). Complications associated with fluid overload can occur if too much fluid resuscitation is administered. Half of the volume is administered during the first 8 hours and the second half during the next 16 hours. A-fib often sets the stage for the sequel of events that progress to premature ventricular contractions. and BUN:Cr ratio within range Lactate level stable (Fahlstrom. Indications That We Are We Giving Enough Fluid Urine output of 30 mL to 70 mL per hour Osmolality within normal range Renal function values: BUN. Special fluid replacement considerations are given for the patient’s unique situation. A urine output of 30-70 milliliters per hour is maintained. Fluid Balance Fluid administration is a central component of burn management. which are isotonic fluids that contain electrolytes. creatinine. and ventricular fibrillation. This reduces the risk for hypovolemic shock. calcium. creatinine. the patient is determined to be out of the initial resuscitative phase. A weight gain up to 15% of the patient’s pre-treatment body weight can be expected as a result of the massive fluid replacement. glucose. For instance. Any patient with traumatic injury is at risk for atrial fibrillation. blood glucose and electrolytes. Boyle. but are an especially important to initiate early on for cases of potential electrical injury and for patients with a cardiac history.Diagnostics Chest X-ray: a chest x-ray is obtained in the trauma room but may also be ordered later (this is very important if there’s a suspicion of inhalation injury). and carboxyhemoglobin Draw blood for the CBC (hemoglobin and hematocrit being the most important components) Fluid Resuscitation Fluid Replacement Principles Fluid replacement is one of the primary interventions provided for the patient with a burn injury. and platelets Basic metabolic panel (BMP).

produces high levels of the waste product urea. Hyperlactatemia can suggest that the patient is in shock or at risk of going into to it soon. or hyperlactatemia. and fasciotomy may be included as part of the treatment so wound care considerations must be adjusted for specific needs. including lactic acid. In burn cases.Lactate Lactate values are obtained along with arterial blood gases in order to assess for elevated levels. This is one of the links between the high infection risk in burn cases. neomycin. Range of motion exercises are performed. the reparative phase begins. Various factors predispose the patient to muscular hypertrophy. such as silver nitrate. They’re carefully monitored to guide fluid resuscitation. injuring agent. Escharotomy. Organ dysfunction is present in this case. known as hypercatabolism. and indicates intravascular volume deficit or cardiovascular collapse. Insufficient amounts promote catabolism. and bacitracin. Topical antimicrobial agents are applied to the wound area. and severity of the burn. excessive amounts can induce hypercatabolism. Selection is determined by the physician. which causes azotemia. Additional doses are administered as needed throughout the treatment. Severe hyperlactatemia is considered lactic acidosis when it reaches levels of 5 mmol/L or greater. Sustained elevation or increase suggests that fluid resuscitation is inadequate or not improving perfusion for another reason. Gastric motility must be maintained in order to prevent sepsis from occurring. Tissue hypoperfusion associated with burns (and other severe traumatic injuries. Serum protein levels are monitored throughout therapy. However. Lactic acidosis often occurs in conjunction to metabolic acidosis. which can lead to contracture. an opioid analgesic is administered. and is based off factors such as the location. Considerations for the Reparative Phase Pain control Nutritional support: promotion of gastric motility and prevention of hypercatabolism to lower risk of infection Musculoskeletal support: contracture prevention and functional promotion Wound care and debridement Pain Control Pain control is fundamental part of management. On the other hand. elevated lactate levels. Ability to maintain normothermia is altered by the impaired physiological function. the burn can increase heat loss. disturbing the body’s heat production. the area surrounding more serious burns are also affected by pain. Musculoskeletal Support Physical and occupational therapy usually begins 24 hours after arrival. This is one of the links between metabolic acidosis in burn cases. is indicative of tissue hypoxia associated with the burn injury (burn-related cases of hyperlactatemia are caused by tissue hypoxia). Hypothermic Regulation Thermodynamic regulation is crucial to the patient’s survival. 20-30 minutes prior to wound care. Excessive protein metabolism. Protein delivery is a delicate balancing act. This metabolic state increase the production of various acids. Lactate monitoring is especially valuable as occult tissue hypoperfusion may still be present despite normotension and adequate urine output. First degree and second-degree burns that are superficial are often the most painful as deeper injuries damage the nerve endings involved in nociception (pain stimulus). Nutritional Support Enteral therapy is initiated within 24 hours. Furthermore. or septic or hemorrhagic shock states) trigger anaerobic metabolism. Lactate serves as a clinical marker to determine systemic hypoperfusion or sepsis severity. Hypothermia predisposes the patient to risks such as coagulopathies. This is important for two main reasons: promoting gastric motility and preventing excessive metabolism of protein. Rapid decreases in lactate suggested significant improvement in both tissue perfusion and oxygenation. which can result from translocation of gastrointestinal bacteria. Various products are available. . The amount of cream or ointment that is applied depends upon the needs of the wound and the manufacturer’s directions. Lactate Levels Normal lactate levels are under 2 mmol/L and typically implies that the patient has adequate tissue perfusion Lactate levels between 2 to 4 mmol/L are considered to be a mild-to-moderate elevation Lactate levels greater than 4 mmol/L are predictive for poor patient outcomes and higher mortality rates Lactate levels of 5 mmol/L or greater is defined as lactic acidosis and is often accompanied by metabolic acidosis Reparative Phase Caring for Patients in Recovery Once the diuresis occurs and the patient is not displaying complications associated with pulmonary issues related to inhalation injury. Wound Care Hydrotherapy has become the most highly utilized treatment approach to manage burns. usually with each dressing change and during hydrotherapy.

and invasive therapy Ineffective tissue perfusion related to impaired extremity vascular perfusion with circumferential burns Acute pain related to thermal. or any witnesses about the source of injury. or mechanical methods. Use the Rule of 9’s to determine the TBSA or the Lunds-Browder chart. or radiation burn injury Hypothermia related to decreased heat production and increased heat loss secondary to burn (specify type) injury Altered nutrition. related to increased metabolic demands Nursing Interventions for Fluid Volume Calculate fluid volume to be administered. chemical. hematocrit).Wound Debridement Wound debridement can be performed through surgical. Take note of a shift to the left . The American Burn Association recommends that blisters over centimeters in diameter be debrided. first-responders. The burn wound is initially cleansed with chlorhexidine gluconate solution. After the first 14 hours. Half of the fluid is administered during the first 8 hours and the remainder over the next 16. Debride blisters more than 2 cm in diameter. fluid shifts. Once rinsed. less than body requirements. creatinine). Nursing Care Planning Nursing Assessment Estimate the burn size (TBSA) and severity (degree) Determine if concomitant trauma is present Inquire with the patient (if possible). A weight gain of 15% may be expected due to the massive fluid replacement. and evaporative water loss At risk for infection related to loss of integument. Monitor for potential complications associated with fluid overload by obtaining labs for CBC (hemoglobin. chemical. colloid solutions are administered in combination with fluids without electrolytes for adults Monitor the patients weight. CMP (BUN. family members. electrical. Take the TBSA and plug into the Parkland formula (4 mL x body weight in kg x percentage of TBSA burned = the amount of fluid in mL) or the modified Brooke formula (2 mL x body weight in kg x percentage of TBSA burned = the amount of fluid in mL) Administer lactate ringers for the first 24 hours (volume is determined by a formula such as the Parkland). and lactate Nursing Interventions for Hypothermia Maintain a warm environment in the treatment and recovery areas by eliminating drafts Administer intravenous fluids that are warmed to room temperature Use Mylar blankets (look like tin foil) and warmed blankets Assess the patient’s core temperature frequently Monitor coagulation labs Nursing Interventions for Infection Risk Provide for wound care Facilitate schedule for wound debridement Administer prophylactic antibiotics as ordered Administer a tetanus shot upon arrival to trauma setting. time. per facility protocol Obtain orders for a CBC with differentials to monitor the WBCs. and circumstances surrounding the event Potential Nursing Diagnoses Ineffective airway clearance related to tracheal edema secondary to inhalation injury Impaired gas exchange related to interstitial pulmonary edema Fluid volume deficit related to diuresis. an antibacterial cream is applied and then wrapped with a gauze dressing. impaired tissue perfusion.