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King Saud University

College of Nursing

Burns & Escharotomy

Hatem Alsrour
(nursing college)
Burns are caused by a transfer of energy
from a heat source to the body.
Major burns have a significant risk of
morbidity & death.
The pre-hospital care is a major
contributor to patients final out come.
The skin is the largest organ in the body
It provides Thermal regulation &
prevention of fluid loss by evaporation.
Hermetic barrier to infection.
Contains sensory receptors that provide
information about the environment.
Skin Anatomy
The skin is divided into 3 layers
Epidermis- outer layer of cornified
epithelial cells.
Dermis- the middle layer, mostly
connective tissue. Contains capillaries,
nerve endings, & hair follicles.
Hypodermis- a layer of fat & connective
tissue between skin & underlying tissue
Approach to Burn Patient
Duration of exposure
Type of fire
Consider Abuse in pediatrics
Determine depth, type & extent of injury
Consider Abuse
RULE OF NINESA estimation of the TBSA
involved in a burn is simplified by using
the rule of nines.
The rule of nines is a quick way to
calculate the extent of burns.
The system assigns percentages
in multiples of nine to major body surfaces.
Types of burns
With a first-degree burn, the epidermis (top layer of
skin) is destroyed. A second-degree burn causes
injury to the epidermis, the upper layers of the
dermis (deeper portion of skin), and some injury to
the deeper portions of the dermis. The dermis is
totally destroyed in a third-degree burn, and in some
cases, so is a lot of the underlying tissue, including
portions of bone.
In the case of an extensive burn, cover the area with
a clean, dry sheet or towel. Do not let the burn victim
eat or drink anything on the way to the hospital.
Burn Patients
Burn patients need lots of medical skill
You must identify the amount of burn
You must define degree of burn
You must identify associated injuries
You must establish events preceding the
Establish basic care first
Airway- establish early
Fluids- Two (2) big bore IV’s
Consider Foley for fluid management
Protect from further injury
No food or fluid is given by mouth, and the
patient is placed in a position that will prevent aspiration of
vomitus because nausea and vomiting typically occur
due to paralytic ileus resulting from the stress of injury.
Arrange appropriate referral &/or treatment
Burn Patients
Care of the Patient During the

Emergent/Resuscitative Phase of Burn Injury

1. Maintenance of adequate tissue oxygenation.

Maintain patent airway and adequate airway clearance.
2. Assess breath sounds, and respiratory rate, rhythm, depth,
and symmetry. Monitor patient for signs of hypoxia.
3-Observe vital signs (including central venous pressure or
pulmonary artery pressure, if indicated) and urine output, and
be alert for signs of hypovolemia or fluid overload.
4. Maintain IV lines and regulate fluids at appropriate rates, as
5-Restoration of optimal fluid and electrolyte balance and
perfusion of vital organs.
6-Maintenance of adequate body temperature.

7. Elevate burned extremities.

8.Control of pain
9.Monitor arterial blood gas values, pulse
oximetry readings, and carboxyhemoglobin
10. Prepare to assist with intubation and
11. Monitor mechanically ventilated patient
Airway, Fluids & Urine
(4 ml crystalloid) X (% BSA burn) X (body wt in Kg)

Ex a man weighting 70 Kg with 30% BSA would

require (30) X (4ml) X 70 = 8400 ml in 1st 24 hr.

Half of the fluid is given in the first 8 hr. with the

balance given in the next 16 hr.

Maintain urine output at 1 ml/kg/hour

Circumferential full thickness & deep
dermal burns of the chest or limbs with
circulatory or respiratory compromise

Needed when there is a full thickness

burn involving the extremities or chest.
Escharotomy is indicated when the circulation is
compromised due to increased pressure in the
burned limb and can not be relieved by simple
elevation of the limb.
Escharotomy should be considered when a
circumferential burn of the chest wall
results in respiratory compromise by restricting
normal chest wall movement.
Limbs: incisions should be performed in the “mid axial
line” bilaterally
• Generally no anaesthetic is required in adults- the patient
should be appropriately sedated and given adequate
pain relief. General anaesthetic should be used for
• Always start and finish the incision one centimetre into
unburned healthy tissue where possible (use local
anaesthetic for the unburned skin)
• Sterile procedure with adequate drapes.
• Before starting, the upper limb should be in the supine
position, and the lower limb in the neutral position.
• For the chest, incisions along the mid axillary
lines, continuing over the abdominal wall if the
burn extends to this region.
• Draw a line where you will make the incision
• Full thickness incision into subcutaneous fat
sufficiently to see obvious separation of the
wound edges
• Incision needs to be on both sides of limb or
chest to restore circulation
• haemorrhage control
Incision Lines
First Degree
Second Degree
Second & Third Degree
One Hour Difference
30 Min After Procedure
Note: Chest Incisions
Fat Bulging
Be early
Be aggressive
Airway Control
IV’s, adequate fluids
Consider other injuries
Temperature control