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Incidence
Causes of burn injuries
Prevention
Classification of burn injuries
Pathophysiology
Outcome management
1. Emergent/Resuscitative phase
2. Acute/Intermediate phase
3. Rehabilitation phase
Prepared by: Mrs. Khadije Itani
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Burns are open wounds or injuries that result from
direct contact or exposure to any thermal, chemical, or
radiation source
Burn injuries occur when energy from a heat source is
transferred to the tissues of the body
The depth of injury is related to the temperature & the
duration of exposure or contact
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Burns and fires are the 4th most common cause of
accidental death in children and adults
Young children & elderly persons are at particularly
high risk for burn injury
Nearly 75 percent of all burns in children are
preventable.
Toddlers and children are more often burned by a
scalding or flames.
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Thermal Burns
Chemical Burns
Electrical Burns
Radiation Burns
Inhalation Injury
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Thermal burns are generally the most common type of
burn.
Thermal burns are caused by contact with flames
(fires), steam, hot liquids (scalds), or hot objects
This type of burn commonly occurs in the home while
doing ironing, cooking, or touching hot water
Specific examples of thermal burns are those sustained
in residential fires, explosive automobile accidents,
scalds injuries, clothing ignition & ignition of poorly
stored flammable liquids
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Chemical burns are caused by: tissue contact, ingestion,
inhalation, or injection with strong acids, alkalis, or
organic compounds
The concentration, volume, type & duration of contact
of chemical determine the severity of injury
Chemical burns can result from contact with certain
household cleaning agents & various chemicals used in
industry & agriculture
Chemical injuries to eyes & inhalation of chemical
fumes are particularly serious
The chemical burn injury is typically caused by
coagulation necrosis of tissue rather than by direct heat
production.
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The burning process is continuous as long as the chemical is
in contact with the skin.
The degree of tissue damage takes longer to declare itself
such that after 24 hrs the wound is deeper.
It is important to wash away the chemical burn as soon as
possible and remove clothing and jewelry that may have the
chemical on them.
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Caused by heat that is generated by the electric energy as
it passes through the body
Extent of injury is influenced by duration of contact,
intensity of current (voltage), tissue resistance & pathway
of current through the body
Current that passes through vital organs (e.g. brain, heart,
kidneys) produces more life-threatening conditions than
that which passes through fat or bone
Electrical burns put the victim at risk for: dysrhythmias
(acute or delayed), cardiac arrest, seizures, acute renal
tubular necrosis (due to myoglobinuria from injured
muscle tissues & RBC hemolysis)
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Electrical injury produces coagulation of blood supply & contact
area as electric current passes through the skin.
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Are the least common type of
burns & are caused by
exposure to a radioactive
source:
Therapeutic irradiation
Nuclear radiation accidents
Use of radiation in industry
Sunburn, from prolonged
exposure to UV rays is
considered to be a type of
radiation burn
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Exposure to asphyxiants & smoke commonly occur with
flame injuries, particularly if the victim was trapped in an
enclosed, smoke-filled space
Victims who die at the scene of a fire usually as a result of
hypoxia & carbon monoxide poisoning
Inhalation of hot air or noxious chemicals cause damage to
the tissues of respiratory tract
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Victims with suspected inhalation injury must be
assessed & treated quickly & efficiently then transferred
to the nearest burn unit
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Advise that matches and lighters be kept out of the reach of
children.
Emphasize the importance of never leaving children unattended
around fire or in bathroom/bathtub.
Advise the installation and maintenance of smoke detectors on
every level of the home.
Recommend the development and practice of a home exit fire
drill with all members of the household.
Advise setting the water heater temperature no > 48.9 ˚ C.
Caution against smoking in bed, while using home oxygen, or
against falling asleep while smoking.
Caution against throwing flammable liquids onto an already
burning fire.
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Caution against using flammable liquids to start fires.
Caution against removing the radiator cap from a hot car engine.
Recommend avoidance of overhead electrical wires and
underground wires when working outside.
Advise that hot irons and curling irons be kept out of the reach
of children.
Caution against running electric cords under carpets or rugs.
Recommend storage of flammable liquids well away from a fire
source, such as a pilot light.
Advocate caution when cooking, being aware of loose clothing
hanging over the stove top.
Recommend having a working fire extinguisher in the home and
knowing how to use it.
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Classification & treatment of burns is related to
severity of injury
Severity is determined by:
Depth of burn
Extent of total body surface area (TBSA) burned
Location of burn
Patient risk factors
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Skin is divided into 3 layers:
1.
Epidermis: avascular & thin
protective barrier
2.
Dermis:
contains connective tissue,
bld vs., hair follicles, nerves,
sweat glands
3.
Subcutaneous tissue
contains bld vs, fat, nerves
& lymphatics
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Burns are classified according to the
depth of tissue destruction
1.
First-degree burns (superficial
thickness): are injuries that
involve only the epidermis
2.
Second-degree burns (partial
thickness): involve the entire
epidermis & varying portions of
dermis
3.
Third-degree burns (full
thickness): burns involve total
destruction of epidermis, dermis
& some underlying tissues.
4.
Forth-degree burns (deep burn
necrosis): burns extend into deep
tissue, muscle, or bone.
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Causes:
 Sun burn
 Low-intensity flash
Wound appearance:
 Reddened; blanches with pressure; dry
 Minimal or no edema
 Possible blisters
Symptoms:
 Tingling
 Hyperesthesia (supersensitivity)
 Pain that is soothed by cooling
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Causes:
 Scalds
 Flash flame
 Contact
Wound appearance:
 Blistered, mottled red base; broken epidermis;
 Weeping surface, edema
Symptoms:
 Pain
 Hyperesthesia
 Sensitive to cold air
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Causes:
 Flame
 Prolonged exposure to hot liquids
 Electric current
 Chemical
 Contact
Wound appearance:
 Dry, pale white, leathery, or charred
 Coagulation vessels may be visible
 Edema
Symptoms:
 Pain free
 Shock
 Hematuria & myoglobinuria
 Possible entrance and exit wounds (electrical burn)
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Causes:
 Prolonged exposure
 High voltage electric current
Wound appearance:
 Charred
Symptoms:
Pain free
 Shock
 Hematuria & myoglobinuria
 Possible entrance and exit wounds (electrical burn)
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Commonly used guides for determining the TBSA
burned are:
Rule of nine: easy to remember & is considered
adequate for initial assessment of an adult burn patient
Lund-Browder chart: more accurate because pt’s age, in
proportion to relative body area size, is taken into
account
Palmar method: For irregular- or odd-shaped burns,
the palmar surface of the patient’s hand, including the
fingers, is considered to be approximately 1 % of
patient’s TBSA
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Severity of burn injury is related to the location of the
burn.
Areas of concern that require special care are:
Face & neck: signal possibility of inhalation injury
Circumferential burns to chest / back: inhibit
respiratory function due to mechanical obstruction
secondary to edema, leathery, devitalized tissue
(eschar) tissue formation
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Hands ,feet, joints & eyes: make self care
more difficult
Ears & nose: cartilage has poor blood
supply more susceptible to infection
Buttocks & genitalia: highly susceptible to
infection
Circumferential burns to extremities: may
develop compartment syndrome
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High risk patients include:
Extremes of age: children & elderly people
Preexisting cardiovascular, respiratory, or renal
disease
Patient with diabetes mellitus or peripheral vascular
disease, especially with foot & leg burns
Burn patient who has concurrent trauma: fractures,
head injuries, or others
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2nd degree burns > 10 % TBSA
All 3rd & 4th degree burns in any age group
Burns that involve face, hands, feet, genitalia,
perineum, or major joints
Electrical burns including lightning
Inhalation injury
Chemical burns
Burns in patients with preexisting medical disorders
Any patient with burns & concomitant trauma
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According to the finding of these referral criteria the
extent of burn injury may be classified as:
Major burn injury: all burns that fall in the referral
criteria & should be treated in burn units that have
specialized facility & personnel
Minor burn injury: all burns that fall outside the
referral criteria & can be managed in community
hospitals by non-burn unit personnel either on an
inpatient or outpatient basis
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A 75 year old man sustained 2nd degree burn injuries to his
face, neck, both hands & forearms circumferentially that
occurred when he was working on his car.
Questions:
1. Using the rule of nines, estimate the % of TBSA burned
2. What’s the classification of this burn injury
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Burn wounds are not homogenous. Each burned area has 3
zones of injury.
1.
Zone of coagulation: central area where cellular death
occurs. It sustains the most damage.
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Zone of stasis: The middle area,
describes an area of injured
cells that may remain viable,
but with persistent decreased
blood flow, will undergo
necrosis within 24 - 48 hours
Zone of hyperemia: outermost
area sustains minimal injury &
fully recover over time
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Burns < 20 % TBSA produce local response
Burns > 20 % TBSA produce both local & systemic
response
Systemic response include pathophysiologic changes &
alterations in:
 Fluid & electrolyte
 Cardiovascular
 Pulmonary
 Immunologic
 Renal
 GI
 Thermoregulation
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Patients with severe burns develop massive systemic
edema
As the taut, burned tissue begins to act like a tourniquet,
especially if the burn is circumferential
⇨ pressure on small blood vessels
⇨ obstruction of blood flow
⇨ ischemia
⇨ compartment syndrome
The physician may need to perform
 Escharotomy, a surgical incision into the eschar
(devitalized tissue resulting from a burn)
 Fasciotomy: surgical opening of the full length of fascial
compartment
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Fasciotomy
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Escharotomy
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The greatest initial threat to a patient with a major burn is
Burn Shock resulting in hypovolemic shock. Causes:
 Immediately following a burn injury, inflammatory
mediators are released from the injured tissues resulting in
extensive shift of intravascular fluid into surrounding
interstitium
 Evaporative fluid loss through burn wound may reach 5 L
or more over a 24-hour period ⇨ hyponatremia & edema
 Hyponatremia is also common during the first week of the
acute phase, as water shifts from the interstitial space to the
vascular space.
 Serum potassium alterations:
 Immediately after burn injury, hyperkalemia results from
massive cell destruction.
 Hypokalemia may occur later with fluid shifts and
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During the 1st 24 hrs
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After the 1st 24 hrs
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Cardiogenic shock:
As fluid loss continues, manifestations of hypovolemic shock
are clinically detectable ⇨⇩cardiac output ⇨ cardiogenic shock
Anemia & polycythemia:
 At the time of burn injury RBCs are destroyed.
 Blood losses sustained during surgical procedures, wound
care, and diagnostic studies and ongoing hemolysis further
contribute to anemia.
 Despite this, the hematocrit may be elevated due to plasma
loss.
Abnormalities in coagulation:
 Thrombocytopenia
 Prolonged clotting & prothrombin times
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Types of inhalation
injuries
Upper airway injury:
inhalation injury above
the vocal cords
Lower airway injuries:
CO poisoning or
inhalation injury below
the vocal cords
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It is a thermally produced
injury cause by inhalation of
hot air, steam, or smoke
Mucosal burns of
oropharynx & larynx are
manifested by redness,
blistering & edema
Mechanical airway
obstruction can occur
quickly, presenting a
medical emergency
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Presence of facial burns
Singed nasal hair
Hoarsness
Painful swallowing
Darkened oral & nasal
membranes
Sooty (carbonasceous)
sputum
Clothing burns around the
chest & neck
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The type of injury is usually chemical
Tissue injury is related to duration of exposure to
smoke or toxic fumes
Clinical manifestations such as pulmonary edema may
not appear until 12 - 24 hrs after burn & then may be
manifested as ARDS
Victims with inhalation injuries must be observed
closely for signs of respiratory distress
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As CO is inhaled it displaces O2 on Hgb molecule causing
hypoxia, carboxyhemoglobinemia & ultimately death.
Skin color has characteristically “cherry red” appearance
with CO poisoning
If CO intoxication is suspected, treat victim quickly with
100% humidified O2 & measure carboxyhemoglobin level
when feasible
Presence of soot on face and in the mouth
especially with a facial burn are signs of
smoke inhalation
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Extensive burn injuries result in:
Disruption of body’s primary barrier to infection (skin)
Depression of immune system function
a. ⇩Lymphocyte activity
b. ⇩Immunoglobulin production
c. Altered neutrophil & macrophage function
Together these changes ⇨ risk for infection & life
threatening sepsis
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Renal Dysfunction
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Hypovolemia result in
ATN ⇨ renal failure
Myoglobin (muscle cell
break down) &
hemoglobin (RBC break
down) are released into
blood stream & occlude
renal tubules ⇨ ATN ⇨
renal failure
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GI Problems
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Curling’s ulcer:
gastroduodonal ulcer
characterized by diffuse
superficial lesions, caused by
generalized stress response,
resulting in production of
mucus & gastric acid
secretion
Paralytic ileus:
loss of peristaltic movement
as a result of the body’s
response to major burn
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Loss of skin also results in an inability to regulate body
temperature.
Patients with burn injuries exhibit low body
temperatures in the early hours after injury.
Hypothermia is associated with high risk of infection &
increased mortality rate
Most burn centers have heat panels at the bedside as
additional heating sources to help maintain the
patient’s body temperature.
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Burn care is typically categorized into three phases of care:
1. Emergent/resuscitative phase
2. Acute/intermediate phase
3. Rehabilitation phase
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An overlap in care exists from 1 phase to another
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Phase
Duration
Priorities
Emergent /
resuscitative
From onset of injury to
completion
of fluid resuscitation
•Primary survey: A,B,C,D,E
• Prevention of shock
• Prevention of respiratory distress
• Detection & treatment of concomitant
injuries
• Wound assessment and initial care
Acute /
intermediate
From beginning of
diuresis to near
completion of wound
closure
• Wound care and closure
• Prevention or treatment of
complications, including infection
• Nutritional support
Rehabilitation
From major wound
closure to return
to individual’s optimal
level of physical &
psychosocial adjustment
• Prevention of scars and contractures
• Physical, occupational, and vocational
rehabilitation
• Functional and cosmetic reconstruction
• Psychosocial counseling
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Although the emergent phase is seen as beginning in
ER, initial care can begin in prehospital phase or “Onthe-Scene Care”
Priority is given to removing victim from source of
burn & stopping burn process while preventing injury
to rescuer
Usually, rescue workers cover the wound, establish an
airway, supply oxygen, and insert at least one largebore intravenous (IV) line.
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Immediate primary survey assess ABCDEs:
1. Airway: check for patency with consideration to
protect cervical spine
2. Breathing: check for adequacy of ventilation & gas
exchange
3. Circulation: check for cardiac status
4. Disability including neurologic deficit
5. Expose & examine while maintaining a warm
environment
Secondary survey focuses on obtaining history, the
completion of the total body system assessment, initial
fluid resuscitation, provision of psychosocial support of
conscious victim
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• Extinguish the flames. When clothes catch fire, the flames can be
extinguished if the victim falls to the floor or ground and rolls
(“drop and roll”); anything available to smother the flames, such as a
blanket, rug, or coat, may be used. Standing still forces the victim to
breathe flames and smoke, and running fans the flames. If the burn source
is electrical, the electrical source must be disconnected.
• Cool the burn. After the flames are extinguished, the burned area and
adherent clothing are soaked with cool water, briefly, to cool the wound
and halt the burning process. Once a burn has been sustained, the
application of cool water is the best first-aid measure. Soaking the burn
area intermittently in cool water or applying cool towels gives immediate
and striking relief from pain and limits local tissue edema and damage.
However, never apply ice directly to the burn, never wrap burn victims in
ice, and never use cold soaks or dressings for longer than several minutes;
such procedures may worsen the tissue damage and lead to hypothermia
in patients with large burns.
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• Remove restrictive objects. If possible, remove clothing immediately.
Adherent clothing may be left in place once cooled. Other clothing and all
jewelry should be removed to allow for assessment and to prevent
constriction secondary to rapidly developing edema.
• Cover the wound. The burn should be covered as quickly as possible to
minimize bacterial contamination and decrease pain by preventing air
from coming into contact with the injured surface. Sterile dressings are
best, but any clean, dry cloth can be used as an emergency dressing.
Ointments and salves should not be used. Other than the dressing, no
medication or material should be applied to the burn wound.
• Irrigate chemical burns. Chemical burns resulting from contact with a
corrosive material are irrigated immediately. Most chemical laboratories
have a high-pressure shower for such emergencies. If such an injury
occurs at home, brush off the chemical agent, remove clothes
immediately, and rinse all areas of the body that have come in contact
with the chemical. Rinsing can occur in the shower or any other source
of continuous running water. If a chemical gets in or near the eyes, the
eyes should be flushed with cool, clean water immediately. Outcomes for
the patient with chemical burns are significantly improved by rapid,
sustained flushing of the injury at the scene.
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If the burn is large DO NOT:
Immerse the burned body part in cool water
because this leads to extensive heat loss
Cover burn with ice as this cause frostbite
Remove adherent clothing as this cause further skin
injury
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The patient is transported to the nearest emergency
department (ED) so that life-saving measures can be
initiated & early referral to a burn center can be made
if indicated.
Initial priorities:
1. Airway Breathing Management
2. Fluid resuscitation
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For inhalation injuries:
Early intubation (within 1 hr) to eliminate emergency
tracheostomy
Mechanical ventilator according to ABG’s result
100 % O2 determined by carboxyhemoglobin level
PEEP to prevent collapse of alveoli
Escharotomies of chest for circumferential neck & trunk
burns
Fiberoptic bronchoscopy to assess lower RT for :
carbonaceous material, edema, vesicles, erythema,
hemorrhage & ulceration
Bronchodilators to treat severe bronchospasm
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3rd & 4th degree burn of the chest
can lead to severe restriction of
chest wall motion, especially as
edema develops beneath the
eschar tissue.
Chest wall escharotomy may be
required to relieve the restriction;
This procedure is best done in a
Burn Center unless ventilation is
severely impaired.
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Swan Ganz
Feeding tube
O2 via ET
tube &
ventilator
NG tube
(suction)
IV fluids
Pulse oximetry
Right femoral
artery line
Foley cathter
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Survival of burnt patient depends on adequate fluid resuscitation
Replacing lost fluids & electrolytes is urgent in preventing
irreversible shock
Both under resuscitation & overresuscitation are associated with
poor outcome
Oral & enteral resuscitation is used in < 20 % TBSA burned
IV resuscitation is recommended in > 20% TBSA burned
Large-bore IV lines placed in nonburned skin proximal to
extremity burned
For clients with extensive burns or limited peripheral IV access
sites, a central line is necessary
Total volume & rate of IV fluid replacement are guided by
resuscitation formulas
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The calculation of fluid requirements for the 1st 24 hours
are calculated by the clinician is based on % TBSA
burned & patient’s weight
 Fluid replacement with L/R is initiated using consensus
formulas for adults within 24 hrs post burn injury:
1. For adults with thermal & chemical burns: 2 ml L/R
x pt’s wt in Kg x % TBSA 2nd , 3rd & 4th degree burns
2. For adults with electrical burns: 4 ml L/R x pt’s wt in
Kg x % TBSA 2nd , 3rd & 4th degree burns
 ½ of the calculated volume is administered during the 1st
8 hrs post burn injury. The second ½ is administered over
the next 16 hrs.
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Example: fluid resuscitation with ABA formulas for a 70
kg victim with a 30 % TBSA thermal burns:
1st 24 hrs: 2 ml x 70 kg x 30 % = 4200 ml
1st 8 hrs 2100 ml, next 16 hrs 2100 ml
These formulas are only a guideline
The rate of infusion is titrated hourly according to the
urine output: 30 – 50 ml/hr for thermal & chemical burns
75 –100 ml/hr for electrical burns
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A 35 year old man sustained 3rd & 4th degree electric
burn injuries to 20 % TBSA. His weight is 80 Kg.
Question:
Calculate the fluid resuscitation needed during the first
24 hours post burn injury & determine the flow rate of
each infusion
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Impaired gas exchange
Ineffective airway clearance
Fluid volume deficit
Hypothermia
Pain
Anxiety
Collaborative problems:
 Acute respiratory failure
 Burn shock
 Acute renal failure
 Compartment syndrome
 Paralytic ileus
 Curling’s ulcer
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Begins when client is hemodynamically stable &
diuresis has begun (48-72 hrs post burn injury)
This continues until the burned area is completely
covered by skin grafts or when the wounds are healed
& may take weeks or many months
The emphasis is placed on wound healing
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All oral fluids should be restricted at this time
Client is placed in a position that will prevent aspiration
of vomitus that may occur due to paralytic ileus
NG tube insertion is recommended for unresponsive
clients & clients with > 20% TBSA burn to prevent emesis
A hypermetabolic state proportional to the size of the
wound occurs after a major burn. Failure to supply
adequate calories & protein leads to malnutrition &
delayed healing
NG feedings (high calories, protein, iron & vitamins) may
be started in emergent phase slowly & ⇧ to the goal rate
within 24 - 48 hrs
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Pharmacologic agents:
1.Opioid analgesics:
 Administer IV morphine sulfate
 IM & S/C routes are not used (⇩ absorption)
 Oral route also is not used (GI dysfunction)
2.Other agents used: NSAIDs, anxiolytics & anesthetics
3.Sedatives (benzodiazepines) can be used to control anxiety
Nonpharmacologic therapies:
Relaxation techniques, Distraction, Guided imaginary,
hypnosis, therapeutic touch, humor, music therapy,
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It begins when wounds have healed & patient is able
to resume a level of selfcare activity
This can occur as early as 2 weeks or as long as 8
months after burn injury
Priorities for this period are:
 Prevention of scars & contractures
 Physical & occupational rehabilitation
 Functional & cosmetic reconstruction
 Psychosocial counseling
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Nursing diagnosis: based on the assessment data:
 Activity intolerance related to pain on exercise, limited
joint mobility, muscle wasting, and limited endurance
 Disturbed body image related to altered physical
appearance and self-concept
 Impaired physical mobility related to contractures or
hypertrophic scarring
 Deficient knowledge about post discharge home care
and follow-up needs
Collaborative problems/potential complications
 Inadequate psychological adaptation to burn injury
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The most common complications
during the rehabilitative phase are
skin & joint contractions &
hypertrophic scarring
To prevent contractures therapy is
aimed at the extension of the body
parts because the flexors are
stronger than the extensors
Contracture of elbow
Elastic pressure garments.
Application of pressure garments helps
prevent hypertrophic burn scarring.
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