Burn Care in Developing Countries
CONNIE JARLSBERG, RN, MSN
W O R L DV E N T U R E / N U RS E S C H R I S T I A N F E L LO W S H I P
G L O B A L H E A LT H M I S S I O N S C O N F E R E N C E
NOVEMBER 2012
Burn Prevention

50% of all burn accidents could be prevented

Most burns happen in an instant of carelessness

Most burn patients are victims of their own actions
“It’s a matter of degrees”
If its HOT
enough for
CHAI,
It’s HOT enough
to BURN!
If your clothes catch on fire:
STOP
DROP
ROLL
Communicating Prevention
• Urban vs Rural Areas
• Mothers/Children (big sisters)
• Local Languages
• Literacy
• Raising the national awareness
Functions of the Skin
Protection from infection
Conservation of body fluids
Temperature regulation
Excretion
Secretion
Vitamin D production
Sensation
Appearance
Anatomy of the Skin
Determination of Burn Severity
Extent
Depth
Age of the patient
Past medical history
Part of the body burned
Out Patient Care
• Burns < 20% TBSA not involving the face or hands
• Children over 5 years old
• Adults based on assessment of their age
significant medical history
Assess the patient and or family’s ability to care
for the wound at home OR their ability to come
for dressing changes.
Out Patient Care
Goal:
• Close the wound as soon as possible—within 3
weeks
• Decrease scar and contracture formation
• Maintain function of involved joints
DETERMINATION OF SIZE OF BURN
RULE OF NINES
Head:
9%
Anterior: 18%
Posterior: 18%
Arms:
9% each
Legs:
18% each
Perineum: 1%___
Total
100%
Calculation of Percent with age consideration
Berkow Method
DEPTH OF BURN
Superficial Partial Thickness (1st degree)
Skin is red only epidermis perhaps part of the dermis is
injured
Usual causes: sunburn, hot liquid
Should heal spontaneously within 3 weeks
Deep Partial Thickness (2nd degree)
Skin is red, “weepy” some blister formation
Usual causes, hot thick liquids (porridge vs water)
Depth of Burn Con’t
 Full Thickness (3rd and 4th degree)
Skin appears “leathery” dry, brown, hardened all epidermis
and dermis is destroyed may have
destruction of sub-dermal layers, subcutaneous
tissue and muscle as well.
Wound will not heal, needs skin grafting often
results in significant scarring even with excellent
wound care.
Admission
15 days post burn
Past Medical History and History of the Burn
Does the Patient
1. Have a serious medical condition?
2. Have symptoms of an unknown disease?
3. Take medications?
4. Have allergies to food or medication?
How did the burn occur?
1. Source? Hot liquid, Flame? Caustic substance?
2. Inside or Outside?
3. Was there smoke? Was it inhaled?
Phases of Burn Care
Emergent Phase: The time required to resolve immediate
problems resulting from the burn injury
Acute Phase: From the end of the Emergent Phase until
the wound is closed
Rehabilitation Phase: The entire program of burn care is
focused to this phase. From day one of the injury until
the patient returns to a useful place in society
Emergent Phase
First Aid
1. Maintain airway
2. Assess for concurrent injuries (bleeding
does not occur secondary to burn injuries
If there is external bleeding look for other
causes).
NB: Burn patients are always alert
and oriented, if not assess for head injury
Potential for airway obstruction
Burns to face and neck
especially if in an enclosed
space.
Edema formation—increased
capillary permeability
Fluid Therapy
 Large volumes of fluid escape from the burn surface
causing hypovolemia in any burn greater than 20%
TBSA
IV Therapy: An electrolyte balanced solution
Ringers Lactate (Hartman’s solution) in quantities
enough to maintain adequate BP and urine output
30ml/hr in adults and 0.5ml/kg in children
Oral Fluid Replacement Therapy?
 Effective resuscitation of small (5-10%)moderate and
sometimes severe burn injury.
 Where IV fluids may not be available or in situations with mass
casualties with inadequate IV fluids.
 Drinking or gastric infusion of buffered saline solution.
Similar to WHO oral rehydration solution
1 liter of water + 8 tsps. sugar + ½ tsp salt +
½ tsp of sodium bicarbonate (baking soda)
Kramer, G.C., Michel, M.W. , et al (2003) Journal of Burns and Wound Care
Wound Care
Goal:
Close the wound as soon as possible
Prevent infection both in the wound and systemically
Complete grafting if necessary
Decrease incidence of scarring and contracture.
Wound Care
Topical Agents:
Silver sulfadiazine
Other topical antimicrobials:
Mafanide Acetate (TM: Furacin)
Saline, Hydrogen Peroxide & Sterile water
Betadine/ Iodine
Honey and Ghee
General Considerations: Emergent Phase
Pain management
Nutrition therapy
Positioning /Splints
ACUTE PHASE
Avoid, Detect
and Treat
Complications
Wound Care
Encourage as much activity
as possible
Grafting
NURSING CARE
Emotional support
Rest/Comfort
Diet
Hygiene/Wound care
Positioning
Sometimes its nice
NOT to be the
source of pain
Be sure pediatric
patients have at
least one place
they feel safe.
Try to make that
place their bed
As wounds
heal, pain
decreases,
happiness
makes a
comeback.
Nutrition and Diet
Rehabilitation Phase
Return the patient to a productive
place in society
Accomplish functional and
cosmetic reconstruction
Reconstructive Surgery
Myths and Cultural Care Practices
 Rabbit fur (Rwanda)
 Powdered—un-reconstituted antibiotics (Uganda)
 Sugar
 Honey and Ghee (purified animal fat)
 Worldview
Resources
Artz, C.P.,Moncrief, J.A., Pruitt, B.A. (1979) Burns a team approach.
Philadelphia, PA: W.B. Saunders.
Feller, I., Archambeault-Jones, C. (1978) Teaching basic care. Ann Arbor, MI:
National Institute of Burn Medicine
Iwuagwu, F. C., Bailie, F. (1998) Oral fluid therapy in paediatric burns (5-10%):
an appraisal. Burns 24 pp. 470-474.
Jarlsberg, C.R. (1992) Management of Patients with Burn Injury in Brunner and
Suddarth’s Textbook of Medical Surgical Nursing 7th ed. Eds. Smeltzer, S.C.,
Bare, B. G. Philadelphia: Lippincott
Jarlsberg, C.R. (2006-2012) Unpublished original material
Resources Con’t
Kramer, G. C. et al. (2010) Oral and enteral resuscitation of burn shock.
The historical record and implications for mass casualty care. Republished from
Journal of Burns and Wound Care (2003) 2 (19) (no longer available).
(no longer available) Open Access Journal of Plastic Surgery.
With thanks to Rein Zeeman and Ineka Storm International Plastic Surgery Society
Holland for sharing photographs.
And thanks to the patients at Mulago Hospital Kampala Uganda for their
courage evidenced daily in facing the difficulty of recovering from burn injuries.