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EMS/Nursing
80912/
37212
Burns: Part 1
Toni Galvan, MSN, RN, CCRN, CEN
Charge Nurse II
Medical Intensive Care Unit
Covenant Health System
Lubbock, Texas
EMS/Nursing
80912/
37212
Objectives
1. Identify incidence and
measures for
prevention of burns.
EMS/Nursing
80912/
37212
Objectives
2. Indicate types of burns
and physiological
responses.
EMS/Nursing
80912/
37212
Objectives
3. Identify fluid
replacement measures
used in the treatment
of burns.
Annual Incidence
 450,000 requiring medical
treatment
 3,500 fire and burn deaths
 45,000 hospitalizations
Annual Incidence
 Cost: millions to billions in
dollars, immeasurable in
emotional distress to victims
and families
Where Burns Happen
 Majority in home: 86%
 #1: careless cigarettes
 also water >140° F,
cooking surfaces,
combustibles, space
heaters, chemicals, unsafe
electrical wiring, etc.
Where Burns Happen
 Industry: 10%
 Street/highway: 8%
 Farm and other/unknown:
16%
Financial/Community
Impact
 Care is specialized,
expensive [$3,000-5,000 per
day in burn intensive care
unit (BICU)]
Financial/Community
Impact
 Victim off work, nonproductive for weeks to
months
 Family roles are disturbed
for weeks to years
Financial/Community
Impact
 Prevention is cheaper and
easier!
Mortality/Morbidity in
BICUs
 Survival rate: 94.8%
 Gender: 70% male, 30%
female
 Ethnicity: 63% Caucasian,
17% African-American, 14%
Hispanic, 6% other
Mortality/Morbidity in
BICUs
 Admission cause: 42%
fire/flame, 31% scald, 9%
contact, 4% electrical, 3%
chemical, 11% other
Prevention of Burns
 Hot water heaters: <120° F
 Bath water: about 100° F
 Anti-scald devices on bath
and shower heads
 Supervision of small children
and elders
Prevention of Burns
 Grab bars in showers for
impaired mobility
 NO children in cooking area
 While cooking, all pot
handles and electric cords
out of reach
Prevention of Burns
 Safety handles/knobs on
stoves
 Do not use open flame
heaters
 Meals: hot items in center of
table
Prevention of Burns
 Meals: non-slip placemats
with toddlers
 Meals: no tablecloths with
toddlers or when anyone
using crutches or
wheelchairs
Prevention of Burns
 Hot liquids
 don’t carry while carrying
child
 not on low tables
 Wheelchair: use a tray to
carry hot foods/drinks
Prevention of Burns
 Microwave
 use extreme caution with
plastic wrap and hot
containers
 stir all food before serving
 Fires: no gasoline, aerosols,
or plastic
Prevention of Burns
 Carburetors: don’t prime
with gasoline
 Open flames: don’t combine
with gasoline/kerosene
Prevention of Burns
 Electrical
 use extreme care
 if in doubt, don’t touch
 don’t use questionable
outlets
Prevention of Burns
 Chemical
 use protective gear with all
 never combine bleach and
ammonia or products
containing them
Prevention of Burns
 Christmas trees
 never leave lights
unattended
 use mini-lights only
 Smoke alarms: check battery
monthly
Prevention of Burns
 Children playing with fire:
NO
 Don’t refuel a hot lawn
mower engine
Prevention of Burns
 Sunscreen, hats, long
sleeves for prolonged
exposure
 Routinely check fireplaces,
heaters/furnaces
Prevention of Burns
 Use cool mist vaporizers
with children/disabled/elders
 Flameproof/retardant clothes
for sleep, Halloween, etc.
 Supervise kids carefully
around open flames
Mortality Estimates
 Mortality estimate: %TBSA +
age
 Inhalation injury:
2(%TBSA + age)
 TBSA: total body surface
area (burned)
Estimate Severity
 Size (%TBSA)
 Depth
 Location (hands, feet,
genitalia, face more severe)
 Age [<2 years (yrs) and
>65 yrs more severe]
Estimate Severity
 Past medical history (chronic
disease)
 Concomitant injuries
Minor vs. Major
 Minor: treat at home
 Moderate: community
hospital
 Major: burn unit
Minor vs. Major
nd
rd
 Minor: 2 degree <15% or 3
degree <3% with no other
concerns
nd
 Moderate: 2 degree 25-35%
or 3rd degree <10% on trunk
only
Minor vs. Major
nd
rd
 Major: 2 degree >35% or 3
degree >10% or
face/hands/feet/genitalia or
inhalation injury or
concomitant injuries or
electrical or most chemical
burns
Anatomy and Functions
of Skin
Anatomy and Functions
of Skin
 First barrier to infection
 Prevent loss of body fluid
 Control body temperature
Anatomy and Functions
of Skin
 Excretory organ
 Sensory organ
 Vitamin D production
 Identity (cosmetic, etc.)
Body Response to
Burns
 Local
 evaporation
 loss of heat
 actual fluid loss
 loss of first defense
against infection
Body Response to
Burns
 Cardiovascular
 release epinephrine
 response to shock
 myocardial depressant
factor from inflammation
Body Response to
Burns
 Blood
 damaged red blood cells
(RBCs)
Body Response to
Burns
 Blood
rd
 3
spacing, platelet, and
white blood cell (WBC)
clumping
  coagulation factors
Body Response to
Burns
 Respiratory system if
inhalation injury
 burn upper airway
 decreased chest and neck
expansion
Body Response to
Burns
 Respiratory system if
inhalation injury
 CO poisoning
 smoke inhalation
 acquired respiratory
distress syndrome (ARDS)
Body Response to
Burns
 Renal
 potential acute renal failure
from dehydration
Body Response to
Burns
 Renal
 in chemical, electrical, and
large muscle burns:
myoglobinuria and risk for
rhabdomyolysis
Body Response to
Burns
 Gastrointestinal
 gastric dilation
 paralytic ileus
 Curling’s ulcer
Body Response to
Burns
st
 Neuro: alert, active 1 1-2
hours (hrs), then diminished
level of consciousness
(LOC) from hypoxia
Body Response to
Burns
 Pain: prescribe intravenous
(IV) morphine
Body Response to
Burns
 Emotional and social
 diminished coping, body
image
 familial and work stress
 long and costly healing
 Fluid
shift in burns
 Inflammation opens capillary
pores causing leak of water,
albumin, fibrin, electrolytes
to 4-15x normal
st
1
24 hrs: profound
intravascular fluid and
electolyte deficit; replace
with IV Lactated Ringer’s
(LR)
 2nd 24-72 hrs: capillaries
seal; prescribe IV colloid to
return fluid to vascular tree
Depth of Burns
Zones of Injury for
Burns
1st degree
2nd degree
3rd degree
st
1
Degree Burn
 Like very severe sunburn
 Usually no scarring
 Treat the pain
 Treat with moisturizers
nd
2
Degree Burn
 Hallmark: fluid-filled blisters
 Blisters
débride
don’t débride
controversy
nd
2
degree scald post-débride
rd
3
degree
with some
granulation
Cause: fell
into hot
water
nd
2
and
admit
rd
3
at
Post: minimal
grafting on
arms
Back:
thickest skin
rd
3
degree;
edema
formation;
notice lips
Edema
needing
intubation
to protect
airway
Rule of 9s
 Adult: TBSA estimate
 Advantage: easy
 Disadvantage: not accurate
except 70 Kg adult
Rule of 9s
 Infant
Rule of Palm
 Patient’s palm = 1% patient’s
TBSA
 Used for scattered burns
Berkow Chart
Berkow Chart
 Advantage: more accurate
 Disadvantage: takes time,
need chart
 Are other systems similar?
Parkland Formula Fluid
Replacement
st
 1 24 hrs: 4 ml LR x %TBSA
x Kg = ml fluid to give
st
 50% in 1 8 hrs postburn
nd 8 hrs postburn
 25% in 2
rd 8 hrs postburn
 25% in 3
Parkland Example
 50% TBSA x 70 Kg x 4 ml LR
= 14,000 ml total
 7,000 ml in first 8 hrs
 burn occurred at 12:00,
fluids started at 13:00
Parkland Example
 50% TBSA x 70 Kg x 4 ml LR
= 14,000 ml total
 7,000/7 hrs = 1,000 ml/hr
 then 7,000 ml in remaining
16 hrs at 437.5 ml/hr
Desired Outcome
 Urine output 40 ml/hr
 LOC acceptable
 Mean arterial pressure (MAP)
acceptable
 If not, increase LR
nd
2
rd
3
Parkland
and
24 hrs
 0.35-0.5 ml plasma or
albumin x Kg x %TBSA in 4th
8 hrs
 And 2,000-6,000 ml 5%
dextrose in water (D5W) over
24-48 hrs
nd
2
rd
3
Parkland
and
24 hrs
 Outcome
 urine 40 cc/hr
 acceptable LOC
 hematocrit (Hct) within
normal limits
 Na 140
Adequate Fluid
Resuscitation
 Urine output >1 cc/Kg/hr by
nd
2 hr
 Pulmonary capillary wedge
pressure 4-16 or central
venous pressure 1-5 after 24
hr
Adequate Fluid
Resuscitation
 LOC acceptable
 Heart rate <110 in adults and
by age in children
 Na, Hct, K, pH normal by 2448 hr
Fluid Overload
st
 Urine >200 cc/hr in 1 24 hrs
and remaining high
 Pulmonary edema in 1st
24-48 hrs without inhalation
injury
Fluid Overload
 Signs and symptoms of
congestive heart failure
without preexisting condition
EMS/Nursing
80912/
37212
Burns: Part 1
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EMS/Nursing
80912/
37212
Release Date:
03/01/2012
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EMS
80912
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Nursing
37212
Conflicts of Interest:
Toni Galvan, MSN, RN, CCRN, CEN has disclosed that no financial interests,
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Toni Galvan, MSN, RN, CCRN, CEN has disclosed that no products with offlabel or unapproved uses are discussed within this activity.
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37212
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