An injury that extends down to the third layer (the subcutaneous tissue, which includes fat) is called a full
thickness injury (formerly called a third degree burn). Burns that damage muscles underneath the
subcutaneous skin layer are described as full thickness burns with injury to the underlying muscle
(sometimes formerly called fourth degree burns).
A full thickness burn destroys all three layers of skin, resulting in the loss of not only the skin but also the
hair follicles, sweat glands, and the region where new skin cells are formed. For these reasons, full
thickness burns require skin grafts.
A full thickness burn may be white, charred, black, brown, or leathery. This type of burn injury is often
painless because the nerves are already destroyed. You may still feel pain on other burn areas that are less
damaged.
MEDICATION
Antibiotics: Antibiotics may be given to help treat or prevent an
infection caused by germs called
bacteria.
Pain medicines: Caregivers may give
you medicine to take away or decrease
your pain.
Tetanus shot: This is medicine to
keep you from getting tetanus. It is
given as a shot. You should have a
tetanus shot if you have not had one in
the past 5 to 10 years. Your arm can
get red, swollen, and sore after getting
this shot.
NURSING DIAGNOSIS
Risk for infection r/t burns
Pain r/t burns
disturbed body image/grieving r/t burns
Hypothermia
If the patients were not anesthetized, the initial temperature was
normal. Only the anesthetized and artificial ventilated patients
were hypothermic. We conclude that hypothermia is not a
problem of the non-anesthetized and cold-water-treated patient.
However, all anesthetized patients must be carefully treated to
avoid hypothermia as an important complication in the prehospital management.
PRIORITIES
Air way Burns sustained within an enclosed space suggest
possible inhalation injury

Cardiac monitoring: dysrhythmias may be the first sign of hypoxia and electrolyte or acidbase abnormalities.
 Circulation: severely burned patients may have accompanying injuries resulting in
hypovolaemic shock:
o Blood pressure may be difficult to obtain and may be unreliable.
o Monitoring hourly urinary outputs reliably assesses circulating blood volume and
so an indwelling urinary catheter should be inserted.
Immediate management
 Initial management for major burns may require resuscitation with attention to airway,
breathing, circulation, assessment of conscious level and rapid fluid replacement.3,4
 Airway:
o The airway above the glottis is very susceptible to obstruction because of
exposure to heat. The clinical presentation of inhalation injury may be subtle and
often does not appear in the first 24 hours.
o Clinical indications of inhalation injury include:
 Face and/or neck burns.
 Singeing of the eyebrows and around the nose.
 Carbon deposits and acute inflammatory changes in the oropharynx.
 Carbon-particles seen in sputum.
 Hoarseness.
 History of impaired awareness, e.g. alcohol or head injury, and/or
confinement in a burning environment.
 Explosion with burns to head and torso.
 Carboxyhaemoglobin level greater than 10% if patient is involved in a
fire.
o Management of acute inhalation injury:
 Early management may require endotracheal intubation and
mechanical ventilation.
 Transfer to a burn centre.
 Stridor is an indication for immediate endotracheal intubation.
 Circumferential burns of the neck may lead to swelling of the tissues
around the airway and so require early intubation.
 Stop the burning process:
o Remove all clothing - adherent synthetic clothing and tar should be actively
cooled with water, and left for formal debridement.
o
o
o

Breathing:
o

Dry chemical powders should be carefully brushed from the wound.
Rinse the involved body surface areas with copious amounts of tap water. Cool
the burn with tepid water for up to 20 minutes. Great care is required as cooling
may cause hypothermia, especially in children,3 and those with extensive burns may worsen shock.
Remove constricting clothing and jewelry before covering the patient with warm,
clean and dry linens to prevent hypothermia.
Arterial blood gas determinations should be obtained as a baseline but arterial
PO2 does not reliably predict CO poisoning. Therefore, baseline
carboxyhaemoglobin levels should be obtained, and 100% oxygen should be
administered.
o Elevation of the head and chest by 20 to 30 degrees reduces neck and chest wall
oedema. If a full-thickness burn of the chest wall leads to severe restriction of the
chest wall motion, chest wall escharotomy (burn incised into subcutaneous fat
and underlying soft tissue; no anaesthetic is required) may be required.
o Carbon monoxide (CO) poisoning: has a much greater affinity than oxygen for
haemoglobin and so displaces oxygen.
 Assume carbon monoxide exposure in patients burned in enclosed
areas.
 Diagnosis of CO poisoning is made primarily from a history of
exposure.
 Patients with CO levels of less than 20% usually have no physical
symptoms.
 Higher CO levels may result in headache and nausea, confusion, coma
and death.
 CO dissociates very slowly but this is increased by breathing highflow oxygen via a non-rebreathing mask.
Intravenous access:
o Large-calibre intravenous lines must be established immediately in a peripheral
vein.
o Any patient with burns over more than 20% of the body surface area needs
circulatory volume support.
o Begin infusion with Ringer's lactate solution:
 The patient requires 2 to 4 mL of Ringer's lactate solution per
kilogram body weight per percent second-degree and third-degree
body surface burns in the first 24 hours.
 One-half the total fluid is provided in the first 8 hours after the burn,
and the remaining half is administered in the next 16 hours.
 In children who weigh 30 kg or less, it is necessary to administer
maintenance intravenous fluids containing glucose in addition to the
burn formula.
 The Parkland formula may be used: (4ml crystalloid) x (% body
surface area burn) x (body weight in kg) = fluid replacement for first
24 hrs, half in first 8 hrs. The Galveston formula may be more


accurate in children though more difficult to calculate: 5 litres/m2 x %
body surface area plus 2 litres/m2/24hr of maintainance.
Any resuscitation formula provides only an estimate of fluid need. The
amount of fluid given should be adjusted according to the individual
patient's response, to maintain a urinary output of 0.5-1ml/kg/hr
(adult), or 1-1.5ml/kg/hr (child).
Fluid requirement calculations for infusion rates are based on the time
from injury, not urinary output from the time fluid resuscitation is
initiated.
Secondary survey
 Estimate extent and depth of burn.
 Circumferential extremity burns: assess status of distal circulation, checking for cyanosis,
impaired capillary refilling or progressive neurological signs. Assessment of peripheral
pulses in burn patients is best performed with a Doppler ultrasound.
 Assess for associated injuries
 Weigh the patient
 Flow Sheet: outlining the patient's management; must stay with the patient.
 Baseline determination for the major burn patient:
o Blood: full blood count, type and cross-match, carboxyhaemoglobin, serum
glucose, electrolytes, and pregnancy test in all females of childbearing age.
Arterial blood gases.
o Chest x-ray. Other x-rays may be indicated for associated injuries.
Further management
 Circulatory insufficiency caused by a circumferentially burned limb is best relieved by
escharotomy. Escharotomies are usually not required within the first 6 hours of burn injury.
 Fasciotomy: seldom required, but may be necessary to restore circulation for patients with
associated skeletal trauma, crush injury, high-voltage electrical injury or burns involving
tissue beneath the investing fascia.
 Gastric tube insertion: if nausea, vomiting, abdominal distention, or if burns involve more
than 20% of the total body surface area.
 Analgesia and sedation:
o Severely burned patients may be restless and anxious from hypoxaemia or
hypovolaemia rather than pain. The patient then responds better to oxygen or
increased fluid administration rather than to narcotic analgesics or sedatives that
may mask the signs of hypoxaemia or hypovolaemia.
o Intravenous narcotic analgesics and sedatives may be administered in small,
frequent doses.
 Wound care:
o Partial-thickness (second degree) burns are painful when air currents pass over
the burned surface. Gently covering the burn with clean linen relieves the pain
and deflects air currents.
o Do not break blisters or apply an antiseptic agent.
o Any applied medication must be removed before appropriate antibacterial topical
agents can be applied.
o Application of cold compresses may cause hypothermia. Do not apply cold water
to a patient with extensive burns.


Antibiotics: should be reserved for the treatment of infection.
Tetanus: determination of immunization status is very important.
Full thickness burns: require excision and grafting unless are less than 1cm in diameter.
Grafting is required within three weeks in order to minimise scarring. Therefore early
referral is essential.

http://www.patient.co.uk/showdoc/40001197/
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
Swelling of the upper airway is the earliest consequence of inhalation injury. This usually occurs the
first 6 to 24 hours after injury. Patients who have difficulty breathing are intubated and monitored
closely.