Metropolitan Community College
Fall 2013
Jane Miller, RN MSN
Objectives
• Identify clinical manifestations of depth of burn injuries: superficial,
partial thickness, and full thickness and treatment modalities.
• Define importance of assessment skills and gathering of important
data in determining treatment in the emergent phase of burns.
• Identify burn etiology and significance in treatment
• Identify vascular changes resulting from burn injuries including
fluid shifts, electrolyte changes, gastrointestinal involvement,
cardiac, pulmonary, skin, metabolic changes, and immunologic
changes.
• Identify prioritization of treatment of burns from emergent phase,
acute phase, and rehabilitative phase of burn injury.
• Compare and contrast the Browder-Lund chart and Rule of Nines
chart in calculating total body surface area(TBSA) in a burn injury.
• Apply the Parkland Formula together with the TBSA in establishing
correct fluid replacement in the emergent phase
• Identify airway management in burn injury
• Identify compensatory responses to burn injury
• Evaluate laboratory profiles during the emergent phase of burn
injury.
• Identify the role of burn centers.
• Identify surgical management of burn injury.
• Identify pain management in burn injury and treatments.
• Define prevention of infection interventions.
• Identify would care management to include debridement, dressings,
and types of grafts.
• Compare and contrast types of grafts available.
• Identify nutrition requirements in burn injury.
• Identify nursing interventions for prevention of complications such
as patient position, range of motion, ambulation, pressure dressings,
and post-op cares utilized to prevent complications of burns.
• Identify research in the burn realm that may affect future burn
interventions.
• Identify current/future therapies in the treatment of burn patients.
Burns are…
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Traumatic
Painful
Dehumanizing
Embarrassing
Holistic
Disfiguring
Incapacitating
Fatal
Burn Statistics
• 450,000 people received treatment for burn
injuries in 2011
• 55% of the 450,000 injuries were admitted to
one of the 125 burn centers in the United States
• 70% of burn center admissions were male
• The survival rate of those admitted to a burn
center was 96%
• There were 3,500 fire/burn related deaths
Burn Survivor Resource Center, 2013
Burns and Children
• 85% of fires that injure or kill children occur in a
residence
• 2/3 of residential fires that result in the death of
a child occur in homes without a working smoke
detector
• Fires kill more than 600 children per year and
47,000 are injured but survive.
• Scald and contact burns are the most common
cause of burn-related injuries in children 4 years
old and under
Burn Survivor Resource Center, 2013
Burn Etiology
• Burn injuries occur when there is direct or
indirect contact with a heat source
o Electrical wiring, hot liquid, lightning, sun, caustic chemicals, fire
• No matter the cause, the burn injury results in
loss of skin integrity
• Inhaling smoke causes injury to the lung known
as an inhalation injury
Types of Burns
• Thermal
o Most often from fire
o Extent depends on the length of exposure and temperature of the
heat source
• Scald
o Type of thermal burn caused by hot food or liquid
o Extent depends on the length of exposure and temperature of the
heat source
• Electrical
o Tend to be deeper than other burns
o Extent depends of amount of voltage, length of exposure, type of
current, pathway of flow, and local tissue resistance
o Difficult to assess damage
• Radiation
o Result from overexposure to the sun, radiation treatment,
industrial accidents
o Extent depends on how close the individual was to the source
and length of exposure
• Chemical
o Occur when the skin contacts a caustic agent
o Extent depends on length of exposure
• Inhalation Injury
o Result from inhaled smoke and heated air
o The majority of deaths from burn injuries are due to smoke
inhalation
o Signs include: burns to the face and neck, singed nasal hair, dry
cough, bloody/sooty sputum, labored respiration
Burn Prevention
Keep matches and lighters out of children’s reach
Set water heater no higher than 120o F
Lock up chemicals
Limit exposure to the sun and wear sunscreen
Have a working smoke detector in the home
Don’t overload electrical circuits
Properly extinguish cigarettes and never smoke in
bed
• Have an escape plan
• Community education
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Pathophysiology
• When damage occurs there are 3 distinct zones
of injury
o Zone of coagulation
o Zone of stasis
o Zone hyperemia
Pathophysiology
• Immediately after the injury third spacing begins
• Edema develops in unburned tissue and organs
away from the site of injury
• This process starts at the time of injury, peaks in
12 to 24 hours, and continues for 49 to 72 hours
Vascular Dilation
Decreased Blood Volume
Decreased Venous Return
Decreased Stroke Volume
Decreased Cardiac Output
Decreased Tissue Perfusion
• Cardiac
o Heart failure
o Dysrhythmias and cardiac arrest from the release of
potassium
• Pulmonary
o Pulmonary edema
• Gastrointestinal
o Decreased motility and nutrient absorption due to
shunting of blood
o Paralytic ileus
o Stress gastritis and ulcerations
• Renal
o Decreased urine output
o Renal failure from blocked renal tubules
• Immune
o Impaired immune function
o Increased risk of developing opportunistic infection
and death
• Integumentary
o Fingerprints may be lost
o Permanent loss of hair growth, perspiration, and
sensory abilities
o Impaired temperature control and protection from
infection
Emergency Phase
• Begins with the injury and last 2 to 3 days
• Goals
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Maintain an airway
Treatment of concurrent injuries
Correcting fluid imbalances
Preventing infection
Conserving body heat
Relieving pain
Emotional support
Burn Centers in NE
• Acute care
o The Nebraska Medical Center
o Saint Elizabeth Community Health Center
• Rehabilitation
o Madonna Rehabilitation Hospital
Initial Treatment
• Remove the source of injury if possible
• ABCDEF
• Apply clean saline soaked towels
• Copious irrigation of chemical burns
• Apply a clean blanket
• Do not use oils or salves
• Give a tetanus shot
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Airway assessment and possible intubation
ABGs, CBC, BMP, BUN, BS, Coags
12-lead ECG
Carotid and peripheral pulses
VS
Place 2 large bore IVs
NG tube
Assess concurrent injuries
Maintain body temperature
Prevent infection
Provide emotional support
Assess the burn
Treatment Plan
• Based on five factors
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Size of the injury
Depth of the injury
Age of the patient
Past medical history
Part of the body burned
Rule of Nines
• Size is expressed as a percent of the total body
surface area
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Head and neck = 9%
Each arm = 9%
Each leg = 18%
Trunk = 36%
Perineum = 1%
= 100%
Lund-Browder Formula
• Also assess burn size
• Divides the body into smaller percentage areas
• Considered more accurate, especially for
children
Question
Burn Depth
• Partial thickness
o 1st and 2nd degree
o Partial destruction of skin layers
o Enough epithelial cells, hair follicles, and sweat
glands remain to provide a new dermis
o Heal spontaneously in 2 weeks to 21 days
o Little to no scar or contracture formation
o Characterized by:
• Pink or white, pain, blanchable, thick walled
blisters, firm texture
Burn Depth
• Full thickness
o 3rd degree, involves all skin layers, subcutaneous
tissue, muscles, and bone
o 4th degree, some say burns that involve muscle and
bone are actually 4th degree
o Requires grafting
o Characterized by:
• White or charred black, waxy, not blanchable,
charred vessel visible, no pain, no blisters, dry and
leather like
Age
• The very young and the elderly have the highest
mortality rates due to burn injuries
• Under 2 yrs of age
o Immature immune system
o High body surface area per body mass.
• Elderly
o Burns exacerbate previous medical problems
o Less physiological reserves
Past Medical History
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Cardiac
Respiratory
Renal
Endocrine
Substance abuse
All decrease the rate of survival
Area Burned
• Burns to the head, neck, and chest are more
serious due to pulmonary complications
• Burns in the perineum and upper thigh are more
prone to infection
• Burns to the hands, face, and neck require
special care for both physical and psychological
reasons
A general rule of prognosis
If the age of the patient + the percent of the
body burned = more than 100 there is
little chance for survival
65 yr old + 50% burned = 115
This patient has little chance of survival
Medical Management
• Fluid resuscitation
o 0.9% NaCl or Lactated Ringers
o Once stabilized begin colloids
o Parkland formula
• 4ml/kg x % TBSA of burn = replacement volume
• ½ given in first 8 hours, ¼ in second 8 hours, and ¼ in
the third 8 hours
Example: 100kg male burned over 25% of his body
4 x 100 x 25 = 10000 ml
Fluid Resuscitation
Assessment
• Monitor
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Mental status
Skin color and temperature
Heart rate
Blood pressure
Urine output
Specific gravity
CVP
H&H
GI function
Pain Management
• Opioids such as morphine, fentanyl, and codeine are
given on a non-pain-contingent schedule
• Additional narcotics are given before dressing
changes
• IM needs to be avoided due to poor absorption
• Anti-anxiety meds need to be given as well
• Start on stool softeners
Proper pain management is essential
for improved healing
Acute Phase
• Begins when the patient is hemodynamically
stable and ends with wound closure
• Goals
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Wound cleansing and healing
Pain relief
Maintaining body temperature
Preventing infection
Promoting nutrition
Splinting
ROM
Wound Care
• Clean the burn with chlorhexidine gluconate and
gauze pads to remove dead tissue and debris
• Wound debridement removes further loose
tissue and eschar
• Fasciotomy may need to be performed in order
to restore blood flow to a limb
• Apply temporary dressing
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Xenograft (pigskin)
Allograft (cadaver skin)
Biosynthetic dressings
Synthetic Dressings
Skin Grafting
• Full thickness skin graft
o Entire thickness of skin down to the subcutaneous tissue is
excised
o Use for areas that need thicker covering to prevent breakdown or
improved cosmetic result
• Palm of hand, bottom of foot, joints, face
o Less common
• Split-thickness skin graft
o Partial layer of skin is harvested with a dermatome
o Is either used as a sheet or meshed
o Most common skin graft
Maintaining Mobility
• Splinting and a ROM exercise plan is essential to
maintaining function and motility
• Exercise begins on admission and goes until the
scars are matured
• PT and OT are essential members of the care
team
Nutrition
• Burn patient experience extreme metabolic
stress
• Their resting energy expenditure can increase by
as much as 150%
• Oral route is preferred
• Enteral and parental nutrition may be required
Rehabilitative Phase
• Begins when less than 20% of the wound is open
• Emphasis is on physical and psychological
restorative therapy
• Treatments include:
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PT/OT
ROM exercises
Increased strength and endurance
Pain management
Nutrition
Cosmetic reconstruction
Psychological care
Resources
• Osborn, Wraa & Watson chapter 68
• Burn Survivor Resource Center
o http://www.burnsurvivor.com/
• Split thickness skin graft video
o http://www.youtube.com/watch?v=pvbxmm9
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