1.

ToknowParklandformula
Forexample,apersonweighing75kgwithburnsto20%ofhisorherBSAwouldrequire4x75
x20=6,000mLoffluidreplacementwithin24hours.Thefirsthalfofthisamountisdelivered
within8hoursfromtheburnincident,andtheremainingfluidisdeliveredinthenext16hours.[3]
Thebodysurfaceareainvolvedinburnsforadultscanbecalculatedbyapplyingtheruleofnine:
9%foreacharm,18%foreachleg,18%forthefrontofthetorso,18%forthebackofthetorso,
and9%fortheheadand1%fortheperineum.[4]
Forpeds:Headis18%A+P,Legsare14%eachA+P,otherareasarethesameasadults.
2. Ruleof9

LundBrowderchart.Byconvention,areasofpartialthicknessinjuryarecoloredinblueand
areasoffullthicknessinjuryinred.Superficialpartialthicknessburnsarenotcalculated.B,Rule
ofnineschart.
ExtentofBurn
Twocommonlyusedguidesfordeterminingthetotalbodysurfaceareaaffectedortheextentof
aburnwoundaretheLundBrowderchart(Fig.254,A)andtheruleofnines(Fig.254,B).
(Firstdegreeburns,equivalenttoasunburn,arenotincludedwhencalculatingTBSA.)The
LundBrowderchartisconsideredmoreaccuratebecausethepatient'sage,inproportionto
relativebodyareasize,istakenintoaccount.Theruleofnines,whichiseasytoremember,is
consideredadequateforinitialassessmentofanadultburnpatient.Forirregularoroddshaped
burns,thepatient'shand(includingthefingers)isapproximately1%TBSA.TheSageBurn
Diagramisafree,InternetbasedtoolthatisavailableforestimatingTBSAburned(
www.sagediagram.com).Theextentofaburnisoftenrevisedafteredemahassubsidedanda
demarcationofthezonesofinjuryhaveoccurred.

3. CAREFULLYReviewchapterandpowerpoint(hopefullymylackofaphotographic
memorywillservemewellonMonday!)
4. Burnseverityclassificationandsigns/symptomspatientpresentswith
correspondingtothat
PartialThicknessSkinDestruction
superficial(1stdegreeburn):erythema,blanchingonpressure,painandmildswelling,
novesiclesorblisters(althoughafter24hrskinmayblisterandpeel)
deep(2nddegreeburn):fluidfilledvesiclesthatarered,shiny,wet(ifvesicleshave
ruptured)severepaincausedbynerveinjurymildtomoderateedema
FullThicknessSkinDestruction
(3rd&4thdegreeburns):dry,waxywhite,leathery,orhardskinvisiblethrombosed
vesselsinsensitivitytopainbecauseofnervedestructionpossibleinvolvementof
muscles,tendons,andbones.
5. Prioritiesduringphasesofburncare(exampleEmergent)

ThermalBurns
Smallthermalburns(10%TBSA)shouldbecoveredwithaclean,cool,tapwaterdampenedtowel
forthepatient'scomfortandprotectionuntildefinitivemedicalcareisinstituted.Coolingoftheinjured
area(ifsmall)within1minutehelpsminimizethedepthoftheinjury.Iftheburnislarge(greaterthan
10%TBSA)oranelectricalorinhalationburnissuspected,attentionneedstobefocusedfirstonthe
ABCs:
Airway:checkforpatency,sootaroundnares/onthetongue,singednasalhair,
darkenedoralornasalmembranes.
Breathing:checkforadequacyofventilation.
Circulation:checkforpresenceandregularityofpulses,andelevatetheburned
limb(s)abovethehearttodecreasepainandswelling.
6. MedicationEsomeprazoleforpatientswithburns
Thisisaprotonpumpinhibitor(Nexium)usedprophylactically.Decreases
stomachacidandriskofCurlingsulcer(stressulcer).GIfunctionmaybeslowedorimpaired
duetoshockorparalyticileus

7. Painmanagement

Becauseburninjuriescanbeveryuncomfortable,relievingpainisatoppriority.Morphineisthe
drugmostoftenusedtomanagepain.Heartrateandbloodpressurecanindicateifapatientis
feelingpain.
Typesofpain
a. BackgroundhaveallthetimeMSContin,Oxycontin,MSO4PCA,drip
b. ProceduralPainPainthatisexperiencedwhileaprocedureisbeingdone.
Havetogivemoremedicationbeforeyoudothistopreventanticipatorypain.
c. AnticipatorypainBecomingagitatedbeforeaprocedure,andgettingallworked
upincreasespain,Isdifficulttoworkwith.
d. Anxiety/Fear
Paindecreasesasburnwoundsheal.Buthealthyskinbudsandnerveendingsinhealing
skinarestillextremelysensitive.Skingraftingreducespainintheburnwound,but
temporarypainwillbefeltatthedonorsite.
Addictiontopainmedicationusedinburncareisveryrare.Toavoidwithdrawal
problems,painmedicationisdecreasedgraduallyastheburnpatientrecovers.Patients
generallywillnotaskforpainmedicationwhentheynolongerneedit.
Painiswhatthepersonsaysitis
AnalgesicsaremosteffectivewhengivenonascheduledbasisratherthanPRN
MostmedicationsaregivenintravenouslyasIMareusuallynoteffectiveinedematous
individualsthemedstaysinthemuscleratherthanbeingintroducedintocirculation,the
sameforthestomach,ifthepersonisnottoleratingfeedingstheyprobablynotabsorb
medicationsgivenPO
Bowelregimeshouldbebegunwhennarcoticsarebegun
Agents
PainMorphine,dilaudid,fentonyl,gabapentin,methadone
AnxiolyticsValium,ativan,versed
AnestheticsPropofol,curare,vecuronium
takenfromPowerpoint

8. Priorityofpatientcareafterelectricalburns
Mostofdamageisbelowskindeterminationofelectriccurrentcontactpointsandhxofinjury
mayhelpdetermineprobablepathofcurrentandpotentialareasofinjury
EMERGENCYINTERVENTIONS:
Initial(Rapidassessmentandtransfertoburncenter)
Removeptfromelectricalsourcewhileprotectingrescuer
AssessABCs
Stabilizecervicalspine(suspectfracturerelatedtoelectricalcurrentorfallfrominjury
anticipateXray)
ProvidesupplementalO2asneeded
Monitorvitalsigns,LOC,respiratorystatus,andO2sat.
Monitorcardiacrhythm(EKG,telemetry).Ptatriskfordysrhythmiasorcardiacarrest,which

mayoccurwithoutwarningduringfirst24hafterinjury
Checkpulsesdistaltoburns
Removenonadherentclothing,shoes,watches,jewelry,glasses,orcontactlensesifface
wasexposed
Coverburnedareaswithdrydressingsorcleansheet
EstablishIVaccesswithtwolargeborecathetersifburn>15%TBSA
Beginfluidreplacement(LactatedRingers)
ObtainABGtoassessacidbasebalance
Inserturinarycatheterifburn>15%TBSA(ensuresaccurateU/Omeasurementandprevents
infectionofperiburns)
Elevateburnedlimb(s)abovehearttodecreaseedema
AdministerIVanalgesiaandassesseffectivenessfrequently
Identifyandtreatotherassociatedinjuries(e.g.fractures,pneumothorax,headinjury)
Ongoingmonitoring
Monitorairway
Monitorvitalsigns,cardiacrhythm,LOC,respiratorystatus,O2sat,andneurovascularstatus
ofinjuredlimbs
Monitorurineoutput(Goal:100mL/h)
Monitorurinefordevelopmentofmyoglobinuriasecondarytomusclebreakdownand
hemoglobinuriasecondarytoRBCbreakdown.Myoglobinfromdamagedmuscleisreleasedinto
circulationandcanmechanicallyblocktherenaltubulesbecauseoftheirlargesize.Thiscan
resultinacutetubularnecrosisandpossiblyacuterenalfailureifnottreated
AnticipatepossibleadministrationofNaHCO3toalkalinizetheurineandmaintainserumpH
>6.0.

9. Assess/monitorforcomplicationsofburnpatientswhattoreport,whatordersto
anticipate
Cardiovascular Complications:
-Dysrhythmias
-Hypovolemic shock
-Impaired circulation to extremities (ischemia, paresthesia, necrosis,
gangrene). Anticipate an escharotomy.
-Sludging = increased blood viscosity + impaired microcirculation in small
capillary systems. Anticipate fluid replacement.
Respiratory Complications:
Upper Airway Injury

Edema can lead to total airway obstruction

hoarseness, difficulty swallowing, copious secretions, stridor, substernal and
intercostal retractions. Anticipate intubation.
Burns to neck and chest can produce inelastic eschar which can restrict
respiration. Anticipate escharotomy.
Lower Airway Injury
At the alveolar level, secondary to inhalation of toxic fumes or smoke.
High degree of suspicion if patient was trapped in a fire in an enclosed space
or clothing caught fire, and has facial burns and/or singed nasal or facial hair;
dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status.
Anticipate fiberoptic bronchoscopy, chest xray, and ABG

10. Whatpatienttoassessfirsttypeofquestions
anypatientwithsignsofairwayinjury`
11. Whatpatienttoassigntonursefloatingtoburnfloortypeofquestions
12. CO2poisoning.whichImassuminghemeansCOpoisoning??Thisinfoisfrom
thebook.justrealizeditdoesnotmatchwhattheslidessay!!!
-accounts for the majority of deaths at a fire scene
-produced by the incomplete combustion of burning materials
-when inhaled, it displaces oxygen (O2) on the hemoglobin molecule,
-causes carboxyhemoglobinemia & hypoxia
-CO levels >20% = death
-Skin color is cherry red with severe CO poisoning.
-may occur in the absence of burn injury to the skin.
Slides say the following:

COlevels1120%resultinflushingheadache,decreasedvisualacuity,decreased
cerebaralfunctioningandslightbreathlessness.
2140%resultinnausea,vomiting,dizziness,tinnitus,vertigo,confusion,
drowsiness,paletoreddishpurpleskin,tachycardia
4160%leadstoseizureandcoma
>61%leadstodeath

13. Labsinburnpatients

LaboratoryValues
Becausethebodyisattemptingtoreestablishfluidandelectrolytehomeostasisintheinitial
acutephase,itisimportanttofollowserumelectrolytelevelsclosely.

Sodium
HyponatremiacandevelopfromexcessiveGIsuction,diarrhea,andwaterintake.Manifestations
ofhyponatremiaincludeweakness,dizziness,musclecramps,fatigue,headache,tachycardia,
andconfusion.Theburnpatientmayalsodevelopadilutionalhyponatremiacalledwater
intoxication.Toavoidthiscondition,thepatientshoulddrinkfluidsotherthanwater,suchas
juice,softdrinks,ornutritionalsupplements.
Hypernatremiamaybeseenfollowingsuccessfulfluidresuscitationifcopiousamountsof
hypertonicsolutionswererequired.Othercausesmayberelatedtotubefeedingtherapyor
inappropriatefluidadministration.Manifestationsofhypernatremiaincludethirstdried,furry
tonguelethargyconfusionandpossiblyseizures.

Potassium
Hyperkalemiaisnotedifthepatienthasrenalfailure,adrenocorticalinsufficiency,ormassive
deepmuscleinjury(e.g.,electricalburn)withlargeamountsofpotassiumreleasedfrom
damagedcells.Cardiacdysrhythmiasandventricularfailurecanoccurwithelevatedpotassium
levels.Muscleweaknessandelectrocardiographic(ECG)changesareobservedclinically(see
Chapter17).
Hypokalemiaoccurswithvomiting,diarrhea,prolongedGIsuction,andprolongedIVtherapy
withoutpotassiumsupplementation.Aconstantpotassiumlossoccursthroughtheburnwound.
Manifestationsofhypokalemiaincludefatigue,muscleweakness,legcramps,paresthesias,and
decreasedreflexes(seeChapter17)
DecreasedHemoglobin,ElevatedHematocrit

14. Techniqueofapplicationburndressings
Cleansingandgentledebridement,usingscissorsandforceps,canoccurinacartshower(Fig.
259),regularshower,orpatientbed/stretcherbyyouandphysicians.Extensive,surgical
debridementisperformedintheoperatingroom(OR)(Fig.2510).Duringdebridement,
necroticskinisremoved.Releasingescharotomiesandfasciotomiescanbecarriedoutinthe
emergentphase,usuallyinburncentersbyburnphysicians.
Twoapproachestoburnwoundtreatmentaretheopenmethodandtheuseofmultipledressing

changes.Intheopenmethod,thepatient'sburniscoveredwithatopicalantimicrobialandhas
nodressingoverthewound.Inthemultipledressingchangeorclosedmethod,sterilegauze
dressingsareimpregnatedwithorlaidoveratopicalantimicrobial(Fig.2511).Thesedressings
arechangedanywherefromevery12to24hourstoonceevery14days,dependingonthe
product.Mostburncenterssupporttheconceptofmoistwoundhealingandusedressingsto
covertheburnedareas,withtheexceptionoftheburnedface.
Cleantechniquewhileremovingandcleaning,sterilewhenapplyingnewbandages.
15. Howtotherapeuticallyaddressclientsconcerns
Openandfrequentcommunicationamongthepatient,caregivers,closefriends,andburnteam
membersisessential.Assessmentincludeslivingsituation,occupation,financialconcerns,

socialsupports,emotionalstatus,copingmechanisms,priorbaseline,communicationor
culturalbarriers,preexistingstressors,substanceabusehxptorfamily,previouspsych
problems
UseSocialWorker
ValidatePtfears

16. Typeofburnpatients:
Weirdlyphrased,butcorrelatestoaslide
Flame
Contact
Electrical
Chemical
Scald
Radiation
Cold
17. Measurestopreventburninjuries
TABLE252

TypesofBurnInjuryandRiskReductionStrategies

FlameorContact
Neverleavecandlesunattendedornearopenwindows/curtains.
Encourageuseofchildresistantlighters.
Encourageregularhomefireexitdrills.
Neverusegasolineorotherflammableliquidsasaccelerants.
Neverleavehotoilunattendedwhilecooking.

Neversmokeinbed.
Consideraflameretardantsmokingapronforelderlyand/oratriskpeople.
Exercisecautionwhenmicrowavingfood/beverages.
Scald
Lowerhotwatertemperaturetothelowestpointor120F/40C.
Useantiscalddeviceswithshowerheadorfaucetfixtures.
Supervisebathingwithsmallchildren,olderadults,oranyonewithimpaired
physicalmovement/physicalsensation/judgment.
Afterrunningbathwater,checktemperaturewithbackofhandorbath
thermometer.
Turnhandlestowardbackofstovetopreventscaldinjuries
Inhalation
Installsmoke/carbonmonoxidedetectors.
Chemical
Storechemicalssafelyinapprovedcontainersandlabelclearly.
Ensuresafetyofworkers,studentshandlingchemicals(education,protective
eyewear,gloves,masks,clothing).
Electrical
Avoidand/orrepairfrayedwiring.
Ensureelectricalpowersourceisshutoffbeforebeginningrepairs.
Wearprotectiveeyewearandgloveswhenmakingelectricalrepairs.
Avoidoutdooractivitiesduringelectrical(i.e.,lightning)storms.