1

MANAGEMENT OF
PATIENTS WITH
BURN

Pathophysiology of Burns
Causes of Burn

Burns are caused by a transfer of energy

from a heat source to the body.
Heat may be transferred through
conduction or electromagnetic radiation.
Burns are categorized as thermal (which
includes electrical burns), radiation, or
chemical.
Tissue destruction results from
coagulation, protein denaturation, or
ionization of cellular contents.

Pathophysiology of
Burns contd

The skin and the mucosa of the upper

airways are the sites of tissue destruction.
Deep tissues, including the viscera, can be
damaged by electrical burns or through
prolonged contact with a heat source.
Disruption of the skin can lead to
increased fluid loss, infection,
hypothermia, scarring, compromised
immunity, and changes in function,
appearance, and body image.

Pathophysiology of
Burns contd

The depth of the injury depends on the

temperature of the burning agent and the
duration of contact with the agent.
For example, in the case of scald burns in
adults, 1 second of contact with hot tap water
at 68.9C (156F) may result in a burn that
destroys both the epidermis and the dermis,
causing a fullthickness (third-degree) injury.
Fifteen seconds of exposure to hot water at
56.1C (133F) results in a similar fullthickness injury.
Temperatures less than 111F are tolerated for
long periods without injury.

CLASSIFICATION OF
BURNS

Burn injuries are described according to

the depth of the injuryand the extent of
body surface area injured.
Burn Depth
Burn depth determines whether
epithelialization will occur.
Determining burn depth can be difficult
even for the experienced burn care
provider.

CLASSIFICATION OF BURNS
contd
Burns are classified according to the
depth of tissue destruction as:
1. Superficial partial-thickness
injuries (first degree burn):
In a superficial partial-thickness burn,
the epidermis is destroyed or injured
and
a portion of the dermis may be injured.
The damaged skin may be painful and
appear red and dry, as in sunburn, or it
may blister (very minimal).

CLASSIFICATION OF BURNS
contd
Typical Characteristics for Superficial
thickness burn
Mild to severe erythema (pink to red)
NO BLISTERS
Skin blanches
Painful, tingling
Pain responds well to cooling
Lasts about 48 hours; healing in 3-7 days

CLASSIFICATION OF BURNS
contd
2. Deep partial-thickness injuries (second
degree burn):
A deep partial-thickness burn involves
destruction of the epidermis and upper layers of
the dermis and injury to deeper portions of the
dermis.
The wound is painful, appears red, and exudes
fluid.
Capillary refill follows tissue blanching. Hair
follicles remain intact.
Deep partial-thickness burns take longer to heal
and are more likely to result in hypertrophic
scars.

CLASSIFICATION OF BURNS
contd
Typical Characteristics for deep
partial thickness burn
Large blisters over an extensive area
Edema
Red base with broken epidermis
Wet, shiny and weeping
Sensitive to cold air
Healing in 2-3 weeks
Grafts MAY be needed

10

Partial-Thickness Burn to
the Hand

11

Partial-Thickness Burns
Due to Immersion in Hot
Water

12

CLASSIFICATION OF BURNS
contd
3. Ful-thickness injuries (third degree
burn):
A full-thickness burn involves total
destruction of epidermis and dermis and,
in some cases, underlying tissue as well.
Wound color ranges widely from white to
red, brown, or black. The burned area is
painless because nerve fibers are
destroyed.
The wound appears leathery; hair follicles
and sweat glands are destroyed

13

CLASSIFICATION OF BURNS
contd
Typical Characteristics for Full-thickness
burn

Deep, red, black, white, yellow, or brown

area
Edema
Tissue open with fat exposed
Little to no pain*
Requires removal of eschar and skin
grafting
Scarring and contractures are likely
Takes weeks to months to heal

14

Full-Thickness Thermal
Burn

CLASSIFICATION OF BURNS
contd

15

The following factors are considered

in determining the depth of the burn:
How the injury occurred
Causative agent, such as flame or
scalding liquid
Temperature of the burning agent
Duration of contact with the agent
Thickness of the skin

16

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
Thermal Burns
Caused by flame, flash, scald, or
contact with hot objects
It is the most common type of
burn
Chemical Burns

Result from tissue injury and

destruction
from necrotizing substances
(chemicals)
Most commonly caused by acids

17

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd Burns contd
Chemical

Respiratory and systemic

problems
Eye injuries
Clothing containing the chemical
should be removed
Tissue destruction may continue
for up to 72 hours after a
chemical injury

18

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries

Result from inhalation of hot air or

noxious chemicals
Cause damage to respiratory tract
Important determinant of mortality
in fire victims

19

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries contd

Three types:
Carbon monoxide poisoning
Inhalation injury above the
glottis
Inhalation injury below the
glottis

20

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries contd

Carbon monoxide (CO) poisoning

CO is produced by the
incomplete combustion of
burning materials
Inhaled CO displaces oxygen 200
x more powerful than oxygen
CO is colorless, odorless and
tasteless

21

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke
Inhalation Injuries contd

Carbon monoxide (CO) poisoning

can cause:
Hypoxia in tissues
Carboxyhemoglobinemia
Death

22

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
Smoke
Inhalation Injuries contd
contd

Carbon monoxide (CO) poisoning

Treat with 100% humidified oxygen
CO poisoning may occur in the absence
of burn injury to the skin
Skin color described as cherry red in
appearance
Hot air, steam, or smoke can cause:
mechanical obstruction quickly
May lead to hemorrhage in the
bronchus
ARDS

23

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries contd
Carbon monoxide (CO) poisoning
Signs and Symptoms
Presence of facial burns
Singed nasal hair
Hoarseness,
painful swallowing
Darkened oral and nasal
membranes

24

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries contd
Carbon monoxide (CO) poisoning
Signs and Symptoms contd
Wheezing on auscultation
Edema is the nose and
airways
Flushing
Nausea/vomiting
Syncope, coma, death

25

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Smoke Inhalation Injuries
Injury below the glottis Pathophysiology
Injury is related to the length of
exposure to smoke or toxic fumes
Pulmonary edema may not appear
until 12 to 24 hours after the burn
Decrease is surfactant production
Decrease in ciliary action

26

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Electrical Burns
Intense heat generated from
anelectrical current
May result from direct damage to
nerves and vessels causing tissue
anoxia and death
Severity of injury depends on the
amount of voltage, tissue
resistance, current pathways,
surface area, and on the length of
time of the flow

Electrical Burn- Hand

27

Electrical Burn- Back

28

29

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Electrical Burns contd

Electrical sparks may ignite the

patients
clothing, causing a combination
of
thermal and electrical injury

30

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Cold Thermal Injury (Frostbite)
Usually affects fingers, toes,
nose, and ears
Numbness, pallor, severe pain,
swelling, edema
Blistering in a warm
environment
Handle the tissue carefully!

31

CLASSIFICATION OF BURNS
BY CAUSATIVE AGENTS
contd
Cold
Thermal Injury (Frostbite)

Interventions Frostbite
Warm rapidly and continuously
for 15-20 minutes
AVOID slow thawing
Do not debride blisters

32

CLASSIFICATION OF BURNS
BY EXTENT OF BSA INJURED
Extent of Body Surface Area
Injured
Various methods are used to estimate
the TBSA (total body surface area)
affected by burns; among them are:
the rule of nines,
the Lund and Browder method, and
the palm method.

33

CLASSIFICATION OF BURNS
contd
RULE OF NINES
An estimation of the TBSA involved in a
burn is simplified by using the rule of
nines.
The rule of nines is a quick way to
calculate the extent of burns.
The system assigns percentages in
multiples of nine to major body surfaces.

Rule of Nines Chart

34

Rule of Nines Chart

35

36

CLASSIFICATION OF BURNS
contd
LUND AND BROWDER METHOD
A more precise method of estimating the
extent of a burn is the Lund and Browder
method,
It recognizes that the percentage of TBSA of
various anatomic parts, especially the head
and legs, and changes with growth.
By dividing the body into very small areas and
providing an estimate of the proportion of TBSA
accounted for by such body parts, one can
obtain a reliable estimate of the TBSA burned.
The initial evaluation is made on the patients
arrival at the hospital and is revised on the
second and third post-burn days because the
demarcation usually is not clear until then.

Lund-Browder Chart
37

38

CLASSIFICATION OF BURNS
contd

PALM METHOD
In patients with scattered burns, a method
to estimate the percentage of burn is the
palm method.
The size of the patients palm is
approximately 1% of TBSA.

39

Criteria for Classifying the

Extent of Burn
Injury(American
Burn
Minor Burn Injury
Second-degree burn of less than 15%
Association)

total body surface area(TBSA) in adults

or less than 10% TBSA in children
Third-degree burn of less than 2% TBSA
not involving special care areas (eyes,
ears, face, hands, feet, perineum, joints)
Excludes electrical injury, inhalation
injury, concurrent trauma, all poor-risk
patients (eg, extremes of age,
concurrent disease)

Criteria for Classifying the

Extent of Burn
Injury(American
Burn
Moderate, Uncomplicated
Burn Injury
Second-degree burns of 15%25% TBSA
Association)

40

in adults or10%20% in children

Third-degree burns of less than 10%
TBSA not involving special care areas
Excludes electrical injury, inhalation
injury, concurrent trauma, all poor-risk
patients (eg, extremes of age,
concurrent disease)

Criteria for Classifying the

Extent of Burn
Injury(American
Burn
Major
Burn Injury
Second-degree burns exceeding 25% TBSA
Association)

41

in adults or 20% in children

All third-degree burns exceeding 10%
TBSA
All burns involving eyes, ears, face, hands,
feet, perineum, joints
All inhalation injury, electrical injury,
concurrent trauma, all poor-risk patients

42

LOCAL AND SYSTEMIC

RESPONSES
TO
BurnsBURNS
that do not exceed 25% TBSA

produce a primarily local response.

Burns that exceed 25% TBSA may produce
both a local and a systemic response and
are considered major burn injuries.
These systemic responses are due to the
release of cytokines and other mediators
into the systemic circulation and include
the following:

43

LOCAL AND SYSTEMIC

RESPONSES
tissue
edema
TO
BURNS
contd

effects on fluid, electrolytes and blood

volume
cardiovascular responses (decreased cardiac
out put, hypovolumia, decresed BP,
increased PR)
pulmonary responses (inhalation injury to air
ways, broncho-constriction-major cause of
death,acute respiratory failure or respiratory
distress syndrome )
altered immunological defenses
renal dysfunction, etc

LOCAL AND SYSTEMIC

RESPONSES
Pathophysiologic
TO BURNS contd
changes resulting

44

from major burns during the initial

burn-shock period include:
tissue hypoperfusion
organ hypofunction secondary to
decreased cardiac output,
Hyperdynamic and hypermetabolic
phase.

LOCAL AND SYSTEMIC

RESPONSES
The
TOincidence,
BURNSmagnitude,
contd and duration of

45

pathophysiologic changes in burns are

proportional to the extent of burn injury,
with a maximal response seen in burns
covering 60% or more TBSA.
The initial systemic event after a major
burn injury is hemodynamic instability,
resulting from loss of capillary integrity
and a subsequent shift of fluid, sodium,
and protein from the intravascular space
into the interstitial spaces.

46

Management of the
Patient
With
a
Burn
Burn care must be planned according to the
burn
depth and local response, the extent of the
Injury

injury, and the presence of a systemic response.

Burn care then proceeds through three phases:

Emergent/resuscitative phase (on-the-scene care),

Acute/intermediate phase, and
Rehabilitation phase.

Although priorities exist for each of the phases,

the phases overlap, and assessment and
management of specific problems and
complications are not limited to these phases
but take place throughout burn care.

Table: phases of burn

Phasecare
Duration
Priorities
47

Emergent or From onset of injury to

immediate
completion
resuscitative of fluid resuscitation

First aid
Prevention of shock
Prevention of respiratory distress
Detection and treatment of concomitant
injuries
Wound assessment and initial care

Acute

Wound care and closure

Prevention or treatment of
complications, including infection
Nutritional support

Rehabilitati
on

From beginning of diuresis

to near
completion of wound
closure
From major wound closure
to return
to individuals optimal level
of physical
and psychosocial
adjustment

Prevention of scars and contractures

Physical, occupational, and vocational
rehabilitation
Functional and cosmetic reconstruction
Psychosocial counseling

48

Emergent/resuscitative
phase mgt

Emergency Procedures at the

Burn Scene
Extinguish the flames
Cool the burn
Remove restrictive objectives
Cover the wound
Irrigate chemical burns

49

Emergent/resuscitative
phase mgt

Emergency Medical Management

The patient is transported to the nearest
emergency department.
The hospital nurses (staff) and physician
are alerted that the patient is in route to
the emergency department so that lifesaving measures can be initiated
immediately by a trained team.
Initial priorities in the emergency
department remain airway, breathing,
and circulation.

50

Emergent/resuscitative
phase mgt
Emergency Medical Management contd
For mild pulmonary injury, inspired air is
humidified and the patient is encouraged
to cough so that secretions can be
removed by suctioning.
For more severe situations, it is necessary
to remove secretions by bronchial
suctioning and to administer
bronchodilators and mucolytic agents.
If edema of the airway develops,
endotracheal intubation may be necessary.

51

Emergent/resuscitative
phase mgt

Emergency Medical Management contd

Continuous positive airway pressure and
mechanical ventilation may also be required
to achieve adequate oxygenation.
A large-bore (16- or 18-gauge) intravenous
catheter should be inserted in a non-burned
area (if not inserted earlier).

52

Emergent/resuscitative
phase mgt
Emergency Medical Management
contd
Assessment of both the TBSA burned
and the depth of the burn is completed
after soot and debris have been gently
cleansed from the burn wound.
An indwelling urinary catheter is inserted
to permit more accurate monitoring of
urine output and renal function for
patients with moderate to severe burns.

Management of fluid loss

and shock
53

Fluid Replacement Therapy:

The total volume and rate of intravenous
fluid replacement are gauged by the
patients response.
The adequacy of fluid resuscitation is
determined by:
Output totals of 30 to 50 mL/hour
systolic blood pressure exceeding 100
mm Hg and/or
pulse rate less than 110/minute.

54

Conditions Leading to
Burn Shock

Management of fluid loss

and shock

55

Fluid Requirements:
The projected fluid requirements for the first
24 hours are calculated by the clinician
based on the extent of the burn injury.
Some combination of fluid categories may
be used:
Colloids (whole blood, plasma, and plasma
expanders) and
Crystalloids/electrolytes (physiologic
sodium chloride or lactated Ringers
solution).

Management of fluid loss

and shock
56

Fluid Requirements:
Adequate fluid resuscitation results in
slightly decreased blood volume levels
during the first 24 post-burn hours and
restores plasma levels to normal by the
end of 48 hours.
Oral resuscitation can be successful in
adults with less than 20% TBSA and
children with less than 10% to 15% TBSA.

Guidelines and Formulas

for Fluid Replacement in
Consensus
Formula
Burn Patients

57

Lactated Ringers solution (or other

balanced saline solution): 24 mL kg
body weight % total body surface
area (TBSA) burned.
Half to be given in first 8 hours;
remaining half to be given over next 16
hours.

Guidelines and Formulas

for Fluid Replacement in
The following example illustrates use
Burn Patients

58

of the formula in a management of a

70-kg patient with a 50% TBSA burn:
Steps
1, Consensus formula: 2 to 4 mL/kg/%
TBSA
2, 2 70 50 = 7,000 mL/24 hours
3, Plan to administer: First 8 hours =
3,500 mL, or 437 mL/ hour; next 16
hours = 3,500 mL, or 219 mL/hour

Guidelines and Formulas

for
Fluid
Replacement
in
Evans Formula
Burn1 mLPatients
1. Colloids:
kg body weight % TBSA burned
59

2. Electrolytes (saline): 1 mL body weight % TBSA

burned
3. Glucose (5% in water): 2,000 mL for insensible loss
Day 1: Half to be given in first 8 hours; remaining half over
next 16 hours
Day 2: Half of previous days colloids and electrolytes; all of
insensible fluid replacement
Maximum of 10,000 mL over 24 hours. Second- and thirddegree
(partial- and full-thickness) burns exceeding 50% TBSA are
calculated
on the basis of 50% TBSA.

Guidelines and Formulas

for Fluid Replacement in
Brooke
Formula
BurnArmy
Patients

60

1. Colloids: 0.5 mL kg body weight

% TBSA burned
2. Electrolytes (lactated Ringers
solution): 1.5 mL kg body weight %
TBSA burned
3. Glucose (5% in water): 2,000 mL for
insensible loss

61

Guidelines and Formulas

for Fluid Replacement in
Brooke
Formula contd
BurnArmy
Patients

Day 1: Half to be given in first 8 hours;

remaining half over next16 hours
Day 2: Half of colloids; half of
electrolytes; all of insensible fluid
replacement.
Second- and third-degree (partial- and
full-thickness) burns exceeding 50%
TBSA are calculated on the basis of
50% TBSA.

62

Guidelines and Formulas

for Fluid Replacement in
Parkland/Baxter
Formula
Burn Patients
Lactated Ringers solution: 4 mL kg
body weight % TBSA burned
Day 1: Half to be given in first 8
hours; half to be given over next16
hours
Day 2: Varies. Colloid is added.

63

Guidelines and Formulas

for Fluid Replacement in
Hypertonic Saline Solution
Burn
Patients
Concentrated solutions of sodium chloride

(NaCl) and lactate with concentration of 250

300 mEq of sodium per liter, administered at a
rate sufficient to maintain a desired volume of
urinary output.
Do not increase the infusion rate during the first
8 post burn hours.
Serum sodium levels must be monitored closely.
Goal: Increase serum sodium level and
osmolality to reduce edema and prevent
pulmonary complications.

Nursing Management
64

Includes:
infection prevention,
wound cleansing and
administering topical antibacterial drugs
like:

Silver sulfadiazine 1% (Silvadene)

watersoluble cream,
Silver nitrate 0.5% aqueous solution,
Mafenide acetate 5% to 10% (Sulfamylon)
hydrophilic-based cream,
Acticoat, etc

65

Acute Phase
management
Hemodynamically stable through
diuresis
Capillary permeability is restored
48-72 hours after injury
Goal is restorative therapy
Focus on infection control, wound
care and closure, nutritional support,
pain management, PT
Concluded when the burned area is
completely covered by skin grafts or
when the wounds are healed

66

Acute Phase
management

Pathophysiology

Diuresis from fluid mobilization occurs,

and the patient is no longer grossly
edematous
Bowel sounds return
Healing begins
Formation of granulation tissue
A partial-thickness burn wound will heal
from the edges
Full-thickness burns must be covered by
skin grafts

67

Acute Phase
management
Wound Care
Daily observation
Assessment
Cleansing
Debridement
Appropriate coverage of the graft:

Fine-mesh gauze next to the graft

followed by middle and outer dressings
Sheet skin grafts must be kept free of
blebs (small blisters)

68

Acute Phase
management

Excision and Grafting

Eschar is removed down to the
subcutaneous tissue or fascia
Cultured Epithelial Autographs (CEA):
CEA is grown from biopsies obtained
from the patients own skin
Artificial Skin: used when lifethreatening full-thickness or deep
partial-thickness wounds where
conventional autograft is not
available or advisable

69

Acute Phase
management
Pain Management
Opioid every 1 to 3 hours for pain
Several drugs in combination
Morphine with haloperidol
Nonpharmacologic strategies
Relaxation tapes
Visualization, guided imagery
Meditation

70

Acute Phase
management
Debriding Full-Thickness
Burn

71

Acute Phase
management
Surgeon Harvesting Skin

72

Acute Phase
management
Donor Site After
Harvesting

73

Acute Phase
management
Healed Split-Thickness
Skin Graft

Acute Phase management

Application of Cultured Epithelial
Autograft
74

Rehabilitation Phase
75

The rehabilitation phase is defined as

beginning when the patients burn
wounds are covered with skin or
healed and the patient is able to
resume a level of self-care activity

Complications

Skin and joint contractures

Hypertrophic scarring

Contracture of the Axilla

76

Rehabilitation Phase
77

Both patient and family actively learn

how to care for healing wounds
Cosmetic surgery is often needed
following major burns
Role of exercise cannot be
overemphasized
Constant encouragement and
reassurance
Address spiritual and cultural needs
Maintain a high-calorie, high-protein diet
Occupational therapy