BURNS

Approximately 1.1 million people require medical attention

for burns every year, and about 4,500 persons die of burns
and associated inhalation injuries every year.

Incidence: any person, any time, any place, across

socioeconomic groups

Burn Most burns occur in the home, can occur in workplace

(<4y.o; >65 y.0)
Injuries
Young children and the elderly are at high risk for burn
injuries.

Nurses must play an active role in the prevention of burn

injuries by teaching prevention concepts and promoting
safety legislation.
 40%: flame related

30%: scald injuries: occurs more often

Nature: in children particularly the toddlers

4%: electrical

3%: chemical
 Prevention

Institution of life-saving measures

for the severely burned person
Goals Related to
Burns Prevention of disability and
disfigurement through early
specialized and individualized care

Rehabilitation through
reconstructive surgery and
rehabilitation programs
Classification of
Burns

• Superficial Partial
Thickness
1st degree – involves
epidermis, reddish,
painful
Deep Partial
Thickness
2nd degree –
involves dermis.
Moist surface,
with vesicles,
painful
• Full Thickness
• 3rd degree –
involves
subcutaneous layer,
pearly white, no
pain due to damage to the nerve endings

• 4th degree –
involves the muscles
and bones, blackish
or charred, no pain
 Zones of Burn Injury

Zone of Hyperemia - sustains the least damage

Zone of Stasis - has a compromised blood

supply, inflammation, and tissue injury

Zone of Coagulation - cellular death occurs

 How the injury Causative
occurred agent

Factors to
Consider in Duration of
Temperature
contact with
Determining of agent
the agent
Burn Depth
Thickness of
the skin
 Classification of Burns by Extent of Injury

1. MINOR BURN INJURY

• Second-degree burn of <15% total body surface area (TBSA) in adults or
<10% TBSA in children
• Third-degree burn of <2% TBSA not involving special care areas (eyes,
ears, face, hands, feet, perineum, joints) major burn injury
• Excludes all patients with electrical injury, inhalation injury, or
major burn injury
concurrent trauma and all poor-risk patients (eg, extremes of age,
intercurrent disease)
Classification of Burns by Extent of Injury

2. MODERATE, UNCOMPLICATED BURN INJURY

• Second-degree burns of 15-25% TBSA in adults or 10-20% in children
• Third-degree burn of <10% TBSA not involving special care areas
• Excludes electrical injury, inhalation injury, or concurrent trauma and
all poor-risk patients (eg, extremes of age, intercurrent disease)
Classification of Burns by Extent of Injury

3. MAJOR BURN INJURY

• Second-degree burns >25% TBSA in adults or >20% in children
• All third-degree burns >10% TBSA
• All burns involving eyes, ears, face, hands, feet. Perineum, joints
• All inhalation injury, electrical injury, or concurrent trauma, and all
poor-risk patients
Methods to Rule of nines – quick way; the system assigns
percentages in multiples of nine to a major
body surface
Estimate
Total Body Lund and Browder method – more precise
method; recognizes that the percentage of
surface area of various anatomic parts, esp.
Surface the head & legs, changes with growth

Area (TBSA) Palm method – scattered burns; 1 size of

Burned palm is approximately 1% of the TBSA
lower half of the anterior
aspect of the right upper
extremity

Rule of Nines
Lund and
Browder
Lund and Browder Method

More precise: recognizes

that the percentage of initial evaluation is made
TBSA of various anatomic on the patient’s arrival at
parts, especially the head the hospital and is revised
and legs, and changes with within the 1st 72 hours
growth
 Burns are caused by a transfer of energy
from a heat source to the body.

Pathophysiology
of Burns Thermal – hot objects or substances; due
c
to fires in the home, auto acidents ,
playing with matches, poorly stored gas ,
faulty electrical systems, space heaters,
fire crackers, kitchen accidents, scalding
Chemical – caused by
contact, ingestion,
inhalation, injection of
strong acids or alkali
• Electrical – from contact
with malfunctioning
electrical appliances,
wires, flash electrical arcs
from any high voltage
power lines, machine and
lightning

• Radiation – excessive
exposure to sunlight
 Burn related Respiratory
Injuries:

1. Smoke Inhalation
- Carbon monoxide CO (most common)
- released when organic substances are burned
- Colorless, odorless gas that combines with Hgb 200x
more than O2 causing Tissue Hypoxia
- Causes headache, dizziness, confusion, syncope, coma,
respiratory failure

Treatment: 100% O2
administration;
Hyperbaric O2 chamber to
reduce CO level
2. Smoke Poisoning- results from noxious
chemicals formed in the burning process and is
prevalent with nonorganic substances (plastic);
decreases ciliary action in respiratory tract and
mucosal edema, bronchospasm, carbon-flecked
sputum and then sloughing of the
tracheobronchial mucosa with cough up of
purulent musus

3. Heat Injury- affects the upper airway with

edema causing obstruction in the first 24 to 48
hours after burn
 Burns less than 20% TBSA produce a
primarily local response.

Burns more than 20% may produce a local

and systemic response and are considered
Physiologic major burns.

Changes Systemic response includes release of

immunomodulating agents
cytokines and other mediators into the
systemic circulation.
Fluid shifts and shock result in tissue
hypoperfusion and organ hypofunction.
 Fluid and electrolyte shifts

Cardiovascular effects

Effects of Pulmonary injury

• Upper airway
• Inhalation below the glottis

Major Burn •
•
Carbon monoxide poisoning
Restrictive defects

Injury Renal and GI alterations

Immunologic alterations

Effect upon thermoregulation

third space fluid dehydration Extensive local edema-
shift or third due to shifting of fluids from the Generalized DHN- maximal 24H, begins to
spacing intravascular space to the evaporative loss, fluid resolve 1-
interstitial space
shift 2days;completely
edema resolved 7-10days

Fluid and hypovolemia

Reduced blood volume
and Decreased urine output
Electrolyte hemoconcentration
Hct - (Hct is high) 0.5 - 1.0 mL/kg/hr
E.g. 50 kg patient

Shifts: M: 41 -50%
F: 36 - 48%
25-50 mL/hr

Sodium traps in edema

Emergent Trauma causes release
of potassium into
fluid and shifts into
cells as potassium is
extracellaur fluid:
Phase hyperkalemia.
released:
hyponatremia.
K = 3.5 - 5.0 mEq/L Na = 135 - 145 mEq/L

Metabolic acidosis
pH is low
HCO3 is low
 Hemodilution (↓HCT)-
Fluid re-enters the
results as fluid enters the
vascular space from the due to
IVC; loss of RBCs dt lysis at
interstitial space.
burn site

Increased urinary output-

F&E Shifts: Fluid shift into IVC
increases renal blood flow
Hyponatremia: Sodium is
lost with diuresis and due
to dilution as fluid enters
Acute Phase and causes increased urine
formation
vascular space

Potential Hypokalemia :
Potassium shifts from Metabolic acidosis
extracellular fluid into cells
 5 to 6 L/min
• ↓ Cardiac Output even without significant changes in blood
volume decreased CO, increased vascular resistance, hypovolemia, hypoperfusion
• SNS stimulation due to Burn Shock releases Adrenal corticoid
hormones and Catecholamines leading to vasoconstriction→
further ↓ in CO
Cardiovascular • 24-36 hrs (peak at 6-8H)= Fluid Leak
↓
Alterations: Increases Blood volume (hypervolemia)
↓
Increased renal perfusion
↓
DIURESIS( up to 2 weeks)

• Anemia due to destruction of RBC (but HCT level is increased)

 Pulmonary Alterations
thromboxane
Bronchoconstriction- Histamine, serotonin, thrombnoxane
for platelet coagulation,
vasoconstriction & proliferation

Upper airway-above glottis edema

Inhalation below the glottis-decrease ciliary function, Hypersecretion,

Severe mucosal edema, Bronchospasm, decrease surfactant leading to
Atelectasis → Acute Respiratory Failure
• Treatment: Intubation, Mechanical ventilation

Carbon monoxide poisoning (headache, dizziness, weakness, upset

stomach, vomiting, chest pain, and confusion

Restrictive defects - Escharotomy compartment syndrome

circumferential burns
 • Due to decreased blood volume, hemolysis (Hgb
in the urine), and muscle damage (Myoglobin)
↓
Renal Occlusion of the renal tubules
↓
Alterations Acute tubular necrosis
↓
RENAL Failure
 • Diminished resistance to infection
↓
SEPSIS
Immunologic
▪ Abnormal inflammatory factors, altered level of
Alterations: found in the linings of the respiratory tract and digestive tract; saliva, tears, breastmilk
IgA, impaired neutrophil functions, decrease
lymphocytes for viral/bacterial infections

for production of antibodies

↓
Immunosuppression
• Loss of skin integrity
• Release of abnormal
inflammatory factors, altered
levels of immunoglobulin and
serum complement, impaired
neutrophil function,
lymphocytopenia
 Normal = 5 to 35 bowel sounds per minute

↓peristalsis and bowel sounds

hypoactive bowel sounds

GI Gastric distention and Nausea= vomitting

Alterations:
Gastric bleeding due to massive physiologic
stress= CURLING’s ulcer (acute ulcerative
Stress Ulcer
duodenal disease 24 H post burn)
 Emergent or resuscitative phase

• Onset of injury to completion of fluid

resuscitation

Phases of Acute or intermediate phase

• From beginning of diuresis to wound

Burn Injury closure

Rehabilitation phase

• From wound closure to return to optimal

physical and psychosocial adjustment
 Emergency procedures at the Burn Scene:

1. Extinguish flames 2. Cool the burn 3. Remove restrictive objects

> application and > clothing and jewelry
> victim "drops and rolls" soaking with removed to
cool water on prevent constriction due to
> smother the flames burned areas edema
> effects on standing and > no direct
running application of ice
> disconnect electrical source

4. Cover the wound 5. Irrigate chemical burns

> immediate covering with sterile
dressings > rapid, sustained flushing

> minimize bacterial contamination > brush off chemical agents

> prevent air from contact with burned > remove clothes
areas immediately
> no medication/ material applied except > rinse off the body with cool
sterile dressings water
 Prevent Prevent injury to rescuer.

Stop Stop injury: extinguish flames, cool the

burn, irrigate chemical burns.
Emergent or Establish
ABCs: Establish airway, breathing, and
circulation.
Resuscitative
Phase: Start Start oxygen and large-bore IVs.

On-the- Remove
Remove restrictive objects and cover the
wound.
Scene Care Do assessment, surveying all body systems,
Do and obtain a history of the incident and
pertinent patient history.

Note: Treat patients with falls and electrical

Note injuries as for potential cervical spine injury.
 Patient is transported to emergency department.

Rapid assessment; v/s q 15mins

Maintain ABC; look for signs of inhalation injury

Emergent or Fluid resuscitation is begun.

Resuscitative Foley catheter is inserted.

gastric decompression
Phase Patients with burns exceeding 20-25% should have an NG tube inserted and placed to suction.

Patient is stabilized and condition is continually monitored.

Patients with electrical burns should have an ECG.

Address pain; only IV medication should be administered.

Psychosocial consideration and emotional support should be given to patient and family.
 Maintain BP above 100 mm Hg systolic and urine output of 0.5-
1.0mL/kg/hr. Maintain serum sodium at near-normal levels.
Consensus formula
Management
Evans formula
of Shock:
Fluid Brooke Army formula

Resuscitation Parkland Baxter formula

Hypertonic saline formula

Note: Adjust formulas to reflect initiation of fluids at the time

of injury.
 Plain Lactated Ringer's - PLR
Lactated Ringer’s Solution (or other
balanced saline solution)

CONSENSUS
FORMULA
2 mL x kg body weight x % TBSA burned
2-4 mL x kg body weight x % TBSA burned

Half to be given in 1st 8 Remaining half to be

hours given over next 16 hours
 Colloids: 1mL x kg body weight x
%TBSA

Electrolytes (Saline): 1mL x kg body

weight x %TBSA
EVANS
(D5W)
FORMULA Glucose (5% in water): 2000 mL for
insensible loss
• Day 1: Half to be given in the first 8 hours and
the remaining half over next 16 hours
• Day 2: Half of previous day’s colloids and
electrolytes
 Colloids: 0.5 mL x kg body
weight x % TBSA burned

Electrolytes (lactated
Ringer’s solution): 1.5 mL x
BROOKE body weight x % TBSA
burned
ARMY Day 1: Half to be given in first
8 h; remaining half over next

FORMULA Glucose (5% in water): 2000

16 h.

mL for insensible loss

Day 2: Half of colloids; half of
electrolytes; all of insensible
Second and third-degree fluid replacement.
(partial- and full-thickness)
burns exceeding 50% TBSA
are calculated on the basis of
50% TBSA.
PARKLAND/BAXTER
FORMULA
• Lactated Ringer’s solution: 4 mL x kg body weight x %
TBSA burned
➢ Day 1: Half to be given in first 8 h; half to be given
over next 16 h
➢ Day 2: Varies. Colloid is added.
End of Part 1