BURNS

DEFINITION:

1. “A burn is a traumatic injury to the skin and underlying tissues.”

– Barbara.
2. “An injury to tissue that result from direct contact or exposure to any thermal,
chemical, electrical or radiation source are termed burns.”
- Luckmann.

INCIDENCE:
• Third leading cause of accidental death in all age groups
• Occurs in females more than males

RISK FACTOR:

• Most accidents occur at home (Kitchen, bathroom, Wood burning stove)

• Very young and elderly are most likely at risk

• Major cause of fires in the home

• Carelessness with cigarettes!!
• Hot water from water heaters set at high levels above 140 degrees F (60 degrees C)
• cooking accidents
• Heaters
• combustibles - gasoline, lighter fluids, etc.
• chemicals

ETIOLOGY:

1. Thermal burns – Exposure to flames, hot liquids, semi liquids (steam), semisolids (tar),
hot objects.
2. Chemical burns-are the result of tissue injury and destruction from necrotizing substances
Chemical may be from household cleaning agents, chemicals used in industry, agriculture,
and military.
3. Electrical burns – Exposure to electrical source (duration of contact and voltage level)
A.C. – alternating current (residential); D.C. – direct current (industrial/lightening)
Electrical burns-results from coagulation necrosis that is caused by intense heat from an
electrical current
4. Radiation burns – Exposure to radioactive source.
5. Smoke & inhalation injury-inhaling hot air or noxious chemicals
6. Cold thermal injury-frostbite.

PATHOPHYSIOLOGY:

Burn injuries result in both local and systemic responses.

I. LOCAL RESPONSES:

Local response

• The three zones of a burn were described by Jackson in 1947.

• Zone of coagulation—This occurs at the point of maximum damage. In this zone there is
irreversible tissue loss due to coagulation of the constituent proteins.
• Zone of stasis—The surrounding zone of stasis is characterised by decreased tissue
perfusion. The tissue in this zone is potentially salvageable. The main aim of burns
resuscitation is to increase tissue perfusion here and prevent any damage becoming
irreversible. Additional insults—such as prolonged hypotension, infection, or oedema—
can convert this zone into an area of complete tissue loss.
• Zone of hyperaemia—In this outer most zone tissue perfusion is increased. The tissue here
will invariably recover unless there is severe sepsis or prolonged hypoperfusion.
• These three zones of a burn are three dimensional, and loss of tissue in the zone of stasis
will lead to the wound deepening as well as widening.

Fig:12.3 Pathophysiology of burns

 II. SYSTEMIC RESPONSES

Fig:12.4 CARDIAC SYSTEM

Vasoactive substance released catecholamine, histamine, prostaglandins

Capillary permiability HR

Plasma enters tissues

Intracellular & interstitial fluid intravascular fluid

Body edema

BLOOD

Destruction of cells

Anaemia, Thrombocytopenia and Fibrinogen

Fig:12.5. G.I SYSTEM

Sympathetic nervous system activity

Mesentric blood flow

Peristalsis

Fig:12.6. RENAL SYSTEM

GFR

Oliguria

Fig:12.7. IMMUNOLOGIC ACTIVITY

 Immunoglobulin

cellular immunity

Bacterial growth

wound sepsis

Fig:12.8. RESPIRATORY SYSTEM

O2 consumption

Hyperventilation

SYSTEMIC RESPONSE

• The release of cytokines and other inflammatory mediators at the site of injury has a
systemic effect once the burn reaches 30% of total body surface area.

In fig:12.4 Cardiovascular changes—Capillary permeability is increased, leading to loss

of intravascular proteins and fluids into the interstitial compartment. Peripheral
vasoconstriction occurs. Myocardial contractility is decreased, possibly due to release of
tumour necrosis factor α. These changes, coupled with fluid loss from the burn wound,
result in systemic hypotension and end organ hypoperfusion.

Fluid Shifts
Massive fluid shifts out of blood vessels as a result of increased capillary
permeability. When capillary walls become more permeable, water, sodium, and later plasma
protein (esp. albumin) moves into interstitial spaces & other tissues. The colloidal osmotic
pressure decreases with loss of protein from the vascular space. This is called second
spacing.

Third Spacing
A fluid goes into areas with no fluids and this is called third spacing. Examples of
third spacing are exudate and blister formation.Net result is decreased volume and due to
fluid shifts edema occurs, decreased blood pressure, and increased pulse
In fig:12.5.G.I system – There is decreased mesenteric blood flow due to Sympathetic
nervous system activity and as a result peristaltic movement is decreased
In fig:12.6. Renal system – Decreased glomerular filtration rate and oliguria occurs

In fig:12.7. Immunological changes—Non-specific down regulation of the immune

response occurs, affecting both cell mediated and humoral pathways.
 In fig:12.8. Respiratory changes—Inflammatory mediators cause bronchoconstriction,
and in severe burns adult respiratory distress syndrome can occur.

Metabolic changes—The basal metabolic rate increases up to three times its original rate.
This, coupled with hypoperfusion, necessitates early and aggressive enteral feeding to
decrease catabolism and maintain gut integrity.

CLASSIFICATION OF BURN SEVERITY:

I. Depends on:
• Depth of burn
• Extent of burn
• Location of injury
• Patient’s age
• Presence of associated injury or diseases

1. Depth of a Burn

Fig:12.10 Burn depth

A. First degree burn
• Involves only the epidermis
• Tissue will blanch with pressure
• Tissue is erythematous and often painful
• Involves minimal tissue damage
• Sunburn

B. Second degree burn

• Referred to as partial-thickness burns
• Involve the epidermis and portions of the dermis
• Often involve other structures such as sweat glands, hair follicles, etc.
• Blisters and very painful
• Edema and decreased blood flow in tissue can convert to a full-thickness burn

B. Third degree burn

• Referred to as full-thickness burns
• Charred skin or translucent white color
• Coagulated vessels visible
• Area insensate – patient still c/o pain from surrounding second degree burn area
• Complete destruction of tissue and structures

C. Fourth degree burn

• Involves subcutaneous tissue, tendons and bone

Burn extent
❖ The extent of a burn is expressed as the total percentage of body surface area (TBSA)
affected by the injury.

❖ Multiple methods have been developed to estimate the TBSA of burns.

Measurement charts
A. Rule of Nines:
❖ The best known method, the "rule of nines," is appropriate for use in all adults.
❖ Quick estimate of percent of burn.
❖ Most universal guide for initial estimate.
❖ Deviates in children due to larger head surface area. In the adult, most areas of the body
can be divided roughly into portions of 9%, or multiples of 9. This division, called the rule
of nines, is useful in estimating the percentage of body surface damage an individual has
sustained in burn.
❖ In small children, relatively more area is taken up by the head and less by the lower
extremities. Accordingly, the rule of nines is modified. In each case, the rule gives a useful
approximation of body surface.
 Fig:12.15 Rule of nine
B. Lund and Browder: The Lund and Browder method covers all age groups and is
considered the most accurate method to use in pediatric patients.

Fig: 12.16 Lund and Browder

C. Rule of Palms:
❖ Good for estimating small patches of burn wound
❖ The surface area of a patient’s palm can also be used to estimate the extent of small or
patchy burns.

❖ Classically, the palm has been considered to represent 1 percent of the TBSA.

❖ However, a recent study demonstrated that the palm more accurately represents 0.4
percent of the TBSA, and the entire hand represents 0.8 percent of the TBSA.
 3. Burn Location
Burns of
• Head , neck and chest leads to pulmonary complications
• Face leads to corneal abrasions
• Hands and joints requires occupational therapy
• Perineal area - Contamination by urine and faces

4. AGE
• Mortality rate high in
• Children < 4 yrs of age and
• > 65 yrs of age

5. Presence of associated injury or disease

• Cardiac disease
• Pulmonary
• Endocrine- Diabetes
• Renal disease – renal failure
• Alcoholism - Influence clients response to injury and treatment.

II. American burn association classifications of burn severity

1. Major burn injury - >25%
2.Moderate burn injury – 15 – 25%
3.Minor burn injury - < 15%

SIGNS AND SYMPTOMS:

A. INTEGUMENTARY SYSTEM

❖ Skin colour changes from light pink to black

❖ Edema or blister
❖ Pain except in full thickness burn
B. RESPIRATORY SYSTEM

❖ Dyspnea
❖ Hyperventilation
❖ Infection

C. G.I SYSTEM

❖ Gastric distension
❖ Nausea
❖ Vomiting
❖ Loss of appetite
❖ Bowel sounds

D. RENAL SYSTEM

❖ Oliguria
❖ Creatinine clearance in urine

E. CARDIOVASCULAR SYSTEM

❖ Hypotension
❖ Tachycardia
❖ Thirsty feeling , edema

F.HEMATOLOGIC SYSTEM

❖ Anaemia
❖ Thrombocytopenia
❖ Lymphocytopenia

G. Metabolic changes

❖ Burn fever (Temp 102’F to 103’F)

❖ Body wasting
❖ Weight loss.

INVESTIGATIONS:

Non- invasive method:

• History and physical findings
• Chest X Ray
• Plain Films / CT scan
• 12 Lead EKG

Invasive method:
Blood
• CBC
• Chemistry profile
• ABG with carboxyhemoglobin
• Coagulation profile

Urine Analysis
• CPK and urine myoglobin (with electrical injuries)

MANAGEMENT:

MEDICAL MANAGEMENT:

MEDICAL MANAGEMENT

Emergent phase Acute phase

(starting of injury till48- 72hrs) (>48 – 72 hrs)

A. Prehospital care B. Emergency Management

i) EMERGENT PHASE :

A. PRE HOSPITAL CARE

• Warm the Patient

• Keep patient covered
• Administer pain medication as per protocols
• Avoid IV access in burn unless necessary
B. EMERGENCY MANAGEMENT

I. Minor burns(<15%)

1. Pain management (Morphine)

2. Teatnus prophylaxis (T.T 5yrs once booster dose)
3. Initial wound care- Antimicrobial creams e.g silversulfadiazine, silvernitrate(10%),
cerium nitrate(1.74%)
4.Teach Range Of Motion exercise, follow up.

II. Major burns(>25%)

1.ABC
2. Fluid resuscitation
3.Urinary catheter, Nasogastric tube
4. Escharatomy
5.Vital signs , lab reports
6.Pain management
7. Teatnus prophylaxis
8. Data collection
9. Wound care

Fig:12.17. FLUID RESUSCITATION

First 24 hrs Second 24 hrs

Formula Electrolyte colloid Dextrose Electroly Colloid Dextrose

name containing in water te
solution

Evans NS 1ml/kg/%b 2000ml ½ of the first 24 hrs 2000ml

1ml/kg/%burn urn requirement

Brooke RL1ml/kg/%b 0.5ml/kg/ 2000ml ½- 3/4 of the first 24 2000ml

urn %burn hrs requirement
 Modified RL None None None 0.3 - Titrate
brooke 2ml/kg/%burn 0.5ml/kg/% to
burn maintain
urine
output

Parkland RL None None None 0.3 - Titrate

4ml/kg/%burn 0.5ml/kg/% to
burn maintain
urine
output

Hyperton Fluid None None Same None None

ic saline containing solution
solution 250meq of to
sodium/litre to maintain
maintain hourly
hourly urine urine
output of 70ml output of
in adults 30ml in
adult.

Resuscitation Fluid
• Related to:
– extent of burn (rule of nines)
– body size (pre-injury weight estimate)

• Delivered through large bore peripheral IV

– Attempt to avoid overlying burned skin
– Can use venous cut down or central line

Monitoring of Resuscitation
• Urinary output is a reliable guide to end organ perfusion
– Adults: 30-50 ml per hour
– Children (less than 30 Kg): 1 ml/Kg per hour
– Infusion rate should be increased or decreased by 1/3 if urine output falls or
exceeds limits by more than 1/3 for 2-3 hours
Performing an Escharotomy

• Escharotomies (incisions through eschar) done to restore circulation to compromised

extremities
• Bedside procedure
• Sterile technique (sharp division or electrocautery)
• Local anesthesia not required/
– Control anxiety
• Avoid major nerves & vessels
• Extend incision into subcutaneous fat
• Incision to be carried across involved joints
• 2nd incision on contralateral aspect of limb may be required

ii) ACUTE PHASE(>48 – 72hrs)

1. Infection control
2. Wound care
A. Cleansing (Hydrotherapy) formerly called hydropathy involves the use of water for
soothing pains and treating diseases.)
B. Wound debridement (mechanical- scissors, forceps and enzymatic – proteolytic,
fibrinolytic enzymes)
C. Wound Dressing (open-ointment and closed – gauze dressing)

✔ FIRST DEGREE- Superficial…. “sunburn”

❖ Clean the wound
❖ Apply Topical ointment
• Bacitracin
• Vaseline gauze
• Xeroform
❖ Keep the wound moist
✔ SECOND DEGREE- Partial Thickness – Superficial
 • Debridement
• Dressing: silversulfadiazine/ Mafenide

✔ THIRD DEGREE- Full Thickness

• Excise early: 24-48 hours
• Graft
3. Nutrition :
(Bowel sounds+)K. cal/day=(25 k.cal x body wt in kg) + (40k.cal x %TBSA)
4. Pain management
5. Physical therapy
A. Therapeutic positioning
B. Control of scarring (antiscar support garment)
C. Exercise
D. Splinting.

SURGICAL MANAGEMENT
1.Tangential excision (special blade thin layer of skin removed)
2. Fasical excision (till subcutaneous tissue and fascia)
3. Wound coverings
❖ Biological split thickness graft – meshed graft
❖ Sheet graft (no slits) used for Face
❖ Biosynthetic (biobrane)
❖ Artificial (collagen with thin silastic sheet)

Surgeons use a dermatome (left) to remove donor skin and a mesher (right) to put holes in
it.

NURSING MANAGEMENT:

S.no Nursing Goal Nursing Interventions

diagnosis
1. Fluid volume Restore • Start 1 or 2 large bore IV replacement lines (may need
jugular or subclavian)
deficit related to fluid
fluid shift volume • Cutdown is rare due to increased risk of infection & sepsis
• Fluid replacement is based on: size/depth of burn, age of
pt., & individualized considerations--example.
Dehydration in preburn state, chronic illness
• Options- RL, D5NS, dextam, albumin, etc.
• There are formula’s for replacement: Parkland formula and
Brooke formula

2 Altered Promote ● Remove jewelry and clothing.

peripheral tissue peripheral ● Elevate extremities.
perfusion related circulation
● Escharatomy if circulation is impaired
to edema

3 Pain related to Reduce • Analgesics.

burn wound and pain • Teach relaxation exercise like breathing exercise, etc.
skin tightness
• Change positions with support of pillows

4 Altered Ensure ● Weigh the patient.

nutrition nutritional ● Dietician consultation.
lessthan body intake will
● Administer vitamin and mineral supplements
requirement meet 10% TBSA – protein
10- 20% TBSA – High protein and calorie
related to metabolic
20 – 30% TBSA – Enteral nutrition
hypermetabolic needs 30 – 40% TBSA – parenteral nutrition
response to burn ● Burn patients need more calories & failure to provide will
injury. lead to delayed wound healing and malnutrition.
● Give calorie containing liquids instead of water due to need
for calories and potential for water intoxication.
● Enteral feedings into the duodenum is recommended, it can
reduce nausea & vomiting, and increase wound healing!

5 Impaired Promote ● Initiate passive and active range of motion exercise.

physical ROM and
 mobility related ability to ● Inform Physical / Occupational therapist
Maintain splints.
to edema, pain perform
ADL ● Avoid flexion of burned joints

6 Ineffective Enhance ● Provide opportunities for patient to express thoughts,

feelings, fears and anxieties regarding injury.
individual effective
coping related to coping ● Encourage family members and friend’s communications

fear and anxiety strategies ● Administer anti anxiety medications.

7 Body image Preserve ● Collect preburn self image and life style.
disturbance positive ● Be honest but positive in responding to Patient and family
related to body
● Arrange for patient to see burned area (mirror)
cosmetic and image
● Arrange to talk with other patient who had similar injury.
functional
sequelae of burn
wound

8 Impaired skin Protect Cleansing and Debridement

and
integrity related • Can be done in tank, shower, or bed
reestablish
to burn injury skin
• Debridement may be done in surgery. (Loose necrotic
integrity
skin is removed)
• Bath given with surgical detergent, disinfectant, or
cleansing agent to reduce pathogenic organisms
• Coverage is the primary goal for burn wounds. Since
usually there may not be enough unburned skin for
immediate skin grafting, other temporary wound closure
methods are used
• Allograph or homograft (same species which is usually
from cadavers) is used for wound closure-- temporary--3
days to 2 wks
• Porcine skin-heterograft or xenograft (different species)--
temporary--3 days to 2 wks
 • Autograft or cultured epithelial autograft- (patient’s own
skin and cell culture)- permanent

9 Risk for Prevent • Source of infection is patient’s own flora, predominantly

Infection related infection from the skin, respiratory tract, and GI tract.
to loss of skin
barrier and • Prevention of cross contamination from other patients is
altered immnune the priority for nurses!
response
• 2 methods used to control infections in burn wounds...
• Open method- patient’s burn is covered with a topical
antibiotic and has no dressing
• Closed method-uses sterile gauze impregnated with
topical antibiotic. Dressings changed 2-3 times q 24 hrs.
• Staff should wear disposable cap, gowns, gloves, masks
when wounds are exposed
• Follow appropriate use of sterile techniques like keeping
room warm, careful hand washing and bathing areas
disinfected before and after bathing

10 Ineffective Improve ● Provide semi fowlers position

breathing pattern breathing
related to chest pattern ● Ensure chest dressings is not constricting
burn, upper
● Escharotomy can be done
airway
obstruction ● Encourege deep breathing and incentive spirometry exercise.

PREVENTION:

● Keep matches, lighters, chemicals, and lit candles out of kids' reach.

● Put child-safety covers on all electrical outlets.

● Get rid of equipment and appliances with old or frayed cords and extension cords that
look damaged.

● Make sure older kids and teens are especially careful when using irons, flat irons, or
curling irons.

● Don't smoke inside the house

 ● Don't use fireworks or sparklers.

Bathroom

❖ Set the thermostat on your hot water heater to 120°F (49°C), or use the "low-medium
setting." A child can be scalded in 5 seconds in water if the temperature is 140°F (60°C).

❖ Always test bath water with your elbow before putting your child in it.

❖ Always turn the cold water on first and turn it off last when running water in the bathtub
or sink.

COMPLICATIONS:

• Immediate
1.Hypovolemic shock
2. Infection
3.Paralytic ileus
4. Stress ulcers / curling’s ulcer
5. Pulmonary edema
6. Pneumonia

• Late

1.Renal failure
2. Contractures
3. Septicaemia

REHABILITATION PHASE:
• It begins when the patient’s burn wound is covered with skin or healed and patient is
capable of assuming some self-care activity.
• Can occur as early as 2 weeks to as long as 2-3 months after the burn injury
• Goal is to assist patient in resuming functional role in society & accomplish functional and
cosmetic reconstruction.

Nursing management during rehabilitation phase

• Must be directed to returning patient to society, address emotional concerns, spiritual and
cultural needs, self-esteem, teaching of wound care management, nutrition, role of
 exercises and physical therapy explained. A common emotional response seen is
regression.

Special needs of the nursing staff

• The staff of burn units is prone to higher rates of burn-out. The care of a burn patient is a
long journey that the patient, nurse, and significant others must travel. The road to recovery
is full of potential threats to the patient. Support services are necessary for the medical team
of any long-term burn patients.

C. RECONSTRUCTIVE SURGERY
DEFINITION: Reconstructive surgery is corrective surgery to repair the body due to birth
defects, disease or trauma.
PURPOSE:

● Returning function to the body,

● Can be used to improve the appearance of a person.
● Examples: Repairing scar tissue from burns or other trauma,Repairing a cleft palate or
lip

RESTORATION PROCESS:
The reconstructive burn surgery restoration process is comprised of three elements: recovery,
reconstruction, and rehabilitation, with each process being distinct and unique.

❖ Recovery means to return to original form. Typically, we recover from physical injuries,
but this term may also indicate emotional recovery. Many burn victims also struggle with
recovery from posttraumatic stress syndrome.

❖ Reconstruction means to rebuild, but not necessarily to the exact previous form, as
reconstruction has its inherent limitations. Reconstruction can return both form and
function, and provides hope to the healing burn patient. With burn wounds, some tissues
heal, some tissue is lost or replaced, and some tissue is irreparably damaged and endured.

❖ Restoration literally means to make whole again, which is to become a whole person
again, not just physically but spiritually and emotionally.

1. The timing of reconstructive burn surgery, therefore, varies from patient to

patient, depending upon need and stage of healing.

2. In reality, reconstructive burn surgery has already begun during treatment and
surgery for the initial burn injury.

3. All burn surgeons operate with the foresight of an attainable goal in the final post-
burn form.
4. Early reconstructive burn surgery implies surgery while the scars are still very
immature, which is generally believed to be within the first six months following
the burn injury.

5. In the majority of cases, early reconstruction assists the process of recovery.

6. Late reconstructive burn surgery occurs more than six months post-burn, or when
the scars are believed to be mature.

7. Late reconstruction may lead to fewer surgeries and more successful

reconstructive efforts.

8. With time, some difficulties may have already been acceptably rehabilitated,
making surgical correction unnecessary.

9. A patient who wants all burn scars removed and if expectations are not realistic,
any reconstructive effort is doomed to fail.

10. Physical problems can occur, such as infections, blood clots, or wound
breakdown.

11. The reconstructive burn surgery does not end until the patient has recovered.

12. The reconstructive burn surgery process affects more than the physical form, also
affecting the psychological side of a person.

13. Many believe that the mental and emotional damage is greater than the physical
scarring in most severely injured burn victims.

14. Recovery from the intangible effects of the burn is the key to restoration following
burn injury.

15. Reconstructive burn surgery, both physically and mentally, helps with healing of
the tangible and intangible effects in burned people.

16. The reconstructive process assists the recovery process and the rehabilitation of a
burn victim.

17. The greatest quality of reconstructive burn surgery is assisting in the restoration
of burned people through positive reinforcement, care, and hope.