Burn Training

Assessment & Management

Dr. D. N. Bid

Contents

▪ Anatomy of Integumentary System Review

▪ Determining Severity of Burn

▪ Assessment

▪ Management

▪ Transfer to Burn Center

Anatomy of the Integumentary System (Skin)

• Skin covers ~ 1.5-2.0 square meters in the average adult

▪ Largest organ of the body

▪ Two principal layers

-Epidermis

-Dermis

Subcutaneous Tissue

• Contains major vesicular networks, fat, nerves,

and lymphatics

• Acts as a shock absorber and heat insulator for underlying structures of muscles, tendons, bones, and internal organs

Anatomy of the Skin

Function of the Skin• Protection

– Against external forces– Against infection

• Sensation– Nerves report touch & status in environment

• Temperature control- Blood vessel dilation/constriction- Sweat evaporates

Burn wounds occur when there is contact between tissue and an energy source such as

- heat (thermal) - chemicals

- electrical current - radiation

Extent of burns are influenced by

- intensity of the energy

- duration of exposure

- type of tissue injured

Zones of Burn Injury

• 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 is characterized 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 edema—can convert this zone into an area of complete tissue loss.

• Zone of hyperemia -In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.

Zones of Burn Injury

Zones of Burn InjuryClinical image of burn zones. There is central necrosis,

surrounded by the zones of stasis and of hyperemia

Depth of Burns• Superficial

(first-degree) burns

• Involve only top skin layer

Superficial - First degree burns

• Epidermis only damaged

• Painful to touch

• Area initially erythematous due to vasodilatation

• Epidermis sloughed off in 7 days with complete scarless healing

Depth of Burns• Partial-thickness

(second-degree) burns

• Involve epidermis and some portion of dermis

• Can be either

superficial or deep

Partial thickness – Superficial Second degree burns

• Epidermis & various degrees of dermis destroyed

• Are pink to cherry red and wet

• May or may not have intact blisters and are very painful when touched or exposed to air

• Heal in 7-14 days with topical antimicrobials or wound dressings

Partial thickness – Superficial Second degree burns

Partial thickness – Deep Second degree burns

• Epidermis & deeper degrees of dermis destroyed

• Are pink to cherry red, wet, shiny with serous exudate

• Very painful when touched or exposed to air

• Heal in 14- 28 days with scarring

• May need early excision and grafting

Partial Thickness-Deep Second degree burns

Depth of Burns

• Full-thickness (third-degree) burns

• Extend through all layers of skin

Need better phtls

• Will appear as thick, dry, leathery, waxy white to dark brown regardless of race or skin color

• May have a charred appearance with visible thrombosis of blood vessels

• Will have little to no sensation because nerve endings have been destroyed except in surrounding tissues with partial thickness burns

Full-thickness – Third degree burns

Full Thickness-Third degree burns

Depth of Burns

• Fourth-degree burns

• Extend through all layers of skin as well as extending to underlying fat, muscle, bone or internal organs

Need better phtls Fig 13-7

Burn Size Estimation

• Critical to providing adequate resuscitation

• 3 common guidelines used – Rule of Nines – Lund-Browder Chart– Palmer Method

Rule of Nines

• In the adult, most areas of the body can be divided roughly into portions of 9% or multiples of 9.

• In the child, similar portions are assigned

• This division is useful in estimating the percentage of body surface damage an individual has sustained in burn.

Rule of Nines

Lund-Browder Chart

Palmer Method

• The palmer surface of the patient’s hand –from crease at wrist to tip of extended fingers- equals ~ 1% of the patient’s total body surface area

Severity of Burn Injury

• Treatment of burns is directly related to the severity of injury

• Severity is determined by– depth of burn– external of burn calculated in percent of total

body surface (TBSA)– location of burn– patient risk factors

Minor Burns

• Full-thickness burns involving less than 2% of the total body surface area

• Partial-thickness burns covering less than 15% of the total body surface area

• Superficial burns covering less than 50% of the total body surface area

Moderate Burns

• Full-thickness burns involving 2% to 10% of total body surface area excluding hands, feet, face, upper airway, or genitalia

• Partial-thickness burns covering 15% to 30% of total body surface area

• Superficial burns covering more than 50% of total body surface area

Critical Burns (1 of 2)

• Full-thickness burns involving hands, feet, face, upper airway, genitalia, or circumferential burns of other areas

• Full-thickness burns covering more than 10% of total body surface area

• Partial-thickness burns covering more than 30% of total body surface area

• Burns associated with respiratory injury

Critical Burns (2 of 2)

• Burns complicated by fractures

• Burns on patients younger than 5 years old or older than 55 years old that would be classified as moderate on young adults

Pediatric Needs

• Burns to children are considered more serious than burns to adults.

• Children have more surface area relative to body mass than adults.

Minor Burns in Infants and Children

• Partial-thickness burns covering less than 10% of total body surface area

Moderate Burns in Infantsand Children

• Partial-thickness burns covering 10% to 20% of total body surface area

Critical Burns in Infantsand Children

• Full-thickness burns covering more than 20% of total body surface area

• Burns involving hands, feet, face, upper airway, genitalia

Location of Burns

• Has a direct relationship to the severity of the burn.

• Face, neck & chest burns may inhibit respiratory illness RT mechanical obstruction secondary to edema or eschar formation

Patient Risk Factors

• Older adults heals slower & has more difficulty with rehab

• common complications are:– infection & pneumonia– preexisting illnesses: cardiovascular,

pulmonary, or renal disease– DM or PVD is at increased risk for gangrene &

poor healing

Types of Burn Injury• Thermal Burn-can be caused by flame, flash, scald,

or contact with hot objects

• Chemical Burn-are the result of tissue injury and destruction from necrotizing substances

• Electrical Burn-results from coagulation necrosis that is caused by intense heat from an electrical current

• Smoke & inhalation injury-inhaling hot air or noxious chemicals

• Radiation Burn/Exposure- burns are usually localized & are indicative of high radiation doses to affected area

Thermal Burns

• most common type

• result from residential fires, automobile accidents, playing with matches, improperly stored gasoline, space heaters, electrical malfunctions, arson, terrorism

• inhaling smoke, steam, dry heat (fire), wet heat (steam), radiation, sun, etc...

Thermal Burns• Thermal burns cause a number of effects

described in the ‘Zones of injury”

Chemical Burn

2 types of chemical burns

• acids-can be neutralized

• alkaline- adheres to tissue, causing protein hydrolyses and liquefaction

– examples: industrial or agricultural sites, highways and battlefields > cleaning agents, drain cleaners, lyes, and military grade agents, etc.

Chemical Burn

• With chemical burns, tissue destruction may continue for up to 72 hours afterwards.

• It is important to remove the person from the burning agent or vice versa.

• Chemicals, heat, and light rays can burn the eye.

Electrical Burns

• Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current.

• Can cause tissue anoxia and death

• The severity depends on amount of voltage, tissue resistance, current pathways, and surface area in contact with the current and length of time the current flow was sustained.

External signs of an electrical burn may be deceiving.Entrance may be small, while deeper tissue damage may

be massive.

Electrical injury can cause:

• Fractures of long bones and vertebra

• Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury

• Severe metabolic acidosis--can develop in minutes

• Myoglobinuria--acute renal tubular necrosis- myoglobin released from muscle tissue whenever massive muscle damage occurs--goes to kidneys--and can mechanically block the renal tubules due to the large size!

Electricity can instantaneously destroy tissue. This child has a burn that resulted from biting on an electrical cord. These burns often occur at the

corners of the mouth, as seen here.

Smoke and Inhalation Injury

• Can damage the tissues of the respiratory tract

• Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.

3 Phases of Burn Management

–Emergent (resuscitation)• 0 – 48 hours, can be up to days later

–Acute (definitive care) ▪ day 3 until wounds heal

–Rehabilitation• Begins during resuscitation and continues

throughout lifespan

Emergent Phase (Resuscitative Phase)

• Lasts from onset to 5 or more days but usually lasts 24-48 hours

• Begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins

• Greatest initial threat is hypovolemic shock to a major burn patient

Emergent Phase – Initial Management/Care

• MAKE SURE YOU ARE SAFE !!!

• Remove patient from area! Stop the burn!

• Airway-check for patency, soot around nares, or signed nasal hair. 100% O2 via NRM @ 15L. Watch for early upper airway edema >intubate is in doubt.

• Breathing- check for adequacy of ventilation, consider need for early intubation or early escharotomy if ventilation is impaired

Emergent Phase –Initial Management/Care• Circulation-check for presence and regularity

of pulses, consider early escharotomy if circulation to a limb is impaired

• Disability- AVPU, altered mental status in burn patient is not normal >think carbon monoxide poisoning. Check pupils. Check for movement in all extremities.

• Expose- Remove clothing and jewelry. Do not pull on clothing stuck to skin > Cut away clothing or soak it off. Cover with dry sterile sheet and tuck in sides.

Emergent Phase –Initial Management/Care• Fluid Resuscitation- estimate TBSA burn

percentage and weight then calculate fluids for first 24 hour period using Parkland formula

• Foley catheter- to monitor urine output

• Secondary survey starting with a good scene and patient history then head to toe exam

• Pain Management- early and often based on patient’s hemodynamic status and pain scale

• Psychosocial issues- consider need for religious intervention, legal consult for family affairs, etc for patients with life-threatening burns

Secondary Survey History• Flame• How did the burn occur?

Did the burn occur outside or inside?Did the clothes catch on fire?How long did it take to extinguish the flames?How were the flames extinguished?Was gasoline or another fuel involved?Was there an explosion?Was there a building/house fire?Was the patient found in a smoke-filled room?How did the patient escape?If the patient jumped out a window, from what floor?Were others killed at the scene?Was there a motor vehicle crash?How badly was the vehicle damaged?Was there a motor vehicle fire?Are there other injuries?Are the purported circumstances of the injury consistent with the burn characteristics?

Secondary Survey History

• Chemical

• What was the agent?How did the exposure occur?What was the duration of contact?What decontamination occurred?Was there an explosion?

Secondary Survey History

• Electrical

• What kind of electricity was involved?What was the duration of contact?Did the patient fall?What was the estimated voltage?Was there loss of consciousness?Was cardiopulmonary resuscitation administered at the scene?

Specific burn –Treatment notes

Care for Thermal Burn

– For <10% TBSA burn-apply moist cool sterile dressings to small burn

– For larger-cover area with dry sterile dressings or sheet

Specific burn –Treatment notes Care for Chemical Burn (1 of 2)

• Remove the chemical from the patient.

• If it is a powder chemical, brush off first.

• Remove all contaminated clothing.

Care for Chemical Burn (2 of 2)

• Flush burned area with large amounts of water for 30 minutes or more.

• Transport quickly.

Chemical Burn- Eyes• Occur whenever a

toxic substance contacts the body

• Eyes are particularly vulnerable.

• Fumes can cause burns.

• To prevent exposure, wear appropriate gloves and eye protection.

Chemical Burn- Eyes

• For chemicals, flush eye with saline solution or clean water.

• You may have to force eye open to get enough irrigation to eye.

• With an alkali or strong acid burn, irrigate eye for about 20 minutes.

• Bandage eye with dry dressing.

Irrigating the Eye

Specific burn –Treatment notes Care for Electrical Burn

• Cardiac Monitor

• Fluids -Ringers Lactate or other fluids to flush kidneys if myoglobinuria is present

• Assess for bone fractures and treat appropriately if found

Complications during emergent phase of burn injury may occur

in 3 major organ systems

–Cardiovascular

–Respiratory

–Renal

Cardiovascular System

• Arrhythmias, hypovolemic shock which may lead to irreversible shock

• Circulation to limbs can be impaired by circumferential burns and then the edema formation

• Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene

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

Respiratory System

• Vulnerable to 2 types of injury– 1. Upper airway burns that cause edema formation &

obstruction of the airway– 2. Inhalation injury can show up 24 hrs later-watch

for respiratory distress such as increased agitation or change in rate or character of respirations

– preexisting problem (ex. COPD) more prone to get respiratory infection

• Pneumonia is common complication of major burns

• Is possible to overload with fluids--leading to pulmonary edema

Renal System

• Most common renal complication of burns in the emergent phase is Acute Tubular Necrosis (ATN) (muscle destruction > myoglobulin release > protein leak clogs kidney cells >ischemia) Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.

Patient management in the Emergent Phase

• Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn)

• Ventilator - ABGs - Escharotomies

• Bronchoscopy to assess lower respiratory tract

6-12 hours later

• High Fowler’s position-cough & deep breathe every hour, turn q 1-2 hrs, chest physiotherapy, suction prn

Fluid Shifts

• Massive fluid shifts out of blood vessels as a result of increased capillary permeability.

Third Spacing

• Net result is decreased volume, depletion due to fluid shifts = edema, decreased blood pressure, and increased pulse

Hypovolemic Shock

• Occurs when there is a loss of intravascular fluid volume. The volume is inadequate to fill vascular space and is unavailable for circulation

• Burns have a direct loss of fluid due to evaporation

Fluid Therapy• 1 or 2 large bore IV replacement lines (may need

jugular or subclavian)

• Cutdowns are rare due to increased risk of infection & sepsis

• Fluid replacement based on: size/depth of burn, age of pt., & individualized considerations--ex. Dehydration in preburn state, chronic illness

• Options- RL, D5NS, dextam, albumin, etc.

• Parkland formula to determine adequate amount to give

Parkland Formula

Lactated Ringers solution is recommended 4ml/kg/%TBSA burn = ml’s in first 24 hours– ½ of this total given in the first 8 hours post injury – remaining ½ given in the next 16 hours.

– Titrate to maintain urinary output as well.

Assessment of adequacy of fluid replacement

• Urinary output is most commonly used parameter– Adequate urine output is 30 ml/hr in adults and

1 ml/kg/hr in a child less than 30 kg

– Cardiopulmonary factors- BP (systolic 90-100 mmHg), pulse less than 100, resp 16-20 breaths per min. (BP more accurate with arterial line)

• Sensoruim-alert, oriented to time, place, & person

Inflammation & Healing

• Burn injuries cause coagulation necrosis whereby tissues and vessels are damaged or destroyed

• Wound repair begins within the first 6-12 hours after injury.

Immunologic Changes

• Are caused by burns

• Skin barrier destroyed and all changes make the burn patient more susceptible to infection

• Patient may be in shock from pain and hypovolemia

Considerations (1 of 2)

• Full-thickness burns and deep partial thickness burns are initially anesthetic because nerve endings are destroyed

• Superficial to moderate partial thickness burns are very painful

Considerations (2 of 2)

• Severe dehydration is possible even though the patient may be edematous

• May have an dynamic ileus due to body’s response to massive trauma and potassium shifts

• Shivering due to chilling caused by heat loss, anxiety, and pain

• Patient unable to recall events due to hypoxia associated with smoke inhalation, or head trauma or overdose of sedatives or pain meds

Wound Care for Burns

• Can wait until patent airway, adequate circulation, fluid replacement is assured

Cleansing and Debridement

• Can be done in tank, shower, or bed

• Debridement may be done in surgery (Loose necrotic skin is removed)

• Bath given with surgical detergent, disinfectant, or cleansing agent to reduce pathogenic organisms

Infection is the most serious threat to further tissue injury

and possible sepsis

• SURVIVAL is related to prevention of wound contamination– Source of infection is pt’s own flora,

predominantly from the skin, resp. tract, and GI tract

– Prevention of cross contamination from other patients is the priority for patient care staff

Wound Management Methods

• Open method- pt’s burn is covered with a topical antibiotic and has no dressing

• Closed method-uses sterile gauze impregnated with or laid over a topical antibiotic. Dressings changed 2-3 times q 24 hrs.

Wound Care

• Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed

• Appropriate use of aseptic- sterile vs. nonsterile techniques

• Keep room warm• Careful handwashing• Disinfect patient bathing areas before and after

bathing

• Coverage is the primary goal for burn wounds. There is usually not 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- (pt’s own skin and cell culture)- permanent

Surgeons use a dermatome (left) to remove donor skin and a mesher (right) to put

holes in it.

• Surgeons agree that no single product or technique is right for every burn situation.

• There is no true replacement for healthy, intact skin, which is the body's largest organ, and one of the most complex

Example of healing burn

Other care measures

• Face is vascular and subject to increased edema- use open method if possible to decrease confusion and disorientation

• Eye care-use saline rinses, artificial tears

• Hands &arms-extended and elevated on pillows or in slings to minimize edema, may need splints to keep them in functional positions

• Ears- keep free of pressure –use no pillows Neck burns should not use pillows in order to decrease wound contraction

• Perineum- must be kept clean & dry Indwelling Foley will help in this & provide hourly outputs

• Lab tests– Baseline studies: hematocrit, electrolytes, blood

urea nitrogen, urinalysis, chest x-ray– Special studies as needed: arterial blood gas,

carboxyhemoglobin, ECG, glucose

• Physical therapy started immediately

Drug Therapy

• Analgesics and Sedatives

• given for patient comfort

• IV pain medications initially due to– GI function is slowed or impaired because of

shock or paralytic ileus– IM injections will not be absorbed well

Drug Therapy

• Tetanus immunization- given routinely to all burn patients because of the likelihood of anaerobic burn-wound contamination

• Antimicrobial agents-usually topical due to little or no blood supply to the burn eschar so little delivery of the antibiotic to wound

• Drug of choice is: Silver sulfadiazine

Nutritional Therapy

• Fluid replacement takes priority over nutritional needs in the initial emergent phase

• NG tube is inserted and connected to low intermittent suction for decompression

• When bowel sounds return (48-72 hrs) after injury, start with clear liquids and progress up to a diet high in proteins and calories

• Burn patients need more calories & failure to provide will 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 (recommended) can: reduce nausea /vomiting, provide more continuous feedings, and increase wound healing

Nutritional Therapy

Calorie Intake Formula

(25 x wgt in kg) + (40 x TBSA burn)

Example for 50 kg patient with 50% TBSA burn:

(25 x 50) + (40 x 50) = 1250 + 2000 = 3250 Kcals

Acute Phase

• Begins with mobilization of extracellular fluid and subsequent diuresis

• Is concluded when the burned area is completely covered or when wounds are healed. May take weeks or months

• Patient is no longer grossly edematous due to fluid mobilization, full & partial thickness burns more evident, bowel sounds return, pt more aware of pain and condition

• Healing begins when WBCs have surrounded the burn and phagocytosis begins, necrotic tissue begins to slough, fibroblasts lay down matrices of collagen precursors to form granulation tissue

• Partial-thickness burns (if kept free from infections) will heal from edges and from below. (10-14 days)

• Full-thickness burns must be covered by skin grafts

Laboratory Values• Sodium- Hyponatremia can occur due to: silver

nitrate topical oints as a result of sodium loss through eshcar, hydrotherapy, excessive GI drainage, diarrhea, excessive water intake– S/S of hyponatremia: weakness, dizziness, muscle

cramps, fatigue, HA, tachycardia, & confusion

• Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, inappropriate fluid administration– S/S of hypernatremia: thirst; dried furry tongue;

lethargy; confusion; and possible seizures

• Potassium- hyperkalemia is note if pt is in renal failure, adrenocortical insufficiency, or massive deep muscle injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness & EKG changes are noted.– Hypokalemia is noted with silver nitrate therapy

and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplementation. Constant K+ losses occur through the burn wound.

Rehabilitation Phase• Defined as beginning 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 throughout the patient’s lifespan

• Goals for this time is to assist patient in resuming functional role in society & accomplish functional and cosmetic reconstruction

Clinical Manifestations

• Burn wound either heals by primary intention or by grafting

• Scars & Contractures may form

• Mature healing is reached in 6 months to 2 years

• Avoid direct sunlight for 1 year on burn

• New skin sensitive to trauma

Complications

• Most common complications of burn injury are skin and joint contractures and hypertrophic scarring

• Because of pain, patients will assume flexed position. It predisposes wounds to contracture formation

• Use of physical therapy, pressure garments, splints, etc. are used to prevent/treat these

Example of Contracture

Example of a pressure garment

Transfer to Burn Center• Minimal Criteria for Transfer to a Burn Center• Partial thickness burns > 10% Total Body Surface

Area (TBSA)• Third degree burns in any age group• Electrical burns, including lightning injury• Chemical burns• Inhalation burns• Burn injury in a patient with pre-existing medical

disorders that could complicate management, prolong recovery, or affect mortality

• Any patient with burns and concomitant trauma (such as fractures). If trauma poses more of a mortality risk, then consider stabilization at a trauma center prior to transfer to a burn center

Transfer to Burn Center

• Secondary Criteria for Transfer to a Burn Center • Burns involving face, hands, feet, genitalia,

perineum, or major joints

• Burn injury in patients who will need special social, emotional, and/or long-term rehab intervention

Transfer to Burn Center• Preparation for Transfer• Primary and secondary assessments complete• Initial treatments for respiratory, circulatory, GI, burn

wounds, pain management accomplished• Documentation complete and copied: to include Hx,

PE, lab results, flowsheet with fluid resuscitation, pain management, all medications, nutritional therapies recorded

• Contact with verbal report given to receiving Burn Center, both physician-to-physician and nurse-to-nurse; as well as nurse-to-transporting agency EMT/PM/RN