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Flashcards in Week 10: Burn Patient Management Deck (87):

Burn injury prevention

  • Pre-emptive counseling of families essential
  • Decreasewater heater temperature from 54oC to 49oC (130-->120oF) increases time for full thick-ness scald from <30 seconds to 10 minutes
  • Cigarette misuse responsible for >30% of house fires
  • Smoke detector installation/maintenance


Burn risks related to age

  • infancy: bathing related scalds; child abuse
  • toddlers: hot liquid spills
  • school age children: flame injury from matches
  • teenagers: volatile agents, electricity, cigarettes
  • introduction of flame retardant pajamas


Causes of Burns

  • Thermal burns are caused by steam, fire, hot objects or hot liquids.
  • Most common burns for children and the elderly
  • Electrical burns are the result of direct contact with electricity or lightning
  • Chemical burns occur when the skin comes in contact with household or industrial chemicals
  • Radiation burns are caused by over-exposure to the sun, tanning booths, sun lamps, X-rays or radiation from cancer treatments
  • Friction burns occur when skin rubs against a hard surface, e.g. carpet, gym floor, concrete or a treadmill


Thermal Burns

**The most common burns**
*Exposure to heat
-Friction (contact with hot objects)
-Scaling: Steam, liquids


Pathophysiology of Electrical Burns

  • Small cutaneous lesions may overlie extensive areas of damaged muscle → myoglobin-->ARF.
  • Monitor for at least 48 hours after injury for cardiopulmonary arrest
  • May see vertebral compression fractures from tetanic contractions or other fractures from a fall.
  • Visceral injury is rare but liver necrosis, GI perforation, focal pancreatic necrosis and gallbladder necrosis have been reported.
  • Look for motor and sensory deficits—motor nerves are affected more than sensory nerves.
  • Thrombosis of nutrient vessels of the nerve trunks or spinal cord can cause late onset deficits.  Early deficits are direct neuronal injury.
  • Delayed hemorrhage can occur from affected vessels
  • Cataracts may form up to 3 or more years after electrical injury
  • Microwave radiation damages tissues via a heating effect.  Subcutaneous fatty tissue is often spared given its lower water content.


Effect of Electricity

  • Effects of current depend on several factors
  • Type of circuit
  • Voltage
  • Resistance of  body
  • Amperage
  • Pathway of  current
  • Duration of contact
  • High voltage (>1000V) causes underlying tissue damage. 
  • Deep tissues act as insulators and continue to be injured.
  •          • Damage more related to cross-sectional area which explains extremity injuries without trunk injuries.


Electrical Storms/Lightning

  • Burns are characteristically  superficial and present as a spidery or arborescent pattern.
  • Cardiopulmonary arrest is common following lightning injury.
  • Coma and neurologic defects are also common but usually clear in a few hours or days.
  • Watch for tympanic membrane rupture
  • Usually lethal in 1/3 of patients.
  • World record for surviving lightning strikes is Roy C. Sullivan who was a park ranger from VA.  Roy was struck 7 times from 1942-1977.





Effect of Chemicals Acids

  • coagulation necrosis: denaturing proteins upon tissue contact
  • area of coagulation is formed and limits extension of injury
  • exception is hydrofluoric acid, which produces a liquefaction necrosis similar to alkalis.
  • Acid damaged skin can look tanned and smooth; do not mistake for a suntan.


effects of chemicals alkalis

  • liquefaction necrosis
  • potentially more dangerous than acid burns: liquefy tissue by denaturation of proteins and saponification of fats
  • In contrast to acids, whose tissue penetration is limited by the formation of a coagulum, alkalis can continue to penetrate very deeply into tissue
  • Can cause severe precipitous airway edema or obstruction.




Grading of Burn Wounds

  • Mild: < 5% TBSA
  • Moderate: 5-15% TBSA
  • Severe: > 15% (95% of burns seen)
  • May require Burn Unit care because of potential for disability despite small TBSA (face, hands, feet, perineum)


Rule of 9's for calculating percentage of body burned

  • Child: 18% for head, front/back torso, head, 9% each arm, 14% each leg, subtract 1% each year over the age of 1, add 1/2% each year for each year over 1
  • Adult: Front/back torso, each leg: 18%, head, each arms:9%, 1% for perineum
  • Looks at body percentage


patient’s own palm is about 

1% of his body surface area.



first degree burns

  • burns are limited to the epidermis.
  • A typical sunburn is a first-degree burn.
  • Painful, but self-limiting.
  • First-degree burns do not lead to scarring and require only local wound care. 


second degree buns

  • point of injury extends into the dermis, with some residual dermis remaining viable
  • Partial thickness or Full thickness
  • those requiring surgery vs those which do not 


third degree burns

  • full-thickness burns involve destruction of the entire dermis, leaving only subcutaneous tissue exposed. 


fourth degree burn

  • burn is usually associated with lethal injury.
  • Extend beyond the subcutaneous tissue, involving the muscle, fascia, and bone.
  • Occasionally termed transmural burns, these injuries often are associated with complete transection of an extremity


Burn Zones

  • Circumferential zones radiating from primarily burned tissues, as follows:
  1. Zone of coagulation - A nonviable area of tissue at the epicenter of the burn
  2. Zone of ischemia or stasis - Surrounding tissues (both deep and peripheral) to the coagulated areas, which are not devitalized initially but, 2° microvascular insult, can progress irreversibly to necrosis over several days if not resuscitated properly
  3. Zone of hyperemia - Peripheral tissues that undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable




Pathophysiology of Burns

  • Cell damage and death causes vasoactive mediator release:
  • Histamines
  • Thromboxanes: help with platelet formation
  • Cytokines
  • Increasing capillary permeability causes edema, third spacing and dehydration
  • Possible obstruction to circulation (compartment syndrome) and/or airway




Burn Edema and Inflammation

  • Generalized edema found in burns > 30% TBSA
  • Heat directly damages vessels and causes increases permeability
  • Heat activates complement --> histamine release and more permeability --> thrombosis and coagulation systems


Systemic Response to Burn Injury

  • Accelerated fluid loss 2° leaky capillaries
  • Decreases Host resistance to infection
  • Multisystem Organ Failure
  • Infections in burns <20% TBSA are well tolerated.
  • > 40% TBSA with infection has very low survival rate
  • Initially decreases CO, subsequent hypermetabolic state w/ doubling of CO in 24 – 48 hours 


Inhalation Injury

  • Heat dispersed in upper airways leads to edema
  • Cooled smoke and toxins carried distally
  • Increased blood flow to bronchial arteries causes edema
  • Increased lung neutrophils – mediators of lung damage – release proteases and oxygen free radicals (ROS)
  • Exudate in upper airways – formation of fibrin casts


Stages of Inhalation Injury

*Stage 1 – acute pulmonary insufficiency, Signs of pulmonary failure at presentation
*Stage 2 – 72-96 hrs after presentation (ARDS picture)
increased extravasation of water, Hypoxemia, Lobar infiltrates
Stage 3 – bronchopneumonia
        -Early – Staph pneumonia (frequently PCN resistant)
        -Late - Pseudomonas




inhalation injury bronchoscopy findings

  • erythema
  • intraglottic soot
  • ulceration


Primary assessment of burn

  • Cause of the burn
  • Time of injury
  • Place of the occurrence (closed space, presence of chemicals, noxious fumes)
  • Likelihood of associated trauma (explosion,…)
  • Pre-hospital interventions




initial pt treatment of burn

  • Stop the burning process
  • Consider burn patient as a multiple trauma patient until determined otherwise

  • Perform ABCDE assessment
  • Avoid hypothermia!

  • Remove constricting clothing and jewelry 


what to do inititally with burn pt.

  • cut clothing off the patient
  • wrap them in saran wrap to keep moisture and heat in


Estimation of Burn Wound Depth

  • Initial assessment is often unreliable
  • Ignore mild erythema when calculating fluid requirements
  • Pink areas that blanch are usually superficial
  • Deeper wounds are dark red, mottled or pale and waxy
  • Insensate areas are usually deep (3rd degree or greater)


Factors Influencing Wound Depth

  • Temperature and duration
  • Thickness of skin (thin on eyelids, thick on back)
  • Age (children and elderly have proportionally thinner skin in comparison to adults)
  • Vascularity
  • Agent – oil vs water; acidic vs alkalotic
  • Time to definitive care




Criteria for Burn Center Transfers

  • Deep Partial Thickness burns>10% TBSA
  • Burns that involve the face, hands, feet, genitalia, perineum, or major joints
  • Full thickness burns in any age group
  • Electrical burns, including lightning
  • Inhalation burns requiring intubation
  • Chemical burns that involve deep and extensive TBSA burned




Care of small burns

  • Clean entire limb with
  •     soap and water (also under nails).
  • Apply antibiotic cream
  •     (no PO or IV antibiotic).
  • Dress limb in position of function,                                       and elevate it.
  • No hurry to remove blisters unless infection occurs.
  • Give pain meds as needed (PO, IM, or IV)
  • Rinse daily in clean water; in shower is very practical.
  • Gently wipe off with clean gauze.





  • In the pre-hospital setting,  there is no hurry to remove blisters.
  • Leaving the blister intact initially is less painful and requires fewer dressing changes.
  • The blister will either break on its own, or the fluid will be resorbed. 


Burn “looks worse” when?

the next day because of  blisters breaking and oozing


Blisters show what kind of thickness?

  • probable partial thickness burn.
  • Area without blister might be deeper partial thickness.


Wound dressing biologic?

  • Autograft: get it from another portion of a patients body.  Donor site is much more painful for patient
  • Allograft
  • Cultured Epithelial Autograft (CEA)




wound dressing biosynthetic

  • Integra: skin generated from cadavers
  • Alloderm: a soft-tissue implant fabricated by a proprietary method of processing cadaveric skin. This method produces an acellular dermis that is free of the cells responsible for the antigenic response to allograft skin. After processing, the skin is reduced to a basement membrane and properly oriented dermal collagen matrix. The end result is an acellular human dermis that theoretically will not be rejected.
  • Biobrane: Like a sleeve (membrane) kind of like a sausage.  Protects the area as if it's a second skin




synthetic wound dressing

  • Aquacel: for deeper wounds, in a string or ribbon.  Can fill cavity with that
  • Acticoat: antimicrobial compound on it, black sheet looking that is applied to skin
  • Duoderm: thick with absorbant component for drainage, waterproof film on the top, thickened and coated so it works as a barrier
  • mepilexAG: protective barrier, antimicrobial pad
  • Artificial substances that have been generated




Burn care products

  • < 20% TBSA  2nd degree – Silvadene (SVC) Cream BID
  • Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID
  • 3rd degree burn – SVC and SMC alt BID
  • *SMC only to the ears        
  • * Bacitracin Opth to face


Silver- impregnated dressings


  • Apply wet silver dressing directly on the burn.
  • Creams or dressings under the silver dressing impede the antimicrobial action.
  • Keep it moist!
  • Remove it, rinse it out, replace it on the burn.


burns of the face

  • Be VERY concerned for the airway!!
  • Eyelids, lips and ears often swell alarmingly.
  • In fact, they look even worse the next day.
  • But they will start to improve daily after that.
  • Cleanse eyes with warm water or saline. 
  • Apply antibiotic ointment or liquid tears until lids are no longer swollen shut.
  • Bacitracin cream/ointment will serve


burns on hands and feet

  • This is rather deep and might require grafting. But initial management is basic
  • Dressings should not impede circulation.
  • Leave tips of fingers exposed.
  • Keep limb elevated.
  • Allow use of the hands in dressings by day.
  • Splint in functional position by night.
  • Keep elevated to reduce swelling.
  • Fingers might develop contractures if active measures are not taken to prevent them.


burns to genetalia

Shower daily, rinse off old cream, apply new cream.
Insert Foley catheter if unable to urinate due to swelling.


Causes of death in burn patients


  • Facial edema, and/or airway edema



  • Toxic inhalation (CO, +/- CN)
  • Respiratory failure due to smoke injury or ARDS

Circulation: “failure of resuscitation”

  • Cardiovascular collapse, or acute MI
  • Acute renal failure
  • Other end organ failure
  • missed non-thermal injury




Edema Formation from burns (when does it peak)

  • Amount of edema can be immense (even without facial burns)
  • Depression of mental status can worsen problem
  • Edema peaks at 12 to 24 hours
  • Pediatric patients even more concerning


Patients with larger burns what do you do first and later?

First assess

  • CBA’s
  • “Disability” (brief neuro exam)
  • Exposure


  • Examine rest of patient
  • Calculate IV fluids
  • Treat burn


flash burns

  • “Flash” burns may refer to those that suddenly flare up, then die down quickly.
  • Patients may have burnt facial hair and carbon on lips.
  • Patients with this kind of facial burn will probably NOT need an artificial airway.
  • Give humidified oxygen while under close observation.


circulation portion of burns nursing care

*Record vital signs.
*Check distal pulses and nail beds.
*Keep him warm!
           -Loss of skin impairs ability to retain heat and fluids.
           -Being cold will cause vasoconstriction.
*Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr
*Monitor at least HCT and urine specific gravity.
*When available, monitor electrolytes.


neuro status in burn patients

  • The burn itself does not alter the level of consciousness.
  • If patient is not alert, think of other causes:hypovolemia,carbon monoxide, head injury
  • Don’t allow swollen eyelids to prevent you from examining the pupils.
  • Test sensation and motion in burned extremities.


clothes on a burn patient in the hospital?

-Undress the patient to examine the whole body.
But burned patients lose body heat quickly, so keep them warm.
-To keep warm, use whatever means available:
          -heating lamps




Carbon Monoxide Intoxication

  • Carbon monoxide has a binding affinity for hemoglobin which is 210-240 times greater than that of oxygen.
  • Results in decreased oxygen delivery to tissues, leading to cerebral and myocardial hypoxia. 

  • Cardiac arrhythmias are the most common fatal occurrence.


Signs and Symptoms of Carbon Monoxide Intoxication

  • Usually symptoms not present until 15% of the hemoglobin is bound to carbon monoxide rather than to oxygen.
  • Early symptoms are neurological in nature due to impairment in cerebral oxygenation

  • Confused, irritable, restless
  • Headache
  • Tachycardia, arrhythmias or infarction
  • Vomiting / incontinence
  • Dilated pupils
  • Bounding pulse
  • Pale or cyanotic complexion
  • Seizures
  • Overall cherry red color – rarely seen


what senses in burns are decreased first?



Carboxyhemoglobin Levels/Symptoms

0 – 5: Normal Value

15 – 20: Headach/confusion

20 – 40: Disorientation, fatigue, nausea, visual changes


40 -  60: Hallucinations, coma, shock state, combativeness

> 60: Mortality > 50%


Management of Carbon Monoxide Intoxication

  • Remove patient from source of exposure.
  • Administer 100% high flow oxygen


Half life of Carboxyhemoglobin in patients:

  • Breathing room air: 120-200 minutes
  • Breathing 100% O2: 30 minutes


Upper airway injury 

(above the glottis):   Area buffers the heat of smoke – thermal injury is usually confined to the larynx and upper trachea. 




Lower airway/alveolar injury 

  • Below the glottis
  • Caused by the inhalation of steam or chemical smoke.
  • Presents as ARDS often after 24-72 hours


Criteria for intubation

  • Changes in voice
  • Wheezing / labored respirations
  • Excessive, continuous  coughing
  • Altered mental status
  • Carbonaceous sputum
  • Singed facial or nasal hairs
  • Facial burns
  • Oro-pharyngeal edema / stridor
  • Assume inhalation injury in any patient confined in a fire environment
  • Extensive burns of the face / neck
  • Eyes swollen shut
  • Burns of 50% TBSA or greater




Pediatric intubation considerations

  • Normally have smaller airways than adults
  • Small margin for error
  • If intubation is required, an uncuffed ETT should be placed
  • Intubation should be performed by experienced individual – failed attempts can create edema and further obstruct the airway
  •   AGE/4  +  4  =   ETT size



Ventilatory therapies

  • Rapid Sequence Intubation
  • Pain Management, Sedation and Paralysis
  • PEEP
  • High concentration oxygen
  • Avoid barotrauma
  • Hyperbaric oxygen




Resuscitation Period

  • days 0-3
  • Hypodynamic, with need for close fluid resuscitation monitoring
  • Massive, diffuse capillary leak 2° to inflammatory mediators; abates 18-24 hrs after injury and volume requirements abruptly decline
  • increased leak can be seen in those with delayed resuscitation 2° systemic release of O2 radicals upon reperfusion
  • Extravascular extravasation of fluid, lytes, colloid molecules
  • Other variables affect resuscitation: preexisting fluid deficits, delay until treatment, inhalation injury, depth of wound
  • Must reevaluate resuscitation progress and endpoints frequently; do not just use a formula




parkland formula


What would the fluid replacement be for patient who weighed 60kg and had 30% TBSA burned???

1st 8 hours= _____or ____cc/hr
2nd 8 hours= _____or ____cc/hr
   3rd 8 hours= _____or ____cc/hr


1st 8 hours=  3600 or  450 cc/hr
2nd 8 hours= 1800 or  225 cc/hr
   3rd 8 hours= 1800 or 225 cc/hr

24 hour total: 7200

(4cc X pt kg x % burned=total gluids in 24 hours.  1/2 infused in first 8 hours, 1/4 infused in second 8 hours, 1/4 last 8 hours)


Colloids not given with burns until?

  • after capillary permeability decreases and returns to normal
  • proteins will escape through increased permeability of the membranes initially, which is why we don't use until later


colloids used to expand plasma with burns

albumin, dextran, FFP


Calculate fluid requirements with burns

  • How do we know if this is too much fluid, or too little?
  • Monitor at least:   urine output  - in adults, around 50 cc / hr
  • Decreasing urine output = need for more fluids.




Fluid requirements in children with burns

-Use same formula for fluids to replace loss from burns.
In children, add this amount to normal maintenance rate:
-10 kg - about 40 cc / hr maintenance fluids
-20 kg - about 60 cc / hr
-30 kg - about 70 cc / hr

-Expected urine output for child:   1 cc / kg /hr   
                                        for infant:  2 cc/ kg / hr


20 kg child with 30% burn

calculate fluid replacement?

  • 20 (kg)  x  30(%)  x  2 (cc/kg/%)  =   1200 cc in 24 hr
  • Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially
  • 75 cc / hr for burn loss  +  normal 60 cc / hr maintenance = 135 cc / hr initially


How do you know if the patient is getting too much fluid,
    or too little

Check urine output, urine specific gravity, HCT



Abdominal Compartment Syndrome

  • Patients with severe burns (>30 percent total body surface area) with or without concomitant trauma are also at risk for ACS
  • ACS impairs the: Cardiovascular system, Respiratory system, Renal system, GI system, Hepatic System, CNS


Treatment of ACS


  • Decompression: Nasogastric decompression, Rectal decompression, Percutaneous abdominal decompression, Surgical decompression
  • Ventilatory support
  • hemodynamic support
  • Attention should be paid to patient positioning and the patient should be placed in a supine position since elevation of the head of the bed (>20°), which is commonly used to reduce the risk of ventilator-associated pneumonia, increases intraabdominal pressure and also impacts the measurement of intraabdominal pressure 


Circumferential burn

  • Limb is burned all the way around.
  • Soft tissues under the skin always swell with burns (due to capillary leak of fluids in first day or so).
  • There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue
  • Pressure inside limb gradually increases.
  • Eventually, pressure inside limb exceeds arterial pressure.
  • This requires escharotomy to relieve the pressure.


Compartment syndrome P's

  • Pain
  • Pallor
  • Paralysis
  • Paresthesia
  • Pulselessness
  • Poikilothermia: If something attempts to achieve room temperature


Escharotomy - indications

  • Circulation to distal limb is in danger due to swelling.
  • Progressive loss of sensation / motion in hand / foot.
  • Progressive loss of pulses in the distal extremity by palpation or doppler.   
  • In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.


Escharotomy - complications


  • Bleeding: might require ligation of superficial veins
  • Injury to other structures: arteries, nerves, tendons
  • NOT every circumferential burn requires escharotomy.
  • In fact, most DO NOT need escharotomy.
  • Repeatedly assess neuro-vascular status of the limb.
  • Those that lose circulation and sensation need escharotomy.





  • Eschar = burned skin
  • Escharotomy = cut burned skin to relieve underlying pressure
  • Similar to bivalving a tight cast.
  • Cut along inside and outside of limb from good skin to good skin
  • Knife can be used, or cautery.
  • Use local or no anesthesia.
  •     (Full-thickness burn should have  no sensation, but underlying  tissues do!)
  • These large burns are often
        treated by the “open” technique, that is, without dressings. 




Electrical burn

  • Outer skin might not appear too bad.
  • But heat was conductedalong the bone.
  • Causes the most damage.
  • Burns from inside out.
  • Usually requires fasciotomy





  • Fascia = thick white covering of muscles.
  • Fasciotomy = fascia is incised (and often overlying skin)
  • Skin and fascia split open due to underlying swelling.
  • Blood flow to distal limb is improved.
  • Muscle can be inspected for viability.



  • Particles of phosphorus must be removed from under the skin.
  • Pick them off with forceps.
  • Must apply wet dressing to prevent re-igniting.




Pain Management with burn pain

  • Major thermal injuries are a significant cause of pain and disability.
  • Burn pain is affected by the size and depth of the burn; it is exacerbated by infection.
  • Burn pain has several facets and is difficult to manage; it is therefore often under-treated.
  • Pre-emptive, multimodal analgesia is the best approach and can include regional nerve block and non-pharmacological methods.
  • Not all pain is due to the burn; consider other causes such as fractures, compartment syndrome, infection and rarer complications of the burn.




Acute Phase/Postresuscitation Period

  • Day 3 until 95% wound closure
  • Hyperdynamic, febrile, protein catabolic state
  • Tachycardia can be normal in burn patients
  • Blood pressure may be hard to obtain due to circumferential burns
  • Release of more inflammatory mediators, cortisol, glucagon, catecholamines, bacteria from wound
  • High risk of infection and pain
  • Remove non-viable tissue or close wounds to avoid sepsis
  • Nutritional support essential
  • Maintain and support body temperature with high ambient temps and humidity


Recovery Period

  • 95% wound closure until 1 year post-injury
  • Continued catabolism and risk of non-healing wound
  • Anticipate septic events, treat complications, and continue nutritional support


hypertrophic scaring.  Need to apply an elastic pressure dressing to keep the skin from multiplying out


Elastic Pressure Dressing


nursing care of burn patient comfort

Promote comfort

  • Narcotics and sedatives are used while intubated
  • Once extubated switch to oral narcotics and NSAID’s
  • Nurses need to perform regular pain assessments
  • Premedicate prior to wound management



nursing care of burn patient infection

  • Asepsis is critical
  • > 30% TBSA burn with infection has high mortality rate.
  • Most common infections: Satph Aureus, Pseudomonas Aeruginosa, ClostridiumDifficile,MRSA




nursing care of burn patient nutritional support

*Hypermetabolic state requiring 100X normal nutritional needs

*Start nutritional support within 48 hours

*Enteral feeding may be required:

  • Duotube
  • High calorie
  • High protein (1.5- 2.0 gm/kg)
  • Micronutrients are needed: Vitamin A,C,D, iron, zinc,selenium, Glutamine & Arginine


nursing care of burn pt. psychosocial

  • Patient family centered care
  • Patients often use: Dissociation, Disintegration, Depersonalization
  • PTSD common
  • Counseling and group support needed