A burn is a damage to your body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

There are three types of burns:

•First-degree burns damage only the outer layer of skin

•Second-degree burns damage the outer layer and the layer underneath

•Third-degree burns damage or destroy the deepest layer of skin and tissues underneath

A burn is a damage to your body's tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

There are three types of burns:

•First-degree burns damage only the outer layer of skin

•Second-degree burns damage the outer layer and the layer underneath

•Third-degree burns damage or destroy the deepest layer of skin and tissues underneath

Burns can cause swelling, blistering, scarring and, in serious cases, shock and even death.

They also can lead to infections because they damage your skin's protective barrier. Antibiotic creams can prevent or treat infections.

After a third-degree burn, you need skin or synthetic grafts to cover exposed tissue and encourage new skin to grow. First- and second-degree burns usually heal without grafts.

Burns can cause swelling, blistering, scarring and, in serious cases, shock and even death.

They also can lead to infections because they damage your skin's protective barrier. Antibiotic creams can prevent or treat infections.

After a third-degree burn, you need skin or synthetic grafts to cover exposed tissue and encourage new skin to grow. First- and second-degree burns usually heal without grafts.

Thermal burns may result from any external heat source (flame, liquids, solid objects, or gases).

Thermal burns may result from any external heat source (flame, liquids, solid objects, or gases).

Radiation burns most commonly result from prolonged exposure to solar ultraviolet radiation (sunburn) but may result from prolonged or intense exposure to other sources of ultraviolet radiation (eg, tanning beds) or from exposure to sources of x-ray or other non solar radiation.

Radiation burns most commonly result from prolonged exposure to solar ultraviolet radiation (sunburn) but may result from prolonged or intense exposure to other sources of ultraviolet radiation (eg, tanning beds) or from exposure to sources of x-ray or other non solar radiation.

Chemical burns may result from strong acids, strong alkalis (e.g, lye, cement), phenols, cresols, mustard gas, or phosphorus. Skin and deeper tissue necrosis due to these agents may progress over several hours.

Electrical burns result from the electrical generation of heat; they may cause extensive deep tissue damage despite minimal apparent cutaneous injury.

Chemical burns may result from strong acids, strong alkalis (e.g, lye, cement), phenols, cresols, mustard gas, or phosphorus. Skin and deeper tissue necrosis due to these agents may progress over several hours.

Electrical burns result from the electrical generation of heat; they may cause extensive deep tissue damage despite minimal apparent cutaneous injury.

Modifiable Risk Factors•Careless smoking: Cigarettes are the leading cause of house fires.

•Absent or nonfunctioning smoke detectors: The presence of a functioning smoke detector decreases risk of death by fire by 60 percent.

•Use of wood stoves

•Exposed heating sources or electrical cords

•Unsafe storage of flammable or caustic materials

•Water heaters set above 120°F

•Microwave heated foods and containers

•Substandard or older housing

•Substance abuse: Use of alcohol and illegal drugs increases risk.

Non Modifiable Risk Factors

•Age: Children under 4 who are poorly supervised are at particular risk.

•Gender: Males are more than twice as likely to suffer burn injuries.

•A detailed history and physical examination is the first step. The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection.

•Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.

•Routine blood work for a patient with a burn injury includes a complete blood count, platelet count, clotting studies, liver function studies, and carboxyhemoglobin, electrolyte, blood urea nitrogen, glucose and creatinine levels.

•Urinalysis may reveal myoglobinuria and hemoglobinuria.

•If pt. is 35 or older, he’ll also need an electrocardiogram.

•Chest x-rays and arterial blood gas levels allow the evaluation of alveolar function. Fiber optic bronchoscopy shows the condition of the trachea and bronchi.

PathophysioloPathophysiologygy

Burn Injury

Local and Systemic edema

Endothelial Injury

Leukocyte sequestratio

n

Tissue Injury

Tissue Ischemia

Hypovolemia and

hyperviscosity

• Acidosis• Depressed cardiac Fx

• Multiorgan dysfunction

Direct tissue injury Capillary

Permeability

Systemic InjuryCapillary

Permeability

Estimating the Extent of a BurnEstimating the Extent of a Burn•In adults: "Rule of Nines" is used as a rough indicator of % TBSA

Rule of Nines for Establishing Extent of Body Surface Burned Anatomic Surface

•% of total body surface

•Head and neck =9%

•Anterior trunk =18%

•Posterior trunk =18%

•Arms, including hands =9% each

•Legs, including feet =18% each

•Genitalia/Perineum =1%

•In adults: "Rule of Nines" is used as a rough indicator of % TBSA

Rule of Nines for Establishing Extent of Body Surface Burned Anatomic Surface

•% of total body surface

•Head and neck =9%

•Anterior trunk =18%

•Posterior trunk =18%

•Arms, including hands =9% each

•Legs, including feet =18% each

•Genitalia/Perineum =1%

•In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults

•Lund-Browder diagrams improve the accuracy of the % TBSA for children.

•Palmar hand surface is approximately 1% TBSA

Estimating Percent Total Body Surface Area in Children Affected by Burns (A) Rule of "nines" (B) Lund-Browder diagram for estimating extent of burns

•In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults

•Lund-Browder diagrams improve the accuracy of the % TBSA for children.

•Palmar hand surface is approximately 1% TBSA

Estimating Percent Total Body Surface Area in Children Affected by Burns (A) Rule of "nines" (B) Lund-Browder diagram for estimating extent of burns

9

189

18

9

181

•Blisters

•Pain (the degree of pain is not related to the severity of the burn -- the most serious burns can be painless)

•Peeling skin

•Red skin

•Shock (watch for pale and clammy skin, weakness, bluish lips and fingernails, and a drop in alertness)

•Swelling

•White or charred skin

•Impaired gas exchange

•Ineffective tissue perfusion

• Risk for Infection

•Risk for Post trauma Syndrome

BURN INTERVENTIONS

•MAINTAIN AIRWAYMAINTAIN AIRWAY

• FLUID RESUSCITATIONFLUID RESUSCITATION

• RELIEVE PAINRELIEVE PAIN

• PREVENT INFECTIONPREVENT INFECTION

• PROVIDE NUTRITIONPROVIDE NUTRITION

• PREVENT STRESS ULCERATIONPREVENT STRESS ULCERATION

• PROVIDE PSYCHOLOGIC SUPPORTPROVIDE PSYCHOLOGIC SUPPORT

• PREVENT CONTRACTURESPREVENT CONTRACTURES

MANAGEMENT OF THE BURN INJURY

Phases of Management of the Burn Injury

Resuscitative phase

- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased

- the amount of fluid administered is based on the client’s weight and extent of injury

- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion

Emergent phase

- begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury

- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ functioning

- includes prehospital care and emergency room care

Rehabilitative phase

- final phase of burn care

- overlaps the acute care phase and goes well beyond hospitalization

- goals of this phase are designed so that the client can gain independence and achieve maximal function

Acute phase

- begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun

- usually begins 48 - 72 hours after the time of injury

- emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved

- the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy

PAIN MANAGEMENT• Administer morphine sulfate or meperidine (Demerol), as prescribed, by

the IV route

• Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring

• Avoid administering medication by the oral route, because of the possibility of GI dysfunction

• Medicate the client prior to painful procedures

NUTRITION• Essential to promote wound healing and prevent infection

• Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed

• Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition

• Provide a diet high in protein, carbohydrates, fats and vitamins

ESCHAROTOMY• A lengthwise incision is made through the burn eschar to relieve

constriction and pressure and to improve circulation

• Performed for circulatory compromise resulting from circumferential burns

• After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure

• Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed

• Apply topical antimicrobial agents as prescribed

FASCIOTOMY• An incision is made, extending through the SQ tissue and fascia

• Performed if adequate tissue perfusion does not return after an escharotomy

• Performed in OR under GA, after procedure assess same as above

• ESCHAROTOMY

• FASCIOTOMY

WOUND CARE

1. The cleansing, debridement and dressing of the burn wounds

2. Hydrotherapy

a. Wounds are cleansed by immersion, showering or spraying

b. Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress

c. Client should be premedicated prior to the procedure

d. Not used for hemodynamically unstable or those with new skin grafts

3. Debridement

a. Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing

b. May be mechanical, enzymatic or surgical

c. Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily

WOUND CLOSURE• Prevents infection and loss of fluid

• Promotes healing

• Prevents contractures

• Performed on the 5th to 21st day, depending on the extent of the burn

AUTOGRAFTING• Permanent wound coverage

• Surgical removal of a thin layer of the client’s own unburned skin, which is then applied to the excised burn wound

• Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence

• Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed

• Care of the graft site

• Care of the donor site