Burn Depth
damage only to the epidermis
pink to red, NO BLISTERS, mild edema, no eschar
painful, heals in 3-6 days
sensitive to heat
no scarring
Example: sunburn, flash burn
Superficial (1st degree)
Modified for pediatric clients assumes all adults have the sameldistribution of BSA
Each region represents 9% of TBSA
Head = 9% total
Each arm = 9% total
Anterior trunk = 18%
Posterior trunk = 18%
Each leg = 18% total
Genitalia = 1%
Rule of Nines
Most common type: Injury to the oropharynx, nasopharynx, and larynx
May be thermal or chemical
Swelling can occur within minutes to hours
Emergent intubation may be required
Upper Airway Injury – above the Glottis
Skin largest barrier to infection and sepsis
Burns increases client’s exposure to environment
Burns release cytokines which cause WBC dysfunction; Results in immunosuppression
Systemic Inflammatory Response Syndrome- exaggerated systemic inflammatory response
All major burn victims experience SIRS
Sepsis: Leading cause of death after the first 24 hours
Infection Control: contact precautions, disposable single-patient use equipment
Skin changes in major burns
2 ml LR x kg x TBSA% = Total volume given in first 24 hours after injury
Example: Pt weighing 80 kg with 36% TBSA burn
2 mL X 80 kg X 36 = 5,760 mL over the first 24 hours
Half of the total fluid requirement is administered over the first 8 hours
The other half is administered over the next 16 hours
Parkland Formula
damage to entire epidermis & part of the dermis
pink to red, blisters, mild to moderate edema, no eschar; painful, heals in 2-3 weeks
no scarring but may result in changes to skin pigmentation
Example: brief contact with a hot pan
Superficial Partial Thickness Burn (2nd Degree)
Burns involving less than 15% TBSA
No involvement on perineum or face
No functional or cosmetic loss
Minor burns
Chemical injury – caused by prolonged exposure to smoke
Wheezing and tracheobronchitis within minutes to hours
Lower Airway Injury – below glottis
ON –THE-SCENE-CARE; Begins at time of injury
Primary goal is treatment of immediate life-threatening issues
A = Airway = establish airway, may require intubation
B = Breathing = provide 100% high-flow oxygen by mask
C = Circulation = large bore IVs, elevate extremities,
neurovascular checks prn, fluid resuscitation
D = Disability = neurological assessment
E = Examine = extent & depth of burn wounds; associated trauma; remove tight jewelry or clothing, prevent hypothermia
Emergent Phase
Urine output: 0.5 mL/kg/hr minimum
If myoglobin in urine then increase to 1 mL/kg/hr minimum
Systolic Blood Pressure > 100 mm Hg
Heart Rate < 120 bpm
Central Venous Pressure 5 – 10 mm Hg
Indicators of Adequate Fluid Resuscitation
damage to entire epidermis and deep into the dermis
red to white appearance but blanchable; rarely has blisters;moderate edema
painful and sensitive to touch around the edges
heals in 3-6 weeks; scarring likely
Examples: prolonged exposure to grease or hot objects
Deep Partial Thickness (2nd degree deep dermal)
Full-thickness burns of 2% to 10% TBSA
Partial-thickness of 15% to 20% TBSA
Moderate burns
Binds to hemoglobin; Tissue hypoxia
Manifestations: Headache, Confusion, Nausea, Vomiting, Dizziness, Dyspnea
Treatment: 100% oxygen
Carbon monoxide poisoning
Begins 48-72 hours after injury; Goals are wound healing, pain management, infection prevention, optimal nutrition
Wound care:hydrotherapy, clean technique and infection control
Wound grafting: Autografts- Patient’s own skin: Most common donor site: thigh; Elevate & immobilize the graft site
Monitor both sites for infection
Prevention of hypothermia- Warm blankets, warm room
Insert Foley catheter- to closely monitor urine output
Insert N/G tube- to reduce risk of aspiration & decompress the stomach
Clean sheets – protect burn
wound care will be delayed until life-threatening concerns have been addressed; minimizes evaporative fluid loss
IV pain medications: morphine, fentanyl, hydromorphone
Emergent Phase steps to prevent infection or injuries
damage to the entire epidermis and dermis, full thickness may extend
to subQ tissue; deep FT extends to muscle, tendons, and bones
dry, leathery, charred, white, brown, eschar hard and inelastic
NERVE DAMAGE; minimal or absent sensation
will not heal w/o intervention; scarring; grafting required
example: Grease, tar, chemical burns
Full Thickness or Deep Full Thickness (3rd Degree)
Full-thickness burns greater than 10% TBSA
Partial-thickness burns greater than 25% TBSA
Age older than 60 years
Electrical burn injury
Inhalation injury or other complicated injury
Burns to the eyes, ears, face, hands, feet, or perineum
Major burns
Massive fluid shifting
Inflammatory response causes increased capillary
permeability (leaky vessels)
Plasma moves from inside the vessel (intravascular space) into the interstitial space - Third spacing
Results in edema and decreased blood volume
Hypovolemia is 2nd most common cause of death of burn patient in the first 24 hours
Burn Shock
Promote wound healing
Minimize deformities
Increase strength and function
Provide emotional & psychiatric support
PTSD; Body image disorder, anxiety, depression
support groups for burn survivors and their families
Rehabiltative Phase
CBC
PT/PTT/INR
Complete Metabolic Panel
ABG
ECG
Chest x-ray
Toxicology screen
Carboxyhemoglobin
Trapped/injured in enclosed space
Facial burns
Singed nasal/facial hair
Carbonaceous (soot) sputum
Tachypnea, retractions, nasal flaring
Redness, edema of nasal or oral/throat mucosa
hoarse voice
Cough
Agitation/anxiety (hypoxia)
Indicators of Inhalation injury
Smoke – heat, particulates, Inhalation Injurysystemic toxins
increase RR due to anxiety results in increased smoke inhalation
Extent of damage directly related to temperature and concentration of toxic gases
Significantly increases mortality risk
Inhalation Injury
Hypovolemia: d/t leaky vessels & evaporative fluid loss from denuded body surfaces; evaporative fluid loss may be up to 5 L/day
Potassium: Hyperkalemia initially r/t massive cell destruction; Hypokalemia will occur later with fluid shifts
Sodium: Hyponatremia r/t fluid & electrolytes shifting to the interstitial space
F/E imbalances
Burns are Hypovolemic Shock
Analgesics: IV - morphine, hydromorphone, fentanyl; Oral - oxycodone, NSAIDs, acetaminophen
Sedation/Anxiolytics: Sedation: haloperidol, propofol, dexmedetomidine hydrochloride; Anxiolytics: lorazepam, diazepam, midazolam
Anticoagulant Therapy: enoxaparin, heparin
Gastrointestinal Support: Decrease stomach acid: famotidine (H2 Blocker), pantoprazole (PPIs); Promote stomach emptying: metoclopramide
Medications
Fluids for burns;Fluid resuscitation initiated for burns > 20% TBSA
Airway/Breathing
LR
100% High-flow oxygen