Management of Patients With Burn Injury

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• Burns are caused by a transfer of energy from a heat source to
the body
• The largest proportion, 43%, were reported as flame related, 34%
were scalds, 9% were from direct source contact, 4% were
electrical,
• Men have more than twice the incidence of burn injury than
women
• For both men and women, the most frequent age group for burns
is between 20 and 30 years

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• Burns will be caused by
– Fire
– Hot or boiled liquids
– Hot objects
– Electricity
– Chemicals
– Radiations

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 Classification of Burns
• Can be based on:
– Mechanism of injury
– Depth of the injury
– Extent of body surface area injured

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 Mechanism of injury
• Thermal burns
– Caused by fire, hot liquids, flames and direct contact with hot objects
• Electrical burns
– Caused by electric shocks due to exposure to electricity
• Chemical burns
– Caused by exposure to acids, alkalis, or other organic substances
• Radiation burns
– Results from exposure to radioactive sources
– Eg. Sun burn

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 Burn depth
• Superficial (10 )
– Involves only the outer epidermis
– Heals without scarring

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 Partial-Thickness (20 )
– Involves epidermis & the upper portion of the dermis
– Pain & blisters
– Heals with min to no scarring
– Hair follicles and skin appendages remain intact

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 Full-Thickness (30 )
– Complete destruction of the epidermis & dermis
– Blisters and edema
– Heals with hypertrophic scars
– Wound color ranges widely from pale white to red, brown, or
charred.
– The burned area lacks sensation because nerve fibers are
damaged.
– The wound appears leathery and dry
– hair follicles and sweat glands are destroyed
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 Full-Thickness (deep burn necrosis) (40 )
– Complete destruction of the epidermis & dermis
– Involves the subcutaneous fat layer
– May also involve muscle & bone
– Require grafts & susceptible to infection

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Extent of Body Surface Area Injured
• Expressed as the total body surface area (TBSA) injured
• Classified as:
– Minor burns
• Burns with < 25% TBSA injured
– Major burns
• Burns with >25% TBSA injured

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Measurements of the extent of burn wounds
• It is an important part of wound assessment

• Expressed as percentage of total body surface area injured

• The cornerstone of the management of patients with burns

• Used to establish
– The need for fluid resuscitation

– The calculation of fluid requirements

– Evaluation of prognosis

– Monitoring the progress of healing

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• Methods used to estimate the TBSA injured are
– The rule of nines
– The palm method
– The Lund and Browder method

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Rule of Nines
• Quick way to calculate the extent of burns

• Area of burn in adults

– Head and neck - 9 %
– Anterior trunk - 18 %
– Posterior trunk - 18%
– Left arm - 9 %
– Right arm 9%
– Perineum - 1 %
– Left leg- 18 %
– Right leg - 18 % 18
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• Area of burn in children
– Head and neck - 18 %
– Anterior trunk - 18 %
– Posterior trunk - 18%
– Rt hand - 9 %
– Lt hand - 9%
– Lt leg - 14%
– Rt leg - 14%

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Palm Method
• Used in patients with scattered burns
• The size of the patient’s palm is approximately 1% of TBSA

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• Factors which determine severity of burn
– Size of burn
– Depth of burn
– Age of victim
– Body part involved
– Mechanism of injury
– History of cardiac, pulmonary, renal, or hepatic disease

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 Pathophysiology of Burns
• Burns < 25% TBSA
– Produce primarily local response
• Burns > 25% TBSA
– Produce both local and a systemic response

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 Local response
• Zone of coagulation
– Area with tissue protein coagulation
– Irreversible cell death
• Zone of stasis
– Area with compromised circulation
– Untreated it will lead to necrosis
• Zone of hyperemia
– Area with increase blood flow
– No cell death 26
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Systemic responses
Loss of skin barrier
• Loss of skin may result in
– Loss of thermoregulation
– Evaporative fluid loss through the burn wound
– Loss of water, electrolytes, proteins and heat due to vascular
permeability
– Infection

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Electrolyte loss
• Immediately after burn injury, hyperkalemia results from
massive cell destruction
• Hypokalemia may occur later with fluid shifts and inadequate
potassium replacement

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 Cardiovascular Response
Hypovolemia

Decreased perfusion and oxygen delivery

Cardiac output decreases

Blood pressure drops

SNS releases catecholamine

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• At the time of burn injury, some RBCs may be
destroyed and others damaged
• Resulting in anemia
• The hematocrit may be elevated due to plasma loss
• Decrease in platelets (thrombocytopenia)
• prolonged clotting and prothrombin times.

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Pulmonary Response
• Inhalation injury is the leading cause of death in fire
victims
• Carbon monoxide is probably the most common cause
of inhalation injury

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• Indicators of possible pulmonary damage
– Burn occurred in an enclosed area

– Burns of the face or neck

– Singed nasal hair

– Hoarseness, dry cough, sooty sputum

– Bloody sputum

– Labored breathing

– Erythema and blistering of the oral or pharyngeal

mucosa
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 Gastrointestinal Alterations

• Three of the most common GI alterations in patients

with burns are;
 Paralytic ileus (absence of intestinal peristalsis),
 Curling’s ulcer, and
 Translocation of bacteria

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 MANAGEMENT
• Three phases of treatment for severly burned patients
– The emergent phase
– The acute phase
– The rehabilitation phases

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EMERGENT PHASE
• On the Scene Care
– Extinguish the flames
– Cool the burn
– Remove restrictive objects
– Cover the wound
• Emergency Medical Management
– Primary care
– Secondary care

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On the Scene Care
Extinguish the flames
• Flame: stop, drop and roll
• Chemical: remove contaminated clothing if not adhering
to skin
• Electrical: disconnected the electrical source

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Cool the burn
• Application of cool water
• Adherent clothing are soaked with cool water
• Applying cool towels
• Never apply ice directly to the burn
• Never wrap burn victims in ice
• Never use cold soaks or dressings

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Remove restrictive objects
• If possible, remove clothing immediately
• Adherent clothing may be left in place once cooled
• Other clothing and all jewelry should be removed

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Cover the wound
• The burn should be covered to
– Minimize bacterial contamination
– Decrease pain
• Sterile dressings are best, but any clean, dry cloth can be used
as an emergency dressing
• Ointments and salves should not be used
• No medication or material should be applied to the burn

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Irrigate chemical burns
• Brush off the chemical agent
• Remove clothes immediately
• Rinse all areas of the body that have come in contact
with the chemical by running water

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Emergency Medical Management
 The patient is transported to the nearest emergency department

Primary care
• The initial priorities remain ABCDEF
• Provision of Tetanus Prophylaxis

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Air way

• Inspect the airway for foreign material/edema

• Immediate therapy is directed toward establishing an airway

• In case of a suspected injury to the cervical spine keep

movement of the neck to a minimum

• If smoke inhalation is suspected intubation is done before

edema makes it difficult or impossible

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Breathing and Ventilation
• Breathing must be assessed
• Expose the chest and ensure that chest expansion is adequate and
bilaterally equal
• Palpate for rib fractures
• Auscultate for breath sound bilaterally
• Administer humidified 100% oxygen
• No food or fluid is given by mouth
• Placed in a position that will prevent aspiration
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Circulation with Hemorrhage Control
• Inspect for any obvious bleeding
• Stop bleeding
– With direct pressure
– Elevation
– Suturing
• The circulatory system must also be assessed quickly
• Apical pulse and blood pressure are monitored frequently

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Disability - neurological status
• Check the level of consciousness (LOC)
– A = Alert
– V = response to Vocal stimuli
– P = response to Painful stimuli
– U = Unresponsive
– Examine the pupils for light reaction

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Exposure with environmental control
• Keep patient warm
• Keep environment warm
• Check for any adherent clothing, cut around it, when removing
clothing

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Fluids Resuscitations
• The total volume and rate of IV fluid replacement are gauged by
the patient’s response
Fluid Requirements
• For the first 24 hours, calculated by the extent of the burn injury

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• Fluid categories:
– Colloids
• Whole blood, plasma
– Crystalloids
• NS and RL
– Glucose
• DW

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Parkland/Baxter Formula
• RL solution: 4 mL × kg body wt ×% TBSA burned
• Day 1: Half to be given in first 8 hours; half to be given over
next 16 hours
• Day 2: Colloid is added.

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Secondary care

• Validate
– Time of the burn injury
– Source of the burn
– Place where the burn occurred
– How the burn was treated at the scene
– Any history of falling with the injury
– A history of preexisting diseases
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• Criteria for Hospitalization
– Second-degree burns :
• > 25% TBSA in adults
• >20% in children
– Third-degree burns >10% TBSA
– All burns involving eyes, ears, face, hands, feet, perineum, joints
– All inhalation injury
– All electrical injury

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ACUTE OR INTERMEDIATE PHASE
• Begins 48 to 72 hours after the burn injury
• Includes
– Infection prevention
– Burn wound care
• Wound dressing
• Wound debridement
– Pain management
– Nutritional support

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Complication of Wound Healing
• Scars
• Keloids
• Failure to Heal
• Contractures
• Infection

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REHABILITATION PHASE OF BURN CARE

• Focuses on the alterations in self-image and lifestyle that may

occur

• Wound healing, psychosocial support, and restoring maximal

functional activity remain priorities

• The focus on maintaining fluid and electrolyte balance and

improving nutritional status continues

• Reconstructive surgery to improve body appearance and function

may be needed
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THANK YOU!

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