Burns
Prepared
Aseem.B,MBA,MSN, PGDHA
Assistant Professor,
SP Fort College of Nursing,
Trivandrum

Definition
• Burns are a result of the effects of thermal
injury on the skin and other tissues
• Human skin can tolerate temperatures up to
42-440 C (107-1110 F) but above these, the
higher the temperature the more severe the
tissue destruction
• Below 450 C (1130 F), resulting changes are
reversible but >450 C, protein damage
exceeds the capacity of the cell to repair

• A burn injury occurs as a result of destruction
of the skin from direct or indirect thermal
force.
• Burn are caused by exposure to heat, electric
current, radiation or chemical.
• Scald burn result from exposure to moist heat
(steam or hot fluids) and involve superficial.

Types
1. Thermal burns.
2. Chemical burns
3. Electrical burns
4. Radiation burns

Mammootty's kind hearted gesture
gives hope to acid attack victim.

incidence
• About 2.4 million people suffer burns annually
• Account for an estimated 700,000 ER visits per
year and 45,000 require hospitalizations
• Between 8,000-12,000 burn patients die, and
approximately one million will sustain substantial
or permanent disabilities

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Classification According to
Depth
• First-degree Burns (mild): epidermis
 Pain, erythema & slight swelling, no blisters
 Tissue damage usually minimal, no scarring
 Pain resolves in 48-72 hours

• Superficial Second-degree Burns: entire
epidermis & variable dermis
 Vesicles and blisters characteristic
 Extremely painful due to exposed nerve
endings
 Heal in 7-14 days if without infection

Superficial

Partial thickness (second degree)

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Full thickness (3°burn)

• Midlevel to Deep Second-degree Burns:
 Few dermal appendages left
 There are some fluid & metabolic effects

• Full-thickness or Third-Degree:
• entire epidermis and dermis, no residual
epidermis
 Painless, extensive fluid & metabolic deficits
 Heal only by wound contraction, if small, or if
big, by skin grafting or coverage by a skin
flap

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Blister may ↑size because continuous
exudation and collection of tissue fluid

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Eschar:composed of
denatured protein

Burn Photos
Chemical (Acid) Burns
Radiation (Flash) Burns

Burn Photos
Electrical Burns
Entrance Wounds
Electrical Burns
Exit Wounds
Entrance wound of electrical
burns from an overheated tool
Severe swelling
peaks 24-72 hrs after
Electrical burns mummified
1st 2 fingers later removed

Chemical Burn

Pathologic Features
• Zone of coagulation (necrosis): Superficial area of
coagulation necrosis and cell death on exposure to
temperatures >450 (primary injury)
• Zone of stasis (vascular thrombosis): Local capillary
circulation is sluggish, depending on the adequacy of the
resuscitation, can either remain viable or proceed to cell
death (secondary injury)
• Zone of hyperemia (increased capillary permeability)

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Zone of injury

Burns
Assessment/Physiology/ Classification
Based on:
• Depth/Degree of injury,
• Percent of body surface areas involved,
• Location of the burn,
• Association with other injuries.

Classification According to Extent
• Mild: 10%
• Moderate:
10-30%
• Severe: > 30%
• Hospitalization
for > 10% of
body surface
area
• Rule of nines-An estimated of
the TBSA involved as a result of
a burn.
• The rule of nines measures the
percentage of the body burned
by dividing the body into
multiples of nine.
• The initial evaluation is made
upon arrival at the hospital.

Rule of nine

For small children, the head represents a greater portion
of the body mass than adults.
Lund and Browder first described a method for
compensating for the differences and
the Lund and Browder Chart is used to calculate Body Surface Area (BSA) in children.
If the chart is
unavailable, one can estimate
body surface area
and adjust for age, as
:follows
.

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Factors determining severity of burns
• Size of burn
• Depth of burn
• Age of victim
• Body part involved
• Mechanism of injury
• History of cardiac, pulmonary, renal, or
hepatic disease
• Injuries sustained at time of burn.

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Effects of a severe burn
1. Cardiovascular
2. Respiratory
3. Immune
4. Integumentary
5. Gastrointestinal
6. Urinary

Cardiovascular system
• Blood pressure falls-fluid leaks from intravascular
to interstitial (sodium and protein)
• Hypotension
• tachycardia
• Blood flow in intravascular is concentrated and
cause static.
• Cardiac output ↓,
• Due to that tissue perfusion ↓,

Hematologic changes
• Thrombocytopenia, abnormal platelet
function, depressed fibrinogen levels, deficit
plasma clotting factors.
• Life span ↓RBC.
• Blood loss during diagnostic and therapeutic
procedure.

Respiration system
• Majority of deaths from fire are due to smoke
inhalation.
• Pulmonary damage can be from direct inhalation
injury or systemic respond to the injury.
• Damage to cilia and cell in the airway-
inflammation.
• Mucociliary transport mechanism not
functioning-bronchial congestion and infection.
• Pulmonary edema, fluids escape to interstitial.
• Airway obstruction

Gastrointestinal
• Burn >20% experience ↓peristalsis, gastric
distention and ↑risk of aspiration.
• Paralytic ileus due to secondary to burn trauma.
• Stress ulcer (stomach/duodenum) due to burn
injury.
• Indication of stress ulcer-malena stool or
hematemesis.
• These signs suggest gastric or duodenal erosion
(Curling`s ulcer)
• Gastric distention and nausea may lead to
vomiting.

CURLING’S ULCER
• Acute ulcerative gastro duodenal disease
• Occur within 24 hours after burn
• Due to reduced GI blood flow and
mucosal damage
• Treat clients with H2 blockers,
mucoprotectants, and early enteral
nutrition
• Watch for sudden drop in hemoglobin
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Immunologic changes
• Skin barrier to invading organisms s destroyed,
circulating levels of immunoglobulins are ↓
• Changes in WBC both quantitative and
qualitative.
• Depression of neutrophil, phagocytic and
bactericidal activity is found after burn injury.
• All this changes in the immune system can
make the burn patient more susceptible to
infection

PHASES OF BURN INJURIES
• Emergent (24-48 hrs)
• Acute
• Rehabilitative

MANAGEMENT OF THE BURN INJURY
Phases of Management
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

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

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

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

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

Diagnosis
• 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.

Lab Tests
• 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.

BURN INTERVENTIONS
• Maintain Airway
• Fluid Resuscitation
• Relieve Pain
• Prevent Infection
• Provide Nutrition
• Prevent Stress Ulceration
• Provide Psychologic Support
• Prevent Contractures

Management
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

FLUID IMBALANCES
• Occur as a result of fluid shift and
cell damage
• Hypovolemia
• Metabolic acidosis
• Hyperkalemia
• Hyponatremia
• Hemoconcentration (elevated blood
osmolarity, hematocrit/hemoglobin)
due to dehydration
4/1/2011 53

Formula for estimating fluid
replacement
• Brooke (Modified) : lactated ringers solution :
2..0ml/kg/% TBSA burn: half given during first 8
hours and half given during next half hour
• Parkland (Baxter) lactated ringers solution 4ml
/kg/% TBSA burn; half given first 8 hr, ¼
• Given each next 8 hr

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

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&FASCIOTOMY

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

Hydrotherapy cart shower

Hubbard Tank (old method)

Dermatome-harvesting donor skin from
thigh (courtesy : google images)
6/20/2015 61

6/20/2015 62
courtesy : google images
• For graft to SURVIVE and be effective:
– Recipient bed must have adequate blood
supply
– Graft must be in close contact with recipient
bed
– Graft must be firmly fixed or immobile
– Free from infection

Acid attack survivor laxmi courtesy : google images