Management of Patients with Burn Injury

ARNAZER D, GAN RN MAN

RN must play an active role in the prevention of burn injuries by teaching PREVENTION concepts and promoting SAFETY legislation

4 Major Goals Related to Burns

Prevention

Institution of life-saving measures for the severely burned person

Prevention of disability and disfigurement through early specialized and individualized care

Rehabilitation through reconstructive surgery and rehabilitation programs

Causes of BURN:

Thermal Burn

Dry heat such as flames Moist heat such as steam and hot liquids

Mechanical Burn Caused by the friction or abrasion that occurs when skin is

rubbed harshly against a coarse surface

Electrical Burn

Faulty electrical wiring Immersion in water that has been electrified Lightning strikes Chemical Burn Result from direct contact, ingestion, inhalation or injection of

various substances: acid or alkali

Radiation Burn Typically associated with sunburn or radiation therapy as for

cancer treatment 

 

Classification of Burns: BURN DEPTH

Burn injuries are described according depth of the injury and the extent of the body surface area injured.

Burns are classified according to the depth of tissue destruction as superficial- partial thickness injuries, deep partial thickness injuries or full thickness injuries.

Superficial Partial Thickness Burns / First Degree

Involve superficial injury to the epidermis marked by an uncomplicated erythematous area

Localized pain Skin barrier remains intact; fluid and electrolyte loss not a

problem

Deep Partial Thickness Burns / Second Degree Involve damage to the epidermis progressing to the dermis Blisters present Mild to moderate edema and pain

Possible capillary damage

Possible regeneration of the epithelial layer

Fluid and electrolyte imbalances associated with second degree burns that cover significant areas of the body

Full Thickness Burns / Third Degree Involve all skin layers

Regeneration impossible

Skin elasticity lost, appearance altered significantly (color varies from red to black to white)

No blister present

No pain if nerve endings are damaged

Carry greatest risk of fluid and electrolyte imbalance

Determining the Severity of Burns:

• MAJOR BURNRequire care in a special burn facility and include:

Second degree burns on > 25% of an adult’s BSA or more than 20% of child’s BSA

Third degree burns on > 10% of BSA regardless of body size Burns of the hands, face, eyes, ears, feet or genitalia

All inhalation and electrical burns Burns complicated by fractures or other major trauma All burns in high risk patients, such as children younger than age

2, adults older than age 60, and patients who have preexisting medical conditions such as heart disease

 • MODERATE BURNRequire care either burn care facility or a general health care facility and include:

Third degree burns on 2% - 10% of the BSA regardless of body size

Second degree burns on 15% - 25% of an adult’s BSA and 10% - 20% of a child’s BSA

 • MINOR BURN

Can be treated on an out patient basis and include:

Third degree burns on < 2% of the BSA regardless of body size

Second degree burns on < 15% of an adult’s BSA and on < 10% of a child’s BSA

Phases of Burn

Fluid Accumulation Phase / Hypovolemic Phase:

Several reasons for fluid imbalances:

• Damage to capillaries from the burn injury• Diminished kidney perfusion• Production and release of stress hormones such as aldosterone

and anti diuretic hormone in response to burn injury (cause kidneys to retain Na and water)

                ALERT !!! FLUID IS PRIOTY TO PREVENT SHOCK

Last for 36 to 48 hours after a burn injury

Fluid shifts from vascular compartment to interstitial space; process called 3rd space shift

Edema caused by shifter fluid (which typically reaches maximum extent within 8 hours after injury)

Circulation possibly compromised and pulses diminished from severe edema

CONTINUATION Respiratory Problems occurs secondary to compromised edematous

airway or because of circumferential burns and edema of the neck or chest can restrict respirations and cause shortness of breath

Muscle and tissue injury cause release of acids that can cause a drop in pH level and subsequent metabolic acidosis

GI problems including Curling’s ulcer occur as result of decreased blood flow to stomach

Electrolyte imbalances (hyperkalemia, hyponatremia, hypernatremia and hypocalcemia) due to body’s hypermetabolic needs and priority that fluid replacement takes over nutritional needs during emergency phase

Fluid Remobilization Phase / Diuretic Phase:

Starts about 48 hours after the initial burns

Fluid shifted back to vascular compartment Edema at burn site decreased, blood flow to the kidneys

increased

Sodium lost through increase in diuresis, potassium either moved back into the cells or lost through urine

Fluid and electrolyte imbalances present during the initial phase after burn: can change during fluid remobilization phase may include hypokalemia, hypervolemia and hyponatremia

Convalescent Phase:

Begins after 1st two phases have been resolved

Characterized by healing or reconstruction of burn wound

Major electrolyte imbalances exist as result of inadequate dietary intake

Anemia common at this time (severe burns typically destroy RBC)

 

Tissue destruction = coagulation / protein denaturation / ionization of cellular contents

Tissue hypoperfusion = due to DEC. Cardiac output

SHOCK will occur?

Burns < 25% TBSA produce a primarily local response.

Burns > 25% may produce a local and systemic response and are considered major burns.

Systemic response includes release of cytokines and other mediators into the systemic circulation.

Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction

Cardiovascular Response

Cardiac output decreases before any significant change in blood is evident

Burn Shock/hypovolemia (as fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drop).

In response to symphathetic nervous system releases catecholamines resulting in an increase pulse peripheral resistance (vasoconstriction) increases pulse rate.

Peripheral vasoconstriction further decreases cardiac output

Myocardial contractility may be suppressed by the release of inflammatory cytokine necrosis factor

Management:Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output to prevent shock

Normal range only to prevent EDEMA

Burn Edema

Burns involving less than 25% TBSA

The loss of capillary integrity and shift of fluid are localized to the burn itself, resulting in blister formation and edema only in the area of injury

Severe burns OR < 25% TBSA

massive systemic edema will developed

NOTE: Edema is usually maximal after 24 hours. It begins to resolve 1 to 2 days post-burn and usually completely resolved in 7 to 10 days post-injury

IF REMAIN INCREASE : Pressure on small blood vessels and nerves in the distal extremities causes an obstructionof blood flow and consequent ischemia. AKA compartment syndrome

MANGEMENT : ESCHAROTOMY, a surgical incision into the eschar (devitalized tissue(SCAB) resulting from a burn), to relieve the constricting effect of the burned tissue.

Effects on Fluids, Electrolytes, and Blood Volume:

Circulating blood volume decreases dramatically during burn shock. In addition evaporative fluid loss through the burn wound may reach 3 to 5 liter or more over a 24hr. period until the burn surface is covered.

During burn shock, serum sodium levels vary in response to fluid resuscitation.

Usually hyponatremia is present. Hyponatremia is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space

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

At the time of burn injury, some red blood cells may be destroyed and other damaged, resulting in anemia

Despite this, the hematocrit may be elevated due to plasma loss. Abnormalities in coagulation including a decrease in platelets and

prolonged clotting and prothrombin times also occur with burn injury.

Pulmonary Response:

Inhalation injury is the leading cause of death in fire victims

Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor, as well as chest constriction secondary to circumferential full-thickness chest burns causes this deterioration.

hypoxia (oxygen starvation in tissue) may be present (how?)

• catecholamine release in response to the stress of the burn injury alters peripheral blood flow, thereby reducing oxygen delivery to the periphery. Later, hypermetabolism and continued catecholamine release lead to increased tissue oxygen consumption, which can lead to hypoxia

MANAGEMENT: airway management and oxygen may be needed.

UPPER AIRWAY INJURY  (Usually carbon monoxide poisoning)

Mechanical obstruction of the upper airway, including the pharynx and larynx ( below the glottis )

Because of the cooling effect of rapid vaporization in the pulmonary tract, direct heat injury does not normally occur below the level of the bronchus.

MANAGEMENT:

Upper airway injury results from direct heat or edema may occur for 2 days after burn injury

Treated by early nasotracheal or endotracheal intubation.

sulfur oxides, nitrogen oxides, aldehydes, cyanide, ammonia, chlorine, phosgene, benzene, and halogens

Other gasses cause upper airway injury

Cause loss of ciliary action, hypersecretion, severe mucosal edema, and possibly bronchospasm.The pulmonary surfactant is reduced, resulting in atelectasis (collapse of alveoli). Expectoration of carbon particles in the sputum is the cardinal sign of this injury

CARBOXYHEMOGLOBIN

Carbon monoxide combining with hemoglobin = hypoxia

Management: intubation and mechanical ventilator 100% oxygenation needed.

Indicators of possible pulmonary damage include the following:• History indicating that the burn occurred in an enclosed area• Burns of the face or neck• Singed nasal hair• Hoarseness, voice change, dry cough, stridor, sooty sputum• Bloody sputum• Labored breathing or tachypnea (rapid breathing) and othersigns of reduced oxygen levels (hypoxemia)• Erythema and blistering of the oral or pharyngeal mucosa

Diagnostic exam for inhalation injury

Serum carboxyhemoglobin levels, Arterial blood gas levels, Bronchoscopy and xenon-133 (133Xe) ventilation-perfusion scans

Complications = ARDS & ARF if untreated

Other Systemic Responses

kidney Renal function may be altered as a result of decreased blood

volume

Destruction of red blood cells at the injury site results infree hemoglobin in the urine (hematuria)

Myoglobin is released from the muscle cells and excreted by the kidney (If muscle damage occurs)

MANAGEMENT: Adequate fluid volume replacementrestores renal blood flow, increasing the glomerular filtrationrate and urine volume

UNTREATED: The hemoglobin and myoglobin occlude the renaltubules, resulting in acute tubular necrosis and renal failure

Loss of the skin integrity

Exhibit low body temperatures in the early hours after injury.

Hypermetabolism resets core temperatures, burn patients become hyperthermic for much of the postburn period, even in the absence of infection

The immunologic defenses of the body are greatly altered by burn injury

Sepsis remains the leading cause of death in thermallyinjured patients

Gastrointestinal complications

Paralytic ileus Absence of intestinal peristalsis

Curling’s ulcer Acute gastroduodenal ulcer

Clinical manifestations : occult blood in the stool, regurgitation of “coffee ground” material from the stomach, or bloody vomitus

Diagnostic Findings:

Rule of Nines

LUND AND BROWDER METHOD

A more precise method of estimating the extent of a burn

Recognizes that the percentage Of TBSA of various anatomic parts, especially the head and Legs, and changes with growth

The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then.

PALM METHOD

The size of the patient’s palm is approximately 1% of TBSA.

Other diagnostic test ABG levels maybe normal in early stages, may reveal hypoxemia

and metabolic acidosis in later stages Carboxyhemoglobin level; may reveal extent of smoke inhalation

due to presence of CO 

Phases of Burn Injury

Emergent or resuscitative phaseOnset of injury to completion of fluid resuscitation

• First aid• Prevention of shock• Prevention of respiratory distress• Detection and treatment of concomitant injuries• Wound assessment and initial careAcute or intermediate phase

From beginning of diuresis to wound closure• Wound care and closure• Prevention or treatment of complications, including infection (goal)• Nutritional supportRehabilitation phase

From wound closure to return to optimal physical and psychosocial adjustment

• Prevention of scars and contractures• Physical, occupational, and vocational rehabilitation• Functional and cosmetic reconstruction• Psychosocial counseling

Medical Management( IN GENERAL)

Removal of smoldering clothing (soaking first in NSS if stuck to patient’s skin), rings and other constricting items

Immersion of the burned area in cool water or application of cool compresses (wrap cool towel intermittently)

Pain medications as needed or an anti inflammatory drug Coverage of the area with an antimicrobial and a non sticky bulky

dressings (after debribement)

Prophylactic tetanus injection as needed Prevention of hypoxia by use of several steps:

• Maintaining an open airway• Assessing airway, breathing and circulation• Checking for smoke inhalation immediately• Assisting with ET insertion• Administering 100% oxygen

Coverage of partial thickness burns over 30% of BSA or full thickness burns over 5% of BSA with a clean, dry, sterile bed sheet

Immediate IV therapy to prevent hypovolemic shock and maintain cardiac output

The Parkland Formula is a commonly used formula for calculating fluid replacement in patients with burns. Always base the volume of fluid replacement on the patient’s response, especially his urine output. Urine output of 30 – 50 ml/ hour is a sign of adequate renal perfusion

Over 24 hours: 4 ml of LR x kg of body weight x % of BSA burned (using Rule of Nines or Lund Browder Classification)

Give ½ of the total over the 1st 8 hours after the burn and the remainder over the next 16 hours

Day 2 : Varies. Colloid is added. 

Antimicrobial therapy

Insertion of NGT to decompress the stomach and avoid aspiration of stomach content

Irrigation of wound with copious amounts of NSS (chemical burns)

Surgical intervention including skin grafting and more through surgical cleaning (major burns)

Nursing Management(IN GENERAL)

Assess airway obstruction

Provide oxygen therapy as ordered Assess cardiac and hemodynamic status (hypovolemia and

hypervolemia) Assess skin for location, depth and extent of the burn

Administer IV fluid therapy as ordered Assess for signs and symptoms of metabolic acidosis

Monitor ECG readings Assess fluid and hydration status monitor ABG values and serum

electrolyte levels If bowel sounds are present, provide a diet high in potassium,

protein, vitamins, fats, nitrogen and calories to maintain the patients preburn weight

If necessary, feed the patient enterally until he can tolerate oral feedings; if he cant tolerate oral or enteral feedings, administer TPN

Monitor for signs and symptoms of infection

Management of the Patient with a Burn Injury:

Emergent / Resuscitative Phase of Burn CareOnset of injury to completion of fluid resuscitation

Assess Airway, Breathing and Circulation Breathing must be assessed and a patient airway established

immediately during the initial minutes of emergency care Immediate therapy is directed toward establishing an airway and

administering humidified 100% oxygen If such a high concentration of oxygen is not available under emergency

condition oxygen by mask or nasal cannula is given initially

No food or fluid is given by mouth and patient is placed in a position that will prevent aspiration of vomitus

Emergency Medical Management(ER) Initial priority ABC

After adequate respiratory and circulatory status has been established attention is directed to the burn wound itself

All clotting and jewelry are removed

Flushing of chemical burns with water is continued

Transfer to Burn Center

The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn center

If the patient is to be transported to a burn center, the following measures are instilled before transfer

A secure IV line is placed with fluid infusing at the rate required to attain urine output of at least 30 ml/hr

A patent airway is secured Adequate pain relief is attended Adequate peripheral circulation is established in any burned

extremities. Wounds are covered with clean dry sheet and the patient is

kept comfortably warm 

Acute or Intermediate Phase (begins 48 to 72 hours) From beginning of diuresis to wound closureNurse should assess for sign of infection

Wound Care

Open Method: Closed Method:

A topical agent or wound covering is placed on the wound and left exposed to the air.

Superficial burns Allows the nurse to visualize the wound more readily and assists in range of motion because of absence of constricting dressings

Disadvantages: heat loss and accidental removal of the topical agent

 

The nurse places the topical agent or wound covering on the wound and covers it with gauze wrap

Promotes adherence of the topical agents to the wound and limits fluid loss and wound drying.

Nurse should change dressing quickly as possible to reduce pain and discomfort

Topical Agents Indications Implications Silver Sulfadiazine

 Deep  –  Partial  to  Full thickness burn.

 Penetrates  eschar  to  inhibit  bacterial growth.MINIMAL ONLY Soothes pain ¼ in layer applied directly  Inhibits epithelial tissue development May  cause  slimy,  grayish  discoloration with repeated application. Side Effects:Skin rash on unburn areasDecrease WBC for 24 – 48 hours 

 Mafenide Acetate

 Deep – Partial to Full thickness burn. electrical burn

 Penetrates thick eschar and cartilage; inhibits epithelial tissue development Side Effects:Pain on applicationMetabolic AcidosisHypersensitivity, RashFungal growth 

Silver Nitrate

Deep – Partial to Full thickness burn.

Poor penetration to eschar Side Effects:Black stain on woundsPain on applicationDecreases electrolytes

Wound Cleaning

Hydrotherapy

Using shower tub or a spray table facilitates the removal of topical medications and loosens debris, sloughing eschar and exudates

Wound care in a tub permits immersion of the patient into water or antimicrobial solutions

Soaking help remove topical agents and eschar, and facilitates range of motion.

Therapy is limited to 30 minutes intervals to prevent heat loss.

Tub therapy is avoided in critically ill patient and those with wound infection

 

Wound Débridement

As debris accumulate in the wound = retards keratinocyte

GOALS = to remove tissue contaminated with bacteria = to remove devitalized tissue or eschar in preparation

for grafting & wound healing

Types :

Natural eschar seperation, affected by topical anti-bacterial

Mechanical Use of scissors/scalpels/forceps to separate eschar• Done every dressing change• Done even in pain / bleeding occurs

SurgicalExcision of eschar to level of fascia/shaving• Occlusive dressing applied/ skin graft• Disadvantage – extensive blood loss/ anesthesia

effects

Grafting the Burn Wound= spontaneous reepithelialization is not possible (full-thickness burn)

Homograft/ allograft

• Cadaver or organ donor tissue• Used to cover deep or partial

thickness burn• Enables blood supply to regenerate

but carries some risk for disease transmission

Temporary

Heterograft/ Xenograft

• Pig skin most commonly used• Closes and protects wound while

permanent options are being considered

Temporary

Synthetic Substitutes

• Biobrane adheres to the wound fibrin, which binds to the nylon–collagen material. Trimming of separated biobrane is necessary in healing

Temporary

Autograft• Patient’s own unburned skin

removed and applied to woundPermanent

Cultured epithelial Autograft (CEA)

• Patient’s own skin removed in small squares and grown into larger pieces in laboratory((Keratinocytes)

Permanent

Integra(Artificial Skin)

• Two layer man made membrane used to replace dermis(animal collagen) and covered with autograft, forming functional dermis and epidermis

Permanent

Alloderm• Man made collagen matrix used to

provide dermal layer covered with autograft

Permanent

Graft Care:

Staples prevent movement of the graft

Dressing covered with large, occlusive, bulky dressing to hold new skin securely in place

Splints are applied to help provide immobilization and maintain the position of the grafted areas

Fluid can be removed by aspiration with a needle, rolling the fluid with a cotton tip or cutting a small slit in the graft to drain the fluid.

Dressing is removed slowly and carefully to that graft is not disturbed.

Pain Management

Burn pain = one of the most severe forms of acute pain

Pain accompanies care and treatments such as wound cleaning and dressing changes.

Types of burn pain

Background or resting

Procedural

Breakthrough

exists on a 24-hour basis.

caused by procedures such as burn wound care or range of motion exercises

Occurs when blood levels of analgesic agents fall below the level required to control background pain

Analgesics

IV use during emergent and acute phases

Morphine

Fentanyl

It is titrated to obtain pain relief based on the patient’s self-report of pain using a standardized pain rating scale. Prevent addiction

Particularly procedural burn pain

Anxiety and pain go hand in hand for burn patients.

Sedation with anxiolytic medications such as lorazepam (Ativan) and midazolam (Versed) may be indicated in addition to the administration of opioids.

Music therapy has gained interest recently in the treatment of pain

Nutritional Support

Burn injuries produce profound metabolic abnormalities. Patients with burns have great nutritional needs related to stress response, hypermetabolism, and wound healing.

GOAL= a state of (+)nitrogen balance

Effective nutrition management depends on how well the energy expenditure due to the burn injury can be estimated and matched with appropriate amounts of micronutrients, carbohydrates, lipids, and protein.

Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

Nursing Process: Care of the Patient in the Emergent Phase of Burn Care: Diagnosis

Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstructionGoal: Maintenance of adequate tissue oxygenation

Provide humidified oxygen.

Humidified oxygen provides moisture to injured tissues; supplemental oxygen increases alveolar oxygenation.

Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia.

These factors provide baseline data for further assessment and evidence of increasing respiratory compromise.

Observe for the following:a. Erythema or blistering of lips or buccal mucosa b. Singed nostrils c. Burns of face, neck, or chest d. Increasing hoarseness e. Soot in sputum or tracheal tissue in respiratory secretions

These signs indicate possible inhalation injury and risk of respiratory dysfunction.

Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels.

Increasing PCO2 and decreasing PO2 and O2 saturation may indicate need for mechanical ventilation

Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately.

Immediate intervention is indicated for respiratory difficulty.

Prepare to assist with intubation and escharotomies.

Intubation allows mechanical ventilation. Escharotomy enables chest excursion in circumferential chest burns.

Monitor mechanically ventilated patient closely.

Monitoring allows early detection of decreasing respiratory status or complications of mechanical ventilation.

Nursing Diagnosis: Ineffective airway clearance related to edema and effects of smoke inhalationGoal: Maintain patent airway and adequate airway clearance

Maintain patent airway through proper patient positioning, removal of secretions, and artificial airway if needed.

A patent airway is crucial to respiration

Provide humidified oxygen

Humidity liquefies secretions and facilitates expectoration.

Encourage patient to turn, cough, and deep breathe. Encourage patient to use incentive spirometry. Suction as needed.

These activities promote mobilization and removal of secretions

Nursing Diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn woundGoal: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs

Observe vital signs (including central venous pressure or pulmonary artery pressure, if indicated) and urine output, and be alert for signs of hypovolemia or fluid overload.

Hypovolemia is a major risk immediately after the burn injury. Overresuscitation might cause fluid overload.

Monitor urine output at least hourly and weigh patient daily.

Output and weight provide information about renal perfusion, adequacy of fluid replacement, and fluid requirement and fluid status.

Maintain IV lines and regulate fluids at appropriate rates, as prescribed.

Adequate fluids are necessary to maintain fluid and electrolyte balance and perfusion of vital organs.

Observe for symptoms of deficiency or excess of serum sodium, potassium, calcium, phosphorus, and bicarbonate.

Rapid shifts in fluid and electrolyte statusare possible in the postburn period.

Elevate head of patient’s bed and elevate burned extremities.

Elevation promotes venous return.

Notify physician immediately of decreased urine output, blood pressure, central venous, pulmonary artery, or increased pulse rate.

Because of the rapid fluid shifts in burn shock, fluid deficit must be detected early so that distributive shock does not occur.

Other interventions

Promote early ambulation to prevent DVT