MANAGEMENT OF PATIENTS WITH BURN INJURY

Burn Depths
o First degree: erythematous burns, epidermis still in tact
o Nikolskys sign- if rubbed, burned tissue does not separate
o Second degree: involve the entire epidermis, painful, blisters,
hair follicles and skin appendages remain intact
o Third degree: destruction of the epidermis and dermis and
sometimes underlying tissue
o Color: white, charred, brown, red
o Lack sensation because nerve fibers burned
o Leathery appearance because follicles and sweat glands
are destroyed
o Fourth degree: deep burn necrosis; into fat, muscle, bone
Cardiovascular Alterations
o Immediate decrease of cardiac output loss of plasma volume
o Compensatory response of vasoconstriction increase heart
workload
o Hyporvolemia decreased perfusion and oxygen delivery
o Fluid loss decreased vascular volume CO decreases BP
drops
o Burn shock: combination of direct cutaneous injury, intravascular
volume loss, systemic inflammatory mediators release of free
oxygen radicals that increase vascular permeability peripheral
edema
o SNS releases catecholamine vasoconstriction
increased pulse
o Need fluid resuscitation to prevent distributive shock
o Fluid leak occurs in first 24 to 36 hours after the burn peaks at
6-8 hours
o Capillaries will begin to regain integrity and burn shock will
resolve as fluid returns to the vasculature diuretics will
begin and continues for several days to 2 weeks
Fluid and Electrolyte Alterations
o Edema will form within 4 hours for a superficial burn and within
18 hours for a deeper burn
o Caused by an increased perfusion to area and reflects amount of
micro vascular and lymphatic damage
o Burnt tissue is taut due to underneath edema and acts like a
tourniquet
o Pressure on small vessels in extremities cause an
obstruction of blood flow and ischemia compartment
syndrome

o Tx

Escharotomy
Incision into eschar
Fasciotomy
o Hyperkalemia- from massive cell destruction
o Hypokalemia- occurs later with fluid shifts
o Hyponatremia- plasma loss
o Can also occur during first week of the acute phase as
water shifts from the interstitial space and returns to
vascular space
Pulmonary Alterations
o Inhalation injury- caused by inhalation of thermal/chemical
irritants
o Smoke- heat, particulates, and systemic toxins
o Tachypnea= inhale more toxins
o Extent of damage directly related to temperature and amount of
toxic gases
o Indications of inhalation injury
o Injury occurring in an enclosed space
o Burn of face or neck
o Singed nasal hair
o Hoarseness, high pitched voice change, stridor
o Soot in sputum
o Dyspnea or tachypnea and other signs of hypoxemia
o Erythema and blistering of the oral or pharyngeal mucosa
o Upper Airway Injury
o Thermal or chemical
o Edema due to thermal injury obstruction of pharynx and
larynx
o Lower Airway Injury
o Chemical
o Loss of ciliary action, inflammatory response, mucosal
edema, and bronchospasm
o Carbon monoxide + hemoglobin = carboxyhemoglobin
hopoxia
o Bronchoconstriction & chest constriction
Kidney Alterations
o Function alterations due to decreased blood volume
o Damages RBC = free hemoglobin in urine
o Muscle damage= myoglobin excreted by kidneys
o Inadequate blood flow occlusion of tubule by hemoglobin and
myoglobin

Immunologic Alterations
o Skin is largest barrier to infection sepsis
o Alterations cause immunosuppression
Thermoregulatory Alterations
o Loss of skin results in inability to regulate body temperature
o Hypothermia
o Metabolic response can cause core temperature to be higher (~2
degrees)
Gastrointestinal Alterations
o Large TBSA risk for life-threatening abdominal compartment
syndrome sustained intra abdominal hypertension
o Large volumes of fluid required for resuscitation
o Fluid shift causing edema formation
o Decreased abdominal wall compliance due to eschar
formation
EMERGENT/ RESUSCITATIVE PHASE
On-the-Scene Care= onset to completion of fluid resuscitation
o Establish airway and supply 100% oxygen
o Insert IV line
o Cover wound
o Irrigate chemical injury
o ABCDE survey
Medical Management
o 100% humidified oxygen and cough to remove secretions
o more severe situations require suctioning and
administrating bronchodilators and mucolytic agents
o Fluid resuscitation
o Needed for greater than 20% TBSA
o Baseline weight and labs should be taken prior
o Under resuscitation can cause shock, ischemic
complications, and MODS
o Over resuscitation can cause heart failure and pulmonary
edema
o IV access required and central venous access for larger
burns
Lactated ringers is crystalloid of choice because its
osmolality resembles plasma
o Children: 2mL LR x weight in kilograms x TBSA %

o Adults: 4mL LR x weight in kilograms x TBSA %

- over 8 hours
- over next 16 hours
o urine output of 30-50 mL/hr is an indicator of fluid
resuscitation and 75-100mL/hr for electrical burns
o NG tube needed for suctioning when intubated