Initial Care of Burns

Connie Handel RN
University of Wisconsin Hospital and Clinics
Objectives

Discover whos getting burned?

Discuss Burn pathophysiology.
Understand why some treatments are better
than others.
Review treatment options.
Skin Structures

Epidermis outermost layer of keratinized cells

Dermis contains skin appendages, vascular supply
and nerve endings
Subcutaneous Tissue
Functions of the Skin

Barrier to infection Control of body fluids

Protection from external Sensory organ

injury
Determines identity
Temperature control
What is a burn?

Cutaneous injury caused by heat, electricity,

chemicals, friction, or radiation.
Burn Depth
 First Degree Burns

Epidermis affected only

Red or pink, dry, painful,
blanches to touch
Epidermis is intact
Spontaneous healing
within 7 days. Outer
injured epithelial cells peel
Seldom clinically
significant
 Superficial Partial Thickness

Entire epidermis & portion of

dermis (Papillary dermis)
Homogenous pink
Painful
Blisters
Blanches
Hair usually intact
Does not scar, may pigment
differently
Sup 2nd degree
Deep partial thickness

Reticular dermis
Mottled red and white
Not painful to pinprick or pressure
Does not blanch
Heals > 3 weeks
Usually scars
Need to excise and graft
Deep Partial Thickness
Deep dermal
 Full Thickness:
3rd degree

May go into fat or

deeper
Red, white, brown,
black
Inelastic and leathery
painless or numb
Heals only from the
periphery
Always excise and graft
Full-thickness
Etiology
Types of burns
Circumstances of injury
Where do burns occur
Admissions by age
% of admissions vs. burn size
Inhalation Injury

Exposure to heat and toxic products of combustion

50% of fire deaths are related to inhalation injuries

Asphyxia/Carbon Monoxide displacement of oxygen
Inhalation injury diagnosis

Closed-space fire
Face burns
Terminology

Inhalation injury nonspecific

Thermal injury
Upper airway
Heat and toxic fumes
Local chemical irritation
Throughout airway
Primarily toxic fumes
Systemic toxicity
CO
Signs and symptoms

Lacrimation Conjunctivitis
Cough Carbonaceous
Hoarseness sputum
Dyspnea Singed hairs
Disorientation Stridor
Anxiety Bronchorrhea
Wheezing
Pathophysiology

The main factor responsible for mortality in

thermally injured patients
Carbon monoxide the most common toxin
200 times greater affinity
Competitive inhibition with cytochrome P-450
Poison management = CO

500 unintentional deaths each year

Persistent Neurologic Sequelae
May improve over time
Delayed Neurologic Sequelae
Relapse later
Carbon Monoxide Poisoning

10% COHb asymptomatic, seen most often

in smokers, truck drivers, traffic police
20% COHb - headache, nausea, vomiting,
loss of dexterity
30% COHb - confusion & lethargy, possible
ECG changes
40-60% COHb - coma
60% + - usually fatal
Poison management = CO

Treatment
CO level means nothing to predict outcome
Length of hypoxia is the determining factor
Oxygen
HBO
No studies show benefit in treatment
 Reduction of CO

80

Room Air
60 100% Oxygen
3 ATM
% CO

40

20

0
0 20 40 60 80
Time in Minutes
Determine Burn Severity

% BSA involved
Depth of injury
Age
Associated/pre-existing
disease or illness
Burns to face, hands,
genitalia
 Difficulties with accurate initial
assessment of burn size & depth

Soot, blisters, adherent clothing or debris

obscure wound
Burns are dynamicProgression is always a risk
 Burn Extent

Total Body Surface Area (TBSA)?

Rule of nines
Lund and Browder chart
Patients palm = about 1% TBSA
Extent of Burn :Rule of Nines

Adult anatomical areas

= 9% BSA (or multiple)
Not accurate for infants
or children due to larger
BSA of head & smaller
BSA legs.
Burn diagrams illustrate
adult child differences
Lund &
Browder
Chart
 Extent of Burns

Patients palmar surface (hand + fingers) = 1% TBSA

Burn Depth

Factors
Temperature
Duration of contact
Dermal thickness
Blood supply
Special Consideration: Very young and
very old have thinner skin
 Burns begin at 44 degrees C

6 hours for burns to occur at

111 degrees F (44 C)

1 second of burns to occur at

140 degrees F (60 C)
 Time For Full Thickness
Burns To Occur In Scalds

5 seconds in water @ 140 F (60 C)

30 seconds in water @ 130 F (55 C)

5 minutes in water @ 120 F (49 C)

Pain control
Ice Pack-----DO NOT USE EVER

DOES NOT
Reverse temperature
Inhibit destruction
Prevent edema
DOES
Delay edema
Reduce pain
Non-medication methods

Cover burns with plastic wrap

Wet dressings will stick and cause more pain
Other burn dressings are expensive and not
necessary
Quik Clot is expensive and will not provide any
patient benefit
Medication

Medications
Opioids
Narcotics
Pain medications
IV Analgesia
Resuscitation
IV access

< 15% TBSA oral resuscitation

15 40% TBSA one large bore IV
> 40% -- two large bore IVs
IVs should be in the upper extremities
Suture IVs started through burns
Field resuscitation

Start IV with LR, through burn OK

< 6 years = 125mL/hr

6-13 years = 250mL/hr
>13 years = 500mL/hr


Contact


Contact Burn


Scald Burn


Flame Burn


Grease Burn

 ABA Burn Referral Criteria
The ABA identifies the following as injuries requiring a Burn Center referral:

2nd degree burns > 10% TBSA

Burns to face, hands, feet, genitalia, perineum, major joints
3rd degree burns
Electrical injury
Chemical burns
Inhalation injuries
Burns accompanied by pre-existing medical conditions
Burns accompanied by trauma, where burn injury poses greatest
risk of morbidity or mortality.
Burns to children in hospitals without pediatric services.
Patients with special social, emotional or rehabilitative needs.
 UWHC Burn Center
Verified by the American Burn Association
7 ICU beds
General care bed
expansion available as
needed
Open to all burns, all
ages, all times
Capability of providing
specialized care for all
patients, from pediatrics
to geriatrics
Full time Surgical
Staff, House Staff,
Nursing, Respiratory,
Occupational and
Physical Therapists,
Social Worker,
Nutritionist, Health
Psychologist, Child Life
and Pharmacist
 UWHC Burn Center
Verified by the American Burn Association
Closely integrated
inpatient, rehabilitation
and outpatient services
Outreach programs
Burn Support Group
Burn Camp
Burn Buddies
Juvenile Fire Starters
Program
School Reintegration
Burn Education to School
and Community Groups