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Burn and Scald

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 Burn & Scald
Etiology
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.

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 Types of burn injury

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

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Chemical burns

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 Types of burn injury
Electrical burns.
-severity depends on the type and duration of
current, and amount of voltage.
-difficult to assess, due to electrical insulator.

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 Types of burn injury
Radiation burns.
-sunburn or radiation treatment of cancer.
-involve outermost layers tends to be superficial.
-all function skin is intact.

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 Burn
• The depth of a burn is dependent on the
temperature of the burning agent and the length
of time.
• Tissue damage may occur at temperatures of
48°c.
• Irreversible damage to the dermis occurs at 70°.
• Burn injuries are described as:-
1.Superficial (first-degree burns)
2.Superficial or deep partial thickness (second-
degree burns).
3.Full thickness (third-degree burn)
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Burn:
Classification
1. Superficial
(first-degree
burns)

Involve only the

epidermal layer
of the skin.
sunburns are
commonly first-
degree burns.

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 1° burn

2° burn

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 Superficial burn (1° burn)

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Burn:
Classification
2. Superficial or deep
partial thickness
(second-degree burns).

Destruction of the
epidermis and varying
depths of the dermis.
Usually painful
because nerve endings
have been injured &
exposed.
Ability to heal because
epithelial cells is not
destroyed.

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 Partial thickness (2°burn)

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Burn:
Classification
Present of blisters indicates
superficial partial-thickness injury.
Blister may ↑size because
continuous exudation and collection
of tissue fluid.
Healing phase of partial thickness,
itching and dryness because
↑vascularization of sebaceous
glands, ↓reduction of secretions and
↑perspiration.

• Blister may ↑size because

continuous exudation and
collection of tissue fluid

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Burn:
Classification
3.Full thickness (third-degree burn)

Eschar may be formed due to surface

dehydration.
Black networks of coagulate
capillaries may be seen.
Need skin grafting because the
destroyed tissue is unable to
epithelialize.
Deep partial-thickness burn may
convert to a full-thickness burn
because of infection, trauma or
↓blood supply.

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3° burn

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Eschar:composed of
denatured protein

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Full thickness (3°burn)

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 PSEUDOMONAS

• General characteristics:
• Aerobic
• They are saprophytes, enjoying soil, water & other moist environments

• Members:
• Pseudomonas spp.
• Stenotrophomonas spp. (Stenotrophomonas maltophillia has ~60%
mortality in haem malignancies)
• Burkholderia spp. (cepacia complex)
• Ralstonia spp.

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Ps. aeuroginosa:

1) General:
very adaptable organism
can be very resistance to
ABx/disinfectants

Hospital infections:
localized e.g. CR UTIs, ulcers, bed
sores, burns, eye infections
bacteraemia in those who are
debilitated or
immunocompromised.
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ecthyma
gangrenosum
Black necrotizing
skin lesions

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 Pathopysiology
• Local tissue response
• Systemic response to burn injury.

Local tissue response

• Damage to skin from thermal injury cause tissue changes
know as zone of injury.
• If the heat is severe, a zone of coagulation is formed, in this
area protein has been coagulated and the damage is
irresversible.

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 Local tissue response
• Therefore, blood vessels are damage, resulting in
↓perfusion.

Zone of statis
• Poor blood flow and tissue edema will cause risk for
death over a few hours or days.
• Further necrosis can happen, because other factors
e.g dehydration and infection.
• Due to these wound have to be clean/care,
hydration and prevention of infection are essential
to limit further destruction.

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 Local tissue response
• Zone of hyperemia or inflammation is at the
outer edge of the burn.
• Here blood flow is ↑because of vasodilation.
• Vasodilation because of the release of
vasoactive substances.
• ↑blood flow brings leukocytes and nutrients
to promote wound healing.

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Zone of injury

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 Thermal injury Vasoactive substance

Vasodilatation
Inflammation & ↑blood flow

Leukocytes
& nutrient promote
healing
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Normal Vasodilatation

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 Systemic response to burn injury:
severe burn
• Every organ system is affected by a major
burn injury.
• Systemic changes known as burn shock
develop with a burn greater than 25% of
the total body surface area (TBSA)-major
burn injury.
• Damaged tissue released cellular
mediators and vasoactive substances.
• e.g., histamine, serotonin & prostaglandins

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 Systemic response to burn injury

• These substances induce a systemic

inflammatory response and cause
vasoconstriction & capillary permeability
• Vasoconstriction occur for a short period
due to vascular system attempts to
compensate for fluids loss.
• Vascular permeability, resulting in
hypovolemia and edema.
• This phase begins at injury, peaks in 12-
24 hours, and last for 48 to 72 hours
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Osmotic pressure ↓,
Due to protein plasma
Escape out to interstitial
•↓blood flow & hypovolemia Edema

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Intravascular
Normal

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Burn
Shock
First 24
hours

Burn
Shock
after 24
hours

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 Thermal injury

Inflammation

Histamine release

↑capillary permeability ↑Protein

Vasoconstriction
leakage
Fluids leakage and
↑blood pressure Loss from injury Hypoproteinemia
Site (edema)

↓intravascular fluid
↑blood flow to injury ↓Plasma osmotic
pressure 33
Hypovolemic shock
 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

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 Cardiovascular system
• Blood pressure falls-fluid leaks from
intravascular to interstitial (sodium and
protein)
• When blood pressure is low, pulse rate ↑.
• Blood flow in intravascular is concentrated
and cause static.
• Cardiac output ↓,
• Due to that tissue perfusion ↓,
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 Hematologic changes
• Some RBC is destroys to the burn injury.-
anemia
• Thrombocytopenia, abnormal platelet
function, depressed fibrinogen levels, deficit
plasma clotting factors.
• Life span ↓RBC.
• Blood loss during diagnostic and therapeutic
procedure.
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 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.

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 Factors determining inhalation injury or
potential airway obstruction

 Burns to face and neck

 Singed hairs, nasal hair, beard, eyelids or
eyelashes
 Intraoral charcoal, especially on teeth and gums
 Hoarseness
 Smell of smoke on victims clothes or on victim.
 Respiratory distress.
 Copious sputum production.

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Features of respiratory failure
Inability to speak due to dyspnea
Sweating
Apparent exhaustion/tired
Tachycardia
Tachypnea [R. Rate > 40 /min in adults ]

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 Management
Anaesthetic consultation
High flow oxygen
Tracheobronchial [ bronchoscopy]
Physiotherapy
Close monitoring [preferably ICU ]
Ventilatory support
Hemodynamic support, when required

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 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.
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 Urinary system
• Hypovolemic state, blood flow to kidney ↓,
causing renal ischemia.
• If this continues, acute renal failure may
develop.
• Full thickness and electrical burns, myoglobin
(from muscle breakdown) and heamoglobin
(from RBC breakdown) are released into the
bloodstream and occlude renal tubules.
• Adequate fluid replacement and diuretics can
counteract this obstruction.
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Myoglobinuria

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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.
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 Complications
Early
 Hypovolemia
 Fluid overload  Pulmonary dysfunction
 Renal dysfunction
 Hemoglobinuria  Local / systemic sepsis
 Stress gastroduodenal
ulcers

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 Complications
Late
 Scarring –hypertrophic,
keloid  Disfigurement
 Contractures – limbs,  Functional disability
neck  Posttraumatic stress

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 Extent of surface area burned
 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.

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Rule of nines

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 Lund and Browder
More precise method of estimating
Recognizes that the percentage of BSA of
various anatomic parts.
By dividing the body into very small areas and
providing an estimate of proportion of BSA
accounted for by such body parts
Includes, a table indicating the adjustment for
different ages
Head and trunk represent larger proportions
of body surface in children. 52
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 Lund and Browder chart
Age in years 0 1 5 10 15 Adult

A-head (back or 9½ 8½ 6½ 5½ 4½ 3½
front)

B-1 thigh (back 2¾ 3¼ 4 4¼ 4½ 4¾

or front)

C-1 leg (back or 2½ 2½ 2¾ 3 3¼ 3½

front)
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Emergency Disaster
in
Burn Related Cases

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 Prehospital patient management
Rescuers must ensure their own safety, ones
safety is establish:-
Eliminate the heat source.
Stabilizing the victim condition.
Identify the type of burn.
Preventing heat loss.
Reducing wound contamination.
Restrict jewelry and clothing is removed
Preparing for emergency transport.
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 Stop the burning process:Thermal
burns.
Stop the flame: extinguish the flame/lavage
with water.
Cool the burn
Do not used ice water for cooling it causes
vasoconstriction and may result in further
injury.
Cover the wound to minimize bacteria
contamination
Cover victim to prevent hypothermia.
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 Chemical burns
 Immediately remove the clothing and a hose or
shower to lavage the involved area for a minimum 20
minutes.
Electrical burns
-Serious harm to victim and rescuer.
-Ensure source of electrical has been disconnected.
-Use non conductive device to remove victim.
-If victim unresponsive, assess respiration and pulse.
-Commenced CPR (cardiopulmonary resuscitation) if no
pulse.
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 Radiation burn

Usually minor, involved epidermal layer of

skin.
Helping the normal body mechanism to
promote wound healing
Shielding, establishing distance.
Limit time of exposure to radioactive source.

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 Phases of treatment
 3 phases of treatment can be identified in
the care of the severely burned patient.
1. The emergent phase refers to the first 24 to
48 hours after a burn.
2. Acute phase
3. Rehabilitation phase.

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Burn bedspace

1. Plastic sheet top

2. bottom sterile Microdon sheeting
3. Caps, masks, sterile gloves, gowns
4. Intravenous fluids/equipment
5. Intubation equipment
6. Oxygen therapy
7. Cardiac monitoring
8. Catheter, syringes, needles
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 Isolation
Reverse Isolation is designed to prevent
transmission of microorganisms to patient.
Burn patient are protected from infection
from other patients, visitors, and health care
providers.
Universal precautions, apply to all burn
patients.
The minimum requirements: Universal
Precautions are……………..
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 Universal Precautions

1. All patients have a private room

2. Handwashing is required before entering and
after leaving the patient's room.
3. Gowns, gloves and masks,
4. Health care provider having URTI are not
allowed to enter room

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 Assessment Vital signs
History

Intravenous
Nasogastric line
tube
ER
Indwelling
Neurological
assessment
catheter
Physical
examination
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 Emergency department Management:
Emergent/immediate phase

1. Assessment
-Health history, how, when, duration of contact,
location, age, medical history.
2. Physical examination
 Respiration, patent airway, sign of inhalation injury.
 Listen for hoarsenes and crackle. Need intubation.
 Observe for upper body burned, erythema or
blistering of lips or buccal mucosa or pharynx
 Area of body burned-face, hands, feet, perineum. 65
 Emergency department Management:
Emergent/immediate phase

Cardiac monitoring, is indicated for cardiac

history, electrical injury or respiratory
problems.
Vital signs-BP, PR. For severe burn an arterial
catheter is used for blood pressure.
Large bore intravenous lines and an indwelling
urinary catheter are inserted to assess and
monitor fluid intake and output.
May assist in determining the extent of
preburn renal function and fluids status. 66
Emergency department Management:
Emergent/immediate phase

Nurse needs to know the maximal volume of

fluid the patient should receive.
Infusion pumps and rate controller are useful
devices for correctly delivery.
Insert nasogastric tube to remove gastric juice,
which can prevent aspiration and vomiting.
The neurologic assessment focuses on the
pateint`s levels of consciousness, psychologic s
status, pain, behavior and anxiety.
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 Support vital sign
If the patient has no pulse and not breathing,
begin CPR.
Establish airway-nasotracheal suction and
endotracheal intubation.-oxygen 100% via
face mask.
Connect to cardiac monitor and observe for
arrhytmia.
Pulse oximeter-assessment for patient oxygen
saturation.
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 Pulse oximeter
The pulse oximeter probe contains two
electrodes, which emit light of specific
wavelength through a cutaneous vascular bed,
such as that of the digits or the ear lobe.

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Pulse oximeter

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 Support vital sign; pulse rate
1. Following
a burn, tachycardia is inevitable,
 due to hypovolemia as a result of tissue trauma and pain.

2. A pulse rate lower than 120 beats/min

 usually indicates adequate volume.
 Whereas a pulse rate higher than 130 beats/min
 usually suggests inadequate resuscitation

3. Beware that in the elderly or those with

 preexisting heart disease, the heart rate may not be able to
increase in proportion to the stimulus.

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 Support vital sign
Continue assess heart output.
A minimal mean arterial pressure of
-90mmHg should be maintained for adequate
tissue perfusion.
If the patient is hemodynamically unstable,
-the extremities are burned or if frequent
measurement of arterial blood gases are
required, insertion of an arterial catheter may
be necessary.
Obtain Arterial blood gases, 72
carboxyheamoglobin.
 Arterial blood gases

PH ↓ 7.35-7.45

PCO2 ↑ 35-45 mmHg

PO 75-100mmHg

*To assess acid-base balance due

to a respiratory disorder, respiratory acidosis.
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 Support vital sign
Cover patient to maintain body temperature
and to prevent wound contamination
Initiate fluids replacement
Urine output, this is the single best monitor of
fluid replacement.
Weight should be measured daily, as changes
in weight from admission allow an
assessment of fluid balance

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 Insert Foley catheter
1.Foley catheter should be placed in all patients
undergoing resuscitation for severe burns and
in patients with smaller burns with a history of
difficulty voiding.
2. A loose-fitting catheter should be placed to
prevent urethral stricture.
3.The catheter should remain in place
throughout resuscitation.
4. Acceptable values are 0.5ml/kg/hr in an adult
and at least 1ml/kg/hr in a child

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Summary; Emergent
phase

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 Emergency Management

Site

-Maintain clear airway

-Remove from source of injury
-Prevent ongoing thermal injury
-Keep others safe
-Arrange prompt transfer to Burns Unit

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 Emergency Management

Hospital Priorities
-Airway
-IV access – large bore peripheral line
-Analgesia – diluted opioids,
-intravenously, large bore.
Catheterise bladder
Investigations [ see box below]

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 Diagnostic test
Initial
Essential Optional
Full Blood Count CXR
Urea & electrolytes ECG
Blood sugar Carboxyhemoglobin
Grouping & typing ABGs
Urinalysis
Later
PCV until stable ABGs
Daily FBC
Daily urea , electrolytes
Swabs for culture &sensitivity
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 Emergency Management
History of accident
General Examination
Estimate the Area and the depth of the burn.
Look for signs of inhalational burns
• Stridor
• Respiratory distress
• Cough
• Sooty sputum
• Singed nasal hair
• Nasolabial burns
• Airway swelling
• Document all findings
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 Estimation of Total Body Surface Area
Burned [ TBSA]
Major Burns : >10 % BSA deep burn in a child
>25% BSA deep burn in an adult
All major burns WILL need parenteral fluid
resuscitation , since the main cause of early
mortality is Burns Shock.

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 Pathophysiology:
Fluids replacement

A. Four major processes are thought to contribute to the major

loss of intravascular fluid.

1. change in microvascular membrane integrity

2. change in tissue forces

3. cellular shock

4. evaporative losses

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 B. Changes in microvascular integrity

1. Following a burn there is a massive release

of inflammatory mediators.

2. Histamine is released early, which increase

capillary permeability

3. Polymorphonuclear leukocytes adhere to the

endothelium.
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 C. Changes in tissue forces

1.The capillary leak causes fluid and plasma

proteins to shift from the intravascular
to the interstitial space.
2. This causes hypoproteinemia, decreased
intravascular osmotic pressure and increased
interstitial osmotic pressure.
3.Edema results when the volume of interstitial
fluid exceeds the capacity of the lymphatics
to remove it.

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 E. Evaporative Losses
Additional evaporative losses through the
burn wound can be between 4 and 20 times
greater than normal and persist until
complete wound closure is obtained.

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 Fluids resuscitation
Lactated Ringer’s (LR) solution is the most
popular resuscitation fluid used.
There are numerous formula that can be used
for fluid resuscitation.
No fluid resuscitation formula has proven to
be superior.
All formulas are only a starting point.
Administered fluids through 2 large bore
needle.
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 Fluids resuscitation
Fluid prescription for adults commonly uses
the Parkland Formula which is:
4cc X weight (kg) X %TBSA burn = cc’s for 1st
24 hours (Ringer's Lactated)
 First half of this total is administered over the
first 8 hours,
And the second half over the next 16 hours.
Over 24 hours, >30% burn, provide 5%
dextrose
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 Example: Parkland
• 4cc X weight (kg) X %TBSA burn
• 4cc x 50kg x25% = 5000cc

5000 ÷ 500mls = 10 bottles.

• 50% to be administer = 2500 cc x 8 Per hours ~
312.5cc.
• Second half to be administer = 2500cc x 16
hours.
Per hour~156.25cc
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 Fluids resuscitation; Over 24 hours

4cc X weight (kg) X %TBSA burn

4cc x 50kg x25% = 5000cc
5000cc of Ringer's Lactated + 5%
Dextrose water.

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 Fluids resuscitation

Calculate fluid deficit and decide fluid

requirement
2 types of fluids –Crystalloids and Colloids

Crystalloids [e.g. –Ringer’s Lactate]

-Several formulas: Evans, Brookland etc.
3 – 4 ml / Kg. bodyweight / % Burn during the
first 24 hours,
-half of which is to be given in the first 8 hrs
[from the time of injury] 90
 Crystalloid Solutions
Plasma 0.9% Saline Ringer’s
lactate
Na 141 154 130 mEq/L
Cl 103 154 109 mEq/L
K 4-5 -- 4 mEq/L
Ca/Mg 5/2 -- 3/0 mEq/L
Buffer Bicarb. -- Lactate (28) mEq/L
(26)
pH 7.4 5.7 6.7
Osmolality 289 308 273
(mosm/kg)
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 Colloids [e.g. Human Albumin Solution ]

1.Proteins in plasma generate osmotic pressure

and serve to maintain the intravascular
volume.
-The administration of colloid compensates for
this protein lost.

2. Early infusion of colloid solutions may

decrease overall fluid requirements and
reduce edema. However, excessive use of
colloid risks pulmonary complications.

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 Colloids

3.Guidelines for adding colloid to crystalloid

regimen:
a. patients with burns less than 30% TBSA do
not usually require colloid
b. patients with burns greater than 30% TBSA
should receive colloid eight hours after injury
c. patients with inadequate urine output
d. colloid is administered by adding 50g of
albumin to each liter of crystalloid
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 Rate of infusion
 Adult formula: Fluid  if shock present give bolus
first 24 hours = 4cc x % of fluid until perfusion
restored
total body surface x
body weight (one half in
first 8 hours)  then use constant rate,
adjusting as needed
after 10 to 12 hrs.

 gradually decrease infusion

rate to avoid excess edema
while maintaining perfusion

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 Intravenous Access

A peripheral vein catheter through nonburn

tissue is the route preferred for fluid
administration.
A central line or pulmonary artery line is only
occasionally needed to monitor the patient
during the initial resuscitation period and is
removed as soon as it is no longer needed.
The possibilities for intravenous access are:

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 Choices For Access

 First choice: Peripheral vein; nonburn

area

 Second choice: Central vein; nonburn

area

 Third choice: Peripheral vein; burn

area

 Worst choice: Central vein; burn area

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 Choices For Access
Central venous access

1. subclavian vein- most desirable site due to

lowest infection rate
2. internal jugular vein
3. femoral vein

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 Interventions:Ineffective airway
clearance

• Baseline assessments respiratory status.

• Chest x-ray, ABG, vital signs.
• Intubation for burns of chest, face or neck.
1. Maintain the head of the bed at 30°.
2. Turn patient side to side every 2 hours to
prevent hypostatic pneumonia.

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 Ineffective airway clearance

Encourage coughing and deep breathing

exercise promote airway clearance of mucus
and fibrin.
Chest physiotherapy - via percussion and
vibrations, assists with bronchial drainage
Positioning - patients are shaken and turned
side to side every two hours to aid in secretion
mobilization
Early ambulation - allows adequate air
exchange in lung regions that are normally
hyperventilated while the patient is 99
 Ineffective airway clearance

To keep airway clear, suction the client

frequently, removes accumulated secretions
that cannot be removed by spontaneous
cough.
Caring of patient with nasotracheal tube
placement and orotracheal-more than 3
weeks tracheostomy performed.
Aseptic procedure for suctioning.
Patients should be hyperoxygenated with
100% oxygen prior to suctioning. This should
not be continued for more than 15 seconds
without further oxygenation.
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 Ineffective airway clearance

• Medication to dilate constricted bronchial

passages.-via intravenous/inhalants to control
bronchospasms and wheezing.
• Proper positioning to ↓the work of breathing
and promote chest expansion.
• Ensure adequate tissue oxygenation-pulse
oxymeter.
• Oxygenation therapy, ↓oxygenation
saturation.
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Burn victim

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Endotracheal tube

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Tracheostomy

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