Module Overview

This main purpose of developing this module is for the academic purpose, i.e., for the partial
fulfillment of the Master in nursing 2 nd year curriculum. This module deals with the
introduction of the burn, its causes, classification, pathophysiology, types, classification
(according to depth/degree of injury), complications, management i;e emergency
management, therapeutic management (minor burn management and major burn
management) and nursing management. The module has two sessions; the first session deals
with the review of anatomy and physiology of integumentary system with burn injury
introduction and the second session deals with therapeutic and nursing management as well
as its prevention.

Burn injuries are among the most devastating of all injuries and a major global public health crisis.
Burns are the fourth most common type of trauma worldwide, following traffic accidents, falls, and
interpersonal violence. Approximately 90 percent of burns occur in low to middle income countries.
Burns are 2nd most common injury among children in rural Nepal accounting 5% of
developmental disabilities. Smoking & Fire-related burns are generally more common in
colder climates. Specific risk factors include cooking with open fires or on the floor.
Immediate management is needed for preventing the complications.

So with the aim of preventing morbidity & mortality related to burn injury, this module has
been prepared for the nursing staffs (staff nurse), working in hospital, especially for those
working in emergency & burn ward staffs who had to deal with emergency cases of burn
injury. This module aims is to increase knowledge about burn injury and their management
(Therapeutic & Nursing).

Session plan
1
 Session: 1
S.N Specific Objectives Time Teaching Teaching Learning Evaluation
Duration Learning Media methods
Method
Pre-test 10 Written test
minutes (SAQ)
At the end of the session the
participants will be able to
1. review the anatomy of 10 Discussions LCD What are the
integumentary system minutes and interactive integumentry
lecture organs?

2. explain the function of skin 3 minutes What are

LCD, whiteboard the functions
+marker of skin?
3. describe about the epidermal 2 minutes whiteboard + What are the
derivatives marker, LCD epidermal
derivatives?

What are the

explain about burn, its causes, 40 causes,
5. classification, signs & minutes Whiteboard + classification
symptoms, pathophysiology, marker, LCD pathophysiol
local & systematic responses ogy, local &
systematic
responses of
burn?

S.N Specific Objectives Time Teaching Teaching Evaluation

Duration Learning Learning methods
Method Media
Post test of session one 10 Minutes Review the
anatomy &
physiology
of
integumenta
ry system,
with burn
pathophysiol
ogy.
At the end of the session the
participants will be able to:

1. explain the emergency 5 minutes Interactive LCD + What is the

management of burn injury lecture & Whiteboard + emergency
Discussion Marker management
of burn
injury?

2
2. explain the therapeutic 20 minutes LCD + What is the
management of burn injury whiteboard + therapeutic
marker management
of burn
injury?
3. explain the nursing management of 10 minutes LCD+ What is the
burn injury Whiteboard + nursing
marker management
of burn
injury?
5. describe the complications & 5 minutes LCD + What are the
prevention of burn injury Whiteboard+ complicatio
marker ns &
Prevention
of burn
injury?
6. post-test of session 1 & 2 10 Written test
minutes (SAQ)
Session: 2

Background
Skin as a coat of armor for the human [Link] a burn injury occurs, it causes a break in
the skin and may subsequently cause an infection if it is not treated appropriately or the right
away Burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity,
chemicals, friction, or radiation. Burns can also occur as a result of self-harm or violence
between people. Burn injuries are among the most devastating of all injuries and a major
global public health crisis. Burns are the fourth most common type of trauma worldwide,
following traffic accidents, falls, and interpersonal violence. Approximately 90 percent of
burns occur in low to middle income countries, regions that generally lack the necessary
infrastructure to reduce the incidence and severity of burns (Haagsma, JA; Graetz, N;
Bolliger, 2016).

3
Most burn injuries occur in a domestic setting, with cooking as the most common activity.
Pediatric burns occur more commonly in the home (84%) and while children are
unsupervised (80%) (Peck, D.M, 2016).

Sepsis is an independent risk factor of mortality in the burned patient. This is a diagnostic
challenge because the signs of sepsis (ie, elevated temperature, tachycardia, tachypnoea, and
leukocytosis) may be present in the burned patient without underlying infection so regular
monitoring of burn wounds allows for early recognition of infection. Prolonged inpatient stay
is one of the strongest risk factors for the development of colonization or infection, as longer
hospitalizations increase the potential exposure to other colonized or infected patients and to
environmental contamination. Large burn injuries are another strong risk factor, as open
wounds are known to harbor bacteria (Fonseca, A.J, 2016).

This module’s aim is to build up knowledge, understanding and skills associated with
management of burn injury among specific nursing staffs, so that the mortality/morbidity of
any presenting child with burn injury in the health facilities can be prevented.

4
SESSION 1: Anatomy and Physiology of Integumentary
System
Introduction

The skin is the largest organ of the body in service area and weight. In adults the
skin covers an area of about 2 square meters and weights 4.5 to 5kg. Its thickness
is 0.5mm to 4.0mm, depending on location.

The skin and its derivatives (hair, nails, sweat and oil glands and the specialized
nerve receptors for sensation) make up the integumentary system.

FUNCTION OF THE SKIN:

The skin has several important functions, including sensation, thermoregulation,
protection and synthesis of vitamin D.

Regulation of body temperature

Receptors in the skin monitor temperature and transmit impulses to central

control mechanisms in the hypothalamus. The hypothalamus is a region of the
forebrain that co-ordinates the autonomic nervous system, including the control of
body temperature, thirst, hunger and other homeostatic systems.

Thermoregulatory mechanisms occurring in the skin include insulation, sweating

and control of blood flow. The body is insulated by subcutaneous adipose tissue.
The skin is also provided with an abundant blood supply, which aids
thermoregulation.

The body’s core temperature has to remain constant to maintain homeostasis. In

response to high environmental temperature or heavy exercise the evaporation of
sweat from skin surface helps an elevated body temperature to normal. In
response to low temperature production of sweat is decreased, which helps
conserves heat. Change in flow of blood also helps to regulate the body
temperature.

Mechanisms used for heat loss from body are

5
 radiation evaporation

conduction convection

Thermoregulatory mechanisms are immature in children and their large body

surface area increases the risk of hypothermia.

6
a. Protective function: The skin covers the body and provides a physical barrier that
protects underlying tissues from abrasion, bacterial invasion, dehydration, and UV
radiation.

b. Vitamin D synthesis: Vitamin D is synthesized by the skin as a consequence of

the exposure of the skin to UV light. Synthesis of vitamin D begins with
activation of precursor molecule in the skin by UV rays. Enzymes in liver and
kidney then modify the molecules producing calcitriol (the most active form of
vitamin D). Vitamin D is necessary for controlling the amount of calcium and
phosphorus that is absorbed through the small intestine and mobilised from the
bone.

Vitamin D is a hormone since it is produced in one location, transported by blood

and then exerts its effect in another location. For this reason skin can be

7
 considered as endocrine organ.A deficiency of vitamin D can lead to rickets in
children and osteomalacia in adults.

c. Sensation: This contains abundant nerve endings and receptor that detect external
stimuli such as cold, heat, pain, touch and pressure. It is supplied with
approximately one million nerve fibres, most of which end in the face and
extremities (hands and feet).

d. Excretion: this helps to remove heat and some water from body. Sweat also act as
vehicle for loss of a small amount of ions and several organic compounds.

e. Immunity: certain cells of epidermis are important component of immune system.

f. Blood reservoir: the dermis houses extensive network of blood vessels that carry
8% to 10%of total blood flow in resting adult.

Human skin is made up of different layers with its epidermal derivatives:

 Epidermis

8
  Dermis

 Subcutaneous layer.

1. Epidermis:

It is composed of keratinized stratified squamous epithelium that contain four

principal types of cells.

Keratinocytes- About 90% of the epidermis cells are keratinocytes(this produce

keratine). Melanocytes- contains 8% of epidermal cells (this produce pigment
melanin that contributes to color and absorbs UV rays

Langerhans cells- these arise from bone marrow and migrates to epidermis.
These interact with WBC called helper T cells in immune responses and are
easily damaged.

Merkel cells are also found within epidermis. Langerhans cells are involved in the
immune response and Merkel cells function in the sensation of touch. The
epidermis is avascular and is dependent on blood vessels of the dermis for
oxygenation, metabolite provision and removal of metabolic waste products.

The epidermis is made up of several layers. These layers represent the different
stages of maturation of the cells and their movement from the stratum basale up to
the stratum corneum, where they are shed. The epidermis renews itself through
cell division in its deepest layer. These layers are:

i. Stratum basale:It consist of a single layer of columnar epithelium which is

adhered to the basal [Link] is the deepest layer of epidermis, also known as the
stratum germinativum. Nutrition is supplied from the underlying capillaries of the
dermis. The stratum basale also contains tactile discs that are sensitive to touch.

ii. Stratum Spinosum: Overlying the basal cell layer is a layer of the epidermis that
is 8-10 layers of polyhedral cells that fits closely together which act like bridge
between cells. When cells move into this layer, they shrink apart when the tissue
is prepared for microscopic examination. Long projection of the melanocytes
which take in melanin by phagocytosis of these melanocyte projection.

9
 Keratinization begins in the stratum spinosum and continues in the stratum
granulosum.

iii. Stratum Granulosum: This consists of three to five layers of flattened cells that
develops darkly staining granules of a substance called [Link]
compound is the precursor of keratin. Keratin molecules assemble and forms a
barrier to deeper layers from injury and microbial invasion and make skin
waterproof.

iv. Stratum Lucidum: The stratum lucidum more apparent in the thick skin, such as
the palms of the hands and soles of the feet. This layer contains three to five layers
of clear, dead keratinocytes that are flattened and made up of large amounts of
keratin and thickened plasma membranes. The stratum lucidum lies between the
stratum granulosum and the stratum corneum and provides some degree of
waterproofing to the skin.

v. Stratum Corneum: It is the uppermost layer and consist of 25-30 layers of

flattened, dead cells completely filled with [Link] cells are continually shed
and replaced by cells from deeper strata. This layer serves as

Dermis

The dermis lies below the epidermis and above the subcutaneous layer, and is
responsible for providing nutrients and physical support to the epidermis. The
dermis contains lymph vessels, nerve endings, hair follicles and glands. The
dermis is composed of two layers:

Reticular region

This id deeper portion of dermis. It consists of dense, irregular, connective tissue

containing interlacing bundles of collagen and some coarse elastic fibers are
occupied by hair follicles, nerves, oil glands, the ducts of sweat gland and small
quantity of adipose tissue. Due to varying thickness of reticular region thickness
differs. The combination of collagen and elastic fibers in the reticular region
provides the skin with strength, extensibility and elasticity.

Papillary layers
10
The papillary layer is the superficial portion of dermis and consists one-fifth of the
thickness of total layer. Its surface area is greatly increased by small fingerlike
projections called dermal papillae. Some dermal papillae contains tactile
receptors called corpuscles of touch and the nerves endings that are sensitive to
touch.

Subcutaneous layer

It is the bottom layer of skin, also known as hypodermis. This layer is made up
mainly of fat, or adipose tissue. The adipose tissue acts as cushion i.e. it acts as a
sort of shock absorber, protecting underlying organs from injury. It also functions
to insulate the body to maintain body temperature.

Blood and lymph vessels: Arterioles from a fine network with capillary branches
supplying sweat glands, sebaceous gland, hair follicles & dermis. Lymph vessels
form a network throughout the dermis.

EPIDERMAL DERIVATIVES

Organs that develops from the embryonic epidermis are

Hair

Hair is the growth of epidermis and found all over body surfaces. These are made
of dead, keratinized epithelial cells no any blood vessels or nerves present.
Primary function is protection. It consists of a shaft (above scalp) and a root
(portion below scalp).Root is surrounded by hair follicle. At the base of each
follicle is an enlarged layered structure that is bulb.

Growth – growth through a growth cycle that consist growth stage and a resting
stage. In growth stage hair is formed by cells of matrix and in resting stage the cell
matrix is inactive and the hair follicles atrophies. After this new cycle begins

Colour -Hair colour is determined by the type of melanin produced (yellow,

brown or black). With ageing melanocytes become less active and melanin is
replaced with air bubbles, which gives hair white appearance.

11
Glands

Several types of glands are associated with skin. They are sebaceous gland,
sudoriferous gland, ceruminous glands and mammary glands.

Sebaceous gland- Oil glands that secrets sebum that is mixture of fats, cholesterol
protein and inorganic salts. This prevents drying, becoming brittle, excessive
evaporation of water and makes skin soft. The secreting portion of glands lies in
dermis and opens into necks of hair follicles or directly onto a skin surface. Sebaceous
glands unconnected with hair follicles occur along the margin of the lips, in the
nipples, in the glans and prepuce of the penis, and in the labia minora. This is absent
in palm and soles.

Sudoriferous gland - This is the plateform for three to four million sweat glands
empty their secretion

Sweat glands- There are 2 types of sweat glands in skin: apocrine and eccrine.

Apocrine glands are epitrichial because they have a duct that opens into a hair
follicle. Apocrine glands are largely confined to the axillary and perineal region and
do not become functional until just after puberty.

Eccrine glands are simple, coiled, tubular glands usually extending into the papillary
dermis. Eccrine glands are atrichial because their duct opens onto the skin surface
independently of a hair follicle. Eccrine glands are found over the entire body surface,
except the margins of the lips, eardrum, inner surface of the prepuce, and glans penis.

Nails

They are derived from the same cells of epidermis & consist of hard, horny
kertain plates. They protect the tips of the fingers & toes. The nail plate is the
exposed part that has grown out from the germinative zone of the epidermis called
the nail bed. Finger nails grow more quickly than toe nails & growth is quicker
when the environmental temperature is high.

12
 BURN INJURY

Introduction

Injuries that results from direct contact with or exposure to any thermal, chemical,
electrical or radiation sources as termed as burns.

Burn injury usually attributes to the extreme heat but many also results from
exposure to cold.

Even burn involves large body surface area but in pediatrics and geriatrics
population often benefits from treatment in specialized burn centers.

Thermal injuries are 3rd most common cause of accidental deaths in children.
Burns are 2nd leading cause of injuries in age between 1 to 14years and most
occurs at home.

Following patterns of burn are common

Hot water scalds- most common in toddlers

Flame related burns- older children

10% to 20% child abuse related to burns

Children playing with lighter or matches account 1 in 10 houses fires.

Burns in children have higher mortality because they have:

 Thin and highly sensitive skin

 large body surface area
 Immature immune system
 Limited physiological reserves
 Significant metabolic and systemic disturbance
 Increased fluid requirement

HISTORY

Health professionals have been treating children with burns for millennia. However,
pediatrics as a separate specialty only came about in the early part of the 20th century, and
burn units only started to appear at the time of the Second World War. Medical advances
13
over the past three decades have resulted in declining mortality and shorter periods of
hospitalization for children with burns when treated in a specialist burns unit (Janzekovic
1970, Herndon and Blakeney 2007). From this time, it was also realised that morbidity was
reduced if occupational therapists, physical therapists, dieticians, psychologists and social
workers became an integral part of burns care, thus the advent of the first true
multidisciplinary burns team. Guillaume Dupuytren (1777–1835) who developed the degree
classification of burns Cave paintings from more than 3,500 years ago document burns and
their management. The earliest Egyptian records on treating burns describes dressings
prepared with milk from mothers of baby boys, and the 1500 BCE Edwin Smith Papyrus
describes treatments using honey and the salve of resin. Many other treatments have been
used over the ages, including the use of tea leaves by the Chinese documented to 600 BCE,
pig fat and vinegar by Hippocrates documented to 400 BCE, and wine and myrrh by Celsus
documented to 100 CE French barber-surgeon Ambroise Paré was the first to describe
different degrees of burns in the 1500s. Guillaume Dupuytren expanded these degrees into six
different severities in 1832.
The first hospital to treat burns opened in 1843 in London, England and the development
of modern burn care began in the late 1800s and early 1900s. During World War I, Henry
D. Dakin and Alexis Carrel developed standards for the cleaning and disinfecting of burns
and wounds using sodium hypochlorite solutions, which significantly reduced mortality.
In the 1940s, the importance of early excision and skin grafting was acknowledged, and
around the same time, fluid resuscitation and formulas to guide it were developed. In the
1970s, researchers demonstrated the significance of the hypermetabolic state that follows
large burns.

Epidemiology

An estimated 2, 65,000 deaths every year are caused by burns and the vast majority
occurs in low and middle income countries .Nonfatal burn injuries are leading cause
of morbidity. Burns occurs mainly in home and is preventable. In India over 1000000
people are moderately or severely burnt every year (WHO fact sheet, 2014).

It is estimated that over half a million children are hospitalized with burn injuries per
year in the world, with the majority occurring in low to middle income countries in
Asia and Africa (Burd and Yuen 2005). Low socio-economic status of the family and
low educational level of the mother are the main demographic factors associated with
14
 a high risk of burn injury (Ahuja and Bhattacharya 2004, Van Niekerk et al. 2004).
Other factors associated are: high population density, high levels of household
crowding, absence of water supply and psychological stress within the family.
Children who were not the biological son or daughter of the head of the household are
also at increased risk for burns (Delgado et al. 2002). Non-accidental burn injury (i.e.,
abuse) is present in a higher proportion of families with a single parent, a younger
mother, a low income or an unemployed parent (Brown et al. 1997). Many children
with non-accidental burns have a higher incidence of previous notifications for
suspected abuse or neglect to child protection agencies (Andronicus et al. 2009).

Causes of burn injury:

1. Thermal burn: Majority of burns results from contact with thermal agents such
as flames, hot surfaces, or hot liquids.

a. Scald burn: This type of burn caused by contact with moist heat (water or oil)
and steam. The most common hot liquids are liquid foods such as hot water, tea,
coffee, milk. It is common in toddlers because of curiosity they pull hot water,
spills hot cup of tea or may enter into a tub of hot water.

b. Flame burns: This type of burn is the 2ndcommon cause of burn and a leading
cause of mortality among children. During playing with lighter, candles, matches
or open fire in winter seasons or from fireworks during festivals.
c. Contact with hot objects: This type of burn is occurs due to direct contact with
stove, heater, cylinder of motorbike, cigarettes smoking in bed and un-
extinguished cigarettes etc.
d. Cold exposure (frostbite): Frostbite is a severe, localized cold-induced injury due to
freezing of tissue. Immersion foot (also referred to as trench foot) is a nonfreezing cold
injury (NFCI) that may also cause tissue loss and long-term sequelae. Milder forms of
injury include frostnip and pernio:

Frostnip refers to cold-induced, localized paresthesias that resolve with rewarming. There is
no permanent tissue damage.

Pernio, or chilblains, is characterized by localized inflammatory lesions that can result from
acute or repetitive exposure to damp cold above the freezing point. Lesions are edematous,
often reddish or purple, and may be very painful or pruritic. Pernio is most common in young
15
women, but both sexes and all age ranges may be affected. Damage occurs to the skin and
underlying tissues when ice crystals puncture the cells or when they create a hypertonic tissue
environment. Blood flow can be interrupted, causing hemoconcentration and intravascular
thrombosis with tissue hypoxia

2. Electrical burns: Devastating injury caused by high voltage electrical contact.

These burn injuries are common in toddler and adolescent, specially associated
with risk taking behaviour of the boys, i.e., when playing with electrical out let,
extension cords, touching high tension wires and using electrical appliance.
Young children may poke objects in electrical outlets, bite or suck connected
electrical cord.

This type of burn injuries may lead to cardiac arrhythmias, cardiac arrest and
unexpected falls with resultant factures. Direct contact with high or low voltage
current, as well as lightning strikes, is the most frequent mechanism of injury.

3. Chemical burn: Most chemical burns are seen in paediatric population and can
cause extensive injury. Because of the curious nature, children are exposed with
the different kinds of household chemical products. A variety of common
household products, especially cleaning products contains noxious agents which
may cause localized damage as well as systemic toxicity. Contact burns may
occur due to heated liquids as Tars.

The severity of the injury is related to the chemical agent as acid, alkali or organic
compound and duration of contact. The mechanism of injury differs from other
burns in that there is a chemical disruption and alteration of the physical
properties of the exposed body area.

4. Radiation burn: This type of burn due to prolonged exposure to ultraviolet rays
(UV) of the sun or to other sources of radiation, such as x-ray or gamma radiation
therapy for cancer. Damage may occur due to exposure to ionizing radiation.

Characteristics of burn injuries

The severity of burn injuries is assessed on the basis of percentage of total body
surface area (TBSA) burned and depth of the burn.

16
 Among school age and younger children a burnt that is 10% TBSA can be life
threatening if not treated correctly. Other factors for seriousness of the injury are

 Location of the wound

 Child’s age and general health
 Causative agent
 Presence of respiratory involvement
 Any associated injury or conditions

Classification of Burn Injury

Traditionally the terms 1st degree, 2nd degree and 3rd degree have been used to describe
the depth of tissue injury. Currently these has been replaced by more descriptive term
based on the extent of destruction of the epithelializing elements of the skin with the
current emphasis on wound healing.

A. According to depth/degree of burn injury

1. Superficial (1st degree) Burn
2. Partial thickness (2nd degree) burn
3. Full-thickness (3rd degree) burn
1. Superficial Burn Injuries (1st degree Burn)

This usually involves epidermal layer that followed by erythema in latent phase
and usually minor in nature. There is minimal tissue damage with no blistering.
Protective function of skin remains intact and systemic effects are rare. Healing
takes place after several days without scarring. Pain is a predominant symptom.
Burn injury heals within 5 to 10 days without scarring.

Eg Mild sunburn

2. Partial-thickness (Second degree) Burn:

This type of injuries results involves epidermis and varying degree of the dermis.
Wound are painful, moist, red and [Link] these burn injuries, some portion of
the skin appendages remains viable, allowing epithelial repair of the burn wound
without skin grafting.

Types

17
 a) Superficial partial-thickness burn involves the epidermis and
superficial (papillary) dermis, dermal elements are intact. Wound heals
within 14 to 21 days with varying degree of scarring. These burns
appear pink, moist, and soft. These wounds are very sensitive to
temperature change, exposure to air and even to light touch.
b) Deep partial-thickness burnsalthough classified as 2nd degree deep
thermal burns resemble full thickness injuries in many respects except
that sweat glands and hair follicles remains intact burn may appear
mottled, pink, red or waxy white area exhibiting blisters and edema
formation. It is less painful than superficial partial thickness burns.
Systemic effect may present as in full thickness burn.
Healing- many wounds may occurs spontaneously and may extend
beyond 21 days with extensive scarring.

Because these burns have less capacity for re-epithelializing, a greater potential
for hypertrophic scar formation exists. Splash scalds often cause second-degree
burn

3. Full-thickness (Third degree) burn

These are serious injuries that involve the entire epidermis and dermis and extend
into subcutaneous tissue. The capillary network of the dermis is completely
destroyed. The nerve endings, hair follicles and sweat glands, are destroyed. Color
varies from red to tan, waxy white, brown, or black and is distinguished by dry
leathery appearance.

Full-thickness burns lack sensation in the area of injury because of the destruction
of nerve endings. However, most full-thickness burns have superficial and partial-
thickness burned areas at the periphery of the burn where nerve endings are intact
and exposed. So as the peripheral fibers regenerate, painful sensations return and
children often experience severe pain related size and depth of the burn.

Full thickness injuries are not capable of re-epithelialization so requires surgical

excision and grafting to close the wound.

Fourth degree burn

18
 Fourth-degree burns cause full-thickness destruction of the skin and subcutaneous
tissue and also involve the underlying structures as fascia, muscle, bone.

The wound appears dull and dry, and ligaments, tendons, and bone may be
exposed.

These injuries require extensive debridement and complex reconstruction of

specialized tissues and invariably result in prolonged disability. Fourth-degree
burns result from prolonged exposure to the usual causes of third-degree burns.

B. According to extent of burn Injury

The extent of burn is expressed as a percentage of the total Body Surface Area
(TBSA).Various methods are used to estimate the TBSA affected by burn.
Among them are
o Lund and Browder
o Palm method
o Rule of nine only for older children

The extent of burn injury is expressed as a percentage of the TBSA (Total Body
Surface Area). Various methods are used to calculate the extent of burn injury.

a) Modified Rule of Nine: The "rule of nines" is a practical technique for estimating
the extent of TBSA involved in a burn injury of adult. This approach divides the
major anatomic areas of the body into percentages of TBSA.
For the adult, it allots 9% of the TBSA to the head and neck and to each upper
extremity, 18% each to the anterior and posterior portions of the trunk, 18% to
each lower extremity, and 1% to the perineum and genitalia.
But there is small difference between TBSA of the adult and infant as the size of
the infant's head (18%), which is proportionally larger than that of the adult, and
the lower extremities (14%), which are proportionally smaller than those of the
adult.

b) Lund-Browder Chart: Lund-Brower charts with age-appropriate diagrams can

be used to better estimate the area of burn injury in children. It gives the exact
percentage at different age groups in different parts of the body. It subdivides
body areas into segments and assigns a proportionate percentage of body surface
to each area based on age. Rather than being viewed as a whole, the lower
19
 extremities is divided as foot, leg and thigh. As the child grows the lower
extremities assume more body surface area; the head becomes relatively smaller
compared with the rest of the body. First-degree burns are not included in the
calculation of burn size.

c) Rule of hand/Palm method: Child’s own one hand surface with closed finger,
amounts to 1% (approximately) of body surface area and this can be used for
calculation the extent of burn injury.

d) 100 minus burned area: In very extensive burns it is sometimes easier to

calculate the unburned area & then subtract this from 100.

A. According to the severity of burn injury

The severity of burn injury depends on:
 The extent, depth, and location of burn injury
 age of patient
 etiologic agents involved
 presence of inhalation injury

20
 Co-existing injuries or preexisting illnesses.

The American Burn Association has used these parameters to establish guidelines
for the classification of burn severity.

1. Major Burn Injury:

Major burn injury includes:

 Partial-thickness burns involving more than 25% of TBSA in adults or 20% of

TBSA in children younger than 10 years or adults older than 50 years, or
 Full-thickness burns involving more than 10% of TBSA, or
 all burns involving the face, eyes, ears, hands, feet, or perineum that may result in
functional or cosmetic impairment and burns caused by caustic chemical agents,
high-voltage electrical injury, burns complicated by inhalation injury or major
trauma; or burns sustained by high-risk patients (those with underlying
debilitating diseases).

2. Moderate Burn Injury:

Moderate burn injury includes:
 Partial-thickness burns of 15-25% of TBSA in adults or 10-20% of TBSA in
children or older adults, or
 Full-thickness burns involving 2-10% of TBSA that do not present serious threat
of functional or cosmetic impairment of the eyes, ears, face, hands, feet, or
perineum.
 This category excludes high-voltage electrical injury, all burns complicated by
inhalation injury or other trauma, and burns sustained by high-risk patients.

3. Minor Burn Injuries:

Minor burn injury includes:

 burns involving less than 15% of TBSA in adults or 10% of TBSA in children or
older persons, and
 full-thickness burns involving less than 2% of TBSA that do not present a serious
threat of functional or cosmetic risk to eyes, ears, face, hands, feet, or perineum.

21
 Severity Grading System Adopted by the American Burn Association

Minor Moderate Major

Partial <10% of the >10% to 20% of >20% of TBSA

thickness Burn TBSA TBSA

Full-thickness <2% of the 2-10% of TBSA >10% of TBSA

Burn TBSA

Signs and symptoms

The characteristics of a burn depend upon its depth. Superficial burns cause pain lasting two
or three days, followed by peeling of the skin over the next few days. Individuals suffering
from more severe burns may indicate discomfort or complain of feeling pressure rather than
pain. Full-thickness burns may be entirely insensitive to light touch or puncture. While
superficial burns are typically red in color, severe burns may be pink, white or black. Burns
around the mouth or singed hair inside the nose may indicate that burns to the airways have
occurred, but these findings are not definitive. More worrisome signs include: shortness of
breath, hoarseness, and stridor or wheezing. Itchiness is common during the healing process,
occurring in up to 90% of adults and nearly all children. Numbness or tingling may persist
for a prolonged period of time after an electrical injury. Burns may also produce emotional
and psychological distress.

Layers Appearanc Healing

Type Texture Sensation Prognosis Example
involved e Time
Heals well Repeated
Superficia
Red without sunburns increase
l (1st- Epidermis Dry Painful 5–10 days
blisters the risk of skin
degree)
cancer later in life
Extends Redness
Superficia
into with clear Local
l partial
superficia blister. Very less than infection/cellulitis
thickness Moist
l Blanches painful 2–3 weeks but no scarring
(2nd-
(papillary with typically
degree)
) dermis pressure.

22
Deep Yellow or
Extends Scarring,
partial white. Less Pressure
into deep Fairly contractures (may
thickness blanching. & 3–8 week
(reticular) dry require excision and
(2nd- May be discomfort
dermis skin grafting)
degree) blistering.
Prolonged Scarring,
Full Extends Stiff and
(months) contractures,
thickness through white/brown
Leathery Painless and amputation (early
(3rd- entire No
incomplet excision
degree) dermis blanching
e recommended)
Extends
through
entire Amputation,
skin, and Black; significant
Requires
4th-degree into charred with Dry Painless functional
excision
underlyin eschar impairment, and, in
g fat, some cases, death.
muscle
and bone

PATHOPHYSIOLOGY

The local and systemic inflammatory response to thermal injury is extremely

complex, resulting in both local burn tissue damage and deleterious systemic
effects on all other organ systems distant from the burn area itself. Although the
inflammation is initiated almost immediately after the burn injury, the systemic
response progresses with time, usually peaking 5 to 7 days after the burn injury.
Much of the local and certainly the majority of the distant changes are caused by
inflammatory mediators. Thermal injury initiates systemic inflammatory reactions
producing burn toxins and oxygen radicals and finally leads to peroxidation. The
relationship between the amounts of products of oxidativemetabolism and natural
scavengers of free radicalsdetermines the outcome of local and distant tissue
damage and further organ failure in burn injuries. The injured tissue initiates an
inflammation-induced hyperdynamic, hypermetabolic state that can lead to severe
progressive distant organ failure

Local Response

Cellular Damage: Irreversible cellular damage from protein denaturation occurs

at temperature exceeding 45 degree centigrade. Three zones of injury were
described by Jackson in 1947, which demonstrate the evolution of local tissue

23
damage, i.e., the zone of coagulation, the zone of stasis and the zone of
hyperemia.

The central area of the burn wound, that having the most intimate contact with the
heat source, is characterized by coagulation necrosis of the cells. Therefore, it is
termed the zone of coagulation.

Extending peripherally from this central zone of coagulation lies a labile area of
injured cells with decreased blood flow, which under ideal circumstances may
survive, but which more often than not undergo necrosis in the ensuing 24 to 48
hours following injury. This zone has been designated as the zone of stasis. Lying
farther peripherally is the zone of hyperemia, which has sustained minimal injury
and which will recover over a period of seven to ten days.

The implications of these zones is that improper wound care and resuscitation may
lead to extensive injury. The likelihood of survival depends on optimizing
resuscitation. Improper fluid management may extend the zone of stasis and cause
conversion into the zone of coagulation.

Fluid shift and edema formation: Thermal injury to the vessels in the two outer
zones results in increased capillary permeability. At the same time, vasodilation
causes an increase in hydrostatic pressure within the capillaries. The increased
hydrostatic pressure, combined with the increased capillary permeability, causes
loss of water, protein, and electrolytes from the circulating volume in the
interstitial spaces. In addition, there are changes in the permeability of cells in and
around the burned area that result in an abnormal exchange of electrolytes
between cells and interstitial fluid: especially, sodium enters the cells in exchange
for potassium, resulting in further depletion of intravascular sodium.

Fluid Loss: Burn injured skin is more permeable to fluid, and evaporative water
loss can be calculated approximately as 4000ml/m2 of total body surface area.

The loss is maximum approximately at the 4 th day after injury but continues to
pose problems until the denuded surface are grafted or healed.

Circulatory status: Significant circulatory alteration takes place in the zone of

stasis located around the dead coagulated tissue. Heated red blood cells become
spherical in shape. These heat-damaged cells, together with hemo-concentration
24
 from fluid shifts, depressed cardiac output and tissue edema, reduce the flow of
blood into the burned area, resulting in capillary stasis. Thrombi develop which
further impedes circulation and produces tissue ischemia and necrosis.

Hyperviscosity and impaired blood flow also leads to release of thromboplastin

and clot-activating factors from damaged cells, which cause the production of
microemboli, platelet adhesion and aggregation, and increased pain and edema.

Burn wound: In superficial first-degree injuries, tissue damage is minimal,

protein loss is insignificant and edema is barely perceptible. Burning sensation
and pain resolve in 48-72 hours, and in 3-6 days the damaged epithelium peels off
in small scales or sheets, leaving no scar.

In partial thickness burn there is considerable edema and more severe capillary
damage. With reasonable care, the injury heal spontaneously in approximately 14
days with minimal scarring.

Deep thermal burn heals more slowly by regeneration from the epithelial lining of
skin appendages, sweat glands and hair follicles. A thin epithelial covering
develops in 25 to 35 days, but this type of burn may require several months to
heal, where scarring is common, and infection or trauma may easily convert the
wound to full-thickness burn injury.

Cell destruction by coagulation necrosis occurs in full-thickness burns. Dead

tissue and exudate convert to a thick leathery eschar in 48 to 72 hours; the eschar
liquefies and begins to separate in 12 to 21 days if nor surgically excised. The
dead avascular tissue provides an ideal environment for bacterial growth. If tissue
is not grafted, new granulation tissue forms on the wound bed. The wound heals
slowly by proliferation from the edges, with a high risk of infection and severe
scarring.

Systemic Response
The release of cytokines and other inflammatory mediators at the site of injury has
a systemic effect once the burn reaches 30% of total body surface area.

Cardiovascular changes: Capillary permeability is increased, leading to loss of

intravascular proteins and fluids into the interstitial compartment. Peripheral and
splanchnic vasoconstriction occurs. Myocardial contractility is decreased, possibly
25
due to release of tumor necrosis factor α. These changes, coupled with fluid loss
from the burn wound, result in systemic hypotension and end organ hypo-
perfusion.
Capillary permeability with leakage of fluid takes place both in uninjured and
burn areas. Together with shrinkage of drying eschar, severe edema due to rapid
shift of fluid to the interstitial space may produce a tourniquet effect, resulting in
compartment syndrome.

Hematological changes: Another systemic response is anemia, caused by direct

heat destruction of red blood cells, hemolysis of injured red blood cells, and
trapping of red blood cells in the microvascular thrombi of damaged cells. A long-
term decrease in the number of red blood cells may occur as a result of increased
red blood cell fragility.

Respiratory changes: Inflammatory mediators cause bronchoconstriction, and in

severe burns respiratory distress syndrome can occur.

Renal changes: Loss of fluid from the intravascular compartment causes renal
vasoconstriction that in turn leads to reduced renal plasma flow and depressed
glomerular filtration (GFR) resulting oliguria. When adequate fluids are provided,
the GFR returns to normal, and by 3 rd or 4th day, urinary output increases as edema
fluid is mobilized and eliminated.
Blood urea nitrogen and creatinine levels are elevated as a result of tissue
breakdown, decreased circulating volume and oliguria.

Gastrointestinal Changes: As a result of alteration in blood flow, perfusion in

gastrointestinal tract and liver is decreased. Gastric acid production is initially
suppressed for 43-72 hours after injury and then surpasses to normal level.
Following a major burn injury, gastric ileus may occur, the stomach dilates, with
digestion virtually ceasing.

Metabolic changes:The basal metabolic rate increases up to three times its

original rate. This, coupled with splanchnic hypoperfusion, necessitates early and
aggressive enteral feeding to decrease catabolism and maintain gut integrity.

Immunological changes:Non-specific down regulation of the immune response

occurs, affecting both cell mediated and humoral pathways.

26
SESSION 2: MANAGEMENT OF BURN INJURY

A. Emergency management of Burn Injury

The initial management of the burn patient begins at the scene of injury.

 In case of flame burns the first priority is to stop the burning process
o Place the child in the horizontal position and roll in a blanket, rug or similar
article, with care taken not to cover the head and face because of danger of
inhalation of toxic fumes.
o If nothing is available the victim should lie down and roll over slowly to
extinguish the flames. Remaining in the vertical position may cause the hair to
ignite or the inhalation of flames, heat or smoke.
 Major burn with large amounts of denuded skin should not be cooled. Heat is
rapidly lost from burned areas, and additional cooling leads to drop in core body
temperature and potential circulatory collapse.
 Wet dressings also promote vasoconstriction because of cooling, resulting in
impaired circulation to the burned area and increased tissue damage.
 Chemical burns require continuous flushing with large amounts of water before
transport to a medical facilities. The use of neutralizing agents is contraindicated
because of risk of initiation of chemical reaction that may further damage the
injury.
 If the chemical is in the powder form, the addition of water may spread the caustic
agent. So the powder should be brushed off if possible.
 The burned clothes should be removed to prevent further damage from the
smoldering fabric and hot beads of melted synthetic materials.
 Jewelry should also be removed to eliminate the transfer of heat from the metal ad
constriction resulting from edema formation.
 Assess the victim condition
o As soon as the fire is extinguished the victim should be assessed. Airway,
breathing and circulation are the primary concern.
o Cardiopulmonary complications may results from the exposure to the electric
current, inhalation of the toxic fumes and smoke, hypovolemia and shock.
 Cover the burn

27
o The burned wound should be covered with a clean cloth to prevent contamination,
decrease pain by eliminating air contact, and prevent hypothermia.
o No attempts should be made to treat the burn. Application of topical ointments,
oils, or other home remedies is contraindicated.
 Transport the child to the medical aid
o The child with extensive burn should not be given anything by mouth to avoid
aspiration in the presence of paralytic ileus and upper airway edema and to
prevent water intoxication.
o The child should be transported to the nearest medical facility
o If this cannot be accomplished within a relatively short period, IV access should
be established, if possible, with a large-bore catheter.
o Oxygen should be administered if available, at 100%.
 Provide reassurance to the child and the family.

B. Therapeutic Management of Burn Injury

Assess:

 A: Airway
 B: Breathing: beware of inhalation and rapid airway compromise
 C: Circulation: fluid replacement
 D: Disability: compartment syndrome (edema pressure, tissue damage, loss of
body function).
 E: Exposure: percentage area of burn

a. Management of Minor Burn

 First- and second-degree burns less than 10% TBSA may be treated on an
outpatient basis.
 These outpatients do not require a tetanus booster or prophylactic penicillin
therapy.
 Children who are not current with immunizations should have their immunizations
updated.
 The wound should be cleansed with a mild soap and tepid water. Debridement of
the wound includes removal of any embedded debris, chemicals and devitalized
tissue.
28
 Removal of intact blisters remains controversial. Some authorities argue that
blisters provide a barrier against infection; others maintain that blister fluid is
effective medium for the growth of micro-organisms. However, blisters should be
broken if the injury is due to chemical agent to control absorption.
 The wound should be covered with an anti-microbial ointments to reduce the risk
of infection and to provide some form of pain relief.
 The dressing should consist a non-adherent fine mesh-gauze placed over the
ointment and a light wrap of gauze dressing that avoids interference with
movement.
 Dressings should be changed once daily, after the wound is washed with
lukewarm water to remove any cream left from the previous application.
 Very small wounds, especially those on the face, may be treated with bacitracin
ointment and left open.
 Debridement of the devitalized skin is indicated when the blisters rupture.
 Burns to the palm with large blisters usually heal beneath the blisters, with close
follow-up on an outpatient basis.
 Pain control should be accomplished by using acetaminophen with codeine 1 hour
before dressing changes.
 Systemic antibiotics should be used only when there is signs of infection.
 Wounds that appear deeper than at initial assessment or that have not healed by 21
days may require a short hospital admission for grafting.

b. Management of Major Burn

1. Establishment of adequate airway :

• The first priority of care is airway maintenance.

• Examination of an oral and nasal membranes that reveals edema, hyperemia and
blister or evidence of trauma to the upper respiratory passages all suggest
inhalation of noxious agents or respiratory burns, if there is evidence of
respiratory involvement , 100% Oxygen should be administered and blood gas
values including carbon monoxide( toxic) levels, are determined.

• If the child exhibits sign of respiratory distress, an ET tube is inserted to

maintain the airway.

29
• When severe edema of the face and neck is anticipated, intubation is performed
before swelling make tube placement difficult or impossible.

• When full thickness burn encircle the chest, constricting eschar may limit chest
wall excursion and ventilation of the child becomes more difficult. Escharotomy
of the chest relieves this constriction and improves ventilations.

2. Fluid resuscitation:
 The objectives of fluid therapy are to:
• Compensate for water and sodium losses to traumatized area and the interstitial
space,
• Re-establish sodium balance,
• Re-store circulating volume,
• Provide adequate perfusion,
• Correct acidosis, and
• Improve renal function.
 Fluid replacement is required during the first 24 hours because of fluid shifts that
occurs after the injury.
 Various formulas are used to calculate fluid needs. Parameters such as vital signs
(especially heart rate), urine output, capillary filling and state of sensorium
determine the adequacy of fluid resuscitation.
 Crystalloid Solutions are used during initial phase (1 st 24 hour) of fluid
resuscitation therapy.
 Parkland formula is commonly used to determine the fluid needed for
resuscitation of burns greater than 15-20% TBSA.
 In 1st 24 hour:-The total amount of calculated fluid requirement is- 4ml of RL/Kg
of body weight/% of TBSA burned.
o One half amount of the calculated fluid is given over the first 8 hours, calculated
from the time of injury.
o The remaining half is given at an even rate over the next 16 hours.
 In next 24 hour: - The fluid requirement is calculated as: 2ml of RL per kg of
body weight per % of TBSA burned.
 Pulse and blood pressure should return to normal, and an adequate urine output (1
mL/kg/hr) should be accomplished by varying the intravenous infusion rate.

30
 Because of interstitial edema and sequestration of fluid in muscle cells, patients
may gain up to 20% over baseline pre-burn body weight.
 Patients with burns of 30% BSA require a large venous access (central venous
line) to deliver the fluid required over the critical first 24 hr.
 Patients with burns greater than 60% BSA may require a multi-lumen central
venous catheter; these patients are best cared for in a specialized burn unit.
 During the second 24 hour after the burn, patients will begin to reabsorb edema
fluid and to diuresis.
 Controversy exists as to whether colloid should be provided in the early period of
burn resuscitation.
 One preference is to use colloid replacement concurrently if the burn is greater
than 85% total BSA. Colloid is usually instituted 8-24 hour after the burn injury.
 Adequacy of resuscitation should be constantly assessed using vital signs, blood
gases, hematocrit, and protein levels.
 Some patients require arterial and central venous lines, particularly if undergoing
multiple excisions and grafting procedures as needed, for monitoring and
replacement purposes.
 Femoral vein cannulation is a safe access for fluid resuscitation especially in
infants and children.
 Burn patients who require frequent blood gas monitoring benefit from radial or
femoral arterial catheterization.
 Albumin (5%) infusions may be used to maintain the serum albumin levels at a
desired 2 g/dL. The following rates are effective:
o for total BSA burns of 30-50%, 0.3 mL of 5% albumin/kg/% BSA burn is infused
over a 24-hr period;
o for total BSA burns of 50-70%, 0.4 mL/kg/% BSA burn is infused over 24 hr; and
o for total BSA burns of 70-100%, 0.5 mL/kg/% BSA burn is infused over 24 hr.
 Packed red cell infusion is recommended if the hematocrit falls below 24%
(hemoglobin ≤8 g/dL).
 Sodium supplementation may be required for children having burns greater than
20% BSA, if 0.5% silver nitrate solution is used as the topical antibacterial burn
dressing.
 Oral sodium chloride supplement of 4 g/m2 burn area per 24 hr is usually well
tolerated, divided into four to six equal doses to avoid osmotic diarrhea.
31
 The aim is to maintain serumsodium levels over 130 mEq/L and urinary
sodiumconcentration over 30 mEq/L.
 Intravenous potassium supplementation is supplied to maintain serum potassium
level over 3 mEq/dL.
 Potassium losses may be significantly increased when 0.5% silver nitrate solution
is used as the topical antibacterial agent or when aminoglycoside, diuretic, or
amphotericin therapy is required.
 Oral supplementation may start as early as 48 hour post burn. Milk formula,
artificial feedings, homogenized milk, or soy-based products can be given by
bolus or constant infusion through a nasogastric or small bowel feeding tube.
 As oral fluids are tolerated, intravenous fluids are decreased proportionately in an
effort to keep the total fluid intake constant.

3. Medicine

• Antibiotics are usually not administered prophylactically. The administration of

systemic antibiotics to control wound colonization is not indicated, because
decreased circulation to the injured area prevents delivery of the medication to the
areas of the deepest injury.

• Surveillance culture and monitoring of the clinical course provide the most
reliable indicators of developing infection. Appropriate antibiotics can then be
instituted to treat the identified organism.

• Some form of sedation and analgesia is required for the care of children.

• Morphine Sulphate the drug of choice for severe burn injuries. Continues infusion
and frequent administration of morphine is needed for pain management in burn.

• When combined, midazolam and fentanyl also provides excellent IV sedation and
analgesia to control procedural pain in children with burn.

• Dosage monitoring is essential because tolerance to opioids may develop.

• IV analgesics are most effective when they are administered just before the onset
of procedural pain.

• The short acting anesthetic agents, such as Propofol, Nitrous Oxide and ketamine
also are used to control procedural pain.

32
4. Management of Burn Wound
The objective of wound management include prevention of infection, removal of
devitalized tissue, and closure of the wound.

i. Primary excision-
• In children with large, full-thickness burn wounds, excision is performed as soon
as patient is hemodynamically stable after initial resuscitation.
• Early wound excision has significantly decreased the incidence of infection, and
threat of sepsis.

ii. Debridement-

• Partial thickness of wound require debridement of devitalized tissue to promote

healing.
• Debridement is very painful and require some type of analgesia before the
procedures.
• The medications given for pain needs to be readily available during this
procedure.
• Atarax and Benadryl are often needed for itching that occurs after whirlpool and
debridement. The itching become particularly bothersome as the burn heals.
• Hydrotherapy is used to cleanse the wound and involves soaking in a tub or
showering once or twice a day, for no more than 20 minutes. (The water acts to
loosen and remove sloughing tissue, exudate and topical medications.)
• Mesh gauze entraps the exudative slough and is readily removed during
hydrotherapy.
• Any loose tissue is carefully trimmed away before the wound is redressed.
• Daily dressing changes of the burn wound are recommended to allow for
inspection.

iii. Topical antibiotics:

 Topical antibiotics do not eliminate organism from the wound but can effectively
inhibit bacterial growth. To be effective, a topical application must be non-toxic,

33
 capable of diffusing through eschar, harmless to viable tissue inexpensive and
easy to apply.
 The commonly used topical antibiotics are:
• Silver nitrate 0.5%
• Silver sulfadiazine1%
• Mafenide acetate 10%
• Bacitracin
 Some topical agents are packaged and prepared on fine mesh gauze, which allows
ease of application.

iv. Biological skin coverings-

o Biologic skin covering covers and protect the wound from contamination, reduces
fluid and protein loss, increase the rate of epithelialization, reduce pain and
facilitate movement of joints to retain range of motion.
o Allograft (Homograft):
 is skin is obtained from human cadavers (dead human body) and processed by
commercial skin bank, is particularly useful in the coverage of surgically excised
deep partial-thickness and full-thickness wounds in extensive burns when
available donor site are limited.
 Donors are screened for communicable diseases, and skin is tracked much like
blood transfusions.
o Xenograft – from variety of species (pigs),
 is also commercially available. In large burn, the porcine xenograft is commonly
applied when extensive early debridement is indicated to cover a partial-thickness
burn;
 this provide a temporary covering for the wound until an available autograft can
be applied to the full-thickness area.
 These dressings are replaced daily or every 2-3 days.
 When applied to superficial partial-thickness injury, biologic dressings stimulate
epithelial growth and faster wound healing.

v. Synthetic skin covering

34
 Synthetic dressing are composed of variety of materials can be used very
successfully in the management of superficial partial thickness burns and donor
site.
 Ideally, the dressing should provide many of properties of human skin: adherence,
elasticity, durability, and homeostasis.

Vi. Permanent Skin Covering

 Permanent coverage of deep partial-thickness and full-thickness burns is usually

accomplished with a split thickness skin graft.
 This graft consist of epidermis and a portion of dermis removed from an intact
area of skin by special instrument- dermatome.
 Split-thickness skin grafts may be sheet graft or mesh graft.
 Sheet graft: A sheet of skin, removed from the donor site, is placed intact over the
recipient site and sutured in place; used in areas where cosmetic results are most
visible.
 Mesh graft: A sheet of skin is removed from the donor site and passed through a
mesher, which produces tiny slits in the skin and allow the skin to cover 1.5 to 9
times the area of the sheet graft.
 The donor site is dressed with synthetic wound coverings or fine-mesh gauze until
the dressing separates at 10-14 days when the wound is healed.
 Dressing are not changed on donor site to avoid damage to newly healed, delicate
epithelium.

vi. Artificial skin

 The development of integra, a product that allows the dermis to regenerate, has
produced a significant improvement in burn wound healing and decrease in scar
formation.
 It is a biologic two layer membrane made of collagen (a fibrous protein from
animal tendon and cartilage), and silicone rubber, which is applied to partial
thickness and full thickness burns.
 The silastic layer is peeled off after the dermis is formed.
 The application of artificial skin does not replace the grafting procedure, but it
prepares the burn wound to accept the ultrathin autograft.

35
 C. Nursing Management

 Assess
I. Airway
 Assess for airway patency.
II. Breathing
 Look-respiratory movement, respiratory rate, presence of cyanosis.
 Feel-Perform palpation and percussion
 Listen-Auscultation for normal air entry and breathing sounds equal bilaterally,
absence or addition of noises.
III. Circulation
 Look-Inspect for pallor and capillary refill time
 Feel
• Palpate pulse presence.
• Palpate pulse rate
• Palpate peripheral temperature
 Check-Blood pressure
IV. Disability
 Determine level of patient’s consciousness using AVPU assessment.
• A-Alert (confused/disoriented)
• V-Response to vocal stimuli
• P-Responds to painful stimuli
• U-Unresponsive
V. Exposure:
 Percentage area of burn /depth of burn should be estimated.

 Nursing diagnosis
 Impaired gas exchange related to inhalation injury, pain and immobility.
 Pain related to burn wound and associated treatments.
 Decreased cardiac output related to fluid loss and hypermetabolic state.
 Impaired tissue perfusion related to arrested blood circulation secondary to
decreased intravascular fluid volume
 Fluid volume deficit related to shift of fluid from intravascular to interstitial
tissues.
 Impaired skin integrity related to thermal injury.
36
 Altered nutrition: less than body requirements related to hypermetabolic state and
loss of appetite.
 Impaired physical mobility related to pain; impaired joint movement.
 Body image disturbance related to cosmetics and functional sequelae of burn
wound
 Fear and anxiety related to pain, treatments, procedure and hospitalization.
 Riskof infection related to loss of integrity of skin/injured skin and decreased
immunity
 Risk of development of contractures related to scarring of tissue, pain and
immobility.
1. Achieving adequate oxygenation and respiratory function
o Provide humidified 100% oxygen
o Assess the signs of hypoxemia (anxiousness, tachypnea, and tachycardia).
o Monitor respiratory rate, depth, rhythm.
o Note character and amount of respiratory secretions, report carbonaceous sputum
(carbon), tracheal tissue.
o Observe for signs of inadequate ventilation; monitor ABG and oxygen saturation.
o Keep intubations equipment, nearby and be alert for signs of respiratory
obstruction.
o Encourage coughing and deep breathing
o In moderate to severe inhalation Injury
 Initiate more frequent bronchial suctioning.
 Closely monitor vital signs, urinary output and ABGs.
 Administer bronchodilator treatments as ordered.
 Placed on Mechanical ventilation if needed.

2. Managing pain
A skilled pediatric pain service is invaluable to any burn centre. The service
should provide a 24-hour on-call service, and a twice daily pain rounds. Pain
scoring and ongoing assessment should be recorded hourly on observation charts
by nursing staff using appropriate tools. For very young children the FLACC
(Faces, Legs, Activity, Cry and Consolability) pain assessment tool is appropriate
(Manwaorren and Hynan 2003). For verbalizing four to eight year olds a good
tools is the FPS-R (Revised Faces Pain Scale) (Hicks et al. 2001). Finally for
37
 children older than eight, the self reporting VAS (Visual Analogue Scale) is very
useful (De Jong et al. 2005). Pain scoring is then utilized to identify and
communicate ongoing pain issues if modifications to medications are required.
Assess for signs of pain, such as irritability, crying, increase blood pressure,
decrease mobility and inability to sleep.

o Administer analgesics and/or sedatives to relieve pain either oral or IV according

to severity of pain.
o Opioids analgesics (mild to moderate) is the gold standard for burn pain. Usually
injection morphine 0.1mg/kg body weight 10 minutes prior to dressing, or oral
morphine 0.5 mg per kg of body weight is given 20-30 minutes prior to dressing
should be given.
o Regular NSAIDs should be given unless contraindicated.
o Maintain warmth and prevent chilling
o Provide diversional activities appropriate to age to distract from focus on pain.
o Teach simple relaxation techniques such as relaxation breathing.
o Provide Reassurance and empathy.
o Ensure an adequate sleep routine and establish good sleep hygiene as possible to
minimize sleep disturbances
3. Maintaining adequate tidal volume and unrestricted chest movement.
o Observe rate and quality of breathing.
o Encourage deep breathing and incentive spirometry.
o Place patient in Semi-Fowler’s position to permit maximum chest excursions
(movement)if there are no contra indicatory such as hypotension or trauma.
o Ensure that chest dressings are not constricting.
4. Supporting Cardiac Output
o Give fluids as prescribed
o Monitor vital signs-including apical pulse, central venous pressures, pulmonary
artery Pressures.
o Be cautious to the shock that occur shortly after a severe burn-Tachycardia,
hypothermia, hypotension,pallor, anuria, shallow respiration, etc.
o Take weight of patient daily.
o Place indwelling catheter in case of severe burn.

38
o Monitor and maintain intake and output strictly.

5. Maintaining Fluid and Electrolyte balance

o Replace the lost fluid. The half of the calculated fluid should be given within 8
hours and the remaining fluid within 16 hours.
o Maintain intake and output strictly.
o Prevent from dehydration.
o Sodium and potassium level in the blood should be monitored.
o Hyperkalemia and hyponatremia should be managed in time.

6. Provide wound care

o Provide wound care according to the protocol of the hospital.

o Apply silver sulfadiazine and T-bact.
o Masking, gloving, capping, hand washing should be done for wound care.
o Eschar should be removed.
o Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over
the first several days.

7. Preventing Infection

o Maintain aseptic technique, i.e., hand washing, gowning, capping and prevent
overcrowding of persons.
o Maintain sterile techniques during dressing.
o Observe burn wound with each dressing change; assess drainage for odor, color,
amount and necrosis.
o Apply appropriate antibiotic locally (Silver Sulfadiazine) on the wound, or
systematic antibiotics if prescribed.
o Assess wound for pain, inflammation, and surrounding erythema.
o Observe for sign of toxemia such as fever, tachycardia, vomiting, oliguria and
report immediately.
o Obtain sterile culture as ordered.
o Ensure appropriate and adequate nutrition. Provide food rich in vitamins, proteins,
iron etc.
o In all cases, administer tetanus prophylaxis.

39
o High wash of the ward should be performed on interval basis.

8. Prevent Contracture

o Encourage range of motion exercises, ambulation and positioning to minimizing

joint and skin contracture.
o Apply splints to aid joint positioning and decrease skin contracture
o Arrange for early surgical release of contractures before they interfere with
growth. Apply pressure garments to aid circulation , protect newly healed skin
and prevent and treat hypertrophic scar formation
o Encourage the use of pressure garments as long as 12-18 month after injury until
the healed skin is matured.
o Medicate for pain before therapy or exercise.
o Use play opportunity to help the child accept therapy regimen
o Burn scars on the face lead to cosmetic deformity, ectropion and contractures
about the lips. Ectropion can lead to exposure keratitis and blindness and lip
deformity restricts eating and mouth care. Consider specialized care for these
patients as skin grafting is often not sufficient to correct facial deformity.

9. Provide adequate nutrition

o Patient’s energy and protein requirements will be extremely high due to the
catabolism of trauma, heat loss, infection and demands of tissue regeneration.
o If necessary, feed the patient through a nasogastric tube to ensure an adequate
energy intake.
o Anaemia and malnutrition prevent burn wound healing and result in failure of skin
grafts. So insure the diet have good amount of vitamin and mineral, particularly
Vitamin B, C, Iron and Zinc to promote wound healing and growth.
o Nutritional requirement: Maintain nutritional status by providing calories need
according to TBSA burned.
• Calorie need=60kcal/kg+35kcal/TBSA%
• Protein need=3g/kg+1g/TBSA%
o Monitor nutritional status through weight gain, wound healing, serum transferrin
and serum albumin.

40
10. Preserving Positive Body Image

o Encourage the patient to express concerns regarding changes in self-image or life-

style that may result from burn injury.
o Offer reassurances: if children express feeling of fear with bandages, scars or
pressure garments.
o Treat the child with warmth and affection and encourage parents to provide their
continuous love.
o Encourage early contact with peers, or family members
o Suggest psychiatric consultation for anticipatory guidance
o Positively reinforce appropriate, and effective coping mechanisms.
o Advice parents that returning to home and community and separation from the
hospital environment may produce anxiety in the child's coping. Discuss a plan for
issue of social reentry and perception of friends.
o Initiate family consult with plastic surgeon about future scar revision
o Encourage the older children to engage in long term follow up to address the issue
of concern such as cosmetic surgery or a visit with burn cosmetic specialist or
other rehabilitation options.

11. Reducing fear and anxiety

o Explain procedure, surgeries, and treatments to the child and parents according to
level of understanding.
o Allow the child to express fears through play activities.
o Encourage parents to stay with a young child as much as possible.
o Encourage family involvement with treatment plan and self-care activities.

12. Discharge Teaching

o The home care needs of the family should be addressed long before the child is
ready for discharge. Discharge teaching focus on;

• Nutrition and diet requirements.

• Daily dressing changes and skin care
• Application of splint.
• Daily range of motion exercises to prevent from contractures.
• Prevention of exposure from sun.
41
 • Protection of the burned area from further injury.
• Signs of infection and action to be taken.

COMPLICATIONS OF BURN INJURY

Thermally injured children are subject to a number of serious complications, both from
the wound and from systematic alterations resulting from the injury. The immediate threat
to life is related to airway compromise and profound shock.

During healing, infection- both local and systemic sepsis is the primary complication.
Mortality associated with thermal trauma in children increases with the severity of injury
and decreases as age advances/. In children older than 3 years, the mortality rate is similar
to that of adults. Below this age, the survival rate with burns and their associated
complications lessen considerably.

A less apparent respiratory injury is inhalation of carbon monoxide. Carbon monoxide

has a greater affinity for hemoglobin than does oxygen, thereby depriving peripheral
tissues and oxygen-dependent organs (such as heart and brain). Treatment for either of
these two problems is 100% oxygen, which reverses the situation rapidly.

Pulmonary problems are a major cause of fatality in children with either thermal burns or
complications in the respiratory tract. Respiratory problems include inhalation injuries,
aspiration in unconscious patients, bacterial pneumonia, pulmonary edema, pulmonary
embolus, post-traumatic pulmonary insufficiency, and atelectasis. The most common
cause of respiratory failure in the pediatric age-group is bacterial pneumonia, which
require prolonged intubation and sometime necessitates a tracheostomy.

A less common complication is pulmonary edema resulting from fluid overload or acute
respiratory distress syndrome (ARDS) in association with gram negative sepsis. The
syndrome results in pulmonary capillary damage and leakage of fluid into the interstitial
space of the lung.

PREVENTION OF BURN

We can't keep kids free from injuries all the time, but these simple precautions can reduce the
chances of burns in our home:

42
In General

 Keep matches, lighters, chemicals, and lit candles out of kids' reach.
 Put child-safety covers on all electrical outlets.
 Get rid of equipments and appliances with old or frayed cords and extension cords
that look damaged.
 If we need to use a humidifier or vaporizer, use a cool-mist model rather than a hot-
steam one.
 Choose sleepwear that's labeled flame retardant (either polyester or treated cotton).
Cotton sweatshirts or pants that aren't labeled as sleepwear generally aren't flame
retardant.
 Make sure older kids and teens are especially careful when using irons, flat irons, or
curling, straight irons.
 If anyone smokes, don't smoke in the house.
 Don't use fireworks or sparklers.

Bathroom

 Set the thermostat on our hot water heater to 120°F (49°C), or use the "low-medium
setting." A child can be scalded in 5 seconds in water if the temperature is 140°F
(60°C).
 Always test bath water with our elbow before putting our child in it.
 Always turn the cold water on first and turn it off last when running water in the
bathtub or sink.
 Turn kids away from the faucet or fixtures so they're less likely to play with them and
turn on the hot water.

Kitchen/Dining Room

 Turn pot handles toward the back of the stove in every cook.
 Block access to the stove as much as possible.
 Never let a child use a walker in the kitchen (and health experts strongly discourage
using walkers at all).
 Avoid using tablecloths or large placemats because youngsters can pull on them and
overturn a hot drink or plate of food.
 Keep hot drinks and foods out of reach of children.
43
  Never drink hot beverages or soup with a child sitting on our lap or carry hot liquids
or dishes around kids. If we have to walk with hot liquid in the kitchen (like a pot of
soup or cup of coffee), make sure where kids are.
 Never hold a baby or small child while cooking.
 Never warm baby bottles in the microwave oven. The liquid may heat unevenly,
resulting in pockets of breast milk or formula that can scald a baby's mouth.
 Screen fireplaces and wood-burning stoves. Radiators and electric baseboard heaters
may need to be screened as well.
 Teach kids never to put anything into the fireplace when it is lit. Also make sure they
know the glass doors to the fireplace can be very hot and cause a burn.

Outside

 Use playground equipment with caution. If it's very hot or cold in outside, use the
equipment only in the morning or afternoon.
 Remove our child's safety seat or stroller from the hot sun when not in use because
kids can get burns from hot vinyl and metal. If we must leave our car seat or stroller
in the sun, cover it with a blanket or towel.
 Before leaving our parked car on a hot day, hide the seat belts' metal latch plates in
the seats to prevent the sun from hitting them directly.
 Don't forget to apply sunscreen when going outside. Use a product with the SPF of 15
or higher. Apply sunscreen 20-30 minutes before going out and reapply every 2 hours
or more often if in water.
 Try to keep infants under 6 months of age out of the sun.

Prevention measures either active or passive. In general passive measures such as legislation
are more effective. However, in the pediatric age group it has been shown that there is a lot of
interest & enthusiasm for learning about burn prevention & first aid. Therefore primary &
secondary prevention directed towards school children can be very beneficial.

To maintain an impact prevention measures should be at both community & national level &
reviewed regularly. Getting children involved at an early age through schools or
communities, by designing posters, performing short activities such as stop drop & roll etc is
important. Removing children from direct threats has also demonstrated a positive impact.

44
45
46
Pre- test/Post- test
Circle the right answer.
Part 1: Related to anatomy and physiology

1. Main layer of the skin is…………………

a. Dermis & Epidermis

b. Epidermis, Dermis & Subcutaneous layer

c. Epidermis, Subcutaneous layers & Blood vessels

d. Dermis, Subcutaneous layers , Blood vessels & Nerve ending

2. Functions of skin are………………………

a. Protective, Thermoregulation & Sensation

b. Vitamin D synthesis, Absorption & Excretion

c. Psychological functions, Immunity & blood reservoirs

d. All above

3. Epidermal derivatives are…………………..

a. Hair, Nail & Lips

b. Nail, Glands & Dermis

c. Hair, Nail & Glands(Sebaceous, sudoriferous & sweat)

d. Dermis, Epidermis, Hair & Nail

Part 2: Related to disease

4. The main cause responsible for burn is

a. Premature & small baby

b. IUGR & macrosomia baby

c. Premature & IUGR baby

d. Infected & poor sucking baby

5. RDS’s important symptoms are:

47
 a. Barking cough, tachypnoes, inspiratory stridor, varying sign of respiratory
distress

b. Tachypnoea, central cyanosis, chest retraction, grunting

c. Poor air entry, retraction, tachycardia, low immunity

d. Dry cough, respiratory distress, apnoea, stridor

6. Surfactant is important for

a. Maintaint the lung functionable

b. Airway maturity

c. Term baby

d. Lung maturity & it prevent from completely lung collapse

7. Severe RDS should be managed by

a. NICU care

b. General care

c. Nursery care

d. Pediatric care

8. RDS is preventing by?

a. Pregnancy checkup

b. Regular pregnancy checkup, corticosteroid according to prescribed

c. Ultrasonogram, chest x-ray

d. Regular iron & folic acid taken during pregnancy period

9. Complications of RDS are

a. Apnea, hypoglycemia, fever

b. Apnea, bronchopulmonary dysplasia, tachycardia,ROP

c. Lung abscess, chronic cough, heart disease

d. Cyanosis, lethargy, poor feeding, apnea

48
49
 References
Datta, P. (2007). Pediatric nursing. New Delhi, India: Jaypee Brothers Medical Publishers
(P) Ltd.

1. Fonseca, A. J (2016). Burn Wound Infections Clinical Presentation Emory University

School of Medicine America. Retrieved on January 4th 2016, from
[Link]

2. Ghai, O.P.,& Paul, V.K. (Eds.). (2010). Ghai essential pediatrics (7thed.). India:
Thomas Press.

3. Grant, A. & Waugh, A. (2008). Ross and Wilson anatomy and physiology in health
and illness (10thed.). Philadelphia, USA: Elsevier’s Health Sciences Right
Department.
4. Hockenberry, M.J. & Wilson, D. (2009). Wong’s essentials of pediatric nursing
(8thed.). India: Elsevier, a division of Reed Elsevier India Private Limited.

5. Haagsma, JA; Graetz, N; Bolliger, 2016). "The global burden of injury: incidence, mortality,
disability-adjusted life years and time trends from the Global Burden of Disease study 2014." .
Injury prevention: journal of the International Society for Child and Adolescent Injury

Prevention. 22 (1): 3–18. doi:10.1136/injuryprev-2015-041616. PMC 4752630 .

PMID 26635210. Retrived on January 3rd 2017, from
[Link]

6. NHLBI Health Topics, [Link]

(Retrived on July, 13 2016).
7. Northway Jr, WH; Rosan, RC; Porter, DY (Feb 16, 1967). "Pulmonary disease following
respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia". The New
England Journal of Medicine ,(retrieved on15/7/2016)

8. Peck, D.M. (2016). Epidemiology of burn injuries globally retrived on January 4th 2017
from, [Link]

9. Shrestha, P. & Shrestha, L. Mortality and Morbidity Pattern of Preterm Babies at a Tertiary
Level Hospital in Nepal: Journal of Nepal Paediatric Society > Vol 33, No 3 (2013)
[Link] on 14/7/2016).

50
10. Haagsma, JA; Graetz, N; Bolliger, I (February 2016). "The global burden of injury: incidence,
mortality, disability-adjusted life years and time trends from the Global Burden of Disease
study 2013.". Injury prevention : journal of the International Society for Child and Adolescent
Injury Prevention. 22 (1): 3–18. doi:10.1136/injuryprev-2015-041616. PMC 4752630 .
PMID 26635210.

51