BURNS

INTRODUCTION
• Burns are tissue injuries resulting from direct
contact with a flame, hot liquids, and gases or
with surfaces, caustic chemicals (acids and
alkali), electricity or radiation.
• Most commonly, the skin is damaged which
compromises its function as a barrier to injury
and infection.
Causes
• Dry heat
• Moist heat
• Chemicals
• Lightening
• Electricity
• Friction
Types of burns
• Thermal burns (cold and hot)
• Electrical burns
• Chemical burns
• Inhalation burns
Classification of Burns
• The classification of burns is determined by the depth of
the tissue injured and the extent of the body surface
area involved.
• The depth gives the description of the physical
appearance of the burns and the extent indicates the
percentage of the body surface area that has been
damaged.
• The depth of tissue damage and the destruction of a
burn are indicated by the classification such as
superficial, partial thickness or full thickness.
i. Superficial Burns (First Degree Burns)
• These burns involve the destruction of only the
superficial layer of the epidermal tissue.
• They are characterized by a bright red
appearance (erytherma) there is no loss of the
epidermis and there are no blisters.
• The patient feels severe pain (hyperalgesia).
• Healing takes place between 2 – 10 days and the
result of healing is a normal skin without scarring.
ii. Partial Thickness Burns (Second Degree Burns)
• These burns involve the entire epidermal layer.
• The upper layers of the dermal cells remain undamaged.
• They are usually painful and blisters form due to the
separation of the epidermal and dermal layers caused by
collection of fluid.
• Healing takes places spontaneously between 10 – 14 days.
• The healing is normal with slightly pilled or poorly
pigmented skin.
• Skin grafting may be done at times to quicken recovery and
provide a protective cover on the wound surface.
iii. Full Thickness Burns (Third Degree Burns)
• These burns are characterized by the
destruction of the full skin thickness and its
appendages i.e. hair follicles, sebaceous
glands and underlying tissue e.g.
subcutaneous tissue.
• They appear white and waxy or charred and
do not change on capillary compression.
• Full thickness burns are not painful because of
the destruction of the sensory nerve endings
though the patient may complain of pain due
to the marginal tissue burn of the lesser depth
burnt.
• Spontaneous regeneration and replacement of
skin is not possible due to damage of the
whole skin and underlying tissues.
iv. Complicated Burns (Fourth Degree Burns)
• These burns involve the whole skin depth, underlying
fat tissue, muscle, tendons and even bones.
• This may result in a condition called compartment
syndrome, which threatens both the life and the limb
of the patient.
• Grafting is required if the burn does not prove to be
fatal and damaging marrow tissue.
• These burns are almost always fatal, and if the victim
does survive, will definitely require amputation.
The human skin
Pathophysiology
• The pathophysiology of burns may be divided into
four stages.
• These stages overlap each but in general they are
as follows;
i. Stage of neurogenic shock
ii. Stage of fluid loss
iii. Stage of infection and slough formation
iv. Stage of repair
Stage Of Neurogenic Shock
• This is the first stage in which there is flight, terror
and hysterical or tension reaction of the individual.
• There is a lot of pain produced by the irritation of a
thousand of nerve endings in the skin.
• The tension, terror and flight factors in this stage
precipitate the fall in blood pressure (hypotension)
to shock levels from which the patient may never
recover especially the young and the very old.
Stage Of Fluid Loss – Hypovolaemic Shock
• In this stage there are alterations in the vascular system.
• Immediately after a burn injury occurs, the capillary
permeability is altered especially in the regions of burns but
in severe or large burns, it affects the whole body.
• The plasma leaks out of the blood into the tissue.

• This leak is maximum during the first 8 hours after the burn
injury.
• Capillary permeability returns to normal
between 36 and 48 hours after the injury.
• Fluids containing water, sodium, chloride, and
colloids escape from the intravascular
compartment into the interstitial spaces creating
blisters and swelling called burn edema.
• In addition to fluid shifts and loss, the
destruction of cells and tissues is also
responsible for the loss of electrolytes.
• Systemic effects of this stage are;
 The sluggish blood flow caused by the plasma portion of
the blood which is escaping from the intravascular
compartment as blood becomes thick or
haemoconcentrated.
 The haematocrit rises because there is less fluid to dilute
the solid components of the blood.
 The sluggish blood flow results in a drop in the cardiac
output, decreased tissue perfusion and hypoxia.
 Haemoconcentration results into haemolysis which leads
to anaemia.
Stage of slough and infection formation
• This is the stage when the tissue devitalized by the burn
separates from the underlying viable tissue by the process
of liquefaction leaving a large open wound which is often
infected.
• The infecting organisms vary depending on the affected
body part.
• On the upper of the body, the likely organism to be found
are those from the nose and throat whereas on the lower
part are the colon bacilli.
• The infection is revealed gradually by fever.
NB: The burn wound itself is sterile immediately
after injury and it is soon colonised by bacteria,
the commonest of which are the gram positives
such as staphylococcus aureus and
streptococcus pyogens and gram negatives like
Klebsiella and pseudomonas.
Stage Of Repair
• This stage is divided into repair of the burnt area
and systemic repair;
a) Repair of the Burnt Area
• Repair of the burn wound left by the burn cannot
begin until the area is free from the sloughing
tissue.
• When the entire thickness of the skin has been
destroyed by the burn, repair begins at the edges of
the wound.
• This takes long in large burns and permits an
overgrowth of granulation tissue to occur.
• To minimize this excessive overgrowth of
granulation tissue, the burn wound is covered with
skin grafts.
• Sometimes the burn wound may be covered with
cadaver preserved in tissue banks.
• This provides an excellent temporally covering
which must be replaced by grafts from the patient’s
own skin.
• Xenografts (pig skin) provide another method
of temporal coverage.
• This biologic dressing is changed every third
day and may be used in conjunction with the
patient’s own skin (autograft).
b) Systemic Repair
• Systemic repair includes measures such as
blood transfusion to overcome the anaemia
that usually occurs in the later stages.
• The high calorie and protein diet adds in
replacing the nutritional elements lost from
the draining wound and decreased food intake
during the acute phase of the condition and
treatment.
Clinical features
• Pain: This is usual but is most marked in superficial
burns because the sensory nerve endings in the
skin are exposed.
• Blisters: These result from the collection of fluid
between the epidermis and the dermis and is
common in superficial burns.
• Acute circulatory failure: This is present when the
burns are extensive and occurs due to massive loss
of body fluids.
Emergency room management of a burnt client
Pre admission preparation
• Once notified of admission of a severely burnt
patient, preparation includes assembling of
equipment and preparation of a special area or
room for the patient.
• Patient must be admitted to a burn unit and
the following emergency items should be
mobilised;
Catheterisation tray, Intravenous solutions,
Sterile gloves, Bed cradle, Clean bed linen,
Tracheostomy set, Suctioning and oxygen
therapy equipment, Blood withdrawing syringes
and needles, Cross matching bottles, Laboratory
forms and Nasogastric tube.
Clinical assessment
• Determine the cause of the burn, the condition of
the patient, the extent of the burnt surface and the
depth of the burn.
• It is also necessary to know if the patient was in an
open area, closed area or semi closed area at the
time of injury in order to determine whether actual
or potential endotracheal injury has occurred after
burn accident.
• Take a full assessment as follows;
 Ensure the patient is breathing and that the
heart is beating.
 If not, resuscitate the patient using the ABCs of
resuscitation.
 Check for signs that will indicate airway
obstruction e.g. dyspnoea, hoarseness of voice,
stridor and prolonged expirations.
 Take a full history of the patient from the
patient himself or witness in terms of;
 Age (has a major effect on the outcome or prognosis
as infants and the elderly are at highest risk) and
time of injury.
 Mechanism and nature of burns, source and
duration of exposure.
 Associated injuries such as blunt trauma which may
be sustained from falls or jumping in escape
attempts or even from explosions.
 State of health as pre-existing medical problems like
epilepsy may affect the type of management.
• Assess the parts of the body involved i.e.;
Face and neck; the burns of the face and neck are
likely to be associated with the inhalation of fumes
and lead to damage to the respiratory tree and
subsequent oedema causing airway obstruction.
Colour of sputum and the presence of burnt hair in
the nasal passages; if present, these demand that
close observation of the respiratory status is done
for the next 48hrs even when the patient is
breathing well.
Extremities (both hands and legs); in these
areas be alert for the presence of jewels which
must be removed.
Genitalia; the burns of the genitalia have a
higher risk of infection hence pay extra
attention.
Take the weight of the patient if he is able to
stand as it helps in fluid replacement.
• Approximate the burnt surface area using the rule
of nine (9).
Adults;
Head and neck – 9%
Front trunk – 18%
Back trunk – 18%
Upper limbs – 18% (9% each)
Lower limbs – 36% (18% each)
Perineal area – 1%
Children
Head and neck – 18%
Front trunk – 18%
Back trunk – 18%
Upper limbs – 18% (9% each)
Lower limbs – 27% (13.5% each)
Perineal area – 1%
Other useful information
• For burns that are scattered the palm can be
used to approximate the surface area burnt.
• The palm is taken as 1% of the patient’s body
surface area.
• The depth of the burn can be difficult to
determine, but the history helps.
• Definite partial thickness burns are pinky, wet
and blistered.
• Pressing with a finger (while wearing sterile
gloves) produces a pale patch due to emptying
of blood in which when released goes back to
pink again.
• Definite full thickness burns are white or grey.
• They are dry and stiff when pressed on and
sometime thrombosed vessels are seen
through the dead skin.
Investigations
• Collect blood for full blood count in order to
determine the haemoglobin level, erythrocyte
sedimentation rate (ESR) and blood urea nitrogen
(BUN) levels.
• Do urinalysis which is likely to reveal myoglobinuria
and haemoglobinuria as these sip through the
glomeruli due to circulatory disturbance.
• Do radiography may be done to determine if there is
bone involvement.
Medical and surgical management of burns
• In burns, the main causes of death are shock
and infection.
• Their prevention and treatment are main
objectives of acute care.
• The shock due to burns occurs during the first 48
hours of injury (resuscitation phase) and from
this time until the wound is healed, there is the
danger of infection (infection phase).
• Objectives of treatment Include;
The maintain a clear airway, fluids and nutrition
To prevent shock
To prevent contamination and treatment of
infection
To alleviate pain
To prevent contractures and deformities
To maintain maximum rehabilitation of the client
The following are the guidelines and formula for fluid
replacement;
 The Evans Formula
• According to the Evans’ Formula, partial thickness and full
thickness (i.e. 2nd, 3rd and 4th Degree Burns) and 50% body
surface area burns irrespective of the degree, fluids are
calculated as follows;
i. Colloids; (blood plasma and dextran); 1ml X Kg body weight X
% of area burnt.
ii. Electrolytes; (Normal saline and Ringers Lactate); 1ml X Kg
body weight X % of area burnt
iii. Glucose (5% in water); 2000ml for insensible loss
• A maximum of 10,000mls of total fluid may be given in
a 24 hour period as follows;
 Half is calculated and given in the first 8 hours after
burns; the remaining half is spread evenly over the
remaining 16 hours.
 On the first day post burns; half of the colloids and half
the electrolytes and all of the insensible loss are given.
 On the second day post burns; an assessment is made
based on the patient’s response and vital signs, fluids
can be regulated and given accordingly and as needed.
Application of the Evans’ formula;
i. Paul weighing 50 kg with 30% burns
ii. Colloids + Electrolytes + Insensible loss
iii. 1ml X 30X50= 1500 colloids
iv. 1ml X 30X50= 1500 electrolytes
v. Insensible loss = 2000mls
vi. Total 1500+1500+2000mls= 5000mls
vii. First 8hrs= 2500 next 16hrs =2500
Fluid therapy using Parklands (Baxter) formula
• 4 mls Ringers lactate solution per Kg body
weight per percentage of total body surface
area = total fluid requirement for the first 24
hours.
Application
A 70kg patient with 50% TBSA:
4 mls* 70kg* 50% TBSA burn=14,000mls
=14 litres in 24 hrs
½ of total in first 8 hrs = 7000mls
¼ of total in second 8 hrs = 3500mls
¼ of total in third 8 hours = 3500mls
Note: fluids should be administered at a rate
to produce 30 to 50 mls of urine output per
hour.
• Children with burns more than 10% and adults
with burns more than 15% must receive I.V.Fs.
Fluid volume, composition and rate of flow
• The volume, composition and rate of fluids are
based on the percentage of the body surface
area burnt, the weight of the patient, the
hourly urinary output, the arterial blood
pressure, haematocrit reading and serum
electrolyte concentration especially of
potassium and sodium.
• An adult may require as much as 500mls per hour
intravenously to maintain a urinary output of 30 –
60mls per hour.
• Haematocrit concentrations are usually done 4 – 6
hourly.
• Maintain strict input and output charts while the
patient is on fluid therapy.
• Make sure intravenous fluids are running
sufficiently to avoid overloading of the circulatory
system.
• Overloading of the circulatory system may be
shown by a urinary output of more than
100mls per hour as well as dyspnoea and
coughing in the patient with pulmonary
oedema.
• An indwelling catheter is passed as soon the
patient is admitted so that the hourly urinary
output may be noted.
• This serves as a guide in determining
intravenous fluid requirement and also to
provide information about the patient’s
general circulation status and renal function.
• The urinary output should thus be 30 – 60mls
for an adult, 20 – 25mls for a child and 10 –
20mls for an infant.
• An output which is below normal should be
promptly reported.
Drugs
Analgesics are given intravenously in small
doses every 1 – 2 hours to manage pain while
guarding against hypotension, over sedation
and respiratory depression.
Topical Antimicrobial Agents are the main stay
of burn management against invading
microorganisms.
 The most common organisms complicating burn
injuries include; Staphylococco aureus, Pseudomonas
aeruginosa, Enterococcus, Enterobacteria, Group A
Streptococci and Candida albicans.
 Systemic antibiotics are not usually administered
prophylactically but are reserved for infection. The
common antimicrobial in use include;
 Silver Sulfadiazine Cream (Silvadine); is the
commonly used among the antimicrobial agents as it
is not irritating and has the fewest adverse effects.
 Sulfamylon (Paraffin Gauze) against gram
negative and anaerobic organisms (It is painful
but is readily absorbed systemically).
Tetanus Toxoid for prevention of tetanus 0.5mls
i.m stat.
Stress Ulcer Prophylactic Agents for patients
with major burns and are nil orally; e.g. H2
blockers like Cimetidine, Mucosal barriers like
Sulcrafate, Anti acids like Magnisium Trisilicate.
• Early irrigation and debridement are
performed using normal saline and sterile
instruments to remove dead tissues followed
by the application of topical antimicrobial
agents and sterile dressings.
• However, it is safe to leave blisters intact since
they permit healing in a sterile environment
and offer some protection to the underlying
dermis against contamination.
Types of dressings used for burns
 Open or exposure method
• This method is usually used to treat burns of the face,
neck and perineal area and extensive burns of the
trunk.
• It allows the patient with exudates to dry and form a
hard crust in about 3 days which protects the wound.
• The success of the open or exposure method depends
on keeping the environment free of microorganisms
which may be very difficult to achieve.
Closed method
• This method is used primarily for burns of the
feet and hands.
• The burnt area is highly cleaned and a topical
microbial agent thinly applied followed by a
dressing.
• The dressing is usually changed daily.
Moist dressing
• Moist dressings are usually applied to partial
thickness burns to provide pain relief from air
exposure especially in infants who are at high
risk of hypothermia.
• Cold water may cause vasoconstriction
thereby reducing fluid loss.
• However, guard against chilling the patient.
 Nursing care of a patient with burns
Environment
• The burns patient is best nursed or cared for in a
burns center or unit as earlier mentioned above
where aseptic techniques are closely followed.
• The room should be free from all sources of infection,
well ventilated with a good lighting system.
• Warmth should be provided especially for patients
who have sustained more than 50% burns surface
area and and young children as the skin which
prevents excess loss of heat is destroyed.
• Provide a mackintosh and draw sheet to prevent
soiling the linen.
• A bed cradle will also be provided to lift the linen
off the wound and prevent contamination and pain.
• In severe burns of the face, the patient may need
oxygen therapy and when he presents with stridor
prepare for tracheostomy trolley.
• The linen that the patient is using should be where
possible surgically clean.
Observations
• The first 72 hours is the most critical period for a
burnt patient.
• Establish the baseline data of vital signs from which
you will make comparisons with subsequent
findings of the vital signs and also to show how the
body is functioning like early signs of infection when
there is increased temperature or hypovolaemic
shock evidenced by low blood pressure and weak
thready rapid pulse.
• Observe for signs of respiratory distress such as
labored breathing or stridor.
• Monitor the input and out to ascertain the
function of the kidneys and also monitor the
hydration status.
• Monitor the wound for signs of infection such
as pus formation and for signs of healing such
as granulation tissue.
• Weigh the patient daily to rule out wasting.
Control of Pain
• Assess the patient for pain periodically.
• Reassure the patient to reduce anxiety and give
him the prescribed analgesics to relieve pain
and reduce anxiety since pain causes shock.
• Analgesics may be necessary to be given at
frequent intervals for 3 days to keep the patient
comfortable.
• Analgesics should also be given prior to
wound care/dressing.
• Teach the patient relaxation and breathing
exercises to help him cope with pain.
• Change his position if possible supporting the
extremities with pillows if they are not
involved.
Emotional Support
• Following a severe burn the patient and his family
experience emotional disturbances.
• Long periods of the patient being alone should be
avoided if you can.
• Talk to the patient and not about him while
performing procedures or assessing wound healing.
• Attend to the patient’s fears as and give the patient
honest and realistic explanations of the prognosis.
• Arrange for the patient to talk to other
patients with similar injuries and who are
progressing satisfactorily when the condition
allows.
• Do not give the patient force hopes as the
patient may lose confidence in the medical
team if things happen otherwise.
Wound Care
• Analgesia prior to wound dressing is necessary
for major burns.
• Valium 0.1mg/kgbwt i.m and ketamine
0.5mg/kg i.m is a regimen that is usually well
tolerated.
• Aseptic technique should strictly be observed.
• Do daily wound cleaning with prescribed
medicants.
Control of Infection
• Isolate the patient
• Nursing personnel with infection should not attend
to the patient e.g. those with sore throat.
• Restrict the number of visitors to only close relatives
and explain their role regarding protection of the
patient from infection e.g. wearing protective gowns
when appropriate.
• Be alert for reservoirs of infection and sources of
contamination in the environment.
• Wash hands before and after attending to the
patient.
• Use sterile gloves for all care involving patient
contact.
• Assess the wound daily for local signs of
infection i.e. swelling, redness on wound
edges, purulent discharge and dislodgement
or loss of grafts.
• Promote optimal hygiene for the patient
including cleaning of the burnt area.
• Shave the area near the burnt area as hair
harbors dirt and interferes with tissue
regeneration.
• Pay particular attention and give special care
to intravenous and urinary catheter sites.
Position and Exercises
• Turn the patient every 2 – 3 hours to prevent
respiratory failure and secretory stasis.
• If the limbs are swollen, they must be elevated
on pillows during the initial stage.
• Pay frequent attention to body alignment,
flexion, contraction, outward rotation of
thighs and foot drop should be prevented.
• Involve the physiotherapist if available to
supervise the exercises.
• Range of motion exercises are encouraged
especially during soaking and dressing of
wounds.
• Depending on the part that is burnt, the
patient should not lie on the side affected as
this may disturb the healing process.
Nutrition and Fluids
• Ringers lactate is the fluid of choice for the replacement
of fluids and electrolytes.
• For patients with severe burns, oral fluids are restricted
for 24 – 48 hours because the initial hypovolaemia
produces depletion of gastric motility leading to sluggish
peristalsis.
• A nasogastric tube is inserted in this case for intermittent
suctioning and oral intake introduced as the patient’s
condition improves and signs of bowel movement are
evident.
• Fluid foods are introduced slowly.
• A high calorie, high protein and high vitamin
diet is recommended to provide essential
nutrients for tissue repair and production of
antibodies and blood cells.
• Vitamin C is essential in tissue repair.
Health Education
• Help the patient to think positively about himself.
• Demonstrate and explain the wound care procedures to be
continued after discharge e.g. washing of hands, applying
the topical agent as prescribed.
• He should be taught on local signs of wound infection such
as redness of normal skin around the burnt area, increased
cloudy yellow pus, increased pain, foul odour and elevated
body temperature.
• Provide written instructions concerning care after
discharge.
Hygiene
• Change the linen whenever they are soiled or dirt
to prevent bad odour in the room and infection.
• A deodorant or air freshener may be used in the
room.
• It may be difficult to bath the patient with severe
burns therefore, cleaning of selected areas only
will be done, such as the face, axillae and the
perineal area.
Elimination
• Catheterise the patient to monitor urine output.
• Ensure that the patient is not constipated by
giving him enough fluids, turning him frequently
and giving a diet rich in roughage when he
resumes a normal dietary intake.
• Offer a bed pan and urinal when the patient
wants to open bowels or empty his bladder.
• Assist a severely burnt patient onto the bed pan.
Rehabilitation
• Rehabilitation of a burnt patient is carried out
throughout the acute stages by paying good
attention to body alignment, prevention of
infection and contractures and the
maintenance of joint and limb movement.
• Following recovery from burns, the patient may
require reconstructive surgery and retraining
before he can resume independence.
• Therefore, the patient and relatives require social
guidance as well as financial and psychosocial
support throughout the rehabilitation period.
• Retraining for a different occupation may be
necessary in some cases.
• Some patients find it difficult to resume their
previous social contacts and to take their place
back in society because of the scarring and gross
disfigurement associated with severe burns.
Complications of burns
• They are divided into immediate and late
complications.
• Immediate Complications include shock,
hypothermia, dehydration, renal failure, cardiac
failure and infection.
• Late complications, amputation, anaemia,
toxaemia, septicaemia, liver damage, gas gangrene,
duodenal (stress) ulcer contractures and keloid
formation.
»THANX