TOTAL BODY SURFACE AREA (TBSA)

 Superficial burns are not involved in the calculation

 Lund and Browder Chart is the most accurate because it adjusts for age
 Rule of nines divides the body – adequate for initial assessment for adult burns

Lund and Browder Chart

RULES OF NINES

VASCULAR CHANGES RESULTING FROM BURN INJURIES

 Circulatory disruption occurs at the burn site immediately after a burn injury
 Blood flow decreases or cease due to occluded blood vessels
 Damaged macrophages within the tissues release chemicals that cause constriction of vessel
 Blood vessel thrombosis may occur causing necrosis
 Macrophage: A type of white blood that ingests (takes in) foreign material. Macrophages are key
players in the immune response to foreign invaders such as infectious microorganisms.

FLUID SHIFT

 Occurs after initial vasoconstriction, then dilation

 Blood vessels dilate and leak fluid into the interstitial space
 Known as third spacing or capillary leak syndrome
 Causes decreased blood volume and blood pressure
 Occurs within the first 12 hours after the burn and can continue to up to 36 hours

FLUID IMBALANCES

 Occur as a result of fluid shift and cell damage

 Hypovolemia
 Metabolic acidosis
 Hyperkalemia
 Hyponatremia
 Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration
FLUID REMOBILIZATION

 Occurs after 24 hours

 Capillary leak stops
 See diuretic stage where edema fluid shifts from the interstitial spaces into the vascular space
 Blood volume increases leading to increased renal blood flow and diuresis
 Body weight returns to normal
 Hypokalemia

CURLING’S ULCER

 Acute ulcerative gastro duodenal disease

 Occur within 24 hours after burn
 Due to reduced GI blood flow and mucosal damage
 Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition
 Watch for sudden drop in hemoglobin

PHASES OF BURN INJURIES

1. EMERGENT PHASE
 Knowledge of circumstances surrounding the burn injury
 Obtain client’s pre-burn weight (dry weight) to calculate fluid rates
 Calculations based on weight obtained after fluid replacement is started are not accurate
because of water-induced weight gain
 Height is important in determining body surface area (BSA) which is used to calculate nutritional
needs
 Know client’s health history because the physiologic stress seen with a burn can make a latent
disease process develop symptoms

CLINICAL MANIFESTATIONS IN THE EMERGENT PHASE

 Clients with major burn injuries and with inhalation injury are at risk for respiratory problems
 Inhalation injuries are present in 20% to 50% of the clients admitted to burn centers
 Assess the respiratory system by inspecting the mouth, nose, and pharynx
 Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an
inhalation injury may be present
 Change in respiratory pattern may indicate a pulmonary injury.
 The client may: become progressively hoarse, develop a brassy cough, drool or have difficulty
swallowing, produce expiratory sounds that include audible wheezes, crowing, and stridor
 Upper airway edema and inhalation injury are most common in the trachea and mainstem
bronchi
 Auscultate these areas for wheezes
 If wheezes disappear, this indicates impending airway obstruction and demands immediate
intubation
  Cardiovascular will begin immediately which can include shock (Shock is a common cause of
death in the emergent phase in clients with serious injuries)
 Changes in renal function are related to decreased renal blood flow
 Urine is usually highly concentrated and has a high specific gravity
 Urine output is decreased during the first 24 hours of the emergent phase
 Sympathetic stimulation during the emergent phase causes reduced GI motility and paralytic
ileus

Management

1. Obtain a baseline EKG

2. Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and
pulse oximetry
3. Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50-
mL/hr.
4. Measure BUN, creatinine and Na levels
5. Auscultate the abdomen to assess bowel sounds which may be reduced
6. Monitor for n/v and abdominal distention
7. Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to
prevent aspiration and removal of gastric secretions

IV FLUID THERAPY

 For most, Parkland formula a suitable starting guide (4 ml Ringer’s Lactate/kg body weight/%
BSA burned), ½ to be given over 1st 8 hr from time of onset while remaining over the next 16 hr
 During 2nd 24 hr, ½ of 1st day fluid requirement to be infused as D5LR
 Oral supplementation may start 48 hr after as homogenized milk or soy-based products given by
bolus or constant infusion via NGT

2. ACUTE PHASE OF BURN INJURY

 Lasts until wound closure is complete
 Care is directed toward continued assessment andmaintenance of the cardiovascular and
respiratory system
 Pneumonia is a concern which can result in respiratory failure requiring mechanical ventilation
 Infection (Topical antibiotics – Silvadene)
 Tetanus toxoid
 Weight daily without dressings or splints and compare to pre-burn weight
 A 2% loss of body weight indicates a mild deficit
 A 10% or greater weight loss requires modification of calorie intake
 Monitor for signs of infection

3. REHABILITATIVE PHASE OF BURN INJURY

 Started at the time of admission
 Technically begins with wound closure and ends when the client returns to the highest
possible level of functioning
 Provide psychosocial support
  Assess home environment, financial resources, medical equipment, prosthetic rehab
 Health teaching should include symptoms of infection, drugs regimens, f/u
appointments, comfort measures to reduce pruritus

DIET

 Initially NPO
 Begin oral fluids after bowel sounds return
 Do not give ice chips or free water lead to electrolyte imbalance
 High protein, high calorie

DEBRIDEMENT

 Done with forceps and curved scissor or through hydrotherapy (application of water for
treatment)
 Only loose eschar removed
 Blisters are left alone to serve as a protector –controversial

DRESSING THE BURN WOUND

 After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent
infection
 Standard wound dressings are multiple layers of gauze applied over the topical agents on the
burn wound

First Aid Management for Burns

1. Make sure you and the person who’s burned are safe and out of harm’s way.
2. Move them away from the source of the burn.
3. If it’s an electrical burn, turn off the power source before touching them.
4. Obtain medical care immediately if burns are larger than 2-3 inches or are on the face/hands
5. Assess the consciousness of the victim. Assess for Airway, Breathing and Circulation. If needed,
start rescue breathing if you’ve been trained.
6. Remove restrictive items from their body, such as belts and jewelry in or near the burned areas.
Burned areas typically swell quickly.
***If clothing is burnt unto the wounds, do not force to remove. Instead, cut around the
clothing.
7. Cool the burned area with cool, running water for about 10 minutes. Be careful not to overly
soaked the affected area.
8. Use sheets or towels soaked in water to cool a burn on the face or other areas that cannot be
soaked
When the affected area has been sufficiently cooled, use sterile gloves to apply a sterile
nonfluffy dressing or a sterile bandage. Do not break blisters or remove tissues
9. A water-based gel-soaked sterile dressing is ideal as it helps prevent burn progression.
10. If a suitable dressing is not available, you may improvise using a sterile triangular bandage.
***Do not apply dressing that may have a torniquet effect
Loosely cover with dry; sterile bandages.
 11. If burns cover a large area of the body cover victim with clean/dry sheets to prevent infection
and reduce pain.
12. Elevate the burned area above heart level

Intervention for a Victim with Clothing on Fire

1. Attempt to get the victim flat on the floor-you may have to physically push them over, using a
broom or a fire blanket etc. To ensure you do not get exposed to the flames.
2. Once the victim is flat on the floor try to smother the flames. Ideally, use a fire blanket or
improvise with a cotton blanket.
3. Ensure the victim’s airway, Breathing and Circulation are intact.
4. Cool the burns.

Interventions for Chemical Burns

1. If chemical Burn is suspected, the burn must be irrigated with copious amount of water after the
victim’s ABCs has been assessed.
2. The contaminated skin must be washed under running water for at least 20 minutes.
3. Ensure that the chemical is washed off the skin and not on to unaffected areas.
4. Any contaminated clothing must be removed assuming it is not adhered to the skin to allow the
water to irrigate the skin correctly.
5. Attempt to establish the cause of burn
6. As the majority of chemical burns occur some time after contact, it is advisable to refer all
victims for medical management.