TCA#9

BURNS

INCIDENCE OF BURNS
- APPROXIMATELY 2 MILLION PEOPLE A YEAR IN THE U.S. REQUIRE MEDICAL CARE FOR BURN INJURIES
- 50,000 REQUIRE HOSPITAL ADMISSION
- 4,500 DIE FROM BURN INJURIES
- YOUNG AND ELDERLY ARE AT HIGHEST RISK FOR MORTALITY RELATED TO A BURN – THEIR IMMUNE SYSTEMS AND
BODY SYSTEMS OR EITHER NOT WELL ENOUGH DEVELOPED OR THEY ARE WORN OUT.

GOALS R/T BURNS

- PREVENTION (1 ) ST

- LIFESAVING MEASURES FOR THE SEVERLY BURNED

- EARLY, INDIVIDUALIZED AND SPECIALIZED TREATMENT TO PREVENT DISABILITY AND DISFIGUREMENT GET PATIENT
TO BURN CENTER IF APPLICABLE.
- REHABILITATION THROUGH RECONSTRUCTIVE SURGERY AND REHAB PROGRAMS. A SEVERE BURN GOES ON FOR
YEARS. IT WILL NOT BE OVER IN A SHORT PERIOD OF TIME. THE LENGTH OF REHAB CAN GET PEOPLE REALLY
DOWN. THIS CAN PROFOUNDLY AFFECT SOMEONE’S EMOTIONAL STABILITY.

OUTLOOK FOR PERSONS WITH BURNS

- > 70 YEARS OF AGE ARE SURVIVING BURNS OF 30% TBSA BURNS
- 60-70 YEARS - SURVIVING BURNS OF 50% TBSA BURNS
- 20-30 YEARS - SURVIVING BURNS OF 80% TBSA BURNS
- 2-5 YEARS - SURVIVING BURNS OF 75% TBSA BURNS
- 5 YRS. - 40 YRS. HAVE THE BEST CHANCE OF SURVIVING A BURN

HEAT CAUSES CELLS TO COAGULATE AND BURST, THE PROTEIN DENATURES AND EVERYTHING COAGULATES.

WITH BURNS IT IS NOT JUST THE SURFACE BURN THAT CAUSES DEATH. THE OTHER PART OF A BURN IS THAT WE ARE
BREATHING ALL OF THE TIME. IF YOU ARE IN A SITUATION WHERE YOU ARE IN ENOUGH HEAT THAT IT IS GOING TO BURN
THE SKIN, THEN THE INHALATION BURNS AND INJURIES ARE GOING TO START TO OCCUR. YOU HAVE THIS IN COMBINATION
WITH A THERMAL BURN TO THE SKIN, THEN YOUR CHANCES OF SURVIVAL ARE GOING TO START TO GO DOWN. WE ARE
ALWAYS CONCERNED ABOUT AN INHALATION INJURY WITH A BURN.

WHETHER SOMEONE LIVES OR DIES DUE TO THEIR BURN IS GOING TO DEPEND ON THE DEPTH OF THE BURN, HOW MUCH
BODY SURFACE IS BURNED, WHETHER THEY HAD AN INHALATION INJURY WITH IT AND ON THEIR PRE-INJURY HEALTH
STATUS. THE PATIENT WITH DIABETES, PERIPHERAL VASCULAR DISEASE OR SEVERE CARDIOVASCULAR DISEASE THAT
GETS AN EXTENSIVE BURN, THEIR CHANCES OF SURVIVAL ARE GOING TO GO DOWN BECAUSE OF THEIR ALREADY
DIMINISHED ABILITY TO HANDLE THE STRESS.

CATEGORIES OF BURNS
1. THERMAL (INCLUDES ELECTRICAL BURNS) – GO DEEP, WILL HAVE ENTRY AND EXIT BURN, ONE SEC OF CONTACT
WITH WATER THAT IS 156 DEGREES WILL GIVE YOU A 3 DEGREE BURN.
RD

2. RADIATION
3. CHEMICAL – CHEMICAL HAS REACTION WITH SKIN CAUSING BURN
- WITH A BURN YOU HAVE THE CENTRAL WORST BURN AND THEN OUTSIDE OF THE CENTRAL BURN YOU HAVE
BURNS THAT ARE NOT AS DEEP, SO YOU WILL BE TREATING POSSIBLY 3 DIFFERENT TYPES OF BURNS WITHIN
ONE.
- NO BURN LOOKS THE SAME AS ANOTHER.

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- WHEN YOU HAVE A BURN, YOU HAVE DESTRUCTION OF TISSUE. THE TISSUE IS DESTROYED BECAUSE THERE IS
COAGULATION GOING ON, THERE IS PROTEIN DENATURING, AND THE CELLULAR CONTENT ACTUALLY BECOME
IONIZED. SO THE TISSUE IS BASICALLY DESTROYED.
- THE MAIN PLACES IN BURNS WHERE YOU HAVE THIS HUGE DESTRUCTION COURSE IS GOING TO BE ON SKIN AND
THE MUCOUS MEMBRANE. BURNS CAN BE SO DEEP THAT THEY CAN ACTUALLY BURN THE VISCERA AND BONE.

THE DEPTH AND HOW DEEP THE BURN IS – DEPENDENT ON HOW HOT THE BURNING AGENT IS AND THE AMOUNT OF TIME
THAT THE AGENT IS IN CONTACT WITH THE BODY. THE HOTTER AND THE LONGER -- THE DEEPER AND MORE SEVERE THE
BURN THE RULE TO REMEMBER IS THAT IN AN ADULT (HEALTHY) ONE SECOND OF CONTACT WITH HOT TAP WATER AT
156° CAN CAUSE DESTRUCTION OF THE EPIDERMIS AND THE DERMIS (WHICH IS A FULL THICKNESS BURN). FIFTEEN
SECONDS OF CONTACT WITH 133° TAP WATER WILL ALSO CAUSE A FULL THICKNESS BURN.

THE DEPTH OF A BURN CAN CHANGE FROM ONE AREA TO ANOTHER. WHEN THE SKIN TURNS WHITE AND YOU PUT
PRESSURE ON IT AND IT DOES NOT CHANGE BACK TO A PINK COLOR, YOU CAN SAY THAT IS USUALLY GOING TO BE A FULL
THICKNESS BURN. IT IS WHITE BECAUSE THE BLOOD VESSELS HAVE BEEN BURNED UP IN IT, SO THERE IS NO COLOR IN IT.
THE BLOOD VESSELS ARE OCCLUDED OR THEY ARE GONE.

ANY TIME YOU ARE CONCERNED ABOUT WHETHER A PATIENT HAS BREATHED IN HEAT, YOU ARE GOING TO WANT TO GET
OXYGEN. IF YOU HAVE A BURN UP AROUND THE FACE AND THE NECK (SWELLING COMES WITH BURNS) AND SWELLING
WILL CLOSE OR OCCLUDE THE AIRWAY. YOU ARE GOING TO GO BACK TO AIRWAY, BREATHING AND CIRCULATION
(ABC). THIS IS ALWAYS GOING TO BE THE FIRST PRIORITY WITH ANYTHING AND WITH BURNS YOU ARE GOING TO TAKE
CARE OF THE A, THE B AND THE C LONG BEFORE YOU EVER EVEN LOOK AT THE BURN. THE BURN IS THE LEAST OF
THE PROBLEMS UNTIL ABC ARE TAKEN CARE OF.

CLASSIFICATION OF BURNS
- DEPTH OF BURN INJURY, DEEP BURNS MUST HAVE GRAFTING
- EXTENT OF INJURY, HOW MUCH OF THE BODY HAS BURNED (TOTAL BODY SURFACE AREA – TBSA)
- THIS IS GOING TO START OUR IDEA OF A TREATMENT. WHAT HAS HAPPENED PHYSIOLOGICALLY IN THE BODY IS
DEPENDENT ON THESE TWO THINGS. THE SEVERITY OF THESE TWO THINGS IS GOING TO IMPACT THE SEVERITY
OF THE PATIENT’S RESPONSE.

BURN DEPTH
- FIRST DEGREE BURN – EPIDERMAL LAYER AND A LITTLE DERMAL SKIN
- SECOND DEGREE – DEEPER IN THE DERMAL LAYER (BLISTERS)
- THIRD DEGREE – PAST THE DERMAL LAYER (SUBCUTANEOUS TISSUE, POSSIBLY DISRUPT BONES MUSCLES,
TENDONS, ETC.)

TERMINOLOGY NOW USED:

- SUPERFICIAL PARTIAL THICKNESS BURN – SIMILAR TO WHAT IS KNOWN AS FIRST DEGREE BURN
O SUNBURN, MAY HAVE BLISTERS, DOES NOT KILL SWEAT GLANDS OR HAIR FOLLICLES
O FLASH OF HEAT – LIKE MAYBE OPENING THE OVEN
O THESE ARE VERY PAINFUL BURNS, THEY ARE SOOTHED BY COOLING (DON’T APPLY ICE)
O THEY ARE RED. IF YOU TOUCH THE RED AREA AND REMOVE YOUR FINGER, THEY BLANCHE AND THEN
THEY WILL TURN RED AGAIN.
O USUALLY WILL HAVE COMPLETE RECOVERY WITHIN A WEEK AND VERY SELDOM DO THEY SCAR.
- DEEP PARTIAL THICKNESS – SIMILAR TO 2 DEGREE BURN
ND

O NOT SO DEEP THAT IT KILLS THE NERVE

O HAVE DESTRUCTION OF THE EPIDERMIS, THE UPPER LAYERS OF THE DERMIS AND IT MIGHT EVEN GO
INTO THE DEEPER LAYERS OF THE DERMIS.

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O USUALLY CAUSED BY SCALDS, OR FLASH FLAME
O THESE BURNS ARE PAINFUL, SENSITIVE TO COLD AIR
O NOT UNUSUAL TO SEE BLISTERS
O THE BASE OF THESE BURNS CAN BE A LITTLE BIT MOTTLED IN THE DEEPER AREAS.
O USUALLY HEALS IN A ONE TO TWO WEEKS (UNLESS THEY GET INFECTION)
O CAN GET HYPERTROPHIC SCARRING DUE TO DEPTH
O WILL BE VERY SENSITIVE TO COLD, COVERING THE BURN MAKES BETTER
O USUALLY LOCALIZED SWELLING
O HAIR FOLLICLES AND SWEAT GLANDS WILL REMAIN INTACT WITH THESE BURNS.
O THESE BURNS ARE NOT UNCOMMON IN THE ELDERLY – THE PROBLEMS ARE THINGS LIKE PERIPHERAL
VASCULAR DISEASE AND DIABETES THAT MIGHT BE THERE AND THEN THEY GET INFECTED. BECAUSE OF
THE INFECTION IN THESE TYPE OF PEOPLE, THESE BURNS CAN PROGRESS TO A 3 4 DEGREE
RD TH
OR
BURN. THE TISSUE CONTINUES TO BE DESTROYED. AMPUTATION CAN BE AN OUTCOME WHEN THESES
BURNS PROGRESS IN THIS NATURE.
- FULL THICKNESS BURN – THROUGH THE EPIDERMIS, DERMIS, AND INTO UNDERLYING TISSUE (POSSIBLY ORGAN
OR BONE)
O FLAMES, PROLONGED EXPOSURE TO HOT LIQUIDS, CHEMICALS, ELECTRICITY AND ELECTRICAL CURRENT.
O HAIR FOLLICLES BURN
O SWEAT GLANDS BURN
O NERVE ENDING COMPROMISED – DOES NOT HURT AT WORST SITE, BUT WILL HURT AROUND IT.
O THE COLOR COULD BE ANYWHERE FROM WHITE, BROWN, OR BLACK. IT MAY BE RED. YOU WILL
ALWAYS HAVE SOME OF THE OTHER COLORS IN THERE WITH IT.
O IF ELECTRICAL CURRENT BURN WILL HAVE AN ENTRY AND AN EXIT WOUND. THE ENTRANCE USUALLY
DOES NOT LOOK TOO BAD, BUT WHEN YOU TURN THEM OVER TO LOOK AT THE EXIT WOUND, IT MAY
WORSE. WITH AN ELECTRICAL BURN WITH STIMULUS LIKE A LIGHTENING BOLT OR A BIG CURRENT OF
ELECTRICTY, IF IT GOES IN AND TRAVELS THROUGH YOUR BODY IT IS BURNING OR BASICALLY COOKING
THE INTERNAL ORGANS.
O THE AREA WHERE YOU HAVE THE FULL THICKNESS BURN DOES NOT HURT BECAUSE THE NERVE ENDINGS
HAVE BEEN DESTROYED.
O WHAT WE HAVE TO REMEMBER AS NURSES IS THAT THE WHOLE BURN IS NOT ALWAYS GOING TO BE THE
SAME DEPTH BURN. IF YOU HAVE A FULL THICKNESS BURN, THEY MAY HAVE SOME MARGINS OR PLACES
THAT COULD BE A DEEP PARTIAL THICKNESS BURN OR A SUPERFICIAL PARTIAL THICKNESS BURN. THERE
IS GOING TO BE SOME MAJOR PAIN WITH THIS.

TOTAL BODY SURFACE AREA

- RULES OF NINES – QUICK AND EASY (KNOW THIS)
O BODY IS DIVIDED INTO SECTION – EACH SECTION IS A DEGREEE OF NINE
 HEAD IS 9% - (IF BURN THE FACE, IT WILL BE HALF OF THAT 4½%)
 ANTERIOR TORSO – 18% - (IF IT IS JUST THE CHEST 9%)
 POSTERIOR TORSO – 18%
 GENITALIA – 1%
 R LEG – 18% - (IF BURN FROM THE KNEES DOWN 9%)
 L LEG – 18%
 ARM – 9%
 ARM – 9% (IF JUST FRONT OR SIDE, YOU WILL HAVE TO GET THAT DOWN TO AN APPROPRIATE AMT.)
- LUND AND BROWDER – MORE PRESICE AND TIME CONSUMING
- PALM METHOD – GOOD FOR SCATTERED BURNS
O TAKE PATIENTS PALM (= 1% BODY AREA) AND COMPARE IT TO THE BURNS

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O THIS WILL NOT WORK ON SOMEONE THAT WEIGHS 600 LBS. THIS IS FOR A PERSON THAT IS THE
TYPICAL AVERAGE SIZE. IT WORKS ESPECIALLY WELL FOR CHILDREN.

INITIAL LOCAL RESPONSE TO BURNS

- USUALLY ONLY A LOCAL RESPONSE IF BURN IS LESS THAN 25% TBSA. TYPICALLY THE RESPONSE WILL BE
JUST WHERE THE BURN IS.
O LOCAL RESPONSE ALMOST ALWAYS HAVE EDEMA (INFLAMMATORY RESPONSE). WE HAVE SWELLING
DUE TO CAPILLARIES LEAKING FROM INJURY. THE FLUID LEAVES THE VASCULAR TISSUE IN THAT SPOT
(LOCAL). THE CAPILLARIES GET MORE PERMEABLE, THE FLUID RUNS OUT OF THEM INTO THE
INTERSTITIAL SPACES. WE MAY SEE THIS AS A BLISTER. EVEN IS THERE IS A BLISTER, YOU MAY HAVE
SOME LOCALIZED EDEMA THERE. BEFORE TOO LONG THE SWELLING IS GOING TO GO DOWN AND WHEN
THE SWELLING GOES DOWN, THIS TELLS US THAT THE FLUID HAS RETURNED INTO THE VASCULAR
COMPARTMENT.
OWHEN YOU SEE EDEMA THAT CAN DISFIGURE EXTREMITIES AND SUCH, AS A NURSE WE NEED TO WATCH
FOR COMPARTMENT SYNDROME. THERE IS SO MUCH FLUID THERE THAT IT IS PUTTING A LOT OF
PRESSURE ON THE NERVES AND JOINTS. YOU HAVE A BIG PROBLEM HERE.
O REMEMBER – JUST BECAUSE IT IS A SMALL WOUND (25% OR LESS TBSA), WE STILL HAVE TO
WORRY ABOUT INHALATION. SO WE ARE GOING TO REALLY LOOK AT THIS PATIENT WHEN THEY COME
IN. WE WILL BE LOOKING AT THE NOSE HAIRS (ARE THEY CINGED?). ARE THE EYEBROWS CINGED? IF
THE BURN IS ON THE NECK, THE FACE, THE UPPER CHEST THAT MAY GET ENOUGH EDEMA THERE TO
INHIBIT THE AIRWAY. THEN WE HAVE TO MAKE A DECISION ABOUT WHAT TO DO IF WE SEE CINGED
NOSE HAIRS. THIS IS TELLING US RIGHT OFF THE BAT THAT THEY HAVE HAD TO BREATHE IN HEAT IN
ORDER FOR THAT TO OCCUR. THIS MEANS THEY MAY HAVE SOME DAMAGE TO THEIR UPPER AIRWAY.
WE NEED TO MONITOR THIS AND BE PREPARED FOR POSSIBLE INTUBATION. WE NEED TO HAVE
OXYGEN. WE NEED TO HAVE THE EQUIPMENT NEAR TO MANAGE THIS.
- TBSA GREATER THAN 25% MAY HAVE LOCAL AND SYSTEMIC RESPONSE AND ARE CONSIDERED MAJOR BURNS

SYSTEMIC RESPONSE TO MAJOR BURNS

- OCCURS DUE TO RELEASE OF CYTOKINES AND OTHER MEDIATES INTO THE SYSTEMIC CIRCULATION. THIS MEANS
THAT IF THEY ARE GOING INTO SYSTEMIC CIRCULATION, THEN THEY ARE GOING EVERYWHERE.
- THE RELEASE OF LOCAL MEDIATORS AND CHANGES IN BLOOD FLOW, TISSUE EDEMA, AND INFECTIONS CAN CAUSE
PROGRESSION OF THE BURN INJURY.
- WITH A MAJOR BURN, THE INITIAL SYSTEMIC EFFECT (RESPONSE) IS HEMODYNAMIC INSTABILITY. BECAUSE
WHEN YOU GET A MAJOR BURN, JUST LIKE ANY OTHER MAJOR INSULT, YOU HAVE AN INFLAMMATORY RESPONSE
GOING ON. EXCEPT IN THIS CASE BECAUSE EVERYTHING IS RELEASED SYSTEMICALLY AND IT IS GOING ALL OVER
THE BODY. WELL WITH AN INFLAMMATORY RESPONSE THE FIRST THING THAT HAPPENS TO THE CAPILLARIES, IS
THAT THEY CAN’T’ HOLD ON TO WHAT THEY NEED TO HOLD ONTO ANY MORE. THEY BECOME MORE PERMEABLE,
THEIR INTEGRITY DECLINES. IF THEY CANNOT HOLD ONTO WHAT THEY NEED TO HOLD ONTO THEN THE FLUID
GOES INTO THE TISSUES. SO YOU HAVE VESSELS AND CAPILLARIES THAT ARE LOSING THEIR FLUID. THE FLUID
IS LEAVING THE CIRCULATION AND GOING INTO THE TISSUES. WHEN YOU LOSE WATER, YOU LOSE SODIUM. SO
THE WATER IS LEAVING THE VESSELS INTO THE TISSUE AND THE SODIUM IS FOLLOWING IT. THE PROTEIN IS
ALSO GOING TO LEAVE THE VASCULAR SPACES AND GO INTO THE INTERSTITIAL SPACES. SO NOW YOU HAVE
SALT, WATER AND PROTEIN ALL GOING OUT INTO THE INTERSTITIAL SPACES. SINCE THIS IS SYSTEMIC, IT IS
HAPPENING ALL OVER THE BODY. WHEN THE PATIENT LOSES ALL OF THE VOLUME INTO THE INTERSTITIAL
SPACES, YOU WILL SEE THE RESPIRATIONS INCREASE AND PROBABLY BECOME MORE SHALLOW. THE BRAIN IS
TELLING THE BODY THAT IT NEEDS OXYGEN. THE HEART RATE IS GOING TO INCREASE BECAUSE IT IS NOT
GETTING OUT WHAT IT NEEDS TO BECAUSE IT IS ALL OUT IN THE TISSUES. BLOOD PRESSUE IS GOING TO
STEADILY DROP BECAUSE VOLUME HAS LEFT WHERE IT IS SUPPOSED TO BE AND FOUND A NEW HOME FOR A
LITTLE WHILE.

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- SIGNS OF SHOCK – DUE TO LOW VOLUME, BLOOD PRESSURE DROPS, BREATHING BECOMES RAPID
- PATHOLOGICALLY, IN THE BURN SHOCK PERIOD THE TISSUES ARE BEING HYPOPERFUSED BECAUSE THERE IS NOT
ENOUGH VOLUME TO PERFUSE THEM. SO THERE IS NOT ENOUGH OXYGEN GETTING TO THE TISSUES. THE
REASON IS BECAUSE THE CARDIAC OUTPUT IS DECREASED. WHEN A BODY REALIZES THAT IT CANNOT GET
OXYGEN TO WHERE IT NEEDS TO BE, OUR BODY TRIES TO COMPENSATE BY VASOCONSTRICTION. THE IDEA IS
THAT THE BODY WANTS TO PROTECT ITS CORE. THE CORE IS THE BRAIN, HEART, LUNGS AND KIDNEY. THESE
ORGANS WILL BE AFFECTED IF THE BODY IS NOT GETTING THE OXYGEN THAT IT NEEDS.
- IN BURNS OF 60% OR GREATER THIS HAPPENS VERY FAST AND IS MORE SEVERE. THESE PEOPLE ARE GOING
TO HAVE THE MAXIMUM RESPONSE. ALL OF THE ABOVE WILL BE GOING ON INITIALLY.

WHAT HAPPENS IN EACH SYSTEM INITIALLY?

- CARDIOVASCULAR RESPONSE
O HYPOVOLEMIC – LOSS OF FLUID FROM WOUND – LEAVES THE VASCULAR COMPARTMENT AND GOES
INTO THE TISSUES
O DECREASED PERFUSION AND O2 DELIVERY – THIS IS HAPPENING BECAUSE WE DO NOT HAVE THE
BLOOD VOLUME IT IS ALL OUT IN THE TISSUES
O DECREASED CARDIAC OUTPUT – THERE IS NO FLUID AVAILABLE TO PUMP, IT IS ALL OUT IN THE TISSUES
O CONTINUED DECREASED VASCULAR VOLUME – BECAUSE THE FLUIDS ARE CONTINUING TO BE LOST.
LOSING IT DUE TO THE INCREASED CAPILLARY PERMEABILITY, BUT ALSO LOSING FLUIDS FROM THE
WOUND ITSELF (IT IS OOZING)
O CONTINUED DECREASED CARDIAC OUTPUT
O DECREASED B/P (NOW YOU HAVE BURN SHOCK)
O RESPIRATIONS INCREASE, PULSE INCREASE
O C/V RESPONSE AFTER ONSET OF BURN SHOCK
 RELEASE OF CATECHOLAMINES
 INCREASE IN PERIPHERAL VASCULAR RESISTANCE (VASOCONSTRICTION)
 INCREASED PULSE RATE – THE HEART IS PUMPING HARDER AND FASTER TRYING TO GET
BLOOD WHERE IT NEEDS TO GO. THE PROBLEM SINCE THE FLUID IS NOT THERE, THE HEART IS
PUMPING FASTER BUT WITH THE LACK OF FLUID IT IS NOT GETTING THE VOLUME OUT.
(BRUNNER PG 1708 – STUDY THE DIAGRAM)
 IT IS IMPORTANT AT THIS POINT IN TIME THAT YOU ARE GIVING PROMPT FLUID RESESITATION.
YOU GET THE AIRWAYS GOING AND THE ONLY THING THAT WILL NOW SAVE THIS PERSONS LIFE
IS TO TAKE CARE OF THEIR CARDIOVASCULAR STATUS. THIS WILL BE DONE BY GIVING THIS
PATIENT ENOUGH FLUIDS. THE ONLY THING THAT YOU CAN DO IS PUMP FLUID IN THEM UNTIL
THAT FLUID COMES BACK WHERE IT NEEDS TO BE IN THE VASCULAR COMPARTMENT. THE IDEA
IS THAT IF YOU GIVE THEM ENOUGH FLUID TO KEEP THEIR BLOOD PRESSURE AT WHAT WE
WOULD CONSIDER A LOW NORMAL RANGE. IT PROBABLY WILL NEVER GET TO 120/80 BUT IF
YOU CAN KEEP IT A LOW NORMAL RANGE, YOU ARE DOING O.K. YOU ARE ALSO GOING TO PAY
CLOSE ATTENTION TO THEIR URINARY OUTPUT. YOU WANT THIS PATIENT TO BE PUTTING OUT
SOME URINE. IF THEY ARE NOT PUTTING OUT URINE, YOU ARE PROBABLY GOING TO CONTINUE
TO INCEASE THEIR FLUIDS. WE DO THIS UNTIL ---
 CAPILLARIES BEGIN TO REGAIN INTEGRITY AFTER INTERNAL ORGANS HAVE REGAINED
PERFUSION. THE PATIENT IS GOING TO BECOME MORE STABLE
 BLOOD VOLUME INCREASES
 FLUID THEN RETURNS TO VASCULAR COMPARTMENT – IF HAVE ADEQUATE FLUID
RESUSCITATION.
 WE NOW HAVE TO WATCH FOR FLUID VOLUME OVERLOAD. THEY CAN GO INTO CONGESTIVE
HEART FAILURE. NEED TO PAY VERY CLOSE ATTENTION TO THIS. THERE NEEDS TO BE LOTS
OF MONITORING.

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 THEN THEY WILL GO THROUGH A LONG PERIOD OF DIURESIS BECAUSE THEY HAVE ALL OF THE
EXTRA FLUID (ALL THAT WE GAVE THEM PLUS ALL THAT IS IN THE TISSUES). THEY ARE
USUALLY GOING TO DIURESE FOR UP TO 2 WEEKS. BECAUSE THEY ARE DIURESING SO MUCH,
YOU ARE GOING TO HAVE TO PAY CLOSE ATTENTION TO THEIR FOLEY AND KEEP THE DRAINAGE
BAG EMPTIED AND MAKE SUER THAT IT IS NOT OCCLUDED.

THE GREATEST VOLUME OF FLUID LOSS IS GOING TO HAPPEN WITHIN THE FIRST 24 TO 36 HOURS. THE PEAK AMOUNT
OF FLUID LOSS OCCURS BETWEEN 6 AND 8 HOURS.

SYSTEMIC EDEMA
- CAN BE MASSIVE
- USUALLY MAXIMAL AFTER 24 HOURS
- BEGINS TO RESOLVE IN 1-2 DAYS POST BURN
- USUALLY RESOLVED IN 7-10 DAYS POST BURN (IF STILL PRESENT MAY SIGNIFY LOCALIZED INFECTION) – WHAT
HAPPENS IF THEIR KIDNEYS DIED BECAUSE THEIR BLOOD PRESSURE WAS TOO LOW FOR TOO LONG? THEY VERY
LIKELY WILL NOT RESOLVE. THEY MAY HAVE TO GO ON DIALYSIS. REMEMBER, THE KIDNEYS ARE ONE OF THE
FIRST THINGS AFFECTED BY A LOW BLOOD PRESSURE.
- CIRCUMFERENTIAL BURNS CAN RESULT IN COMPARTMENT SYNDROME AND MAY REQUIRE ESCHAROTOMY DUE TO
ESCHAR (HARD LEATHERY SKIN THAT MAY NEED TO BE SPLIT TO ALLOW FOR SWELLING). ESCHAROTOMIES ARE
PRETTY GRUESOME. THEY ARE USUALLY DONE ON THE FLOOR OR ON THE ICU UNIT. THEY SPLIT THE PATIENT
WIDE OPEN SO TO ALLOW THE JOINTS AND THE NERVES TO HAVE ROOM. HOW DO YOU KNOW THAT SOMEONE
HAS COMPARTMENT SYNDROME? NEUROVASCULAR CHECKS AND THE PATIENT WILL BE COMPLAINING OF
UNRELIEVED PAIN. IF THE PATIENT HAS A FULL THICKNESS BURN, THE PATIENT WILL NOT BE COMPLAINING OF
UNRELIEVED PAIN AND THE BECAUSE THE ESCHAR IS SO THICK YOU MAY HAVE PROBLEMS TRYING TO DO A
NEUROVASCULAR CHECK – SO THIS IS SOMETHING THAT YOU KNOW IS GOING TO BE A PROBLEM. REMEMBER IF
YOU HAVE A FULL THICKNESS BURN ALL THE WAY AROUND OR ANY TIME THAT YOU HAVE A BURN ALL THE WAY
AROUND THE CHEST AREA WHILE TRYING TO BREATHE, YOU ARE NOT GOING TO GET THE EXPASION NEEDED –
SO IT IS LIKELY THAT THEY WILL DO AN ESCHAROTOMY.

SYSTEMIC EFFECTS ON FLUID/ELECTROLYTES AND BLOOD VOLUME

- INITIAL BURN THE VOLUME LEAVES VESSELS AND GOES TO INERSTITIAL SPACE
O CIRCULATING BLOOD VOLUME DECREASES BECAUSE THE FLUID IS IN THE TISSUES
O NA WILL BE LOW DUE TO SALT FOLLOWING WATER TO INERSTITIAL SPACE INITIALLY
- K+ WILL BE INCREASED IMMEDIATELY AFTER INJURY, LATER ON IT MAY DECREASE. POTASSIUM LIKES TO LIVE IN
THE CELL (SODIUM LIKES TO BE OUT OF THE CELL). WHEN THE CELLS ARE DAMAGED THE POTASSIUM RUNS
OUT OF THE CELLS INTO THE BLOOD. SO IF WE WERE TO DRAW BLOOD OUT OF THE VESSEL AT THIS TIME WE
ARE GOING TO HAVE AN INCREASED SERUM POTASSIUM LEVEL.
O PSUEDO-HYPERKALEMIA
- HEMOCONCENTRATION – HCT WILL SHOW HIGH, BIG COMPONENTS WILL BE LEFT IN VESSELS WHEN WATER
LEAVES THE VESSELS AND GOES INTO THE INTERSTITIAL TISSUES.
- MAY LOSE 3 TO 4 LITERS OF FLUID OVER A 24 HOUR PERIOD WITH A MAJOR BURN. A NORMAL ADULT HAS 12
LITERS FLUID – 6L IS BLOOD. SO IF THE BURN VICTIM LOSES 3 TO 4 LITERS OVER THE FIRST 24 HOURS,
THIS PATIENT IS GETTING PRETTY DEHYDRATED. THE NORMAL ADULT HAS 6 LITERS OF BLOOD; OF THAT 3
LITERS IS PLASMA (JUICY PART AROUND THE RBC).
O POTASSIUM’S BEST BUDDY WHEN WE ARE TALKING ABOUT FLUID AND ELECTROLYTES IS HYDROGEN.
HYDROGEN LIKES TO GO WHERE K+ GOES, SO IF K+ COMES OUT OF THE CELL AND GOES INTO THE
SERUM, THEN THE PATIENT WILL BE ACIDOTIC. (LATER ON THE K+ LEVELS WILL DROP BECAUSE THE
FLUID WILL LEAVE THE TISSUES AND GO BACK INTO THE VESSELS. IT WILL BE HEMODILUTION AT THAT
POINT – SO SERUM POTASSIUM LEVELS MAY DROP. PLUS K+ WILL GO BACK INSIDE THE VESSELS.)

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- INCREASED BLOOD VISCOSITY BECAUSE THE FLUID OR JUICY PART LEFT AND IT LEAVES JUST THE THICK RED
CELLS SO BLOOD IS VISCOUS – WHEN BLOOD IS VISCOUS CARDIAC OUTPUT DECREASES. WHEN CARDIAC
OUTPUT DECREASES TISSUE PERFUSION ALSO DECREASES.
- ANEMIA – DUE TO DESTRUCTION OF THE RED BLOOD CELLS FROM INJURY, HOWEVER HCT WILL BE ELEVATED
DUE TO CONCENTRATION BECAUSE THE VESSELS HAVE LOST THE FLUID AND BLOOD IS MORE VISCOUS.
O IF BLOOD IS PART OF THE TRAUMA WHERE THEY ARE ACTUALLY BLEEDING OUT, THIS PATIENT WILL
PROBABLY BE GETTING SOME BLOOD BECAUSE WE WILL BE REPLACING THE TOTAL VOLUME THAT IS BEING
LOST.
- THROMBOCYTOPENIA – PLATELETS DECREASE, ABILITY OF BLOOD TO CLOT CHANGES, CLOTTING TIMES ARE
PROLONGED (TELLS THAT THEY ARE BLEEDING), IF DIC SETS IN THERES NOT MUCH THAT CAN BE DONE.
- OUTPUT DROPS DUE TO DECREASED RENAL PERFUSION. THIS WILL HAPPEN BECAUSE THE ALL OF THE FLUID
THAT HAS BEEN LOST → BECAUSE THE KIDNEYS ARE NOT GETTING PERFUSED → BECAUSE CARDIAC OUTPUT IS
DOWN. ALSO URINE OUTPUT MAY DECREASE BECAUSE THE NA FOLLOWED THE WATER AND THEY ARE
RETAINING ALL OF THIS AND THIS PROCESS IS TELLING THE BODY THAT IT NEEDS TO RETAIN MORE WATER TO
DILUTE THE SODIUM, SO THE BODY IS HOLDING ON TO WHAT IT HAS ALSO AND NOT PUTTING IT OUT (INITIALLY).
- RED BLOOD CELLS IN MUSCLES RELEASE MYOGLOBIN – MYOGLOBIN WILL STOP UP RENAL ARTERIES DUE TO SIZE
AND LOW FLUID VOLUME LEVEL
- METABOLIC ACIDOSIS – BICARBONATE AND NA CHASE THE WATER WHEN IT LEAVES THE CELLS

PULMONARY RESPONSE
- LEADING CAUSE OF DEATH IN FIRE VICTIMS
- INHALATION INJURY NEGATIVELY IMPACTS SURVIVABILITY OF BURN CLIENT
- 1/3 OF ALL BURN VICTIMS HAVE A PULMONARY INJURY.
- DETERIORATION OF BURN CLIENT MAY OCCUR WITHOUT EVIDENCE OF SMOKE INHALATION. REMEMBER THAT
EVEN THOUGH WHEN DOING YOUR ASSESSMENT THAT YOU DO NOT SEE ANY EVIDENCE OF AN INHALATION INJURY
THE BURN PATIENT MAY STILL END UP WITH A MAJOR AIRWAY PROBLEM BECAUSE OF THE INFLAMMATORY
RESPONSE. YOU GET BRONCHIAL CONSTRICTION.
HISTAMINES ARE RELEASED. WE HAVE TO CONTINUE TO
WATCH FOR THIS BECAUSE IT MAY NOT HAPPEN IMMEDIATELY.MONITOR CLOSELY.
- ANY ONE WITH POSSIBLE PULMONARY INVOLVEMENT MUST BE OBSERVED FOR 24 HOURS.
- THE BODY PUTS MORE STRESS ON THE LUNGS BECAUSE OF THE NEED FOR MORE OXYGEN WHICH EXACERBATES
THE PULMONARY INJURY CAUSING WORSE INJURIES
- INDICATORS OF PULMONARY BURN INJURY
O DYSPNEA, TACHYPENIA – BRADYCARDIA IS BAD SIGN
O SINGED NASAL HAIR – ALWAYS INDICATES A PULMONARY PROBLEM
O BURN THAT OCCURRED IN ENCLOSED AREA (THIS IS WHERE GOOD HISTORY TAKING IS IMPORTANT)
O BURNS OF FACE, NECK AND/OR UPPER CHEST
O HOARSENESS, DRY COUGH
O BLOODY SPUTUM
O IF THEY ARE COUGHING UP CARBON PARTICLES OR SOOT
O BLISTERING OF ORAL OR PHARYNGEAL MUCOSA – WILL INTUBATE TO GET AIRWAY SET UP BEFORE
SWELLING OCCURS
- PULMONARY INJURIES
O UPPER AIRWAY INJURY – BREATHING IN HOT AIR, INFLAMMATORY RESPONSE CAUSES SWELLING
O INHALATION INJURY BELOW THE GLOTTIS (INCLUDES CARBON MONOXIDE POISIONING)
O RESTRICTIVE DEFECTS - DUE TO CIRCUMFERENCIAL BURNS THAT WOULD IMPEDE TAKING A DEEP
BREATH AND SUCH.
- UPPER
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O RESULTS FROM DIRECT HEAT OR EDEMA
O MECHANICAL OBSTRUCTION
O WILL BE INTUBATED (EITHER NASOTRACHEAL TUBE OR AN ENDOTRACHEAL TUBE). WE ARE TO GET
THEM AN AIRWAY.
- INHALATION
O RESULTS FROM INHALING THE PRODUCTS OF INCOMPLETE COMBUSTION OR NOXIOUS GASES.
O LEADS TO CHEMICAL IRRITATION OF PULMONARY TISSUES AT ALVEOLAR LEVEL.
O CARDINAL SIGN – COUGHING UP CARBON PARTICLES (BLACK CHUNKS)
O ALWAYS MANAGE THE AIRWAY WITH A TUBE, JUST BECAUSE WE HAVE MANAGED THE AIRWAY DOES NOT
MEAN THAT WE ARE GOING TO KEEP THEM BREATHING IF THEY HAVE A LOT OF DAMAGE DOWN THERE.
THEY MAY HAVE TO BE MECHANICALLY VENTILATED. IF THE ALVEOLAR DAMAGE IS SO SEVERE, THEY
ARE NOT GOING TO RESPOND TO MECHANICAL VENTILATION.
O REMEMBER WITH CARBON MONOXIDE POISONING – WHEN BREATHING IN CARBON MONOXIDE IT BONDS
WITH THE HEMOGLOBIN AND FORMS CARBOXIHEMOGLOBIN AND IT CAN’T CARRY OXYGEN ANY MORE. IF
THERE IS ANY IDEA THAT THIS MAY BE THE CASE, THEY WILL GO AHEAD AND INTUBATE THE PATIENT AND
GET THEM ON 100% O2

- RESTRICTIVE
O MUST HAVE ESCHAROTOMY TO RELIEVE PRESSURE AND ALLOW EXPANSION

OTHER SYSTEMIC RESPONSES

- ALTERED RENAL FUNCTION (POOR PERFUSION – LACK OF BLOOD SUPPLY)
O WILL START DIALYSIS
- DECREASED RESISTANCE TO INFECTION. SEPSIS REMAINS LEADING CAUSE OF DEATH IN BURN VICTIMS
O SKIN IS FIRST DEFENSE AGAINST INFECTION
- INABILITY TO REGULATE BODY TEMPERATURE
O WILL BE IN HEAT BOX TO CONTROL TEMPERATURE
O WILL KEEP THE ROOM ABOUT 98° IF AT ALL POSSIBLE
O NEED IV FLUID TO BE WARM – SO WILL PROBABLY HAVE TO HEAT/WARM THE FLUIDS THAT A PATIENT
WITH A SEVERE PATIENT IS BEING GIVEN.
- PARALYTIC ILEUS (ABSENCE OF INTESTINAL PERISTALSIS)
O NPO ALWAYS WITH BURNS
O WILL USUALLY PUT IN NG TUBE TO DECREASE PRESSURE
- CURLING’S ULCER (STRESS TYPE OF ULCER)
O DUE FROM STRESS
O VERY COMMON, IF NOT TREATED OR IF THERE IS NO RESPONSE TO TREATMENT THEN THERE WILL BE A
GI BLEED. SO THESE BURN PATIENTS ARE GOING TO BE ON SOMETHING LIKE TAGAMET OR PEPCID.
O PREVENTED BY FEEDING AS SOON AS BS RETURN

PHASES OF BURN CARE

- EMERGENT/RESUSCITATIVE PHASE
O FROM ONSET TO COMPLETION OF FLUID RESUSCITATION
- ACUTE/INTERMEDIATE PHASE
O FROM BEGINNING OF DIURESIS TO NEAR CLOSURE OF WOUNDS
- REHABILITATION
O FROM THE MAJOR WOUND CLOSURE ON

EMERGENT ON SCENE
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ON THE SCENE CARE – THE BURN IS NOT THE FIRST PRIORITY. WE ARE CONCERNED WITH AIRWAY, BREATHING
AND CIRCULATION.
- MUST FIRST PREVENT INJURY TO THE RESCUER
- THEN AIRWAY, BREATHING, CIRCULATION FOR THE VICTIM – CERVICAL SPINE IMMOBILIZATION FOR ALL HIGH
VOLTAGE ELECTRICAL INJURIES OR OTHERWISE INDICATED AND CARDIAC MONITORING.
- ASSESS CIRCULATORY, APICAL PULSE AND B/P
- ASSESS NEUROLOGICAL STATUS
- SECONDARY HEAD TO TOE SURVEY TO DETERMINE OTHER LIFE THREATENING PROBLEMS
- ESTABLISH LARGE BORE IV ACCESS – THIS PATIENT IS GOING TO BE GETTING LOTS OF FLUIDS. GET THAT
ACCESS ANYWHERE THAT YOU CAN. IF POSSIBLE, GO TO A NON-BURNED AREA.
- COOL, COVER THE WOUND WITH ANYTHING AVAILABLE. IF YOU GET IT COVERED THIS WILL DECREASE THE PAIN
CAUSED BY THE COLD AIR.
- NOTHING BY MOUTH (PARALYTIC ILEUS AND WE DON’T KNOW WHAT THE AIRWAY IS LIKE AT THIS POINT)

EMERGENT IN ER
- ASSURE ABC’S
- ASSURE IV ACCESS
- FLUID RESUSCITATION IS INITIATED
- OBTAIN BASELINE V/S, HEIGHT, WEIGHT, ABG’S, ELECTROLYTES, BLOOD ALCOHOL -- MAJOR BLOOD WORK IS
GOING ON AT THIS TIME
- MAINTAIN CERVICAL SPINE PRECAUTIONS
- PAIN CONTROL – THERE WILL BE LOTS OF PAIN MEDICINE GIVEN. PAIN MEDICINE WILL BE GIVEN
INTRAVENOUSLY. WE WILL NOT BE GIVING IT PO BECAUSE THIS PATIENT IS NPO.
- NG TUBE (TO SUCTION) IS >25%
- ALWAYS REMEMBER TO CHECK THE BURN VICTIM’S EYE FOR CONTACT LENS. DUE TO THE HEAT OF THE FIRE,
YOU MAY HAVE TO CONSULT OPTHAMOLOGY TO GET THE CONTACT LENS OUT.
- MEASURE I&O’S
- INSERT FOLEY
- TETANUS INJECTION
- OBTAIN HISTORY OF ACCIDENT – NEED FOR R/F PULMONARY COMPLICATIONS
O WHAT KIND OF PLACE WHERE THEY IN
O WAS IT AN EXPLOSION
O ETC….
- WHEN YOU GET THEM STABILIZED THEN LOOK AT THE BURN
- ASSESS AND CLEAN THE BURN (USE STRICT STERILE TECHNIQUE)
- REASSURE CLIENT AND FAMILY – IT IS A GOOD IDEA TO GO AHEAD AND GET SOCIAL WORK INVOLVED. MAKE
SURE YOU THAT YOU ARE TRYING TO EXPLAIN THINGS TO THEM AND TO THE PATIENT.

MANAGEMENT OF FLUID LOSS AND SHOCK

- SURVIVAL DEPENDS ON ADEQUATE FLUID RESUSCITATION
- NEXT TO RESPIRATORY PROBLEMS THE MOST URGENT NEED IS TO PREVENT IRRECERSIBLE SHOCK BY
PROVIDING ADEQUATE FLUID AND ELECTROLYTE REPLACEMENT
- USUALLY AN ISOTONIC FLUID LIKE LACTATED RINGERS WILL BE USED – WE USE AN ISOTONIC FLUID BECAUSE
WE DO NOT THE FLUID WANT TO LEAVE WHERE WE PUT IT. IF YOU PUT AN ISOTONIC FLUID IN THE VASCULAR
SPACE, IT SHOULD NOT CAUSE A SHIFT. WE USE LACTATED RINGERS BECAUSE THEY HAVE SOME ELECTROLYTES
IN THEM, SO WE ARE ACTUALLY REPLACING SOME OF THE ELECTROLYTES THAT THE PATIENT MAY BE LOSING.

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FLUID REPLACEMENT THERAPY
- CONSENSUS FORMULA – GOES ALONG WITH RULES OF NINE TO GET BSA
O 2 - 4 ML. X KG OF BODY WEIGHT X TBSA OF THE BURN
O GIVE HALF OF THE TOTAL AMOUNT IN FIRST 8 HOURS
O GIVE REST (1/2 AMOUNT) OVER THE NEXT 16 HOURS
O USE LACTATED RINGERS SOLUTION OR OTHER BALANCES SALINE SOLUTION
- URINE OUTPUT IS BEST METHOD TO DETERMINE ADEQUACY OF REPLACEMENT
- SYSTOLIC B/P OF GREATER THAN 100 IS DESIRED, PULSE RATE LESS THAN 100/MINUTE
- WACHING THE H&H, SERUM SODIUM LEVELS. AFTER THE FIRST 24 HOURS THEN WE ARE GOING TO TRY TO
MAINTIAN THEIR FLUID NEEDS AND KEEP UP WITH ANY FLUID THAT IS BEING LOST.
- WE WANT TO GET THEM OVER THE FIRST 2 OR 3 DAYS, AFTER THAT HEMODYNAMICALLY THEN THE NEXT THING
TO WORRY ABOUT WILL BE INFECTION.

CONSENSUS FORMULA EXAMPLE:

CLIENT’S WEIGHT IS 38 KG
THE BURN IS COVERING THE FRONT OF BOTH ARMS (4½ + 4½ = 9), THE ANTERIOR TORSO (18), THE FACE
(4½). THIS WILL EQUAL 31½ TBSA.
(CONTINUED NEXT PAGE)
THE MINIMUM WE WOULD GIVE:
2 X 38 KG X 31½ = 2394 (CC’S OVER THE FIRST 24 HOURS)
WE ARE GOING TO GIVE HALF OVER THE FIRST 8 HOURS = 1197 CC’S OR WE ARE GOING TO BE GIVING 149.6
CC’S PER HOUR.

NOW IF THEY DO NOT HAVE AN OUTPUT OR IT IS DROPPING AND THEIR BLOOD PRESSURE CONTINUES TO DROP, WHAT
WOULD YOU DO? WE CAN START INCREASING IT BECAUSE WE HAVE THAT RANGE OF 2 TO 4 CC’S.

DIAGNOSIS
- IMPAIRED GAS EXCHANGE
- INEFFECTIVE AIRWAY CLEARANCE
- FLUID VOLUME DEFICIT
- HYPOTHERMIA
- PAIN
- C/P ACUTE RESP FAILURE, DISTRIBUTIVE SHOCK, ACUTE RENAL FAILURE, COMPARTMENT SYNDROME, PARALYTIC
ILEUS, CURLING’S ULCER

ACUTE/INTERMEDIATE PHASE
- FOLLOWS EMERGEN PHASE
- BEGINS 48-72 HOURS AFTER THE BURN INJURY
- PRIORITIES
O RESP
O CIRCULATORY
O INFECTION PREVENTION (STERILE TECHNIQUE)
O PAIN CONTROL
O NUTRITIONAL SUPPORT
O WOUND CARE
O F/E
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O GI FUNCTION – FIRST BOWEL SOUND = TUBE FEEDING TIME
- HEMODILUTION – FLUID IS COMING BACK TO VASCULAR BED
- OUTPUT SHOULD BE INCREASING
- SODIUM DEFICIT – BECAUSE THE FLUID IS COMING BACK IN AND DILUTING THE SODIUM IN THE VASCUALR
COMPARTMENT
- K+ SHOULD BE LOWERING – K+ IS GOING BACK INTO THE CELLS, PLUS YOU HAVE HEMODILUTION
- METABOLIC ACIDOSIS
- WE ARE NOW BEGINNING TO THINK MORE ABOUT THE WOUND.
- RIGHT AFTER YOU HAVE GOTTEN OVER THAT PERIOD OF BURN SHOCK, THE TEMPERATURE MAY GO UP. IT MAY
GO UP EVEN WITHOUT AN INFECTION BEING PRESENT. THIS IS BECAUSE THE PATIENT GETS INTO WHAT THEY
CALL A HYPERMETABOLIC STATE. THE TEMPERATURE MIGHT GO UP SO HIGH AT THIS POINT THAT YOU MIGHT
END UP PULLING OUT THE HYPOTHERMIA BLANKET. THIS DOES NOT NECESSARILY MEAN THAT THEY HAVE AN
OVERWHELMING INFECTION. IT IS JUST THAT THE METABOLIC DEMANDS OF THE BODY ARE SO MUCH THAT THE
BODY IS WORKING IN OVERTIME. THIS CAN LAST FOR A LONG TIME. SO BECAUSE OF THIS, WE JUST LOST ONE
OF OUR EASY ASSESSMENTS FOR INFECTION. AS FAR AS INFECTION IS CONCERNED WATCH THE VITAL SIGNS,
WATCH THE RHYTHM STRIPS, LOOK FOR SUBTLE CHANGES IN LOC. IT CAN BE A VERY SMALL CHANGE. THIS IS
WHY IT IS SO IMPORTANT IN CRITICAL CARE TO HAVE CONSISTANCY AND TAKING CARE OF THE SAME PATIENT
BECAUSE THE NURSE CAN PICK UP ON SUBTLE CHANGES.

FYI: SKIN WOUNDS ALWAYS GROW STAPH AND STREP

INFECTION CONTROL IN THE ACUTE PHASE

- SEPTIC SHOCK IS MAJOR CAUSE OF DEATH IN CLIENTS WHO HAVE SURVIVED THE FIRST FEW DAYS POST MAJOR
BURN
- PRIMARY SOURCE OF BACTERIAL INFECTION IS THE CLIENT’S INTESTINAL TRACT. THIS IS BECAUSE WHEN THE
CAPILLARIES ARE BECOMING MORE PERMEABLE, SO IS THE INTESTINAL TRACT. IT IS LETTING THE NORMAL FLORA
OF THE GUT COME OUT. SO THE BACTERIA THAT IS NORMALLY IN YOUR GUT TO HELP BREAK DOWN THE FOOD
IS LEAKING INTO THE SYSTEMIC SYSTEM. WE USED TO KEEP THESE PEOPLE NPO FOREVER, NOW AS QUICK AS
THEY GET A BOWEL SOUND AND WE KNOW THAT THEY DO NOT HAVE AN ILEUS, WE START TUBE FEEDING THEM.
BECAUSE WHEN THEY START GETTING TUBE FED, IT HELPS THE GUT TO REGAIN ITS INTEGRITY AND HANG ON TO
ITS OWN BACTERIA. THEN THERE IS MUCH LESS OF A RISK OF SEPTICEMIA.
- WOUND IS USUALLY NOT THE CUASE OF INFECTION, YET STILL CAN BE
- THE ENVIROMENT IS ALSO SOURCE OF SECONDARY INFECTION. THEY CAN NOW GET MRSA, VRE AND
OTHER INFECTIONS.
- WHEN THESE CLIENTS ARE WASHED, THEY USUALLY SCRUB UNTIL THERE IS A LITTLE RED TINGE OF BLOOD.
THEY WANT TO GET THE DEAD TISSUE OFF. IF YOU LEAVE THE DEAD TISSUE ON, IT WILL PROMOTE INFECTION.
- WOUND CLEANING
O BEFORE DOING ANYTHING WITH THE WOUND – GIVE GOOD PAIN MEDS
O HYDROTHERAPY (WHIRLPOOL)
• BEFORE TAKING THEM TO THE WHIRLPOOL – GIVE THEM GOOD PAIN MEDICINE
• MAY BE WITH SHOWERS OR TOTAL IMMERSION
• CAN USE TAP WATER
• MAKE SURE TUBE ARE DECONTAMINATED
• TEMPERATURE OF WATER = 100 DEGRESS F – IF WATER TOO COLD WILL CAUSE EXCRUTIATING
PAIN AND CERTAINLY DO NOT WANT TO BURN THEM FURTHER.
• TEMPERATURE OF ROOM = 80-85 DEGREES F
• LIMIT TO 20-30 MINUTES, VERY STRESSFUL – THERE WILL BE MAJOR CHANGES IN VITAL SIGNS.
NEED TO SLOWLY BUILD UP TIME, IF THEY MANAGE 5 MINUTES AT FIRST THEY ARE DOING WELL.
- TOPICAL ANTIBACTERIAL AGENTS
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O SILVER SULFADIAZINE 1% (SILVADENE)
 MOST BACTERICIDAL
 POOR ESCHAR PENETRATION
 MONITOR BLOODWORK FOR LEUKOPENIA FOR 2-3 DAYS AFTER INITIAL TREATMENT (RESOLVES
AFTER THAT)
 SOOTHING – THE PATIENT WILL TELL YOU THAT IT FEELS GOOD
 WHEN USING SILVADENE EVERY FEW DAYS YOU ARE GOING TO HAVE TO GO IN AND WASH OFF
GELATINOUS FORMATION FROM THE WOUND. THE WHIRLPOOL WORKS WELL FOR THIS.
OTHERWISE, YOU WILL HAVE TO GET A STERILE IRRIGATION SYRINGE AND SOLUTION &
IRRIGATE THE WOUND TO TRY AND GET IT OFF.
 SILVADENE USUALLY GOES ON 2 TO 3 TIMES A DAY
O SULFAMYLON
 GOOD AGAINST GRAM NEG AND POS ORGANISMS
 GOES THROUGH ESCHAR
 10% BEST FOR BURNS
 MONITOR FOR ACIDOSIS
 ALWAYS PREMEDICATE, VERY PAINFUL, SEVERE BURNING PAIN FOR UP TO 20 MINUTES AFTER
APPLICATION
 WITH THIS SOMETIMES THEY WILL LEAVE THE WOUND OPEN
O SILVER NITRATE (0.5% SOLUTION)
 DOES NOT PENETRATE ESCHAR
 MONITOR SODIUM AND K+ - BECAUSE THIS IS A HYPOTONIC SOLUTION AND IT WILL NA & K+
 PROTECT BED LINEN – THIS SOLUTION STAINS EVERYTHING A DARK BROWN, ALMOST A BLACK
COLOR.
 APPLY TO GAUZE/ COVER WOUND/ REMOISTEN EVERY 2 HOURS AND REDRESS 2 TIMES A DAY
O ACTICOAT
 EFFECTIVE AGAINST GRAM NEG AND POS ORGANISMS
 DELIVERS A UNIFORM APPLICATION OF SILVER TO WOUNDS
 MOISTEN WITH STERILE WATER ONLY – NEVER USE NORMAL SALINE
 NEVER USE AN OIL BASED PRODUCT WITH IT
 APPLY TO WOUND AND COVER
 CAN LEAVE DRESSING IN PLACE 3-5 DAYS OR UP TO 7 DAYS
- WOUND CARE
O AFTER CLEANING BURNED AREAS ARE PATTED DRY (NEVER RUB)
O TOPICAL AGENT APPLIED WITH DRESSING
O LIGHT DRESSING OVER JOINTS TO ALLOW MOBILITY. WE WANT TO ENCOURAGE MOBILITY.
O CIRCUMFERENTIAL DRESSING GO FROM DISTAL TO PROXIAML
O DO NOT LET OPEN SKIN TOUCH OPEN SKIN – WRAP FINGERS AND TOES INDIVIDUALLY
O WITH PENDELOUS BREASTS AND SKIN FOLDS/ROLLS MAKE SURE YOU LIFT AND DRESS BECAUSE YOU DO
NOT WANT THESE TISSUES GROWING TOGETHER
O OCCLUSIVE DRESSINGS
O ALWAYS PREMEDICATE

WOUND DEBRIDEMENT
- GOALS
O TO REMOVE CONTAMINATED TISSUE TO PREVENT SPREAD OF BACTERIA
O TO REMOVE DEVITALIZED TISSUE OR ESCHAR IN PREPARATION FOR GRAFTING
- TYPES OF WOUND DEBRIDEMENT
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O NATURAL – WHEN SKIN STARTS DYING IT PEELS OFF (MUCH GREATER RISK FOR INFECTION AND THIS IS
A LONG PROCESS IN THE ELDERLY)
O MECHANICAL – CUT OFF TILL IT STARTS BLEEDING (DONE IN THE WHIRLPOOL A GOOD BIT)
O SURGICAL – INTO OR AND SHED OFF TILL GET TO BLOODY LAYER. WILL REMOVE THE DEVITALIZED
TISSUE AND START GRAFTING. THEY ARE GOING TO COVER THE SURFACE AREA. THE QUICKER THE
SURFACE AREA IS COVERED, THE LESS THE RISK FOR INFECTION AND THE BETTER THE HEALING.

DRESSING AND GRAFTS

- BIOLOGICAL DRESSINGS – QUICK, USED WITH BIGGER BURNS, DECREASE WOUNDS EVAPORATIVE LOSS
(TEMPORARY)
O HOMOGRAFTS – OBTAINED FROM LIVING OR RECENTLY DECEASED HUMANS
O HETEROGRAFTS – SKIN TAKEN FROM ANIMALS (USUALLY PIG) DOESN’T LAST LONG. THIS WILL NOT
BECOME THE PATIENT’S SKIN; IT JUST KEEPS THE WOUND COVERED UNTIL WE CAN GET ENOUGH OF
THEIR OWN SKIN TO COVER IT UP.
- BIOSYNTHETIC (BIOBRANE) –
O SEMITRANSPARENT AND STERILE
O PROTECTS WOUND FROM EVAPORATIVE LOSS AND BACTERIA
O SILATIC MEMBRANE COMBINED WITH COLLAGEN DERIVATIVE
O CAN REMAIN FOR 3-4 WEEKS
O CAN NOT PUT OVER A DIRTY WOUND, THIS HAS TO BE USED BEFORE ANY INFECTION IS PRESENT
- DERMAL SUBSTITUTES (INTEGRA AND ALLODERM) –
O LESS HYPERTROPHIC SCARING
O MINIMAL CONTRACTURE FORMATION
O 2-3 WEEKS CAN STAY ON
O ALLODERM IS PERMANENT AND FROM A CADAVER, PERMANENT DERMAL LAYER REPLACEMTN
O LESS SCARRING
O WHEN THEY PUT THESE THINGS ON IT HELPS TO REVASCULARIZE THE AREA. IT MAKES IT VERY MEATY
AND JUICY. THIS WAY WHEN YOU PUT THE FINAL SKIN ON THERE, THIS SKIN IS GOING TO ADHERE AND
GROW TO IT AND HOPEFULLY SURVIVE.
- AUTO GRAFTS (BEST)
O PREFERRED MATERIAL FOR BURN WOUND CLOSURE FOLLOWING EXCISION
O ARE CLIENTS OWN SKIN AND WILL NOT BE REJECTED
O POSITION AND TURN CAREFULLY TO PREVENT DISLODGEMENT
O MAKE SURE THAT YOU DO NOT LEAVE PRESSURE ON IT ANY LENGTH OF TIME
O DRESSING REMOVED IN 3-5 DAYS UNLESS S/S INFECTION BEFORE.
O WHEN DOING THIS TYPE OF GRAFT, THE CLIENT WILL HAVE ANOTHER WOUND SITE (THE DONOR SITE).
THIS SITE WILL ALSO HAVE TO BE TAKEN CARE OF.
O DONOR SITE CARE
 DONOR SITE MUST BE KEPT CLEAN, DRY AND FREE OF PRESSURE. USUALLY WILL HAVE A
HEAT LAMP ON IT TO KEEP IT DRY.
 MAY HAVE MOIST GAUZE DRESSING OR PETROLEUM GAUZE
 PAINFUL (DONOR SITE USUALLY HURTS MORE THAN THE RECIPIENT SITE)
 PARTIAL THICKNESS WOUND AND WILL HEAL IN 7-14 DAYS WITH PROPER CARE

PAIN MANAGEMENT
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- OFTEN VERY SEVERE PAIN – IT IS INTENSE AND OF LONG DURATION (MORPHINE SULFATE IS USUALLY WHAT IS
USED)
- PARTIAL THICKNESS HAVE EXPOSED NERVE ENDINGS WITH SEVERE PAIN WHEN EXPOSED
- WITH FULL THICKNESS MARGINS OF WOUND ARE HYPERSENSITIVE AND REGENERATING NERVES BECOME PAINFUL
- PAIN MED ARE GIVEN ONLY IV
- FENTANYL GOOD FOR PRECEDURAL PAIN MONITOR CARDIAC AND RESPIRATORY
- MAY RECIVE LARGE AMOUNTS OF PAIN MEDS
- RELAXATION, VISUALIZATION, ANYTHING THAT YOU CAN DO TO EASE THE PAIN

NUTRITIONAL SUPPORT
- HYPERMETABOLISM
- THEY ARE GOING TO NEED LOTS OF PROTEIN AND LOTS OF CALORIES
- MUST PROVIDE ADEQUATE NUTRITIONAL SUPPORT AND CALORIES TO DECREASE CATABOLISM
- MUST PROVIDE A STATE OF POSITIVE NITROGEN BALANCE BY MATCHING NUTRITIONAL UTILIZATION TO
NUTRITIONAL SUPPORT
- ENTERAL FEEDINGS ARE SUPERIOR TO PARENTERAL
- MONITOR ALBUMIN AND PROTEIN
- TUBE FEEDINGS INITIALLY. THEY ARE BETTER THAN PARENTERAL FEEDINGS BECAUSE THEY WILL KEEP THE GUT
INTACT AND THIS IS ONE LESS SOURCE FOR INFECTION.
THERE IS A HIGH RISK FOR INFECTION WITH HYPERAL.
- CONTINUE TO HAVE THE RISK FOR THE CURLING’S ULCER FOR A WHILE.

WOUNDS HEALING
- HYPERTROPHIC SCARS – LIMITS MOVEMENT
O COMPRESSION BANDAGE CAN PREVENT THAT
- KELOIDS
- FAILURE TO HEAL – WHEN YOU ARE NOT MEETING CALORIC AND PROTEIN NEEDS
- CONTRACTURE – DUE TO TISSUES AND TENDONS SHORTENING AND GROWING BACK TO NORMAL
- DARK PIGMENTED SKIN IS MORE SUSCEPTIBLE TO HYPERTOPHIC SCARS AND KELOIDS

NURSING DIAGNOSIS
- FLUID VOLUME EXCESS – FLUIDS ARE GOING BACK TO WHERE THEY CAME FROM
- RISK FOR INFECTION
- ALTERED NUTRITION, LESS THAN BODY REQUIREMENTS
- IMPAIRED SKIN INTEGRITY
- PAIN
- IMPAIRED PHYSICAL MOBILITY
- COPING
- ALTERED FAMILY PROCESS
- KNOWLEDGE DEFICIT

REHABILITATION PHASE
- FROM LAST WOUND CLOSURE TO THE BEST THEY CAN BE
- CAN LAST LIFETIME
- PSYCHOLOGICAL SYPPORT – FAMILY NEEDS TO ALSO GET INVOLVED IN COUNSELING
- EMOTIONAL SUPPORT
- PREVENTION OF HYPERTROPHIC SCARRING – JOBST STOCKING – WITH THIS STOCKING YOU NEED TO WEAR IT
23 HOURS A DAY. WE NEED TO TEACH THEM THAT THEY CANNOT TAKE THIS STOCKING OFF WHEN THEY WANT
TO. IT ONLY COMES OFF FOR BATHS, PAT DRY, USE MOISTURIZERS, DO THEIR SKIN MASSAGE AND THEN THEY
PUT IT RIGHT BACK ON. IT IS USUALLY WORN FOR 1 TO 2 YEARS.

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- IMPROVEMENT OF ACTIVITY TOLERANCE, BODY IMAGE, SELF CONCEPT
- REMEMBER WITH THE SCAR TISSUE THAT IS FORMING THEY ARE GOING TO NEED TO USE SOME TYPE OF
LUBRICANT OR MOISTURIZER. THEY WILL NEED LOTS OF MASSAGE. WE NEED TO TEACH THEM TO DO THIS.

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