N124

Classification of burn injuries

Prof. MGAP Batalla

7/19/12

Burn severity
Factors:
- Depth and size
- Body surface area burned
- Age
- Preexisting medical condition
- Associated trauma
o Blast
o fall
o Airway compromise
o Child abuse

Nursing Care of the Burn Patient

Anatomy and Physiology of the Skin
Skin
-

Burn
-

Largest organ
Parts: epidermis and dermis
Functions:
o Maintains body temperature
o Acts as a barrier to water loss
o Produces Vit. D

Every 15 minutes in the sun

o Prevents microbes from entering the body
o Protects against environment
o Cosmetic

Injury that is d/t tissue damage or loss

Extent depends on:
o Temperature
o Causticity of the burning agent
o Duration of tissue contact with source (
length of exposure)

1 sec with hot tap water at 69

degrees Celsius: full thickness
burn

15 sec with hot water 15 degrees

Celsius: full thickness burn

Zones of injury
Jacksons thermal wound theory: zones of injury
- Areas extending outward from the center area of
injury that sustain various degrees of damage
1.

2.

3.

Zone of coagulation

Most severe damage

Irreversible death occurs (no more

blood supply)
Zone of stasis

Impaired circulation

Potentially salvageable

48-72 hours to determine extent

of damage
Zone of hyperemia

Vasodilation and increased blood

flow

Minimal cell involvement

Early spontaneous recovery

Types of burn injuries

1. Thermal burn
a. From scalds, steam, and contact with
heat
b. Tanning machines, radiation therapy
2. Chemical
3. Electrical
4. Radiation
Depth classification
st
1. Superficial (1 degree)
a. 2 3 layers of the epidermis
b. Usually heals in 2-7 days
c. E.g. sunburn, minor steam burns
d. Assessment findings
i. Reddening
ii. Tenderness and pain
iii. Increased warmth
iv. Blanches with pressure
v. Edema may occur
vi. w/o blistering
2. Partial thickness (2nd degree)
a. Upper third of the dermis
i. Superficial
1. Light to bright red or
mottled
2. Shiny appearance
3. May contain bullae,
moist/wet weeping
4. Very painful (due to
exposed nerve endings)
5. Heals in 7-21 days
ii. Mid-dermal
1. Half the dermis is
destroyed
2. Heals in 4-6 weeks
iii. Deep-dermal
1. Involves majority of the
dermal layer
2. Red and dry with white
areas in deeper parts
3. Healing is 4-10 weeks or
longer
4. There is a certain degree
rd
of pain (unlike 3
degree, no pain)

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3.

rd

Full thickness (3 degree)

a. All skin layers and sq fat are destroyed
b. Painless
c. Pain d/t intermixing with 2nd degree burn
d. Thick , dry, leathery
e. Pale white/pearly grey/charred black, red,
brown
f. Requires grafting

Size of injury
1.

2.
3.

Rule of nines
a. The body surface is divided into areas
representing 9% or multiple
i. 9% head
ii. 9% arm
iii. 1% perineum
iv. 18% leg
v. 18% posterior trunk
vi. 18% anterior
Palm rule
a. 1 % of body surface
Lunder and browder
a. Depends on age

*estimating TBSA (total body surface area) for fluid loss;

1st degree burn is not included
Special considerations
- Location
- Age
o <2, >60
Pediatric burns
- thin skin
- Delicate balance
- Large surface/volume ration
o Rapid fluid loss
- Immature immunological response/sepsis
- Always consider possibility of child abuse
Geriatric burns
- less myocardial reserve
- fluid resuscitation diff
- PVD, DM,
o Slow healing

COPD

Complication of airway injury

poor immunological response

o Increase risk for sepsis

% of mortality is approx.: age + % BSA burned

Burn configuration
- circumferential burns can cause total occlusion of
circulation to an area d/t edema

Minor burn criteria

- 3 degree < 2% BSA
- 2nd degree < 15 % BSA (<10% BSA pedia)
st
- 1 degree < 10 % BSA
Moderate burn criteria
rd
- 3 degree 2-10 % BSA
nd
2 degree 15-20% BSA

Critical
-

burn
3rd degree >10 % BSA
2 >30 % BSA (>20 % BSA pedia)
Burns with respiratory injury
Underlying health problems
Hands, face, feet or genitalia
Burns complicated by other trauma

Phases
1.
2.
3.

of burn management
Resuscitation phase
Acute phase
Rehabilitation phase

Goals of initial burn management

1. Save lives
2. Minimize disability
3. Prepare for definitive care
Initial Burn Management
- ABC!
Respiratory Management
- Circumferential full-thickness eschar to chest wall
can lead to decreased chest wall expansion and
compliance = chest wall restriction = CO2 retention
o Eschar

Black gulaman (Centillo, 2012)

Tough inelastic mass of burnt

tissue

May cause compartment

syndrome

Escharotomies may increase

compliance (too relieve pressure
of the burn area)
Circulatory Management
- IV access
- Fluid restriction
- Continuous ECG monitoring
- Urine output, HR, BP and LOC monitoring

Parkland Formula
o 50% of calculated amount of fluid is given
in the first * hours after injury
o 25% is given in the second 8 hours
o 25% in the third 8 hours

Lactated Ringers: fluid resuscitant of choice, for plasma

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Burn Shock
- Greater than 35% BSA
- Components
o Hypovolemic

Decreased intravascular volume

Decreased venous return
Decreased ventricular filling
Decreased SV Decreased CO
Inadequate tissue perfusion
o Local and systemic

Changes in capillary wall d/t

Direct injury

Indirect mediatormodulated changes

o Histamine
o Prostaglandings
o Kinins
o O2 radicals
leads to
increased
arteriolar
vasodilation
*protein leakage decreased plasma osmotic pressure
Renal Mangement
-

foley catheter/hour output for burns > 15-20 %

BSA
adequate UOP
o for adults: 0.5 1 mL/kg/hr
o for children: 1 mL/kh/hr

*decreased renal blood flow = increase SG; because the

kidneys will conserve H2O
Pain Management
-

during the acute phase of burn injury, the route of

choice for administering pain meds is IV

Pharmacologic treatment
-

morphine sulfate and fentanyl

benzodiazepines for anxiolysis

Pulse extremity assessment

- edema formation may cause neurovascular
compromise
- Doppler flow probe
GI Management
-

More than 20% TBSA: prone to gastric dilation and

paralytic ileus
GI activity resumes in 24 to 48 hours
Prone to Curling stress ulcer

Curling stress ulcers

- Acute ulcerations of the duodenum
- Caused by the sloughing of the gastric mucosa
resulting from loss of plasma volume after severe
burns
Nutritional Management
Goals:
- Minimize metabolic response
o Control environmental temperature
o Monitor F & E
o Control pain and anxiety
o Cover wounds adequately and quickly
- Meet nutritional needs
o Provide adequate kcal to prevent weight
loss of >10 % of usual BW
o Provide adequate CHON for (+) nitrogen
balance and maintenance of visceral
CHON stores
* increased capillary permeability edema and protein
leak protein deficiency increase need for protein
-

Prevent Curlings ulcer

Calculating for energy needs of burn patients

Curreri Formula:
Kcal required per day x [25 kcal x kg usual BMW] + [40
kcal X % TBSA]
Wound Management
- Hydrotherapy
o Improvement of burn surface:

Separation of eschar

Cleaning of the wound

Drainage of pus
o Provide a moist environment for wound
healing
o Facilitation of physical therapy and
mobilization
o Provide comfort and psychological
improvement
- Topical antibacterial therapy
o Silver sulfadiazene
- Wound dressing
o Exposure method

Exposed to air; for drying

Topical agent

No dressing
st

For 1 degree
o Occlusive dressing

Topical agent followed by

occlusive dressing

Used to protect new skin grafts

o Hydrogels

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Wound debridement
o Removal tissue and eschar

Natural

Mechanical

surgical
Skin grafting
o Full thickness skin graft
o Sources

Homografts

From dead people

Heterografts

From animals

Autografts

From self

Biosynthetic

Artificial

Synthetic dressing (nylon

with collagen derivative)

Psychosocial Problems of the Burn Patient

Acute phase
- Facing reality of burn trauma
- Grieving over obvious losses
o Depression
o Regression
o Manipulative behavior
o Withdrawal
o Anger
Rehab phase
- Include the patient in decision making
- Help patient set realistic self goals

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