CLASSIFICATION OF BURNS BY EXTENT OF BODY SURFACE AREA (BSA) INJURED

Extent of BSA Injured Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are:

the rule of nines, the Lund and Browder method, and the palm method.

CLASSIFICATION OF BURNS
RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines. The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

Rule of Nines Chart

CLASSIFICATION OF BURNS
LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patients arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then.

Lund-Browder Chart

PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patients palm -from crease at wrist to tip of extended fingers- equals to1% of TBSA.

Pre-hospital Care
Remove from affected area! Stop the burn! If thermal burn is large--FOCUS on the ABCs A=airway-check for patency, soot around nares, or signed nasal hair B=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of pulses Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth

Pertinent History
How long ago? What care has been given? What was the cause? Burned in closed space?
Products of combustion present? How long exposed? Loss of consciousness?

Past medical history?

Care of

BURNS

B - Breathing, Body image U - Urine output R - Rule of nines, Resuscitation of fluid N - Nutrition S - Shock, Silvadene, Support

B.U.R.N.S.
B- BreathingKeep airway open. Facial burns, singed nasal hair, hoarseness, sooty sputum, bloody sputum and labored respiration indicate TROUBLE!

- Body Image- assist patient in coping by encouraging expression of thoughts and feelings.

B.U.R.N.S.
U- URINE OUTPUTAdult 30-70 cc per hour Child 20-50 cc per hour Infant 10-20 cc per hour Watch the K+ to keep it between 3.5-5.0 mEq/l Keep the CVP around 12 cm water pressure

B.U.R.N.S.
R -RESUSCITATION OF FLUIDSalt & electrolyte solutions are essential over the 1st 24 hrs -First 24 hour calculation starts at the time of injury - of the fluid for the first 24 hrs should be administered over the first 8 hour period - the remainder is administered over the next 16 hours. Maintain B/P at 90-100 systolic. -RULE OF NINESUsed to determine burn surface area

B.U.R.N.S.
N -NUTRITIONProtein & Calories are components of the diet Supplemental gastric tube feedings or hyperalimentation may be used in pts with large burned areas. Daily weights will assist in evaluating the nutritional needs

B.U.R.N.S.
S -SHOCK- Watch the B/P, CVP, and renal function. -SILVADENE- topical antibiotic REMEMBER THESE PATIENTS ARE AFRAID AND NEED SUPPORT !

3 Phases of Burn Management

Emergent (resuscitation)
0 48 hours, can be up to days later

Acute (definitive care)

day 3 until wounds heal

Rehabilitation
Begins during resuscitation and continues throughout lifespan

Emergent Phase (Resuscitative Phase)

Lasts from onset to 5 or more days but usually lasts 24-48 hours Begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins Greatest initial threat is hypovolemic shock to a major burn patient

Emergent Phase Initial Management/Care

MAKE SURE YOU ARE SAFE !!! Remove patient from area! Stop the burn! Airway-check for patency, soot around nares, or signed nasal hair. 100% O2 via NRM @ 15L. Watch for early upper airway edema >intubate when in doubt. Breathing- check for adequacy of ventilation, consider need for early intubation or early escharotomy if ventilation is impaired

Emergent Phase Initial Management/Care

Circulation-check for presence and regularity of pulses, consider early escharotomy if circulation to a limb is impaired Disability- AVPU, altered mental status in burn patient is not normal >think carbon monoxide poisoning. Check pupils. Check for movement in all extremities. Expose- Remove clothing and jewelry. Do not pull on clothing stuck to skin > Cut away clothing or soak it off. Cover with dry sterile sheet and tuck in sides.

Emergent Phase Initial Management/Care

Fluid Resuscitation- estimate TBSA burn percentage and weight then calculate fluids for first 24 hour period using Parkland formula Foley catheter- to monitor urine output Secondary survey starting with a good scene and patient history then head to toe exam Pain Management- early and often based on patients hemodynamic status and pain scale Psychosocial issues- consider need for religious intervention, legal consult for family affairs, etc for patients with life-threatening burns

Secondary Survey History

Flame How did the burn occur? Did the burn occur outside or inside? Did the clothes catch on fire? How long did it take to extinguish the flames? How were the flames extinguished? Was gasoline or another fuel involved? Was there an explosion? Was there a building/house fire? Was the patient found in a smoke-filled room? How did the patient escape? If the patient jumped out a window, from what floor? Were others killed at the scene? Was there a motor vehicle crash? How badly was the vehicle damaged? Was there a motor vehicle fire? Are there other injuries?

Secondary Survey History

Chemical What was the agent? How did the exposure occur? What was the duration of contact? What decontamination occurred? Was there an explosion?

Secondary Survey History

Electrical What kind of electricity was involved? What was the duration of contact? Did the patient fall? What was the estimated voltage? Was there loss of consciousness? Was cardiopulmonary resuscitation administered at the scene?

Specific burn Treatment notes Care for Thermal Burn

For

<10% TBSA burn-apply moist cool sterile dressings to small burn For larger-cover area with dry sterile dressings or sheet

Specific burn Treatment notes Care for Chemical Burn (1 of 2)

Remove the chemical from the patient. If it is a powder chemical, brush off first. Remove all contaminated clothing.

Care for Chemical Burn (2 of 2)

Flush burned area with large amounts of water for 30 minutes or more. Transport quickly.

Chemical Burn- Eyes

Occur whenever a toxic substance contacts the body Eyes are particularly vulnerable. Fumes can cause burns. To prevent exposure, wear appropriate

Chemical Burn- Eyes

For chemicals, flush eye with saline solution or clean water. You may have to force eye open to get enough irrigation to eye. With an alkali or strong acid burn, irrigate eye for about 20 minutes. Bandage eye with dry dressing.

Specific burn Treatment notes Care for Electrical Burn

Cardiac Monitor Fluids -Ringers Lactate or other fluids to flush kidneys if myoglobinuria is present Assess for bone fractures and treat appropriately if found

Complications during emergent phase of burn injury may occur in 3 major organ systems

Cardiovascular

Respiratory
Renal

Cardiovascular System

Arrhythmias, hypovolemic shock which may lead to irreversible shock Circulation to limbs can be impaired by circumferential burns and then the edema formation Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene Escharotomies (incisions through eschar) done to restore circulation to compromised extremities

Respiratory System

Vulnerable to 2 types of injury

1.

Upper airway burns that cause edema formation & obstruction of the airway 2. Inhalation injury can show up 24 hrs later-watch for respiratory distress such as increased agitation or change in rate or character of respirations preexisting problem (ex. COPD) more prone to get respiratory infection
Pneumonia

is common complication of major burns Is possible to overload with fluids--leading to pulmonary edema

Renal System

Most common renal complication of burns in the emergent phase is Acute Tubular Necrosis (ATN) (muscle destruction > myoglobulin release > protein leak clogs kidney cells >ischemia) Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.

Patient management in the Emergent Phase

Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn) Ventilator - ABGs - Escharotomies Bronchoscopy to assess lower respiratory tract 6-12 hours later High Fowlers position-cough & deep breathe every hour, turn q 1-2 hrs, chest physiotherapy, suction prn

Fluid Shifts

Massive fluid shifts out of blood vessels as a result of increased capillary permeability. When capillary walls become more permeable, water, sodium, and later plasma protein (esp. albumin) moves into interstitial spaces & other tissues. The colloidal osmotic pressure decreases with loss of protein from the vascular space. This called second spacing.

Third Spacing

Fluids goes into areas with no fluids and this is called third spacing. Examples of third spacing are exudate and blister formation

Net result is decreased volume, depletion due to fluid shifts = edema, decreased blood pressure, and increased pulse

Hypovolemic Shock

Occurs when there is a loss of intravascular fluid volume. The volume is inadequate to fill vascular space and is unavailable for circulation Burns have a direct loss of fluid due to evaporation

40

Conditions Leading to Burn Shock

Fluid Therapy
41

1 or 2 large bore IV replacement lines (may need jugular or subclavian) Cutdowns are rare due to increased risk of infection & sepsis Fluid replacement based on: size/depth of burn, age of pt., & individualized considerations--ex. Dehydration in burn state, chronic illness Options- RL, D5NS, dextam, albumin, etc.

Consensus (Parkland) Formula

42

Lactated Ringers solution is recommended 2-4ml/kg/%TBSA burn = mls in first 24 hours

of this total given in the first 8 hours post injury remaining given in the next 16 hours. maintain the urinary output

43

Guidelines and Formulas for Fluid Replacement in Burn Patients

Management of a 70-kg patient with a 50% TBSA burn: Steps Consensus formula: 2 to 4 mL/kg/% TBSA 2 70 50 = 7,000 mL/24 hours Plan to administer: First 8 hours = 3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour

Guidelines and Formulas for Fluid Replacement in Burn Patients Evans Formula
44

1. Colloids: 1 mL kg body weight % TBSA burned 2. Electrolytes (saline): 1 mL body weight % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of previous days colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and

45

Guidelines and Formulas for Fluid Replacement in Burn Patients

Brooke Army Formula 1. Colloids: 0.5 mL kg body weight % TBSA burned 2. Electrolytes (lactated Ringers solution): 1.5 mL kg body weight % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss

46

Guidelines and Formulas for Fluid Replacement in Burn Patients

Brooke Army Formula

Day 1: Half to be given in first 8 hours; remaining half over next16 hours Day 2: Half of colloids; half of electrolytes; all of insensible fluid replacement. Second- and third-degree (partial- and fullthickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.

47

Guidelines and Formulas for Fluid Replacement in Burn Patients

Baxter Formula Lactated Ringers solution: 4 mL kg body weight % TBSA burned Day 1: Half to be given in first 8 hours; half to be given over next 16 hours Day 2: Varies. Colloid is added.

48

Guidelines and Formulas for Fluid Replacement in Burn Patients

Hypertonic Saline Solution Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250 300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. Do not increase the infusion rate during the first 8 post burn hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent

Pediatric Consideration
49

In children <30kg also administer D5 LR solution @ maintenance rate of: For the first 1 to 10 kg 100ml/kg/24 hours = 4ml/kg/hour For the second 11 to 20 kg 50ml/kg/24hours = 2ml/kg/hour For any weight 21 to 30 kg 20ml/kg/24hours = 1ml/kg/hour

Pediatric Consideration
50

Example for a 12 kg child:

100 ml/kg for first 10 kg

10 kg x 100 ml = 1000ml

50 ml/kg for each kg between 11 and 20kg 20 ml/kg for each kg between 21 and 30 kg ---

2 kg x 50 ml = 100ml --- none needed =1100ml/24hours

Do not give dextrose solutions (except for maintenance fluids in children)- they may cause an osmotic diuresis and confuse adequacy of resuscitation assessment.

Assessment of adequacy of fluid replacement

Urinary output is most commonly used parameter

Adequate

urine output is 30 ml/hr in adults and 1 ml/kg/hr in a child less than 30 kg

Cardiopulmonary

factors- BP (systolic 90-100 mmHg), pulse less than 100, resp 16-20 breaths per min. (BP more accurate with arterial line)

Sensorium-alert, oriented to time, place, & person

52

Considerations

(1 of 2)

Full-thickness burns and deep partial thickness burns are initially anesthetic because nerve endings are destroyed

Superficial to moderate partial thickness burns are very painful

Considerations

(2 of 2)

Severe dehydration is possible even though the patient may be edematous May have an dynamic ileus due to bodys response to massive trauma and potassium shifts Shivering due to chilling caused by heat loss, anxiety, and pain Patient unable to recall events due to hypoxia associated with smoke inhalation, or head trauma or overdose of sedatives or pain meds

Infection is the most serious threat to further tissue injury and possible sepsis

SURVIVAL is related to prevention of wound contamination

Source

of infection is pts own flora, predominantly from the skin, resp. tract, and GI tract Prevention of cross contamination from other patients is the priority for patient care staff

Other care measures

Lab tests
Baseline

studies: hematocrit, electrolytes, blood urea nitrogen, urinalysis, chest x-ray Special studies as needed: arterial blood gas, carboxyhemoglobin, ECG, glucose

Drug Therapy

Analgesics and Sedatives given for patient comfort IV pain medications initially due to
GI

function is slowed or impaired because of shock or paralytic ileus IM injections will not be absorbed well

Drug Therapy

Tetanus immunization- given routinely to all burn patients because of the likelihood of anaerobic burn-wound contamination Antimicrobial agents-usually topical due to little or no blood supply to the burn eschar so little delivery of the antibiotic to wound Drug of choice is: Silver sulfadiazine

Nutritional Therapy

Fluid replacement takes priority over nutritional needs in the initial emergent phase NG tube is inserted and connected to low intermittent suction for decompression When bowel sounds return (48-72 hrs) after injury, start with clear liquids and progress up to a diet high in proteins and calories

Nutritional Therapy

Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition Give calorie containing liquids instead of water due to need for calories and potential for water intoxication Enteral feedings into the duodenum (recommended) can: reduce nausea /vomiting, provide more continuous feedings, and increase wound healing

Calorie Intake Formula

(25 x weight in kg) + (40 x TBSA burn)
Example for 50 kg patient with 50% TBSA burn: (25 x 50) + (40 x 50) = 1250 + 2000 = 3250 Kcals

Acute Phase

Begins with mobilization of extracellular fluid and subsequent diuresis Is concluded when the burned area is completely covered or when wounds are healed. May take weeks or months Patient is no longer grossly edematous due to fluid mobilization, full & partial thickness burns more evident, bowel sounds return, pt more aware of pain and condition

Healing begins when WBCs have surrounded the burn and phagocytosis begins, necrotic tissue begins to slough, fibroblasts lay down matrices of collagen precursors to form granulation tissue Partial-thickness burns (if kept free from infections) will heal from edges and from below. (10-14 days) Full-thickness burns must be covered by skin grafts

Laboratory Values

Sodium- Hyponatremia can occur due to: silver nitrate topical oints as a result of sodium loss through eshcar, hydrotherapy, excessive GI drainage, diarrhea, excessive water intake
S/S

of hyponatremia: weakness, dizziness, muscle cramps, fatigue, HA, tachycardia, & confusion

Hypernatremia can occur: too much hypertonic fluids, improper tube feedings, inappropriate fluid administration
S/S

of hypernatremia: thirst; dried furry tongue; lethargy; confusion; and possible seizures

Potassium- hyperkalemia is note if pt is in renal failure, adrenocortical insufficiency, or massive deep muscle injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness & EKG changes are noted.
Hypokalemia

is noted with silver nitrate therapy and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplementation. Constant K+ losses occur through the burn wound.

Complications of Acute Phase

Infection- due to destruction of bodys 1st line of defense. Partial thickness wds can convert to fullthickness wds with infection present. Pt may get sepsis from wound infections. Signs of sepsis: high temp., increased pulse & resp., decreased BP, and decreased urinary output, mild confusion, chills, malaise, and loss of appetite. WBC bet. 10,000 and 20,000. Infections usually gram neg. bacteria (pseudomonas, proteus) Obtain cultures from all possible sources:

Cardiovascular- same as in emergent phase Neurologic-possible from electrical injuries Musculoskeletal-has the most potential for complications during acute phase due to healing and scar formation making skin less supple and pliant. ROM limited, contractures can occur Gastrointestinal-adynamic ileus results from sepsis, diarrhea or constipation (due to narcotics & decreased mobility), gastric ulcers due to stress, occult blood in stools possible Endocrine-stress diabetes mellitis might occur-assess glucose prn

Rehabilitation Phase

Defined as beginning when the patients burn wound is covered with skin or healed and patient is capable of assuming some self-care activity. Can occur as early as 2 weeks to as long as 2-3 months after the burn injury throughout the patients lifespan Goals for this time is to assist patient in resuming functional role in society & accomplish functional and cosmetic reconstruction

Complications

Most common complications of burn injury are skin and joint contractures and hypertrophic scarring Because of pain, patients will assume flexed position. It predisposes wounds to contracture formation Use of physical therapy, pressure garments, splints, etc. are used to prevent/treat these