Burns

Definition

Burns is defined as injury to the tissues of the

body caused by heat, chemicals, electric
current or radiation. (LEWIS)

Burns is defined as the injuries that results

from direct contact with or exposure to any
chemical, thermal or radiation source.
(JOYCE M BLACK)
 INCIDENCE

 India records 70 lakh burn injury cases per

year
 Of which 1.4 lakh people die every year
 Burns are in age group from 15- 35 years
 Around 4 out of 5 cases are women and
children
 Etiology

 Smoke and inhalation burns

 Radiation burns
 Electrical burns
 Thermal burns
 Chemical burns
 Smoke and inhalation burns

 It is produced by the incomplete combustion of

burning material
 It results from the inhalation of hot air or noxious
chemical and cause damage to the tissues of the
respiratory tract.
 carbon monoxide poisoning : CO poisoning and
asphyxiation account for the majority of death at a
fire scene.
 It is subsequently inhaled and displaced oxygen on
the hemoglobin molecule, causing hypoxia, carboxy
hemoglobinemia and ultimately death
 Chemical burns

 Chemical burns are caused by contact with

strong acids, alkalis or organic compounds
 It can be resulted from contact with certain
household cleansing agents and various
chemicals used in industry and agriculture
sector
 Thermal burns

 Thermal burns are caused by exposure to or

contact with
- flame
- hot liquids
- semi liquids (e.g. steam)
- semisolids (e.g. tar)
- hot objects (residential fires, explosive
automobile accidents, cooking accident)
 Electrical burns

 It is caused by heat, that is generated by the

electrical energy as it passes through the body.
 It can result from contact with exposed or
faulty wiring or high voltage power lines.
 Direct damage to nerve and vessels causing
tissue anoxia and death can also occur.
 Radiation burns

 This are least common types of burn injury and

are caused by exposure to a radiation source.
 This types of injuries have been associated
with nuclear radiation accidents, the use of
ionizing radiation in industry and therapeutic
irradiation.
 Sun burn from prolonged exposure to UV rays
is also considered to be a radiation burns.
 Classification of burns injury:

Burns injuries are classified according to

1. The depth of the injuries
2. The extend of the body surfaced areas
injured.
1. Depth of the injury

Burns are classified according to the depth of

the tissue destruction as:
A. Superficial burns
B. Superficial partial thickness
C. Deep partial thickness
D. Full thickness
A. Superficial burns

 A typical first degree burn is a sun burn or

superficial scald. This type of injury does not
included in calculation of TBSA.
B. Superficial partial thickness

 In superficial partial thickness, the epidermis is

destroyed or injured and a portion of the
dermis may be injured
 The damaged skin may be painful and appear
red and dry as in sun burn or it may blister
C. Deep partial thickness

 A deep partial thickness involves destruction

of the epidermis and upper layers of the dermis
and injury to the deeper portions of the dermis.
D. Full thickness burns

 Deep tissue ,muscle and bone

 Prolonged exposure or high voltage electrical
injury
 The burned areas is painless.
 It involves total destruction of the epidermis
and dermis.
Full thickness burns
 Degree of burns

 First-degree: These burns only affect the outer

layer of your skin.
E.g.. A mild sunburn
 Skin may be red and painful, but will not have
any blisters. Long-term damage is rare.
 Second-degree: Burns occur in the outer layer
of your skin as well the dermis – the layer
underneath – has been damaged. Your skin will
be bright red, swollen, and may look shiny and
wet. You’ll see blisters, and the burn will hurt
to the touch.
 If you have a superficial second-degree
burn, only part of your dermis is damaged.
You probably won’t have scarring.
 A deep partial thickness burn is more severe.
It may leave a scar or cause a permanent
change in the color of your skin.
 Third-degree: Also called a “full thickness
burns, this type of injury destroys two full
layers of the skin. Instead of turning red, it
may appear black, brown, white or yellow.
Pain sensation is absent as this type of burn
damages nerve endings.
 Fourth-degree. This is the deepest and most
severe of burns. They are potentially life-
threatening. These burns destroy all layers of
your skin, as well as the muscles, tendons and
bones
2. Extent of TBSA injured
A. Rule of nine
B. Palm method
C. Lund and Browder method
Rule of nine
 It is the quick way to estimate the extent of
burns.

 The system assigns percentages in multiples of

nine to major body surfaces.
Palm method
 In patient with scattered burns, the palm
method may be used to estimate the extent of
the burns.
 The size of the patient palm is approximately
1% of the TBSA (total body surface area)
 Lund and Browder method
 The more precise method of estimating the
extent of a burn in the Lund and Browder
method, which recognize that the percentage of
the surface area of various anatomical parts
especially the head and legs.
Clinical manifestations

Cardiovascular system alteration

 Weak pulse
 Prolonged clotting and pro thrombin time
 Decreased in platelet
 Decreased blood pressure
 Decreased cardiac output
 Pulmonary alteration

 Increased work of breathing and eventually

cyanosis
 Dyspnea
 Hypoxia
 Decreased oxygen saturation
 Increased respiratory rate
Fluid & electrolyte alteration

 Dry mucus membrane

 poor skin turgor
 Less urine output
 Hyperkalemia
 Hypernatremia
 Hyponatremia
 Hypovolemia
Renal alteration

 Destruction of RBC result in free hemoglobin

in urine
 Decreased in urine output
 Acute tubular necrosis
 Increased in urea level
 Renal failure
Immunologic alteration
 Reduction in lymphocyte
 Impaired neutrophil function
 Resulting in immuno suppression
 Sepsis

Thermoregulatory alteration
 Low body temperature
 Hyperthermia in the post burn period
Gastrointestinal alteration

 Decreased or absence of bowel sound stool or

flatus
 Nausea, vomiting and abdominal distention
 Paralytic ileus and curling ulcers
Psychological response

 Depression
 Grief
 Anxiety
 Disbelief
 Isolation
 Ineffective coping abilities
Pain response

 Clinical response to pain may include an

increased in BP
 Heart rate
 Respiratory rate with dilated pupils and
 Rigid muscle tone
Diagnostic evaluations

 History
 Physical examination
 RBS, urea and creatinine
 ECG & chest X ray
 Bleeding time, clotting time & time
 CBC
 Na, K, Cl
 ABG analysis
Management
Burns care then proceeds through three phases:
1. Emergent/resuscitative phase
2. Acute/intermediate phase
3. Rehabilitation phase
1. Emergent/resuscitative phase

This phase starts from the onset of injury to

completion of fluid resuscitation
This phase include:
 Cooling of wound
 Establish the airway
 Supply oxygen
 Fluid replacement
 Wound management
 Analgesics
 The circulatory system must be assessed
quickly.
 Apical pulse and BP are monitored quickly.
 Neurological status is assessed quickly in the
patient with extensive burns.
Fluid replacement

Consensus formula

 Ringer lactate solution 2-4 ml X kg body

weight X % Body surface area burned
 Half of fluid to be given in first 8hrs and
remaining half over 16 hrs
 Example: 30% burns

 RL 2ml X 50kgs X 30% burns

 100 X 30 = 3000 ml
 3000/2 = 1500 +1500
 1500 ml first 8hrs
 1500 ml next 16 hrs
 3000 ml in 24 hrs
Evans formula

 Colloids: 1ml X body weight X %body

surface area burned
 Electrolytes (Saline): 1ml X body weight X
%body surface area burned
 Glucose 5%: 2000ml for insensible loss
 Day 1: half to be given in 8 hrs and the
remaining half over 16 hrs
 Day 2: half of previous day colloids and
electrolytes and glucose over 24hrs
 Example: 50% burns

 Colloids- 1 ml X 50 kgs X 50 % burns =

2500ml
 Saline - 1 ml X 50 kgs X 50 % burns = 2500ml
 5 % dextrose- 2000ml
 Total = 7000ml ( 3500+3500)
 3500 ml first 8hrs
 3500 ml next 16 hrs
 7000 ml in 24 hrs
Brooke Army formula

 Colloids: 0.5ml X kg body weight X %body

surface area burned
 Electrolytes: 1.5ml X kg body weight X %
body surface area burned
 Glucose 5%: 2000ml for sensible fluid
replacement
 Day 1: half to be given in 8 hrs and the
remaining half over 16 hrs
 Day 2: half of previous day colloids and
electrolytes and glucose over 24hrs
 Example: 30% burns

 Colloids- 0.5 ml X 60 kgs X 30 % burns =

900ml
 Saline – 1.5 ml X 60 kgs X 30 % burns =
2700ml
 5 % dextrose- 2000ml
 Total = 5600ml ( 2800+2800)
 2800 ml first 8hrs
 2800 ml next 16 hrs
 5600 ml in 24 hrs
Parkland formula:

 Lactate RL: 4ml X kg body weight X % TBSA

burned
 Day 1: half to be given in 8 hrs and the
remaining half over 16 hrs
 Day 2: various colloids are added as required
 Example: 40% burns

 RL 4ml X 50kgs X 40% burns

 200 X 40 = 8000 ml
 8000/2 = 4000 +4000
 4000 ml first 8hrs
 4000 ml next 16 hrs
 8000 ml in 24 hrs
2. Acute/intermediate phase

 Prevention of infection
- Wound dressing
- Antibiotics
- Aseptic techniques
- High calorie & high protein diet

 Topical antimicrobial application

- Silver sulfadiazine
- Silver nitrate 0.5%
- Mycostatin
- Mefenide acetate
 Wound Dressing

(a) Open method or exposure method:

- Leaving the wound open for 48 to 72 hrs

where dressing is not possible

- The crust formation protects the wound
- In this method the wound can be easily

inspected
- Patient has freedom to do exercise or

movement
(b) Closed method or occlusive method:
- Dressing is done and change at least once in a

day
- Bland dressing is done with paraffin gauze or

antibiotic ointment
- It is less experience
- Tubbing is a method of immersing the patient

in water after grafting

- Helps in cleaning the wound and remove

eschar
 Surgery
- Skin grafting
- Desloughing
- Keloid removal
3. Rehabilitation phase

- It is to limit or prevent loss of motion

- Prevent anatomical deformities
- Prevent muscle mass loss
Nursing management
1. Restoring fluid balance
2. Prevention of infection
3. Maintaining adequate nutrition
4. Safety of the patient
5. Promote skin integrity
6. Relieve pain and discomfort
7. Promote physical activity
8. Support patient and family
9. Follow up care
Complications:
 Infection
 Fluid loss
 Hypothermia
 Pulmonary distress
 Cardiac failure
 Renal failure
 Hepatic failure
 Scarring and keloid formation
Thank you