Burns. A burn is an injury that results from direct • Zone of stasis.

The surrounding zone of

exposure to any thermal, electrical, chemical, or stasis is characterized by decreased tissue
radiation source. It occurs when energy from a heat perfusion. The tissue in this zone is
source is transferred into body tissues beyond what potentially salvageable. The main aim of
the body could hold, leading to tissue injury. It is burns resuscitation is to increase tissue
characterized by severe skin damage that causes perfusion here and prevent any damage from
the affected skin cells to die. becoming irreversible. Additional insults—
such as prolonged hypotension, infection, or
Types of Burns edema—can convert this zone into an area
There are many other causes of burns aside from of complete tissue loss.
open flames. They include: • Zone of hyperemia. In this outermost zone
• Thermal burns. A thermal burn is a burn to tissue perfusion is increased. The tissue here
the skin caused by any external heat source will invariably recover unless there is
like a flame, hot liquids, or hot metals. severe sepsis or prolonged hypoperfusion.
• Chemical burns. A chemical burn can be
caused by many substances, such as strong Systemic response
acids, drain cleaners (lye), paint thinner, and The release of cytokines and other inflammatory
gasoline that touches your skin can cause it mediators at the injury site has a systemic effect
to burn. once the burn reaches 30% of the total body surface
• Radiation burns. A radiation burn is the area.
least common type. Sunburn is a type of • Cardiovascular changes. Due to fluid loss
radiation burn and other exposure to nuclear from the burn wound, it results in systemic
radiation, like X-rays or radiation therapy to hypotension, increased heart rate, and end
treat cancer, can also cause these. organ hypoperfusion.
• Electrical burns. An electrical burn occurs • Respiratory changes. Hyperventilation and
when the skin comes into contact with an increased respiratory rate occur.
electrical current and it passes through the Inflammatory mediators cause
body from faulty electrical wiring. bronchoconstriction, and in severe burns
• Friction burns. A friction burn occurs when adult respiratory distress syndromecan
a hard object rubs off some of the skin. It’s occur.
both an abrasion or scrape and a heat burn • Metabolic changes. The basal metabolic
just like motorcycle and bike accidents and a rate increases up to three times its original
carpet burn. rate. For severely burned patients, the
• Cold burns. A cold burn also called resting metabolic rate at thermal neutral
“frostbite” occurs when the skin comes into temperature (30°C) tops 140% of predicted
direct contact with something very cold for a basal rate on admission, reduces to 130%
prolonged period of time. once the wounds are fully healed, then to
• Inhalation injury. An inhalation injury is 120% at 6 months after injury.
caused by smoke associated with flame • Immunological changes. Non-specific
injury or inhaled carbon monoxide which is a down regulation of the immune response
by-product of incomplete combustion. occurs, affecting both cell mediated and
humoral pathways.
Signs and Symptoms of Burn Injury • Electrolyteimbalances. Hyponatremia and
Local Response hyperkalemia occur. Hyponatraemia is
The three zones of a burn were described by frequent, and the restoration
Jackson in 1947. These three zones of a burn are of sodium losses in the burn tissue is
three-dimensional, and loss of tissue in the zone of therefore essential. Hyperkalemia is also
stasis will lead to the wound deepening and characteristic during this time because of the
widening. (National Center for Biotechnology massive tissue necrosis. Hyponatraemia
Information, U.S. National Library of Medicine) (Na) (< 135 mEq/L) is due to extracellular
• Zone of coagulation. This occurs at the sodium depletion following changes in
point of maximum damage to the area of the cellular permeability.
burn tissue. In this zone, there is irreversible • Psychological responses. Effects on
tissue loss due to the coagulation of the psychological health includes shock,
constituent proteins. numbness, disbelief, depression, denial,
mourning, perceived losses.
 Fourth-Degree Burn (Deep Fullness Thickness
Management of Burn Injury Burn). In fourth-degree burn injuries, the affected
Management of burn injury is categorized into three areas go through both layers of the skin and
phases of care: emergent phase, acute phase, and underlying tissue as well as deeper tissue. This
rehabilitation. classification of burn depth involves muscle and
Emergent Phase bone.
The emergent phase starts from the time of burn • Burned part is black/charred
injury and ends when the patient is • Fluid loss is VERY SEVERE
hemodynamically stable, capillary permeability has Assess the burn size and extent.
been restored, and fluid resuscitation has been The size of the burn is expressed through
completed. Usually 48-72 hours from the time of percentage according to the total body surface area
injury. The emergent phase is also known as the (TBSA), Rule of Nines.
resuscitative phase, and the goals of this phase • Small Burns (<25%). Response of the body
include prevention of hypovolemic shock and is localized.
preservation of vital organ functioning. • Large Burns (>25%). Response of the body
Asses for the burn depth. is systemic.
Burn depth is assessed 24 hours after injury as Assess for the burn location.
blisters and other injuries may evolve. The area of a burn injury usually directs treatment.
First Degree Burn (Superficial Partial Thickness Burns on the face, hands, feet, and genitalia, as well
Burn). In first-degree burn injuries, the skin function as large burns in other areas of the body and those
remains intact, and transfer to a burn center is not associated with inhalation injury, are often referred
required. They do NOT count towards total body to burn centers for specialized expertise.
surface area (TBSA) burned. This classification of ADVERTISEMENTS
burn depth affects the epidermisleading to the • Head, Neck, and Chest. Respiratory
following signs and symptoms: • Face. Corneal ulceration
• Erythema • Perineum. Contaminated
• Edema with urine and feces
• Pain but without blisters • Circumferential Burns of
• Fluid loss is MILD Extremities. Compromis circulation
Second Degree Burn (Deep Partial Thickness Airway Management
Burn). In second-degree burn injuries, the skin Airway Management is vital to maintain the airway
function is lost. Deep partial-thickness injuries can and provide supplemental oxygen in patients with
easily convert to or require the same management major burns. Airway management is crucial for types
as full-thickness. An MCI (mass casualty incident) of burns related to inhalation injury.
aims to treat as many 2nd degree injuries as • Oxygenation: CO2 poisoning. 100% of
possible in an outpatient setting. This classification oxygen is delivered via a tight-fitting non-
of burn depth affects the dermis and epidermis, rebreather mask until carbon monoxide falls
leading to the following signs and symptoms: to 15%.
• Erythema • Mechanical ventilator as indicated.
• Edema • Endotracheal suctioning.
• Pain with blisters • Head of the bed is elevated to facilitate
• Pink to reddish skin maximum expansion of the lungs.
• Fluid loss is MODERATE Fluid Resuscitation
Third-Degree Burn (Full Thickness Burn). In third- Fluid Resuscitation refers to replacing fluids in burn
degree burn injuries, skin function is lost, and patients to prevent hypovolemia and hypoperfusion
grafting is required for functional healing. Third- that can result from the body’s systemic response to
degree burns will almost always require hospital burn injury.
admission. This classification of burn depth affects • Initiate fluid administration. Peripheral IV
the subcutaneous tissues, epidermis, and dermis access may initially be used though in larger
leading to: and more severe cases of burns, a central
• Pearly white or charred appearance of the venous access is recommended as a large
skin volume of fluid is required.
• Mottled brown, black, or red burn site • Use American Burn Association (ABA)
• Pain is absent guidelines for fluid resuscitation. The formula
• Fluid loss is SEVERE for the total fluid requirement in 24 hours is
as follows: 4ml x TBSA (%) x body weight
 (kg). [Example: Patient weighs 80 kg with burns. Using these ointments may require
TSBA of 20% = 4mL x 80 kg = 320 x 20 = the use of bandages.
6,400 mL] • Regularly change dressings. Dressings may
• First half of the solution is given in the first 8 need to be changed regularly. The skin and
hours (3,200 mL) the burn wound should be washed gently
• One quarter of the solution is given in the with mild soap and rinsed well with tap water.
second 8 hours (1,600 mL) Use a soft wash cloth or piece of gauze to
• Another quarter of the solution is given in the gently remove old medications.
third 8 hours (1,600 mL)
• Avoid colloid-containing solution for the first Acute Phase
24 hours because it may aggravate edema The acute phase of burn management starts 48-72
due to an increase in capillary permeability. hours from the burn injury when the patient is
• The amount of fluid in the second 24 hours hemodynamically stable with completed fluid
will depend on the patient’s urine output and resuscitation and restored capillary permeability and
hemodynamic studies (Hct, CVP, and ends upon wound closure.
BUN/Crea) Prevent infection. Patients with burns are at the
• Colloid-containing solutions may be given highest risk for healthcare-associated infections
with D5W with glucose. (HAIs). The loss of the skin’s barrier function,
• Monitor urine output. A urine output of 0.5 to combined with necrotic tissue, produces an
1 mL/kg/h is used as an indication of environment conducive to bacterial growth. Nursing
appropriate resuscitation in thermal and interventions to prevent infection includes:
chemical injuries. In electrical injuries, a urine • Watch out for signs of infection. Erythema,
output of 75 to 100 mL/h is the goal. warmth, malodorous exudates, and
Diet tenderness.
The larger the burn size, the more nutrients are • Initiate universal precaution. Use of gowns,
needed for healing. gloves, and eye protection. Including
• Provide additional calories. Patients need frequent hand hygiene.
more calories than normal when they’re • Wound culture and antimicrobial
recovering from a burn injury. That’s therapy. Culture and sensitivity is usually
why nutrition is a major component of burn ordered on admission for patients with burns
treatment. A diet high in calories and protein to test for presence of MRSA.
supports the immune system to decrease • Wound care. Early excision and closure of
risk of infection; helps wounds heal faster; the burn wound helps in preventing
maintains muscle mass; and minimizes infection.
weight loss to support rehabilitation. • Control of hyperglycemia. Insulin is indicated
Pain Management (even without diabetes) for severely burned
Pain due to burns can range from mild to severe to patients to improve protein synthesis,
excruciating. Pain management, which includes attenuate lean body mass loss, decrease
pharmacologic and nonpharmacologic approaches, hypermetabolism, and accelerate donor
is a central component of the complex issues healing time.
involved in treating patients with burns. Provide nutritional support. Nutritional support
• NO intramuscular or subcutaneous through total parenteral nutrition or enteral tube
administration because the patient is feeding for patients with burns is aggressive. There
hypovolemic. should be an increase in calories, proteins, and fats.
• Intravenous analgesics: Morphine, Demerol Provide proper wound care. Wound cleansing
• Oral administration is NOT considered due should be done through hydrotherapy and maybe
to GI dysfunction. submerged in a Hubbard tank.
• Minor burns: per orem Wound Cleansing
• Nonpharmacological: Deep breathing • Wound cleansing through hydrotherapy
exercises, guided imagery • Patient is submerged in Hubbard Tank
Wound Care • Involves immersion, spray, or showering 30
Prescribed topical agents are administered before minutes or less.
the wound is covered with layers of dry dressings. • More than 30 minutes can cause heat loss,
• Use ointments. Antibiotic ointments or pain, and stress.
creams are frequently used to fight or treat • Analgesics before the procedure.
infections in patients with second-degree
Debridement
Debridement is the removal of necrotic tissues to
prevent bacterial growth-promoting wound healing.
• Mechanical Debridement. Involves the use
of forceps and scissors to trim away loose
necrotic tissues.
• Enzymatic Debridement. Involves the use of
proteolytic or fibriolytic enzymes to digest
necrotic tissues.
• Surgical Debridement. Involves excision of
loose necrotic tissues.
Antimicrobial Agents or Ointments
• Silver Sulfadiazine. Once or twice daily.
• Open Method. The wound is left exposed to
air after application.
• Close method. Sterile gauze is impregnated.
Surgical Management
Autografting. Autografting is the surgical removal
of a superficial layer of the patient’s own unburned
skin (donor site) which is subsequently grafted to the
patient’s excised open wound.
Post Op Considerations:
• Promote graft adherence through
immobilization
• Bed rest for 10 days
• Keep graft site free from pressure
• Avoid weight-bearing activities
• To remove exudate, roll a cotton tip
applicator
• Watch out for foul smelling discharge. It may
indicate infection.
• As prescribed, small amount of blood may be
removed beneath the grafted skin by rolling
gauze from the center to the periphery where
the blood can be absorbed by the sterile
gauze.
• Aspirate if with large amount of blood using a
small gauge needle as prescribed by the
physician.
• Apply cocoa butter to prevent dryness.

Rehabilitation Phase
The rehabilitation phase occurs immediately after
the burn has occurred and can extend for years after
the initial injury.
• Minimize functional loss. Burn rehabilitation
includes rehabilitation programs to help
return the patients to their highest level of
function within the content of their injuries.
• Provide psychosocial support. Includes
counseling, patient teaching, and help the
patient reintegrate with society through
various programs aimed at burn survivors