Burns: Classification, Statistics & Skin Anatomy

Problems of Protection: Burns

• Burns are injuries to the body tissues caused by heat, chemicals, electric current, or radiation.
• Simple calculators are typically allowed for quizzes, exams, or finals with burn questions.

Burn Statistics

• Approximately 486,000 Americans seek medical care for burns annually.
• Roughly 3,400 Americans die each year from burn injuries.
• Children aged 4 or younger and the elderly aged 65 or older have the highest mortality rate.

The Skin

• It serves as a barrier to infection and aids in retaining body fluids, regulating temperature, excreting waste, providing sensory input, producing Vitamin D3, and shaping body image.
• The skin's anatomy includes the epidermis, dermis, and subcutaneous tissue (hypodermis).

Classification of Burn Injury

• Burn severity depends on depth, extent (percentage of Total Body Surface Area or TBSA), and location.
• Depth of burn includes partial thickness and full thickness injuries.

Classification of Burn Injury - Patient Risk Factors

• Patient risk factors includes age (very young or very old)
• Health status which includes pre-existing medical history such as diabetes mellitus (DM), congestive heart failure (CHF), or renal disease.

Depth of Burn

• Partial thickness involves superficial, 1st degree burns and deep 2nd degree burns
• Full thickness involves 3rd and 4th degree burns.

Superficial 1st Degree Burn

• Superficial epidermal damage occurs, potentially with mild edema and pain.
• Blisters may appear and peel after 24 hours
• Sunburns or heat flash burns are examples
• Resolution occurs in 7-14 days which does not require admission to a burn center.

Deep 2nd Degree Burn

• These burns involve deeper layers of the dermis with severe pain caused by nerve injury.
• Skin turns white after 3-7 days.
• Fluid-filled red vesicles are often present
• Differentiation from full-thickness burns can be challenging.

Conversion to a Deeper Burn

• Without appropriate fluid resuscitation, deep partial thickness burns can evolve into full thickness burns.

Full Thickness Burn

• Complete destruction of the epidermis and dermis occurs, resulting in no pain because of nerve ending destruction.
• Affected skin becomes dry, waxy white, and leathery and can affect muscle, tendon, and bone.

Percentage of Total Body Surface Area (TBSA)

• Estimation does not include first-degree burns.
• The Lund-Browder Chart and the Rule of Nines are common assessment tools.
• The Palmer Method is relevant for irregular or oddly shaped burns, where a patient's hand (including fingers) represents 1% TBSA.

Percentage of TBSA - Lund-Browder Chart

• A more precise TBSA calculation assigns a percentage to each body part, totaling 100%.
• It is more precise because it relates to the proportion of body area relative to the patient’s age.

Percentage of TBSA - Rule of Nines

• The estimation of burns uses the Rule of Nines which is frequently used used for initial assessments
• In adults, the head and neck are 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, each arm 9%, and perineum 1%.

Location of Burn

• Breathing Issues
• Face/neck, circumferential to chest or back result in a risk of mechanical obstruction due to edema or eschar formation.
• Functional Issues
• Concerns are presented with burns to the feet, hands, joints, and eyes.
• Infection Issues
• Perineum and buttocks burns create contamination risk.

Patient Risk Factors - Preexisting Diseases

• Preexisting diseases such as cardiovascular, respiratory, or renal issues, diabetes mellitus (DM), peripheral vascular disease (PVD), malnutrition, or a history of alcohol or drug abuse.

Zone of Injury

• Cellular death occurs in the zone of coagulation.
• In the zone of stasis, cells are injured with comprised blood supply that will die if it is not restored.
• The zone of hyperemia sustains only minimal cellular injury.

Types of Burns

• Thermal
• Chemical
• Smoke & Inhalation
• Electrical

Thermal Burns

• Thermal burns result from flame, flash, scald, or contact with hot objects.
• These burns are the most common type of burn.

Chemical Burns

• Tissue injury and destruction result from necrotizing substances through contact with acids, alkalis, and organic compounds.
• Acid exposure is the most common cause of chemical burns.

Smoke & Inhalation Burn

• Smoke inhalation is the inhalation of hot air or noxious chemicals that damages respiratory tract tissues.

Smoke & Inhalation Injury

• A quick hazard assessment determines the critical nature of the situation.
• It is a major predictor of mortality in burn patients.

Three Types of Inhalation Injuries

• Metabolic Asphyxiation
• Upper airway obstruction
• Lower airway obstruction

Metabolic Asphyxiation

• Occurs in a fire scene where most deaths are due to smoke elements, primarily carbon monoxide (CO), which results in hypoxia and potentially death.
• Carbon monoxide is odorless and colorless gas.

Carbon Monoxide Poisoning

• It is a result of inhaling carbon-containing compounds, like fossil fuels, which affects the lips and fingernails turning bright red instead of cyanosis.
• ABG's will have a normal p02 level and the patient may alter LOC, have N&V
• Treatment
• Administering 100% oxygen until carboxyhemoglobin (COHgb is less than 15%)

Upper Airway Damage

• Inhalation of superheated air leads to necrosis in the upper airways because the glottis and vocal cords are shielded.
• As a result this may lead to laryngospasm and edema which requires intubation or emergency trach.

Upper Airway Damage - Signs and Symptoms

• Stridor
• Hoarseness
• Painful swallowing
• Soot in the oral cavity and/or sooty sputum
• Dyspnea
• Singed nasal hairs
• Burns of the face, mouth, or neck

Lower Airway Damage

• Damage occurs below the glottis.
• Sloughing of the epithelium results in airway blockage.
• Impaired gas exchange results in decreased PO2 and increased CO2.

Lower Airway Damage - Signs and Symptoms

• Possible impending respiratory distress includes
• Agitation increasing, RR increase, restless
• Rales and rhonchi
• Wheezing
• Hypoxemia
• Sooty sputum
• Chest X-ray with infiltrates
• Patchy white areas

Inhalation Injury Treatment

• Requires intubation, suctioning, humidification, bronchoscopy, and daily CXR.
• Keep HOB elevated.

Respiratory Nursing Diagnoses

• Ineffective Breathing Pattern
• Ineffective Airway Clearance
• Impaired Gas Exchange

Electrical Burns

• Electrical burns result from intense heat generated from an electrical current and presents with an area of entrance and exit point on the body
• Internal tissue continues to burn while outer tissue appears normal

Prehospital Care - Priorities

• Safety is paramount
• First, remove the patient from the burning source while ensuring rescuer safety.
• Stop the burning process.
• Second, with electrical or chemical scenarios, safely remove the patient from the contact source.
• Remove any clothing that contains chemicals to prevent further skin damage.

Prehospital Care

• If a patient is unresponsive, focus on CABs with priority.
• If a patient is responsive, focus on ABCs with priority.
• Cover small burns ( 30% TBSA, >10% TBSA third-degree burns, inhalation injury, severe electrical injury, major trauma, or concurrent illness.
• Also for selected moderate burns in high-risk patients.

Three Phases of Burn Management

• Emergent (Resuscitative) phase
• Acute (Wound Healing) phase
• Rehabilitation (Restorative) phase

Emergent Phase

• Shock is likely to occur and this stage begins with fluid-loss to 72 hours post initial burn
• A primary goal is to arrest the process, and ensure or restore ABCs
• Treating cardiovascular instability & fluid resuscitation is also essential during this period

Fluid Volume Shifts - Emergent Phase

• Burn shock (hypovolemic phase) is defined as edema
• In the emergent phase, difficult visualization occurs due to severe dehydration in someone so edematous, resulting in intravascular fluid deficit

Burn Shock

Characterized by Decreased cardiac output and Increased Systemic Vascular Resistance (SVR) that causes the blood flow to kidneys, liver, and intestines, shunted to vital organs, resulting in decreased oxygen delivery

Edema Formation

• Trauma to cell membranes leads to increased capillary permeability and fluid shifting from the intravascular space to the interstitial space, causing greatly leak.
• Increased capillary pressure is also likely to occur.

Edema Formation - Gaps

• Large caps present in capillary epithelium allows the protein and electrolytes to shift Proteins leak out the vasculature, which pulls in more fluid Increased permeability greatest, but may occur throughout the body

Weighing Patients

• Due to the threat of shock and fluid shift, the admission weights should be utilized in fluid resuscitation formula

Fluid Resuscitation

• American Burn Association Consensus Formulas include only using 2mL to assess fluid volume and following the guidelines.

Fluid Resuscitation - Parkland Formula

• The Parkland formula (2mL x LR x Kg X TBSA) assesses the total fluid volume needed during the first 24 hours of resuscitation It utilizes a percentage of 2nd, 3rd, 4th degree burins counted in the body

Fluid Resuscitation should be considered with 20% and greater for adults and 10% greater for both pediatrics and the older demographic

Fluid Resuscitation - Application

• The plan follows the 50/25/25 rule of administration to optimize the patient with burn shock.
• LR is often the chosen medication for this as it acts an an isotonic with an almost identical composition to normal plasma

Fluid Resuscitation Calculation

• Example: 75kg male with a 50%TBSA burned at 0700 2mL X 75kg X 50%TBSA= 7500mL (7.5L) to be given in first 24 hr 0700-1500 give 3750ml (468.7ml/hr) ½ of total in first 8hr 1501-2300 give 1875ml (234.3ml/hr) ¼ of total in second 8hr 2301-0700 give 1875ml (234.3ml/hr) ¼ of total in third 8hr

Important Considerations

• Burn time starts at the time of initial injury.
• Don't try to catch up for lost time.
• The Resuscitation Formula is just a guide to begin a fluid administration.
• Fluids are then titrated, based on any responses documented.

Fluid Resuscitation Adjustments

• Titrate fluids to achieve a UOP > 30 cc/hour, or (75-100ml/hr if myoglobinuria is present)
• Myoglobinuria is the pigment from damaged muscle tissue that moves to tubules to be released= ATN
• Regularly reevaluate response to resuscitation Over-resuscitation may lead to tissue and or pulmonary edema which has been found to be very common in electrical burns

Other Considerations in the Emergent Phase

• Metabolic alterations
• Hemoconcentration
• Destruction of RBCs
• Abnormal WBC functions
• Alteration in clotting factors
• Traumatic injuries
• Escharotomy

Metabolic Alterations

• Normal basal Metabolic Rate (BMR) will elevate to 2 times what it was and stays up, until nearly all is healed.
• Greatest Catabolic Stimulus causes accelerates tissue erosion
• The O2 will need to be increase by 100 Percent

Metabolic Alterations Effect

• Increase muscular activity, hormonal imbalance, and metabolic alteration effect
• Massive catabolism and Protein synthesis is inhibited causing increased insulin product and effectiveness decreased insulin sensitivity, leading to blood glucose

Hemoconcentration

• Characterized initially as ↑ Hct (can be as high as 55-70) due to lower blood volume
• Hct goes down as fluids are administered and is a good indicator that resuscitation is adequate
• K+ due to cell lysis and usually goes down after 72-96 hours during dieresis Na+ may decrease in the setting of increased permeability

Abnormalities in WBC Function

• WBC Adhesiveness and entrapment may occur due to edema fluid
• If oxygen consumption is not met, platelets and leukocytes will adhere and Thrombosis
• By day 3 post bur, neutrophils' oxygen consumption goes down by 1/2 without any Vitamin C or nutritional support

Alteration in Clotting Factors

• V and VIII typically go up 4-8 times more and stays elevated 2-3 months

Traumatic Burn Injuries & Escharotomy

• Assess for traumatic Injuries Evaluate the burn wound and its status (distal pulse, capillary refill)

Traumatic injuries & Escharotomy

An Escharotomy is a surgical tool that removes eschar tissue by going deep to that fascia

Interventions for Hypothermia during Emergent Phase

• Use Bair huggers and increase fluid and temperatures

Nutritional Support During the Acute Phase

• Important stage once critical is over which typically requires Normal diet supplementation extra nitrogen, with a need for Tube feedings to begin ASAP to prevent Curlings Ulcers 20-40 ML every hour
• Most common is specific/Burns that are caused to acute peptic ulcer

Nutrition Support - Factors that Impair Oral Intake

• Blood flows from the intestine resolves 24 degrees coating the mucus layers
• Facial / oral mucosal burns and anorexia may impair intake
• Airway with burns that may have GI Ulcerartion or Sepsis

Emergent Phase Assessment Includes

• Assessing Pain Control Regularly
• Assessing if they have tetanus or some allergy reactions

Burn Nursing Diagnosis

• Risk for fluid volume imbalance r/t evaporative fluid losses, fluid shifts Acute pain r/t burn injury, open wound
• Risk for infection r/t break in skin, loss of skin
• Imbalanced nutrition: less than r/t hypermetabolic state, oral intake ability impaired
• Disturbed Body Image r/t disfigurement, visible wounds or contractures

Burn Nursing Diagnoses - Potential Complications

• Electrolyte imbalance r/t fluid shift, hypovolemia (burn shock), hydrotherapy Negative Nitrogen Balance r/t hypermetabolic state, catabolism
• (more nitrogen excreted from tissue breakdown than is replaced by intake)

Fluid Volume Excess -Acute Phase Intervention

• A Diuretic Phase between 48-72hrs
• Fluid Shifts to extravascular space, restores integrity and Closes Eschar

Acute Phase

• Begins with onset of diuresis until wound is healed for weeks Months
• Nurse Must work to collaborate with management, wound care & Nutrition

Acute Phase Goals

• Manage all pain and prevent any Infection or sepsis overload that they have

Acute Phase Interventions- Causes of Hyponatremia

• High fluid and topical solutions pulling NA from the open end
• Hydrotherapy's also helps to remove some Na with High H2O intake

Potassium in relation to Acute Phase Treatments

• Hyperkalemia occurs from renal Failure insuffientcy and muscle/injury breakdown from elevated pressure
• Hypokalemia occurs from topical treatments and prolonged losses through wound openings

Wound Management - General Guidelines

• Pre medicate ,wash hands and use top water wash using bacterial soap
• Be gentle and clean to preserve the wound

Topical Antibiotics - Silvadene

• A topical antibiotic with an effective broad spectrum (primarily gram negative) that may result in leukopenia and thrombocytopenia. Sulfamylon
• Effective against aerobes and penetrates Eschar, but still results in acidosis

Topical Antibiotics -Other Treatments

Sulfamylon and Nyastatin Solution

• Can be utilized
• Helpful Skin Infections

Hydrotherapy

• Can inflict high pain and needs lots of care
• Needs to addressed both as mental and emotional care

Dressing changes

• Apply Topical wrapping to pressure and secure
• Give cup support or use a pillow when needed

Burn Wound management

• Patient Teaching is crucial and also must report and and recognize signs of infections, med use or wound healing

Grafting Procedures

• Autograft: own skin Split-thickness Skin uses the person's own cells and uses epidermis
• Ideal for Cultured epithelial

Grafting Procedures -Other

• Allograft: homograft from cadaver and needs temporary protection
• Xenograph: animal skin graft from pig where rejections come fast

Rehabilitation Phase

• After the burn wound closure takes place.
• This may take around 7-8 Months
  • Have the Patients begin to resume all social functions
• May have surgery involved to address complications such as skin
• Use tools to improve Ligament shortening or joint complications

Rehabilitation Phase - Scarring

• Scarring can lead to discoloration if not properly monitored
• Pressure must be added but not worn for more than 72 hrs and may even show sign of itchiness

Ethical Considerations

• Decisions will need to be made based on quality of life
  • In honoring what the family wants
  • What social/emotional needs the patient has

Explore burn injuries: causes, statistics, and skin anatomy. Learn about burn severity based on depth, TBSA percentage, and location. Includes discussion on epidermis, dermis, and hypodermis.