Burns - Introduction and Epidemiology PDF

Burns INTRODUCTION Patients with burns are optimally managed at a burn center, where they have the advantage of an interprofessional team of healthcare providers skilled in the specialized treatment of burn injuries. Currently in the United States, there are only 82 burn centers verified by the Am...

Burns INTRODUCTION Patients with burns are optimally managed at a burn center, where they have the advantage of an interprofessional team of healthcare providers skilled in the specialized treatment of burn injuries. Currently in the United States, there are only 82 burn centers verified by the American Burn Association (a real-time list can be found at https://ameriburn.org/resources/find-a-burn-center/). Burn center referral criteria established by the American Burn Association are listed in Box 51.1. Because of the limited number of burn centers, the majority of patients receive their initial care at local hospitals before transfer to a specialized burn center. For this reason, it is essential for healthcare providers with no specialized education in burn care to have a basic understanding regarding the stabilization and initial management of this patient population. INCIDENCE AND EPIDEMIOLOGY According to the latest data released in September 2022 by the National Fire Protection Agency (NFPA), 1.35 million fires were reported in the United States in 2021, which resulted in 3,800 civilian deaths and 14,700 civilian injuries. (These statistics are updated annually and are available at www.nfpa.org/News-and-Research.) As a result of these fires, property damage was estimated at \$15.9 billion dollars. Fire death rates vary widely by state. Higher state fire death rates are generally found in those states with higher numbers of people below the poverty line, having a disability, currently smoking tobacco, living in rural areas; and/or are Native American, Alaskan Native, African American, or Black. In fact, 9 of the 10 states with the highest fire death rates were also in the bottom 10 states based on 35 health measures, including air pollution, child poverty, violent crime, and other environmental and community factors. These states tend to have multiple needs and resource challenges. Box 51.1 American Burn Association's Burn Center Referral Criteria A burn center may treat adults, children, or both. Partial-thickness burns equal to or greater than 10% of the total body surface area Burns that involve the face, hands, feet, genitalia, perineum, or major joints Full-thickness burns in any age group Electrical injury, including lightning injury Chemical injury Inhalation injury Burn injury in patients with preexisting medical conditions that may complicate management, prolong recovery, or affect mortality Any patients with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient's condition may be stabilized initially in a trauma center before transfer to a burn center. Provider judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. Burned children in hospitals without qualified personnel or equipment for the care of children Burn injury in patients who require special social, emotional, or rehabilitative intervention Questions concerning specific patients can be resolved by consultation with the burn center provider. Outdoor fires (e.g., fields, vacant lots, trash, wildfires) account for approximately 49% of all property fires. Residential and nonresidential structure fires combined account for another 36% of fires. However, structure fires accounted for 79% of fire deaths and 86% of fire injuries. Vehicle fires account for 15% of the total number of fires. The largest percentage (76%) of deaths occurs on residential properties, with the majority of these being in one- and two-family homes (64%). Vehicles account for the second-largest percentage of fire deaths at 21%. According to the American Burn Association (ABA), the two most commonly reported etiologies for burn injury are fire/flame and scald injuries. Admissions to burn centers show admission cause as 40.6% fire/flame, 31.4% scald, 9.1% contact, 3.6% electrical, 3.5% chemical, and 3.4% unspecified. Scald injuries are most prevalent in children under the age of 5, whereas fire/flame dominates all other age groups. The leading cause of both residential and nonresidential structure fires is cooking, with fires caused by heating being the second-leading cause. The two leading causes that result in fatalities and/or injuries for residential fires are cooking- and smoking-related incidents. Examples include grease burns, scald injuries, flame burns, and falling asleep while smoking. The majority of fire-related fatalities and injuries occur in people between the ages of 25 and 64 years. This age group accounts for more than half of the fire injuries reported in the United States. According to data collected by the NFPA, men are 1.7 times more likely to die in fires than women, and data collected by the American Burn Association demonstrate that men account for nearly 68% of all patients admitted to burn centers. Although the exact reasons for this are unknown, possibilities include the greater likelihood of men participating in risk-taking behavior and the more high-risk occupations of men. Men also suffer more injuries trying to extinguish fires and rescuing people. Approximately 30% of all fire deaths in women occur in those 70 years old and older, and this may be due to the fact that women have a longer life expectancy than men and are often performing the majority of the cooking. By contrast, male fire deaths are higher in the age range of 40 to 59. Notably, older women have twice the number of fire injuries when compared with older men. People with limited physical and mental abilities, especially older adults, are at a much higher risk of fire death. Older adults (ages 65 and over) have a risk of dying in a fire that is 2.5 times higher than that of the population as a whole. This risk increases to 3 times for those ages 85 and over. As the baby boomers enter retirement age, a corresponding increase in fire deaths and injuries among older adults is likely. In the past, children age 4 and younger were also considered to be at high risk of death due to fire. However, the risk of fire death in this population is now 50% less than that of the general population---the lowest relative risk for this age group since the mid-1970s. The risk of death for this age group was greater than for older children because as children mature their cognitive and social abilities develop and the risk of fire death drops sharply. For children ages 5 to 9, the fire death risk was 60% less than that of the general population. For those ages 10 to 14 and 15 to 19, the risk of fire death was 80% less than the general population. To reduce the incidence of burn injuries, many burn centers are involved in community prevention activities. These activities focus on the higher-risk population groups, including children and older adults. See Box 51.2 for burn injury prevention strategies. In addition, Healthy People 2030 is now putting more emphasis on the social determinants of health and how that may increase injury risks for certain populations (Box 51.3). PATHOPHYSIOLOGY Classifications Burns are generally classified in terms of etiology, depth of tissue damage, total body surface area (TBSA) involved, and severity. Burn Etiology A burn injury results when the tissues of the body are damaged by a heat source. The heat source may be thermal, electrical, chemical, or the result of radiation. Thermal Thermal burns can be the result of a flash, scald, or contact with hot objects or flames, and common causes include house fires, car fires, cooking accidents, or injuries as a result of careless smoking. Associated accelerant use (e.g., gasoline, kerosene, or propane) may increase the severity of the burn and associated inhalation injury because this adds a chemical insult in addition to the thermal injury. Contact burns are also thermal in nature and are often associated with cooking or heating incidents. Scald injuries are most prevalent among the young and may be associated with accidents or abuse. The two factors that determine the depth of a thermal injury are the temperature to which the skin is heated and the duration of contact with the heat. Electrical Electricity has many devastating effects on the body and may result in a wide spectrum of injuries, ranging from mild to lethal. Each year in the United States, there are about 1,000 deaths as a result of electrical injuries, and there are at least 30,000 shock incidents that are nonfatal. In adults, these injuries are often occupational related and are the fourth leading cause of work-related traumatic death. Electrical injuries are associated with an overall increase in the length of hospital stay, morbidities, and number of required surgeries. This is due to the fact that electrical injuries are often linked to other types of ensuing trauma due to subsequent falls and the potential for cardiac injury. In addition, as electricity passes through the body, it has the potential to cause damage to multiple organs, which then must also be addressed and treated in conjunction with any burns that have occurred. Electrical burn injuries can be associated with extensive burns that may even require amputation. Patients may present with cardiac and/or neurological problems, as well as associated trauma and/or flame burns. Electrical injury may occur by direct contact with the source, by an arc between two objects, or as a result of a flame injury caused by ignition of the surroundings. The effects of electricity on the body depend on certain factors, including the type and strength of the current, the duration of contact, the pathway of flow through the body, and local tissue resistance. The epidermis is the body's best insulation, but once breached, the body acts as a volume conductor. Bone is more resistant to the flow of electricity, and the electricity tends to flow along the top of the bone, often damaging the overlying muscles, nerves, and vessels. Consequently, deep muscle injury may be present even when skin and superficial muscle may appear uninjured. When a person comes into contact with alternating current, the body often becomes part of the circuit. In alternating current, the movement of an electrical charge sporadically changes direction, creating a tetany effect, or involuntary state of muscle contraction that interferes with the person's ability to easily break free from the source. This muscle contraction enables the electric current to flow continuously back and forth between the person and the source, which may either throw the person or draw the person into continual contact with the source. As a result, the current may pass through the body for a greater period of time, exacerbating the severity of the associated injury. Direct current is a one-directional, constant flow of electricity. In the United States, direct current injuries occur from lightning strikes, contact with car or boat batteries, and contact with railway train lines. Electric vehicle charging stations are also a newly identified concern. Electrical current also disrupts the electrical activity of the body and may result in immediate cardiac and/or pulmonary arrest on scene. Box 51.2 Burn Prevention Strategies Burn Prevention Inside the Home Install and maintain working smoke alarms on each level of the home and inside each sleeping area. Each month, check that they are working, and change the batteries every 6 months unless the alarm is hardwired into the home or has a 10-year lithium battery. Install and maintain working carbon monoxide detectors on each level of your home. Develop and practice a home fire escape plan. Make sure everyone in the home knows the meeting place and knows never to return into a burning home for any reason. Keep all windows and doorways free of clutter in case of the need to escape quickly. Keep a flashlight and telephone near the bedside. Keep a working fire extinguisher on each level of the home and know how to use it properly. Never set the water heater above 120°F (48.9°C). Teach children how to stop, drop, and roll while also covering their faces. Keep matches and lighters out of the reach of children. Never leave a child unattended in a bathtub or near a fire/fireplace. Never smoke in bed or while drowsy. Never smoke while receiving oxygen therapy. Never leave burning candles unattended, and try not to burn candles on low surfaces for risk of being knocked or bumped. Always exercise caution while cooking, and do not leave anything unattended on the stove. Avoid wearing long sleeves or flowing clothing while cooking. Never let a child play near the stove/oven while cooking. Always turn pot handles inward and use the rear burners when possible. Never use the kitchen oven as a means to heat the home. Avoid running electrical cords under carpets. Avoid using space heaters in the bedroom or while asleep. While a space heater is in use, there should be a minimum of 3 feet of clearance around the heater in all directions. Avoid falling asleep while using a heating pad. Be sure to use proper protection and ventilation while working with chemicals in the home, including cleaning products. Read all product labels carefully before use. Never store flammable liquids inside the home or near a source of heat. Burn Prevention Outside the Home Always store flammable liquids outside the home in clearly labeled, airtight containers in well-ventilated areas (such as a garage or shed). Never refill a hot engine (i.e., lawnmower or weed whacker). Wait until thoroughly cooled before refilling with gasoline. Never use flammable liquids to start a campfire or grill. Never throw flammable liquids onto an already burning fire. Use caution with campfires, and do not leave children unattended around the fire. Fireworks should be used only by adults and with extreme caution in states where they are legal. Be careful of overhead and underground electrical wires while working outside. If downed electrical wires are found, do not touch! Call the local electric company to report immediately. Caution children never to play near or on electrical boxes or climb trees with electrical wires passing through the branches. Always use sunscreen with an SPF of at least 30 when outdoors, and be sure to reapply often. Consider a wide-brimmed hat and sunglasses. SPF, Sun protection factor. Box 51.3 Healthy People 2030 One of Healthy People 2030's five overarching goals is specifically related to social determinants of health (SDOH): "Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all." SDOH are the conditions of the environments where people live that can affect their quality of life, health, safety, and overall well-being. SDOH include five domains: economic stability; access to and quality of education; access to and quality of healthcare; neighborhood structure and environment; and social/community context. It is imperative that healthcare clinicians assess the SDOH of their patients as they may contribute to a wide range of health disparities and inequities. For example, people who live in homes without functioning smoke alarms are at a much higher risk for burn injury related to house fires. The common household electric circuit carries a charge of 120 volts. High-voltage injuries occur when a person comes into contact with 1,000 volts or greater. These types of injuries are often work related and are more common in men. Patients who sustain high-voltage injuries often present with very deep burns and sequelae from associated trauma. Flash injuries and/or flame burns may also occur as a result of possible ignition of clothing. The hands and mouth are the most frequently injured sites for low-voltage electrical injuries in children as they may have oral contact with electrical cords or sockets. Surgical management and extensive rehabilitation may be required for the best functional outcomes. Of concern since its introduction in 2007 are the number of reports of injuries caused by the overheating, ignition, or explosion of electronic nicotine delivery systems (ENDSs). These injuries appear to have different causes, the most important one being the lithium-ion battery overheating to the point of ignition or explosion causing a subsequent burn injury. This often happens while the user of the device is carrying it in their pocket, which results in clothing ignition and subsequent flame and contact burns. These burns tend to be deep and require skin grafting. There is a need for increased regulation of ENDSs and improved surveillance of related injuries. Healthcare providers and consumers should be made aware of the risks and be advised about how to safely handle these devices. Chemical Chemical burns account for approximately 3% of all burn center admissions and occur in both the industrial and household settings. The three subclasses of chemical burns are acids, alkalines, and organic compounds. Examples of chemical burns include those caused by cement, gasoline, lime, hydrofluoric acid, and bleach. The extent of a chemical injury is dependent on many factors, including the agent, the mechanism of action, the concentration and volume of the agent, and the duration of contact with the agent. Radiation Radiation burns are the least common type of burn injury, and the severity of complications is dependent on the type, dose, and length of exposure. These injuries are often associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment. Sunburn is also considered a radiation burn because it is caused by ultraviolet radiation and is the most common type of radiation burn seen in healthcare settings. Localized radiation injuries often appear similar in nature to thermal burns because they are characterized by erythema, edema, blisters, and pain. Prolonged full-body exposure to ionizing radiation often causes nausea, vomiting, diarrhea, fatigue, headache, and fever. Connection Check 51.1 The nurse recognizes which etiology as consistent with a thermal burn? A.  Direct current B.  Scalding C.  Exposure to organic compounds D.  Ionizing radiation Burn Depth Burns are classified according to the depth of tissue damage: superficial, partial-thickness, or full-thickness injuries. Figure 51.1 presents an overview of burn depth in relation to skin anatomy. Determination of the exact depth of the burn is often impossible on initial inspection, even for the most experienced burn-care provider. This is because burn wounds frequently evolve or "declare themselves" within the first 24 to 72 hours, and it is essential to frequently reassess the burn injury to ensure appropriate resuscitation and treatment. The traditional classification terms of first-, second-, and third-degree are not used in the burn community because they do not give an accurate or descriptive representation as to the true extent of injury. These terms are replaced with the burn-depth classification system, including superficial, superficial partial-thickness, deep partial-thickness, and full-thickness. See Table 51.1 for a summary of burn-depth classifications. Superficial Superficial burns affect only the epidermal layer of the skin and are characterized by mild erythema and hypersensitivity, which typically resolve in 24 to 72 hours. Sunburn is the most common type of superficial burn injury (Fig. 51.2). These types of burns heal quickly, typically do not require medical intervention or admission to a burn center, and do not usually result in scarring. Superficial Partial-Thickness A superficial partial-thickness burn involves the epidermis and the superficial or minimal layers of the dermis (Fig. 51.3). Because of the exposed nerve endings located within the dermal layer of the skin, these burns are often very painful. The patient is extremely sensitive to touch and even to air currents when the wound dressing is removed and the burn is exposed. Superficial partial-thickness burns often have wet, weeping blisters and are pink in color. The capillary refill time on areas of open blisters remains normal. Despite the destruction of the entire epidermis, superficial partial-thickness burns usually heal in 1 to 2 weeks with minimal to no scarring. Depending on the location and extent of the superficial partial-thickness burn, medical management and admission to a burn center may be warranted for wound care and pain management. Treatment of superficial and superficial partial-thickness burns is highlighted in Box 51.4. FIGURE 51.1 Burn depth in relation to skin anatomy. Table 51.1 Burn-Depth Assessment Burn Depth Tissue Involvement Wound Characteristics Pain Assessment Healing Superficial Minimal damage to the epidermis Dry, no blisters; pink or red; blanches easily Hypersensitive 3--7 days with no scarring Superficial partial-thickness Entire epidermis and minimal damage to the dermis Blisters that may be closed or open and weeping; pink or red; mild edema; blanches easily Hypersensitive 7--14 days with no scarring Deep partial-thickness Entire epidermis and deeper layers of the dermis Blisters that may be closed or open; waxy appearance; cherry red, mottled, or pale in the center; edema; sluggish or no blanching Hypersensitive around the wound edges but may be sensitive to pressure only in the center Healing may take 3--6 weeks and may leave some scarring, or the wound may have to be surgically excised and grafted. Full-thickness Destruction of entire epidermis and dermis; may involve subcutaneous fat, muscle, and/or bone Dry, leathery; pale, white, brown, tan, black, charred; no blanching; may be contracted if muscle involvement No pain in the center of the wound but may be sensitive to pressure Will not heal without surgical excision and grafting Deep Partial-Thickness A deep partial-thickness burn involves the epidermis and extends into the deeper portions or bottom layers of the dermis (Fig. 51.4). The patient often reports varying areas of pain and decreased sensation. Deep partial-thickness burns appear waxy and do not have the characteristic weeping blisters that are seen in superficial partial-thickness injuries. This is due to the fact that the entire epidermis and the majority of the dermis have been damaged. The burn may appear light pink or cherry red in color, and capillary refill is decreased or absent. The challenge with a deep partial-thickness burn is determining the true extent of the injury and whether it will heal without requiring surgical intervention. It is essential to engage in close observation of the burn wound to monitor for potential progression from a deep partial-thickness to a full-thickness burn injury. The majority of these types of burns take more than 2 weeks to heal, during which time the risk of infection is paramount because patients with burn injuries are immune-compromised without the skin as a barrier to infection. Unfortunately, burns are not an exact science, and the burn surgeon decides whether to operate or to try to let the burn heal on its own. FIGURE 51.2 Superficial burn. FIGURE 51.3 Superficial partial-thickness burn. A, Before debridement of blisters. B, After debridement of blisters. Box 51.4 Care of the Superficial and Superficial Partial-Thickness Burn Although other mechanisms may cause a superficial burn injury, it is common to see this type of burn from the sun. In a true superficial burn, no blisters are noted. If blisters appear, the burn is then considered partial-thickness. Superficial partial-thickness injuries are commonly seen from scalding liquids. Care of the superficial and superficial partial-thickness burn wound is outlined here. Superficial Do not apply ice or submerge in ice water. May apply a cool compress or run under cool water. A dressing should not be required because there are no open blisters. Lotion should be applied liberally once or twice per day. Choose lotion that is aloe based and/or fragrance-free. Ibuprofen, acetaminophen, or aspirin may be taken as necessary for pain and discomfort. Drink plenty of fluids to rehydrate. Rest. Superficial Partial-Thickness If one to three quarter-sized or smaller blisters appear, try not to open (pop) the blisters. This allows for a moist healing environment, decreased risk of infection, and less discomfort for the patient. If the blister or blisters are broken, wash the area with a mild antiseptic soap and warm water. Apply a thin layer of bacitracin ointment and cover with a nonadherent bandage. The wound should be thoroughly cleansed and the dressing changed at least once per day. The patient may continue with their usual activities of daily living; however, dependent extremities should be elevated to prevent edema and encourage venous return. The patient should be aware of any clinical manifestations of infection, such as fever, increased pain, redness or swelling, purulent drainage, or red streaks radiating from the wound. If noted, the patient should see their primary care provider right away. It is encouraged that the patient follow up with their primary care provider. FIGURE 51.4 Deep partial-thickness burn (blisters debrided). Full-Thickness A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue (Fig. 51.5). All epidermal and dermal structures are destroyed, including hair follicles, sweat glands, and nerve endings. Full-thickness burns do not heal spontaneously. As a result of the extensive damage to the nerve endings, full-thickness burns are often insensate. This absence of pain is often misleading for patients, and many do not comprehend the severity of their injury. Full-thickness burns generally have no blister formation. Although full-thickness burns may take on a variety of colors, they are always very dry and feel like leather to the touch. This full-thickness burn tissue is often referred to as eschar. The charred appearance associated with full-thickness injuries is not common. Because all epithelial elements and structures are destroyed, full-thickness burns do not heal spontaneously and require skin grafting. Burns that extend beyond the subcutaneous layer into muscle and/or bone are also considered full-thickness, as shown in Figure 51.6. Connection Check 51.2 The nurse correlates which clinical manifestation with superficial partial-thickness burns? A.  Eschar B.  Dry, leathery appearance C.  Blisters D.  Waxy appearance Total Body Surface Area Percentage Expressed as a percentage, total body surface area (TBSA) determination is essential to guiding adequate fluid resuscitation and treatment. Both overestimation and underestimation of the size of the burn can have significant effects on outcome. Underestimation can result in inadequate resuscitation, which may cause shock and organ failure. Overestimation can put the patient at risk for complications such as pulmonary edema due to the excess fluid given during resuscitation. Adult patients are resuscitated at injuries of 20% or greater TBSA. The three most common methods for determining TBSA are the rule of palm, the rule of nines, and the Lund and Browder classification. Rule of Palm The size of the patient's hand, including the fingers, accounts for approximately 1% TBSA. This quick method of determining burn size is particularly useful in prehospital settings for very small and/or very large burns, scattered burns, and in mass-casualty situations where time is of the essence. Rule of Nines The "rule of nines" is the most commonly used method in prehospital settings for making a determination of the percentage of TBSA burned. With this method, the adult body surface areas are broken down into 9% or multiples thereof. This division is modified in infants and children because of the large surface area of the child's head and the smaller surface area of the lower extremities. One concern with the rule of nines is that it assumes all physically mature persons, regardless of weight and body shape, have the same distribution of body surface area percentages. The rule of nines diagram is displayed in Figure 51.7. FIGURE 51.5 Full-thickness burn. FIGURE 51.6 Full-thickness burn with muscle and bone involvement. Lund and Browder Classification In the hospital setting and in the majority of burn centers, the most widely accepted and accurate method of determining the percentage of TBSA burned is the Lund and Browder classification. Measurements, which take into account surface area related to age, are assigned to each body part. The Lund and Browder classification chart has come into question because it does not account for the altered body mass distribution in obese patients, and future revisions are currently being considered by burn experts. Only partial- and full-thickness burns are recorded on the Lund and Browder chart because superficial burns are not taken into account during resuscitation. The Lund and Browder chart is not completed until a full and thorough debridement (removal of damaged tissue) of the burn wound has been completed because this TBSA percentage provides the basis for determining the amount of fluid resuscitation. A visual representation of the Lund and Browder diagram is displayed in Figure 51.8. \*\*\*\*\*\*\*\*Severity There are several other factors that play an important role in determining the severity of a burn and directly affect overall patient outcome. These factors include the presence of an inhalation injury, patient age, past medical history, and presence of concomitant injury, as well as the anatomical location of the burn injury. Of these factors, the two that are of greatest significance in the determination of survival and that warrant further discussion include age and past medical history. Even very small burns can prove fatal to older adults because of the inability to tolerate the aggressive fluid resuscitation and surgical management required. As the baby boomer generation enters into retirement, patient age and past medical history will continue to play a key role in patient decisions and outcomes (see Geriatric/Gerontological Considerations). FIGURE 51.7 Rule of nines for determination of total body surface area (TBSA) burn size. This is expressed as a percentage. Geriatric/Gerontological Considerations Burn Care in Older Adults Managing the care of older adults with burn injuries can present many challenges for the burn team. Common age-related changes in this population put them at a much higher risk of burn injury. These changes include reduced mobility, decreased vision, decreased sense of smell, reduced coordination and strength, and decreased sensation. These normal changes can place older adults at a much higher risk of a severe burn injury because they may have difficulty escaping the fire or removing the source of heat. Once a burn injury has been sustained, the older adult patient may be much more difficult to manage because of preexisting medical conditions, decreased immune function, poor nutritional status, decreased pulmonary and/or cardiac function, and poor social support. The skin of the older adult patient is also much thinner and less elastic, which can affect the depth of the injury and the ability of the burn wound to heal. In fact, eschar separation in a full-thickness burn wound is normally delayed in the older adult patient, and many patients are simply not candidates for the operating room because of preexisting medical conditions. For this reason, older adult patients often have prolonged and complicated hospitalizations and recoveries. Early wound excision and grafting are recommended if they can be tolerated by the patient. The goal is prompt closure of wounds and prevention of infection by decreasing the hospital stay as much as possible. \*\*\*\*\*\*\*\*\*Anatomical Changes The functional outcome of the patient is directly related to the depth of the burn injury, with full-thickness burns resulting in the most significant anatomical skin changes. Skin that has been grafted after a full-thickness burn injury can become severely scarred, and normal movement and appearance are usually significantly impaired. The localized tissue response to the burn can be illustrated by the concentric zones of burn injury, as displayed in Figure 51.9, with each zone representing the localized tissue response. The zone of coagulation is the area that had the most contact with the heat source and is the location of the most severe damage. The tissue undergoes protein coagulation, eschar is often present, and the patient often reports no pain within this area because all nerve cells are destroyed. The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation and care. Improper resuscitation or under-resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation, as shown in Figure 51.10. The outermost area is termed the zone of hyperemia and is generally an area of increased blood flow in an effort to bring key nutrients for tissue recovery. This area usually sustains minimal injury and recovers spontaneously within 1 to 2 weeks. The full extent of damage may not be evident for 24 to 72 hours after injury because it may take that long for burns to reveal the true depth of injury. FIGURE 51.8 Lund and Browder classification. FIGURE 51.9 Concentric zones of a burn injury. The zone of coagulation is the area that had the most contact with the heat source and is the location of the most severe damage. The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. The zone of hyperemia is the outermost area and is an area of increased blood flow in an effort to bring key nutrients for tissue recovery. FIGURE 51.10 Burn wound conversion. A, Chest and abdomen post--burn day 1. B, Chest and abdomen post--burn day 2. Connection Check 51.3 The nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation? A.  Zone of stasis B.  Zone of conversion C.  Zone of hyperemia D.  Zone of coagulation \*\*\*\*\*\*\*\*Functional Changes The location of a burn injury plays an important part in determining the level of care required and in the functional changes that may result. According to the ABA, referral criteria to a burn center involve injuries to specific areas of the body, including the face, hands, feet, genitalia and perineum, and burns over major joints. Burns in these locations involve functional areas of the body and may require specialized and highly skilled interventions in order to restore optimal function. Without proper management by the interprofessional burn-care team, long-term morbidity may result from impaired function and altered appearance. Survivors of large burns often require multiple and sometimes lifelong plastic and reconstructive surgical procedures in order to maintain proper function and range of motion. Connection Check 51.4 The nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes? (Select all that apply.) A.  Chest B.  Perineum C.  Elbows D.  Face E.  Hands \*\*\*\*\*\*\*\*SYSTEMIC EFFECTS OF MAJOR BURN INJURIES Burns that are less than 20% TBSA produce a localized tissue response. Burns that are greater than 20% TBSA are considered major burn injuries and produce both localized and systemic responses. All body systems are affected by the release of cytokines and other mediators into the systemic circulation. Respiratory Inhalation injuries, defined as the toxic effects of heat and the chemical products of combustion on the lungs and in the airways, are present in approximately 16% of patients admitted to burn centers and significantly increase morbidity and mortality. In order to minimize complications and decrease the overall mortality rate, rapid diagnosis and management of inhalation injuries are critical (Box 51.5). Recognizing an inhalation injury is particularly important because it has been recognized as the third most important factor, after extent/depth of burn and patient age, in determining mortality. Inhalation injuries should always be considered when the patient was injured or trapped within an enclosed space, such as in a house or car, or there are burn injuries of the face, neck, or chest. There are three main types of airway inhalation injuries: inhalation injury above the glottis, inhalation injury below the glottis, and carbon monoxide poisoning. Inhalation burns are most commonly limited to the upper airway above the glottis (nasopharynx, oropharynx, and larynx) and are usually thermal or chemical in nature. Because of the protective response of the respiratory tract, the majority of heat absorption and tissue damage occurs above the glottis and vocal cords. These above-the-glottis burns are associated with injury to the nose, throat, and mouth, and because swelling can occur within minutes to hours of injury, emergent intubation may be required to maintain the airway. Inhalation injury below the glottis is almost always chemical in nature and is rarely caused by heated air alone. This type of severe inhalation injury is most common in patients with prolonged exposure to smoke, such as those rendered unconscious by fire. Wheezing and tracheobronchitis may be seen in the first minutes to several hours after injury. Box 51.5 Physical and Clinical Manifestations of an Inhalation Injury Facial burns Singed nasal and facial hairs Carbonaceous sputum (soot), hypersecretion Nasopharynx or oropharynx erythema Excessive agitation/anxiety (hypoxia) Tachypnea, intercostal retractions, flaring nostrils Inability to swallow Hoarseness, grunting, brassy voice Rales, rhonchi, diminished breath sounds \*\*\*\*\*\*\*\*Most fatalities that occur at the scene of a fire are due to carbon monoxide poisoning. Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. In cases of suspected carbon monoxide poisoning, oxygen measurement by pulse oximeter is useless because the determination between the oxygen and carbon monoxide molecules saturating the hemoglobin is not possible. Normal carboxyhemoglobin levels are less than 2% but may be as high as 5% to 10% in heavy smokers. Although carbon monoxide may cause a cherry red discoloration of the skin in patients with carbon monoxide levels at 40% or higher, this manifestation is seen only in approximately 50% of cases. More common clinical manifestations observed in patients with carbon monoxide poisoning include headache, confusion, nausea, dizziness, vomiting, and dyspnea. These clinical manifestations are usually seen when carbon monoxide levels reach approximately 30%. Table 51.2 provides a listing of clinical manifestations in relation to the percentage of carbon monoxide levels. Patients with an inhalation injury may present with facial burns, singed nasal and facial hairs, carbon in their sputum, redness of the oral pharynx, inability to swallow, and tachypnea. The respiratory epithelium may be damaged as a result of inhaled gases and particulate matter. Mucus production and impaired ciliary function may result, which ultimately may lead to cell death and sloughing of the respiratory tract. Anxiety and agitation may ensue if the patient begins to experience respiratory distress. Clinical manifestations of respiratory distress may include stridor, progressive hoarseness, rales, rhonchi, and/or retractions of the lower rib cage. Endotracheal intubation should be considered if the patient presents with any of these clinical manifestations. A subset of burn patients that require special consideration are those with smoking-related and/or home-oxygen therapy (HOT)--related burn injuries. While the TBSA of these patients tends to be lower, their morbidity and mortality can be high due the higher risk of inhalational injury. Although smoking cigarettes while on oxygen is itself hazardous, the medical equipment further increases that hazard. Nasal cannulas can emit an intense flame when ignited due to the materials they are made from, and patients can suffer a devastating flash injury to the face and upper airway. Efforts to encourage smoking cessation, educate regarding the hazards of home oxygen therapy burns, and more judicious home oxygen therapy allocation would be beneficial in preventing these unnecessary injuries. \*\*\*\*\*\*\*Table 51.2 Clinical Manifestations of Carbon Monoxide Poisoning Carbon Monoxide (%) Clinical Manifestations 5--10 Mild headache and confusion 11--20 Severe headache, flushing, vision changes 21--30 Disorientation, nausea 31--40 Irritability, dizziness, vomiting 41--50 Tachypnea, tachycardia Greater than 50 Coma, seizures, death \*\*\*\*\*\*\*\*Cardiovascular Initially, the greatest threat to a patient with a major burn injury is burn shock, which is a combination of distributive and hypovolemic shock. This type of shock results secondary to a massive fluid shift. Electrolytes, water, plasma, and proteins leak out of the intravascular space and into the interstitial space because of the increase in capillary permeability, which results from the body's initial inflammatory protective mechanism. The large fluid loss within the intravascular space increases the viscosity of the blood, which results in sluggish blood flow, decreased oxygen delivery, and overall decreased cardiac output. Because of the increased viscosity of the blood, the patient initially presents with an elevated hematocrit. Generally, fluid leakage occurs during the first 8 to 36 hours after the injury, with maximum shifting peaking at approximately 24 hours after the injury. If fluid resuscitation is not adequate, the burn patient begins to demonstrate clinical manifestations of shock, including hypotension, tachycardia, reduced urinary output, and altered mental status. Figure 51.11 provides an overview of the pathophysiological changes occurring during burn shock. If the state of shock continues to progress without proper fluid resuscitation and management, the patient will begin to decompensate, resulting in multiple organ dysfunction syndrome (MODS) and potentially death. In the post--burn shock phase, which begins approximately 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis, and blood pressure and cardiac output begin to normalize. \*\*\*\*\*\*\*Fluid and Electrolytes The two electrolytes of most concern during the burn shock phase are potassium and sodium. Initially, hyperkalemia may result because of the release of potassium from damaged cells into the vascular space. As fluid shifts continue, potassium and sodium begin to leak out of the intravascular spaces, and hypokalemia and hyponatremia may result. Although potassium and sodium are of utmost importance, all electrolytes are closely monitored, and replacement therapy is initiated as warranted. It is extremely important to account for evaporative fluid loss that may occur through the burn wound, as this amount may be as great as 5 L per day and continues until all wounds are closed. FIGURE 51.11 Pathophysiology of burn shock. \*\*\*\*\*\*Renal Because of the initial decrease in circulating blood volume, renal function may also be impaired secondary to decreased renal perfusion. Destruction of red blood cells results in free hemoglobin being released into the body following a major burn injury. If the patient has sustained muscle damage as a result of the burn injury, myoglobin may also be present in the bloodstream. When fluid resuscitation and resulting blood flow are inadequate, myoglobin and hemoglobin have the potential to occlude renal tubules, causing acute tubular necrosis. This is most commonly seen with electrical injuries. \*\*\*\*\*\*\*\*\*Gastrointestinal The patient with a burn injury often has complications of the gastrointestinal system secondary to a decrease in both nutrient absorption and gastrointestinal motility. Paralytic ileus is not seen as frequently in the burn population because of the increased use of prokinetic agents and early initiation of enteral nutritional support. A nasogastric tube is placed in patients with large burns for both long-term feeding access and to relieve initial gastric distention, nausea, and vomiting. Patients with burns who have suffered a significant injury and require massive fluid resuscitation are at risk for developing abdominal compartment syndrome secondary to massive resuscitation volumes. \*\*\*\*\*\*\*\*\*Metabolic A burn injury causes an array of physiological alterations within the body, placing the patient in a constant hypermetabolic state for up to 1 to 3 years after the injury. Burn injuries often double the normal resting energy expenditure and greatly increase the patient's caloric needs. Because the nutritional needs are constantly fluctuating for the patient with burn injuries, determining caloric needs is a dynamic and ongoing process. Factors affecting the metabolic rate in patients with burns include age, sex, infection, concomitant trauma, pain, surgery, sleep, and ambient temperature. Without additional nutritional support in patients with large burn injuries, particularly those with a burn greater than 20% TBSA, wound healing is impaired. Even patients who can feed themselves often require supplementary caloric support and/or enteral feeding because of their hypermetabolic state. Nutrition is so important that many burn centers continue to enterally feed patients up to and throughout their entire operative procedures (see Evidence-Based Practice: Impact of Enteral Feeding in Morbidity and Outcomes in Patients With Burns). Evidence-Based Practice Impact of Enteral Feeding in Morbidity and Outcomes in Patients With Burns Due to the hypermetabolic state that develops in patients with severe burn injuries, there is increased focus on meeting the nutritional needs in this patient population. This study examined current evidence regarding whether early enteral nutrition affects patient outcomes in patients with major burn injuries. Data sources included Medline, Embase, and the China National Knowledge Infrastructure throughout May 2018 and only included randomized controlled trials that reported patient outcomes. In total, 958 articles were reviewed, with seven randomized controlled trials enrolling 527 participants included in the final analysis. For purposes of this study, enteral nutrition was described as a standard formula starting within 24 hours of the burn injury or admission to the intensive care unit (ICU). The findings of the study supported previously reported improvements in clinical outcomes in those patients who received early enteral nutrition. Specific findings included preservation of gut integrity, fewer gastrointestinal hemorrhages, less infectious complications, and reductions in both organ failures and sepsis. Reduced lengths of hospital stays were also associated with early enteral nutrition in this patient population. Greenhalgh, D. G. (2019). Management of burns. New England Journal of Medicine, 380(24), 2349--2359. Pu, H., Doig, G. S., Heighes, P. T., & Allington, M. J. (2018). Early enteral nutrition reduces mortality and improves other key outcomes in patients with major burn injury: A meta-analysis of randomized controlled trials. Critical Care Medicine, 46(12), 2036--2042. Massive amounts of body heat may be lost through open wounds as a result of impaired thermoregulatory function. Once the patient loses skin, it is impossible for the body to successfully regulate temperature. Because of this, it is essential to maintain a high ambient temperature within the patient's room and within the operating room. This is particularly essential when the wounds are exposed. Many burn centers have specialized heating equipment to assist in patient warming (Fig. 51.12). This equipment may include heat shields located in the ceiling above the patient's bed that may be lowered, as well as additional space heaters that are often placed in the room. Many of the newer or newly remodeled burn centers now have radiant heat under the flooring and behind the walls in each patient room. \*\*\*\*\*\*\*\*\*Immunological Patients with burn injuries are at high risk for infection and sepsis because of loss of the protective function of the skin, altered immunological defenses, and the presence of open burn wounds. The loss of skin integrity is compounded by the release of abnormal inflammatory factors, which alter the patient's underlying metabolic profile. As a result of these alterations, patients with extensive burns develop systemic inflammatory response syndrome (SIRS). The term SIRS relates to the exaggerated inflammatory response that occurs in the body after injury and may precede the development of sepsis. All patients with extensive burns exhibit some form of SIRS regardless of whether or not sepsis ensues. Burn professionals demonstrate expertise in recognizing other factors that may indicate sepsis, such as a change in mental status, increased fluid requirements, decreased urine output, and a decline in respiratory function. (See Chapter 14 for more discussion of shock and sepsis.) FIGURE 51.12 Specialized heating equipment in the burn intensive care unit. Sepsis The skin is the body's largest protective barrier, and once it is breached, the patient is continuously at risk for infection. If the patient survives the first 24 hours after the initial burn injury, sepsis is usually the leading cause of death (see Evidence-Based Practice: Infection and Sepsis in Patients With Burns). Current medical definitions regarding sepsis are not applicable in the burn population because many patients with burns may demonstrate all of the criteria of sepsis without actually having an infection and/or being septic. Evidence-Based Practice Infection and Sepsis in Patients With Burns A panel of experts in burn care came together in 2007 to develop a consensus for definitions concerning infection and sepsis among burn patients. This definition is still relevant today. The panel defined sepsis in patients with burns as "a change in the burn patient that triggers the concern for infection." The triggers include at least three of the following clinical manifestations: Temperature greater than 102.2°F (39°C) Progressive tachycardia and tachypnea Thrombocytopenia, low platelet count (does not apply until 3 days after resuscitation) Hyperglycemia Insulin resistance Enteral tube feed intolerance characterized by large amounts of residual tube feeding In addition to these indicators, documented incidence of an infection or clinical response to antimicrobials is also required to make a definitive diagnosis of sepsis in the patient with burns. Greenhalgh, D. G., Saffle, J. R., Holmes, J. H., 4th, Gamelli, R. L., Palmieri, T. L., Horton, J. W., Tompkins, R. G., Traber, D. L., Mozingo, D. W., Deitch, E. A., Goodwin, C. W., Herndon, D. N., Gallagher, J. J., Sanford, A. P., Jeng, J. C., Ahrenholz, D. H., Neely, A. N., O'Mara, M. S., Wolf, S. E., Purdue, G. F.,... American Burn Association Consensus Conference on Burn Sepsis and Infection Group (2007). American Burn Association consensus conference to define sepsis and infection in burns. Journal of Burn Care & Research, 28(6), 776--790. Li, A. T., Moussa, A., Gus, E., Paul, E., Yii, E., Romero, L., Lin, Z. C., Padiglione, A., Lo, C. H., Cleland, H., & Cheng, A. C. (2022). Biomarkers for the early diagnosis of sepsis in burns: Systematic review and meta-analysis. Annals of Surgery, 275(4), 654--662. Infection control is a high priority when dealing with the patient who has suffered a burn injury. Sepsis is a common complication after a large burn injury and major cause of mortality in these patients. The cumulative incidence of sepsis in burn patients ranges from 8% to 45% with a reported attributable mortality of up to 65%. The majority of burn centers employ multiple infection control strategies and techniques, including contact precautions for all patient interactions; disposable equipment, including blood pressure cuffs, stethoscopes, and electrocardiogram (ECG) leads; and antibiotic-coated urinary and central line catheters. Although the prevention of infection in the patient with burns may be difficult, every method should be employed to reduce the overall risk. \*\*\*\*\*\*\*\*SPECIAL CONSIDERATIONS IN THE PATIENT WITH BURNS Inhalation Injuries An inhalation injury can exist in the presence or absence of a cutaneous burn (Fig. 51.13). Regardless of the TBSA burned, an inhalation injury increases the overall mortality rate because the patient may develop pneumonia or hypoxemia and require lengthy ventilatory support. Although inhalation injuries can significantly increase morbidity and mortality, there are few standards for diagnosis, treatment, and the measurement of outcomes. Chest x-rays performed on admission are often normal in patients with an inhalation injury, and as a result, a fiberoptic bronchoscopy examination is recommended for definite diagnosis because this study can reveal damage to the respiratory tract and lungs that is not evident on chest x-ray. It is important that patients are observed closely for approximately 24 hours after burn injury because inhalation injuries may have an insidious onset. Patients with burns rarely exhibit immediate signs of respiratory distress; therefore, it is essential to monitor for less obvious indicators of an inhalation injury, including a change in voice (such as hoarseness), anxiety, and/or confusion. It is also important to note whether the burn injury occurred outside or inside because confinement in a burning environment increases the risk of sustaining an inhalation injury. At any time that airway patency is questionable, early intubation is recommended. Delay may result in severe airway obstruction, at which time intubation may become extremely challenging and may require an emergent tracheostomy. As a result of upper airway edema, an endotracheal tube that becomes dislodged may be almost impossible to replace. It is essential to secure the patient's endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling. An emergency tracheostomy tray is maintained at these patients' bedsides in the event of unplanned extubation. FIGURE 51.13 Inhalation injury characterized by edema around the nose and mouth with soot present in the nares. Endotracheal and nasogastric tubes in place. Connection Check 51.5 The nurse correlates which clinical manifestations with the possibility of an inhalation injury? (Select all that apply.) A.  Facial burns B.  Singed nasal hairs C.  Soot in the sputum D.  Hoarseness E.  Eschar \*\*\*\*\*\*\*\*Because of the risk of carbon monoxide poisoning associated with inhalation injuries, treatment requires immediate application of 100% oxygen by mask, which is maintained until carboxyhemoglobin levels are below 10%. The half-life of carbon monoxide in the blood is approximately 30 minutes to 1 hour on 100% oxygen as opposed to 4 hours on room air. Because the majority of patients with burns are placed on 100% oxygen at the scene, it is important to note that measurement of carbon monoxide levels may be a poor indicator of injury because the majority of the carbon monoxide may have been dissipated by the time the patient arrives at the hospital. \*\*\*\*\*\*\*\*\*Electrical Injuries The American Burn Association describes electrical injuries as "the grand masquerader" because the extent of tissue damage is not always apparent on the surface of the skin. Burn healthcare professionals are making efforts to move away from the terms entrance and exit points because the two may be difficult to distinguish. Instead, the term contact points is used when describing electrical injuries (Fig. 51.14). The patient's entire body is assessed for contact points, with close attention paid to the scalp because contact points may be hidden by the hair. In addition to burn wound management, there are additional priorities to consider when caring for patients with electrical injuries. In some patients experiencing electrical injuries, there is also associated physical trauma secondary to the patient falling or being thrown. Patients with electrical burns should be placed in a cervical collar until cervical spine films are cleared for possible injury. Other priorities when managing patients with electrical injuries include cardiac monitoring, fluid resuscitation, neurological assessment, renal management, and maintenance of peripheral circulation. Continuous cardiac monitoring is recommended for at least 24 to 48 hours for patients presenting with a documented cardiac arrest or dysrhythmia and/or extremes in burn size and age. It is important to obtain a baseline ECG to track any cardiac abnormalities that may arise. Neurological assessments are completed on a regular basis to monitor for any changes in level of consciousness. Fluid resuscitation is calculated based on the TBSA of the burns. However, it is important to remember that this calculation is just a starting point for fluid resuscitation because there may be extensive damage to internal structures underneath the skin's surface that are not obvious with external assessment. Urine output is closely monitored for signs of myoglobinuria, which indicates muscle damage and manifests as red or tea-colored urine. If myoglobin is suspected, a urinalysis is performed. Myoglobin can occlude renal tubules and cause acute tubular necrosis; thus, it is important to maintain a urine output of 1 mL/kg/hr for patients with electrical injuries. FIGURE 51.14 Contact point associated with electrical injury. \*\*\*\*\*\*\*\*Chemical Injuries Early recognition and immediate initiation of continuous irrigation to the affected area is crucial when dealing with chemical burns (Fig. 51.15). The three most common classes of chemicals that cause burn injuries are acids, alkalis, and organic compounds. It is important to note that alkali burns tend to penetrate deeper, causing liquefaction necrosis of the underlying tissue requiring a lengthy irrigation period. Organic compounds, such as gasoline, are also of importance because of their ability to systemically absorb into the body, causing renal and hepatic damage. Tar and asphalt burns are also common injuries but are thermal and not chemical in nature and require immediate cooling rather than removal. Refer to Table 51.3 for additional information on each chemical classification. The use of personal protective equipment by all healthcare team members is crucial when managing suspected chemical injuries to ensure that no one else is injured or affected by the chemical. Initial treatment of chemical burns involves the removal of saturated clothing, brushing off the skin if the agent is in powder form, and continuous irrigation with copious amounts of water. The use of a neutralizing agent is usually not recommended because of the exothermic (heat-producing) reaction that may occur. Irrigation continues until the patient reports a decrease in pain, the patient's temperature can no longer tolerate further irrigation, or the patient is transferred to a burn center. Chemical injuries to the eyes are flushed continuously until an ophthalmologist can complete a full examination. FIGURE 51.15 Chemical injury to the back. Table 51.3 Mechanisms of Action of Chemical Burn Injuries Acids Alkalis Organic Compounds Protein donor that releases hydrogen ions and can reduce pH to values as low as 0; results in coagulation of proteins and possible full-thickness injury Protein acceptor that strips hydrogen ions from protonated amine and carboxylic groups. This increases pH values above neutrality and may cause liquefaction necrosis. This allows for deeper tissue penetration and often results in full-thickness injury. Act by dissolving the lipid membrane of cells and disrupting the protein structure of the cell, which may result in full-thickness injury. This also allows for systemic absorption, which may lead to hepatic and renal damage. Examples: bathroom cleaners, drain cleaners, rust removers, glass etching, home swimming pools Examples: oven cleaners, drain cleaners, wet cement, fertilizers, heavy industrial cleaners Examples: phenols, creosote, and petroleum products (gasoline) Protect yourself! It is imperative that healthcare workers ensure that the scene is safe and protect themselves using the appropriate personal protective equipment when a chemical injury is suspected. \*\*\*\*\*\*\*\*\*Escharotomies and Fasciotomies Any circumferential burn to an extremity is at risk for developing compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments, resulting in compartment syndrome. Involved extremities are elevated, and pulses in both burned and unburned extremities are assessed and compared on an hourly basis. Clinical manifestations of compartment syndrome include progressive diminishing of the pulse, numbness, tingling, and complaint of pain with flexion and/or extension. This pain is often not proportional to the extent of the injury and is unrelenting despite appropriate administration of pain medication. Compartment syndrome is a medical emergency and requires immediate surgical intervention in order to salvage the limb. In full-thickness burns, eschar acts as a tourniquet, and as fluid resuscitation continues, vascular compromise may result. Pulses are monitored on an hourly basis in all affected extremities. In some patients, if it is difficult to palpate pulses, a Doppler may be required to assess peripheral circulation. Other assessments include skin color, temperature, sensation, and capillary refill. It is imperative that the nurse monitor for progressive diminution of pulses and report these data to the healthcare provider rather than waiting until pulses are completely absent. An escharotomy (surgical incision through eschar) is performed to relieve the pressure (Fig. 51.16) and should extend only through the eschar and into the immediate subcutaneous fat. This procedure may be performed at the bedside using a scalpel or an electrocautery device. In circumferential burns to the chest, pulmonary function may be restricted because of the inability of the chest wall to expand with ventilation. The chest wall escharotomy (Fig. 51.17) is considered a medical emergency and in rare instances may be performed by scene first responders after consultation with a burn center. See Figure 51.18 for common escharotomy sites. A fasciotomy is performed when the burn extends into the muscle and is more commonly seen in patients who have sustained an electrical injury and have developed compartment syndrome. A fasciotomy is an incision that extends through the subcutaneous fat and muscle fascia, allowing for expansion of the muscle compartment. Fasciotomies are done by the provider under sterile conditions in the operating room. INTERPROFESSIONAL MANAGEMENT OF BURN INJURIES Although other areas of medicine are traditionally delineated into separate medical and nursing tasks and priorities, burn care is an exception. Burn treatment is based on an interprofessional team approach including physicians, registered nurses, advanced practice registered nurses, physician assistants, wound-care technicians, intensivists, clergy, environmental services, physical therapists, occupational therapists, clinical nutritionists, social workers, case management, psychologists, psychiatrists, respiratory therapists, research coordinators, community outreach educators, child life specialists, and outpatient management services. The primary goal of this extensive team is to return the whole patient to their highest level of function, including the physical, psychological, social, and vocational aspects of their life. Members of the interprofessional burn team work closely together to ensure an optimal outcome during the emergent phase by focusing on the following priorities. Burn management has traditionally been organized into three phases: the emergent (resuscitative) phase, the intermediate phase, and the rehabilitative phase. Care among the phases is not static, and the nursing and medical priorities in each phase may overlap. Although the rehabilitative phase is listed last, planning for rehabilitation and functional outcome starts immediately on admission. FIGURE 51.18 Preferred escharotomy sites. Patient should be placed in anatomical position (palmar surface up), and mid-medial and mid-lateral incisions are made for each extremity, extending the length and depth of the eschar only. The chest wall should have an H-type pattern, with all efforts to avoid the axilla because it contains many lymph nodes, vessels, and nerves. The connecting horizontal line should be placed roughly at the patient's diaphragm. \*\*\*\*\*\*\*\*Emergent Phase Medical Management Although the emergent phase does not officially begin until the patient reaches the hospital, it is vital that basic burn care be initiated at the scene. The initial priorities for emergency personnel on scene include stopping the burn process, airway management, fluid resuscitation, and prevention of hypothermia. Although the receiving registered nurse is given a comprehensive patient report, it is essential that two key pieces of information are provided in the handoff: the circumstances surrounding the injury and the total amount of fluid the patient received during transport. Primary and secondary survey recommendations in the emergent phase are outlined in Box 51.6. During the emergent phase, the primary goal is to resolve immediate life-threatening issues resulting from the burn injury. These priorities include baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, and initiation of wound care. Diagnostic Studies To determine the patient's baseline condition and identify preexisting illnesses, basic laboratory studies and radiographical examinations are necessary for all patients with burn injuries. Specific diagnostic studies include complete blood count (CBC), serum glucose, creatinine, blood urea nitrogen (BUN), prothrombin time/activated partial thromboplastin time (PT/aPTT), international normalized ratio (INR), complete metabolic panel (CMP), arterial blood gases (ABGs), ECG, chest x-ray, and a toxicology screen. A serum carboxyhemoglobin level is obtained on all patients with suspected inhalation injuries, and bronchoscopy is indicated for a definitive diagnosis. For electrical injuries, it is important to obtain a baseline ECG and troponin and creatine kinase-MB (CK-MB) levels. Patients with concomitant trauma require additional diagnostic and radiographical examinations. Common laboratory findings and electrolyte changes are displayed in Table 51.4. \*\*\*\*\*\*\*\*Airway Maintenance The assessment of the patient's airway takes top priority. A nonrebreather mask is placed on all patients with burn injuries, and high-flow 100% oxygen is administered. Patients at risk for intubation include those with facial burns, changes in voice (such as hoarseness), carbon noted in the sputum, and with injury associated with a fire in an enclosed space. If intubation is warranted, the most experienced person performs the procedure, and special care is taken to secure the endotracheal tube, especially if facial burns are present. It is essential to secure the patient's endotracheal tube with umbilical twill or commercially prepared endotracheal tube holders and not adhesive tape because tape does not stick to the burned face and does not allow for swelling. Box 51.6 Primary and Secondary Survey of the Burn Patient in the Emergent Phase Primary Survey Assessment Includes: Airway and C-spine stabilization Maintain a patent airway (may require intubation). Consider cervical spine immobilization if warranted. Breathing Provide high-flow 100% oxygen by mask. Circulation Elevate extremities (no pillow under head). Remove tight jewelry or clothing. Neurovascular checks with circumferential burns and electrical burns to extremities Disability Neurological examination Expose and examine Extent and depth of burn wounds and possible associated trauma Fluid resuscitation Insert a minimum of two large-bore peripheral IV lines and start lactated Ringer's. Secondary Survey Assessment Includes: Circumstances of the injury Cause of burn injury? Exact time of burn injury? Enclosed space? Associated trauma (electrical)? Length of time before rescue? Chemicals involved? Use of accelerant? Medical history, current medications, allergies, and vaccinations Last food and fluid intake documentation Complete "head-to-toe" physical examination Determine the extent and depth of burn injury (calculate TBSA percentage) Cover the wounds with a clean, dry sheet Maintain core body temperature Pain medication, IV narcotics preferred Tetanus status (considered current if received within the previous 5 years) Initial laboratory values/tests: CBC, CMP, PT/aPTT, urinalysis, surveillance cultures ABG and carboxyhemoglobin level for suspected inhalation injury 12-Lead ECG and CK-MB/troponin for electrical injury Fluid resuscitation calculation and IV fluid rate adjustment It is important to note that burn wound care does not begin until the patient is stabilized. The immediate concern is for airway, breathing, and circulation, followed by fluid resuscitation and prevention of hypothermia. ABG, Arterial blood gas; CBC, complete blood count; CMP, complete metabolic panel; CK-MB, creatine kinase-MB; ECG, electrocardiogram; PT/aPTT, prothrombin time/activated partial thromboplastin time; TBSA, total body surface area. Table 51.4 Fluid and Electrolyte Changes in the Emergent Phase Clinical Findings Explanation Generalized dehydration Plasma leaks through damaged capillaries (third spacing) and into interstitial spaces. Reduction in blood volume Secondary to third spacing, blood pressure falls, and cardiac output is diminished. Decreased urinary output Secondary to fluid loss and decreased renal blood flow Hyperkalemia Massive cellular trauma causes the release of potassium into extracellular fluid. Hyponatremia Large amounts of sodium are lost to third spacing, wound drainage, and shifting into cells as potassium is released. Metabolic acidosis Loss of bicarbonate ions accompanies the loss of sodium. Elevated hematocrit Plasma is lost to extravascular spaces, leaving the remaining blood very viscous. Fluid Resuscitation Fluid resuscitation is crucial to the survival of the patient who has suffered a burn of 20% TBSA or greater. The overall objective is to maintain tissue perfusion and organ function while at the same time avoiding potential complications of inadequate or excessive fluid resuscitation. It is important to note that insufficient fluid resuscitation can lead to organ failure and death, and excessive amounts of fluid can also cause morbidity and mortality. Intravenous resuscitation is initiated in adults at 20% TBSA, and if possible, it is recommended to consult with a burn center before the initiation of resuscitation. The fluid of choice for resuscitation is lactated Ringer's. Intravenous access is essential and should be obtained as soon as possible. Ideally, two large-bore, preferably No. 20 gauge or larger, peripheral IV catheters are placed through unburned skin. However, if no such areas exist, the IV lines can be inserted through burned tissue but must be well secured. If obtaining a peripheral IV catheter is extremely difficult, an intraosseous line is also acceptable. Major burn injuries often require the placement of a central venous catheter because of the large volumes of fluid that need to be administered during the emergent phase. There are numerous resuscitation calculations and/or formulas available for burn resuscitation; however, most burn centers throughout the United States follow Advanced Burn Life Support (ABLS) guidelines. These guidelines are based on the patient's age, weight in kilograms (kg), %TBSA burned, and whether electrical injury was involved. The guidelines require 2 to 4 mL of lactated Ringer's per kilogram of body weight multiplied by %TBSA burned. Half of the total volume is given in the first 8 hours after the burn, and the remaining half is given over the next 16 hours. It is important to note that the resuscitation begins from the time the burn injury occurred. For example, if emergency medical services (EMS) personnel were unable to obtain an IV line on the scene and the patient arrives at the emergency department 2 hours after the injury, fluid volume should be adjusted, and the initial 8-hour volume now must be infused over 6 hours. For adults and children age 15 or greater, fluid resuscitation should be initiated at 2 mL per kilogram; for children age 14 or younger, including infants, resuscitation should be initiated at 3 mL per kilogram; and for electrical injuries in all ages, resuscitation should be initiated at 4 mL per kilogram. An example calculation of the fluid-resuscitation formula is provided in Box 51.7. Some providers choose to introduce the use of colloids before the 24-hour resuscitation mark or after the 24-hour mark. This decision is often based on patient response to resuscitation and laboratory values. Examples of colloids given include albumin or plasma. During fluid resuscitation, an indwelling urinary drainage catheter is placed in the bladder to closely monitor urine output because this is the most reliable indicator of adequate fluid resuscitation. Urine output should be maintained at 0.5 mL/kg/hr. If myoglobin is present in the urine, output should be maintained at 1 mL/kg/hr until clearing of the urine occurs to prevent the development of acute renal failure. Diuretics are not indicated during the emergent phase, and if urine output drops, the rate of fluid administration is increased. Other parameters that are monitored (as listed in Table 51.5) during fluid resuscitation include heart rate, blood pressure, central venous pressure, serum chemistries, hemoglobin, and hematocrit. Box 51.7 Fluid-Resuscitation Example Patient weight: 70 kg TBSA burned: 50% flame burn The patient is a young healthy adult with no pertinent past medical history. Resuscitation Calculation: 2 mL × 70 × 50 = 7,000 mL of lactated Ringer's in the first 24 hours First 8 hours: 3,500 mL, rate = 438 mL/hr Calculate from time of injury. Next 16 hours: 3,500 mL, rate = 218 mL/hr TBSA, Total body surface area. Table 51.5 Indications of Adequate Fluid Resuscitation Urine output 0.5 mL/kg/hr 1 mL/kg/hr if myoglobin present Systolic blood pressure Greater than 100 mm Hg Heart rate Less than 120 bpm Central venous pressure (CVP) 5--10 mm Hg Pulmonary Lungs sound clear, blood pH within normal range (7.35--7.45) Gastrointestinal Abdomen soft, nontender; no nausea, vomiting, or ileus; bladder pressure less than 10 mm Hg Level of consciousness Clear; alert; and oriented to person, place, and time (keep in mind any narcotics that may have been administered for pain) The calculated fluid volume is the starting point in the fluctuating fluid-resuscitation process. Patients with inhalation injuries, electrical injuries, associated trauma, and/or alcohol and drug dependencies may require higher volumes of fluids related to preexisting medical conditions or poor health. If there is a delay in starting fluid resuscitation, patients usually require higher volumes of fluid. It is also important to note that some patient populations, such as older adults, children, and those with preexisting cardiac disease, may be very sensitive to fluid and should be closely monitored for signs of fluid volume overload. Inadequate fluid resuscitation, which results in inadequate blood flow, may also result in conversion of the burn wound within the first 24 to 72 hours, as shown in Figure 51.10. During the emergent phase while administering fluid resuscitation to a patient with a large burn injury, the nurse should notify the healthcare provider immediately if the hourly urine output is below 30 mL. \*\*\*\*\*\*\*\*\*\*Prevention of Hypothermia Hypothermia is commonly seen in patients with burns because the skin, their primary insulation, is no longer intact. It is imperative to keep the patient covered at all times and to closely monitor their temperature, especially in the emergency department, where patients are typically exposed for assessments. The ambient room temperature is usually increased to decrease heat loss in patients with significant burn injuries. Most designated burn centers have specialized warming equipment in each patient room. Wound Care Typically, the burn wound is not the first priority during the emergent resuscitative phase because more life-threatening issues often take precedence. Although the burn wound is covered with clean, dry blankets to prevent hypothermia, the initiation of wound care may be delayed for several hours until the patient is stabilized because there are more life-threatening concerns for the patient at this point. Pain Management A burn is one of the most painful injuries an individual can sustain. Intravenous narcotics, such as morphine sulfate (morphine), are used for the initial management of pain. The intramuscular route of administration is avoided because there may be impaired medication absorption due to edema formation and decreased peripheral perfusion. Pain medication is administered intravenously in doses no larger than those needed to manage pain. The nurse monitors closely for signs of respiratory depression when giving large doses of pain medication. Although morphine sulfate (morphine) is commonly used, other types of narcotics may also be used, including fentanyl (Sublimaze) and hydromorphone (Dilaudid). Medications In addition to pain management, patients with burn injuries are given a variety of other pharmacological therapies. Medications are given to treat common concerns or potential complications facing the burn patient, including anticoagulation therapy, nutritional support, gastrointestinal motility, anxiety, and depression. See Table 51.6 for a listing of medications commonly used in patients with burn injuries. \*\*\*\*\*\*\*Nursing Management Assessment and Analysis During the emergent phase, the priority assessments focus on immediate life-threatening injuries, including airway management, particularly with suspected inhalation injury; fluid volume status; temperature control; and pain management. Clinical manifestations during this phase may include the following: Facial burns Nasopharynx or oropharynx erythema Hoarseness, grunting Carbonaceous (soot) sputum Dyspnea Wheezing Tachypnea Intercostal retractions and flaring nostrils Elevated carboxyhemoglobin levels Tachycardia Hypotension Confusion, agitation, changes in level of consciousness Decreased urine output Hypothermia Headache Complaints of pain Table 51.6 Medications Used in Burn Care Medication Type and Name Medication Purpose Analgesia Morphine sulfate (morphine) Hydromorphone (Dilaudid) Fentanyl (Sublimaze) Ketamine (Ketalar) Oxycodone (OxyContin, Tylox) Methadone (Dolophine) Nonsteroidal anti-inflammatory medications (ibuprofen or naproxen sodium) Acetaminophen (Tylenol) Gabapentin (Neurontin, Gabarone, Gralise) Pain management Sedation Haloperidol (Haldol) Lorazepam (Ativan) Diazepam (Valium) Midazolam (Versed) Propofol (Diprivan) Dexmedetomidine hydrochloride (Precedex) Induce sedation and decrease anxiety Antipsychotic and sedative effects Helps reduce anxiety Helps reduce anxiety and treat alcohol withdrawal Short-acting amnesic effects Short-acting hypnotic agent Initial sedation in mechanically ventilated patients Anticoagulation Therapy Enoxaparin (Lovenox) Heparin Both promote venous return and decrease risk for thromboembolism Nutritional Support Multivitamins Zinc sulfate (zinc) and ferrous sulfate (iron) Oxandrolone (Oxandrin) Provide essential nutrients Promote wound healing Promote hemoglobin formation and cell integrity Preservation of lean body mass and promotion of weight gain Gastrointestinal Support Famotidine (Pepcid) Esomeprazole (Nexium) Pantoprazole (Protonix) Aluminum/magnesium antacid (Mylanta, Maalox) Nystatin (Mycostatin) Metoclopramide (Reglan) Polyethylene glycol 3350 (MiraLAX) Docusate sodium (Senokot) Promote gastrointestinal function Decreases stomach acid and risk of ulceration Decreases stomach acid and risk of ulceration Decreases stomach acid and risk of ulceration Neutralizes stomach acid Prevents overgrowth of yeast in oral mucosa Promotes stomach emptying and decreases nausea Laxative agents for use in constipation Nursing Diagnoses/Problem List Ineffective airway clearance related to airway edema secondary to injury from heat and/or chemicals Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper or lower airway obstruction Risk for fluid volume deficit related to hypovolemia due to third spacing of fluids and inadequate fluid resuscitation Altered tissue perfusion related to decreased cardiac output Risk for hypothermia due to altered skin integrity Risk for infection due to loss of skin integrity and the presence of burn injury Acute pain secondary to the burn injury Anxiety related to fear surrounding the burn injury \*\*\*\*\*\*\*\*\*Nursing Interventions Assessments Breath sounds, respiratory rate, and indicators of inhalation injury Edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, change in voice (hoarseness), and/or dyspnea. Inhalation injuries may impair respiratory function, leading to decreased ventilation and changes in rate and effort, resulting in lower oxygenation. Oxygen saturation, ABGs, and carboxyhemoglobin levels The oxygen molecules may be saturated by carbon monoxide instead of oxygen, which is evident only through measurement of carboxyhemoglobin levels. Carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen; tissue hypoxia results when carbon monoxide levels are above normal. Results of ABGs also provide information related to the acid--base status of the patient. Face and neck for burns, singed nasal and/or facial hair, and singed eyebrows/eyelashes Edema and irritation of the airway may develop secondary to damage caused by heat and chemical irritants as evidenced by hypoxemia, rhonchi, stridor, change in voice (hoarseness), and/or dyspnea. Upper airway Damage and irritation caused by the heat and chemical irritants in smoke may cause the airway to appear red and edematous. The mouth and/or airway may also appear black because of soot. Changes in voice, hoarseness, and swallowing difficulty Damage for the heat and chemical irritants in smoke may cause edema and irritation, resulting in changes in the voice, hoarseness, and/or difficulty swallowing. Vital signs Blood pressure may be low and pulse elevated secondary to potential hypovolemia due to significant fluid losses and shifts. The pulse may also be elevated secondary to increased work of breathing with inhalation injuries, pain, and fear/anxiety. Because of impaired skin integrity, temperature may be decreased. Patient shivering further accelerates the patient's metabolic rate and may exacerbate tachycardia. Urine output Indicators of inadequate resuscitation and development of hypovolemia may be evidenced by urine output less than 0.5 mL/kg/hr. Pain Pain will be noted in areas of partial-thickness burns because nerve endings are exposed. Anxiety Patient anxiety levels may be high because of the appearance of the burn wound and exposure to trauma. Burn wound size and depth Although wound treatment is not a priority in this phase, estimations of %TBSA burned and wound depth are required to determine fluid resuscitation. Actions Place patient on 100% humidified oxygen or assist with intubation if necessary. Immediate intervention is necessary for respiratory distress and to provide humidified oxygen and assist in the clearing of carbon monoxide. The half-life of carbon monoxide while on 100% oxygen is 30 minutes to 1 hour compared with 4 hours breathing room air. Trend ABG values and carboxyhemoglobin levels. Increasing PaCO2 and decreasing PaO2 and oxygen saturation may indicate the need for intubation. As carboxyhemoglobin levels lower, weaning of oxygen support (FiO2) to a minimal level to sustain oxygenation is indicated. Elevate the head of the bed to allow for better oxygenation. Raising the head of the bed decreases the work of breathing by lowering the diaphragm. Maintain emergency airway (intubation and tracheostomy) trays at the bedside. Inflammation and edema secondary to airway injury may make endotracheal intubation difficult or impossible. In patients with an endotracheal tube in place, a tracheostomy tray should be maintained at the bedside in the event of an unplanned extubation. Assist with intubation as necessary. Delaying intubation may result in edema and possible airway obstruction. Ensure securement of the endotracheal tube if the patient is intubated. If the tube is dislodged, it may be impossible to reinsert due to the edema. In addition, the securement device will require adjustment (e.g., twill) as the edema continues to worsen/decrease. Monitor mechanically ventilated patients closely for signs of respiratory compromise. Close monitoring of mechanically ventilated patients allows for early detection of respiratory distress. Place two large-bore IV catheters and begin fluid resuscitation with lactated Ringer's. Adequate fluids are necessary to prevent hypovolemic shock from developing as a result of massive fluid loss and fluid shifts. Lactated Ringer's is an isotonic fluid that supports intravascular volume. Roughly estimate the %TBSA burned and patient weight in kilograms. A quick estimation of the %TBSA burned and patient weight guides the determination of fluid to be administered in the first 24 hours on the basis of the resuscitation formula. Cover wounds with a clean, dry sheet. Minimizes evaporative heat loss and decreases the risk of hypothermia Institute warming measures in the form of blankets or other external heat sources. Minimizes evaporative heat loss and prevents the development of hypothermia \*\*\*\*\*\*\*\*\*\* Teaching Immediately report difficulty breathing and/or swallowing. Respiratory distress may develop quickly or may be delayed in patients with an inhalation injury. Instruct patient to cough and deep breathe every hour. Assists in clearing airway and mobilizing secretions Signs of inhalation injury Because the signs of inhalation injury may be insidious, it is important that the patient and family be able to recognize early signs of compromised airway and breathing difficulties. Explain all procedures to the patient and family in clear and simple terms. Understanding helps alleviate fear and anxiety in the patient, which may result in tachycardia and hypertension. Importance of maintaining a warm environment Decreases risk of heat loss and development of hypothermia Risk factors that increase chances of infection Because of loss of skin integrity, the patient is at increased risk of infection, so family members must follow instructions regarding gloves, gowns, and hand washing. \*\*\*\*\*\*\*\*\*Evaluating Care Outcomes At the end of the emergent phase, the anticipated outcomes include the absence of respiratory distress, appropriate fluid resuscitation manifested by stable vital signs and adequate urine output, temperature regulation, and effective pain management. In the event of inhalation injuries, stabilization of the airway and sufficient oxygenation are positive outcomes during this emergent phase. The nurse anticipates adequate urine output with an expected outcome of 0.5 mL/kg/hr, with the recognition that any decrease in urine output below the recommended level must be immediately reported to the provider. Because patients with burns lose the ability to effectively manage their temperature, the nurse anticipates normothermia with appropriate interventions. Adequate pain management and lessened anxiety are also expected outcomes of management during the emergent phase. \*\*\*\*\*\*\*\*\*Intermediate Phase Medical Management The burn patient enters into the intermediate phase after resuscitation and stabilization have been achieved. This phase usually begins 48 to 72 hours after the initial burn injury. Within the intermediate phase, the management priorities shift to wound healing and closure, pain management, ensuring optimal nutrition, and continued prevention of infection. Although the focus moves away from the life-threatening priorities of the emergent phase, continued assessment and management of respiratory and circulatory status are essential during the intermediate phase. \*\*\*\*Wound Care Hydrotherapy Wound-healing practices vary greatly among facilities and burn centers. Hydrotherapy is the favored cleansing method within most burn centers because it allows for thorough wound cleansing and uses water during dressing changes to assist in the removal of residual topical agents and necrotic tissue. In the past, hydrotherapy involved total immersion into a tank or tub of water. More recently, burn centers have begun using portable shower trolleys covered with disposable plastic liners to help prevent the spread of infection and cross-contamination. For patients who cannot tolerate extensive hydrotherapy, burn wound care may be done at the bedside. Clean Technique and Infection Control It is important to note that burn wound care is a clean, not a sterile, procedure. Sterile technique involves employing techniques to reduce exposure to microorganisms, such as using a sterile field and sterile instruments and gloves. Clean technique involves using techniques to reduce the overall number of microorganisms, such as preparing a clean field and using clean gloves and instruments. Burn wound care is extensive, physically exhausting, and time-consuming, with some dressing changes lasting up to 2 to 4 hours. Often, these dressing changes occur in patient rooms where the temperature is usually set as high as 90°F (32.2°C) to prevent the risk of hypothermia. During every dressing change, it is essential that both the nurse and provider assess the burn wound for progression of healing and evidence of infection. The dressing change is also the ideal time for the physical and occupational therapists to assess the wound, as well as to observe the patient's function and range of motion. Topical Medicines and Wound Dressings There are numerous variations of topical medications and wound dressings that are used on burn wounds. The choice of the agent and dressing depends on wound depth, location of the injury, presence of infection, and provider preference. The most commonly used topical medications and dressings for wound management are outlined in Table 51.7, and a common application is displayed in Figure 51.19. Special care is taken when wrapping fingers and toes because they must be dressed individually to prevent webbing (the growing together of the skin between the fingers and toes) and maintain full range of motion (Fig. 51.20). Table 51.7 Topical Medications and Wound Dressings Antimicrobial Agent Effective Against Wound Indication Application Benefits Disadvantages Nursing Considerations Silver sulfadiazine (Silvadene) Broad-spectrum and Candida coverage Partial- and full-thickness burn wounds ¼-in.-thick application with roll gauze to cover; dressing changes every 12--24 hours Cooling effect when applied; easy, painless application May cause transient leukopenia; may also cause a wound film on partial-thickness burns, making it hard to assess healing Avoid in patients with a documented sulfa allergy. Avoid application to face. Bacitracin No gram-negative or fungal coverage Partial-thickness burn wounds and grafts Thin layer applied with a nonadherent gauze and an outer roll gauze; dressing changes every 24 hours Easy, painless application; only once-per-day dressing change Not as effective on full-thickness burn wounds because of minimal penetration of eschar Best choice for use on a face, but left open to air. Use bacitracin ophthalmic ointment near and around eyes. Mafenide acetate 10% cream or 5% solution (Sulfamylon Cream or Slurry) Broad-spectrum, effective against Pseudomonas but has little antifungal coverage Cream used on full-thickness burns to ears only; solution used on partial-thickness burn wounds and grafts Cream is applied 1/16 in. thick and left open to air. Solution is applied to nonadherent gauze and roll gauze. Cream is changed every 12 hours; solution dressings are changed every 24 hours and may be wet down at 12 hours. Cream penetrates eschar. Solution is only a once-per-day dressing change. Solution is a wet-type dressing and may not be used on initial large burn wounds because it may cause hypothermia. Some patients may complain of stinging on application to partial-thickness burn wounds. Frequent sensitivities noted. Silver sheeting products (Acticoat, Silverlon, Mepilex) Broad-spectrum, effective against MRSA and fungus Partial-thickness burn wounds, Stevens--Johnson syndrome (SJS), and patients with toxic epidermal necrolysis (TEN), donor sites Some products are a wet application with sterile water and roll gauze. Dressing changes every 3--7 days; wet down with sterile water every 12 hours. Some products are applied dry and not wet down. Dressing needs to be changed only every 4--7 days. Expensive. Burn wounds often need to be observed daily. Solution is a wet-type dressing and may not be used on initial large burn wounds because it may cause hypothermia. This is best used in the patient with SJS/TEN as the dressing change process is extremely painful and wounds do not need to be observed daily. May also be of good use in the outpatient setting. Some patients may complain of stinging on application. Do not use with normal saline because it will deactivate silver. Enzymatic cream (collagenase) No antimicrobial effects and thus is often mixed with other ointments and/or creams Full-thickness burn wounds (specifically digests collagen in necrotic tissue without harming intact tissue) Thin layer applied with a nonadherent gauze and an outer roll gauze; dressing changes every 24 hours Easy, painless application; only once-per-day dressing change; may help penetrate and soften eschar for debridement   Considered for use in patients with full-thickness burn wounds who are not candidates for the operating room because of age or medical condition; also considered for use in very small areas of full-thickness burns in an attempt to heal without surgery. MRSA, Methicillin-resistant Staphylococcus aureus. Mechanical and Enzymatic Debridement The preferred method of wound cleansing involves the use of a mild soap or chlorhexidine and sterile water or normal saline along with gentle debridement of the burn wound (Fig. 51.21). The three kinds of debridement are mechanical, enzymatic, and surgical. While cleansing, removal of the loose tissue is important to allow for proper visualization of the burn wound. This is accomplished through the use of tweezers and scissors and is often aided by the removal of gauze dressings and hydrotherapy. An example of a partial-thickness wound before and after debridement is shown in Figure 51.22. Enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation and wound healing. Enzymatic debridement is often reserved for patients with deep partial-thickness wounds where signs of healing are evident. This type of debridement is also considered in patients with full-thickness burns who may not be candidates for surgery. If mechanical and enzymatic debridement are not effective, surgical debridement is necessary. \*\*\*\*\*\*\*\*\*Surgical Debridement and Wound Closure Early excision and grafting of burns decrease the length of hospital stay and greatly increases the survival rates of these patients. Burn excision is considered as soon as the patient is hemodynamically stable and able to tolerate the procedure. It is not uncommon for the patient with a large full-thickness burn to be taken to the operating room for excision and grafting within 24 to 48 hours of admission. Types of skin substitutes and grafts are described in Table 51.8. FIGURE 51.19 Silver sulfadiazine and roll gauze. FIGURE 51.20 Dressing applied to hand. Note that each finger is wrapped loosely and individually. FIGURE 51.21 Wound cleansing with normal saline and chlorhexidine solution and roll gauze. FIGURE 51.22 Wound debridement of a partial-thickness burn. A, Before debridement. B, After debridement. The ideal replacement for lost skin is autograft because it is the patient's own skin and will not be rejected by the body. The epidermis and a partial layer of the dermis (split-thickness skin grafts) are harvested from an unburned area, known as the donor site. The most common donor site is the thigh because of the ability to obtain a continuous donor sheet of skin. However, in patients with large burns, any site on the body may be utilized, including the scalp and scrotum if necessary. Once healed, donor sites may be reharvested numerous times. These split-thickness skin grafts are then applied to the excised wound in the form of a sheet or meshed graft. Sheet grafts are often utilized on exposed areas of the body, such as the face and hands, because they give a more seamless and cosmetic appearance due to the fact that the grafts are not meshed. Skin grafts are meshed (have holes placed in them that allow for expansion) when unburned skin is in short supply in order to provide maximal wound coverage and closure. A mesh expansion ratio of 1:2 upward to 1:4 is commonly utilized. Examples of meshed and sheet autografts are presented in Figure 51.23. In some instances, the burn surgeon may choose to apply a small full-thickness skin graft to allow for the best function in certain anatomical areas, such as the eyelids. Tabl