King Saud University College Of Nursing

King Saud University College of Nursing

Burn Hatem Alsrour

Layers of the Skin

Brunner, 2008, Figure 55.1. anatomic structures of the skin

Epidermis Outermost layer, composed of cornified .epithelial cells .Outer surface cells are dead and sloughed off

Dermis Middle layer, composed primarily of connective .tissue Contains capillaries that nourish the skin, nerve endings and hair follices

Hypodermis Layer of adipose and connective tissue .between the skin and underlying tissues

Function of Skin    

Protection from infection & injury Prevention of loss of body fluid Regulation of body temperature Sensory contact with environment

?What is a Burn 

An injury to tissue from: –Exposure to flames or hot liquids –Contact with hot objects –Exposure to caustic chemicals or radiation –Contact with an electrical current

Types (Causes) of Burn Injury Thermal Open flame, steam, hot liquids

Chemical Acids, strong alkalis, organic compounds

Electrical Direct or alternating current, lightning

Radiation Radioactive agents

Pathophysiology of Burn Injury 

Zone of Coagulation: 

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Zone of Stasis:  

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Irreversible damage Impairment of blood flow Recovery variable

Zone of Hyperemia:  

Prominent vasodilation Usually recovers

Severity of a Burn Depends on:  Depth of burn  Extent of burn  Location of injury  Patient’s age

First degree burn : Superficial Partial Thickness 

Involves only the epidermis    

Skin pink to red Outer layers of skin damaged (epidermis ) Painful Heals without grafting

Second degree burn 

Deep partial thickness        

Involve the epidermis and portions of the dermis Skin red to white Blisters Weeping surface Edema All epidermis and much of dermis damaged Painful Heals without grafting

Partial thickness (second-degree) burns

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Superficial (firstdegree) burns

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Third degree burn      

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Referred to as full-thickness burns Charred appearance(black, brown, leathery) Waxy, white Edema All layers of skin destroyed Nerves, muscle tissue, and bone may be destroyed Grafting preferred

Full thickness (third-degree) burns

Depth of burn injury

Depth of a Burn

First Degree Superficial Second Deep Second Third Degree

Extent of a Burn 

“Rule of Nines” 

Most universal guide for initial estimate



Deviates in children due to larger head surface area

Rule of Nine

”Robyn’s Rule of 4s“

Carbon Monoxide Poisoning   



Colorless, odorless gas Binds to hemoglobin 200 times more than oxygen Most immediate threat to life in survivors with severe inhalation injury Toxicity related directly to percentage of hemoglobin it saturates

Carbon Monoxide Poisoning Signs & Symptoms of Carbon Monoxide Toxicity Carboxyhemoglobin (%)

Signs/Symptoms

0-10

None

10-30

Headache

30-50

Headache, nausea, dizziness, tachycardia

50-60

CNS dysfunction, coma

60+

Death

CO Poisoning: Treatment 

100% oxygen until carboxyhemoglobin levels less than 15

Shock & Fluid Resuscitation Goal: 

To maintain vital organ function while avoiding the complications of inadequate or excessive therapy

Resuscitation Fluid Needs 

Related to:  



extent of burn (rule of nines) body size (pre-injury weight estimate)

Delivered through large bore peripheral IV  

Attempt to avoid overlying burned skin Can use venous cut down or central line



Parkland Formula:  

Adults : 2-4 ml RL x Kg body weight x % burn Children: 3-4 ml RL x Kg body weight x % burn

Monitoring of Resuscitation 

Urinary output is a reliable guide to end organ perfusion  

Adults: 30-50 ml per hour Children (less than 30 Kg): 1 ml/Kg per hour

Chemical Burns 

Occur whenever a toxic substance contacts the body

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Eyes are particularly vulnerable.

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Fumes can cause burns.

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To prevent exposure, wear appropriate gloves and eye protection.

Care for Chemical Burns 

Remove the chemical from the patient.

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If it is a powder chemical, brush off first.

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Remove all contaminated clothing.

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Flush burned area with large amounts of water for about 15 to 20 minutes.

Electrical Burns 

Make sure the power is off before touching the patient.

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There will be two wounds (an entrance and an exit wound) to bandage.

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Arrange for prompt transport and be prepared to administer CPR.

Pre-hospital Care Stop the burning process Thermal – smother; stop, drop, and roll Chemical– remove clothing and flush / irrigate skin / eyes Electrical – shut off electrical current or separate person from source with a nonconducting implement (such as wooden (broomstick Radiation – limit exposure

Emerncy impelementation : Stop the burning process, if still active-1 Remove all clothing and jewelry, rings, in anticipation -2 . of edema formation Ensure patent airway. Prepare for early intubation -3 Administer oxygen via a mask at flow rate sufficient -4 enough to keep reservoir bag inflated; usually requires 12 to 15L\minute Assist Ventilation, if needed-5

Cannulate two veins with large-bore, 14- or 16-gauge -6 catheters, and initiate infusion of an IV solution Infuse a crystalloid solution such as lactated Ringer's -7 .solution according to a pre established fluid protocol Fluid resuscitation is based on the individual patient's -8 response to the injury. Patients who may require more fluid than predicted are those patients who :have An inhalation injury A high voltage electrical injury Delayed fluid resuscitation since the time of injury

Administer analgesic medications, e.g., morphine, IV -9 Insert a gastric tube. If patient has TBSA more -10 than 25%, nausea & vomiting are present Apply cool, saline-moistened, sterile dressings to -11 . TBSA burns less than 10% Do not use ice * Keep the area cool will help to relieve pain * Apply cool dressings within 10 minutes of the * burn to reduce the heat content of the tissues and the depth of the burn injury

ABCs of Emergency Burn Care ((Advanced Burn Life Support      

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A = Airway (with cervical spine assessment) B = Breathing C = Circulation D = Disability E = Exposure and Environmental Control F = Fluid Resuscitation based on Burn Size and Weight Measurement Secondary Survey

A: Airway  

Assess the patient’s airway Upper airway edema due to inhalation injury •

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Rapid or delayed progression

Decision to intubate: individualized

B: Breathing 

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 

Look, listen, feel for breath sounds and chest movement Give 100% oxygen to all victims of major burn beginning in the field Pulse oximetry Arterial blood gases •

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Required for definitive diagnosis of CO

Baseline chest x-ray

C: Circulation 

Who needs fluid resuscitation? • •

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All >20% total body surface area burned (TBSA) Young and old with >10% TBSA

2 large bore peripheral IVs

D: Disability 

Assess level of consciousness: AVPU • • • •

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Alert Responds to verbal stimuli Responds to painful stimuli Unresponsive

Alteration in mental status is not normal Moves extremities

E: Exposure and Environment  

Remove clothing, jewelry Keep warm • • • •

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blankets warm I.V. fluids heating lamps heat the room

Keep Patient Dry

F: Fluid Resuscitation ((based on burn size and weight 



Determine fluid needs based on burn size and weight Burn size: include second and third degree only •

Rule of Nines

Nursing Considerations :Goals Correct fluid and electrolyte imbalance Promote wound healing Support nutrition Control pain Prevent complications of immobility Support patient

Questions Which nursing intervention holds the highest priority of a patient with burns to her face and upper ?respiratory tract A– Elevate the head of the bed to at least 30º B– Administer six liters of oxygen via nasal cannula C– Medicate the patient prior to repositioning the patient in bed D– Prevent moving the skin around the burn

site

: Answer Which nursing intervention holds the highest priority of a patient with burns to her face and upper ?respiratory tract A– Elevate the head of the bed to at least 30º B– Administer six liters of oxygen via nasal cannula C– Medicate the patient prior to repositioning the patient in bed D– Prevent moving the skin around the burn site

Questions What is the highest priority for the nurse when caring for a patient who has just received an electrical ?burn Disconnect the patient from the electrical source B. Ensure the patients have a cervical collar .and be placed on a back board prior to care .C. Monitor for cardiac dysrhythmia D. Patients may require changes in fluid resuscitation as compared to patients with .other types of burns

: Answer What is the highest priority for the nurse when caring for a patient who has just received an electrical ?burn A. Disconnect the patient from the electrical source B. Ensure the patients have a cervical collar .and be placed on a back board prior to care .C. Monitor for cardiac dysrhythmia D. Patients may require changes in fluid resuscitation as compared to patients with .other types of burns