Environmental 3:
Burns Management Portal
Initial assessment of a burn patient is the same as for any trauma patient. Perform a complete trauma assessment beginning with the initial survey. Address the ABCs and, when necessary, intervene to correct life-threatening situations. Eliminate the burn source and stop the burning process. The primary causes of death in burn patients within the first 48 hours are severe inhalation injury and traumatic injuries. Associated injuries must be detected and treated immediately to avoid early life-threatening morbidity.
Airway
- Assess for patency
- Indications of inhalation injury
- History of being in closed space when burn occurred
- Presence of facial burns
- Soot, edema, or sloughing of nasal and/or oral mucosa
- Abnormal airway sounds (stridor/snoring)
- Airway Interventions: establish and maintain a patent airway. Early placement of an airway may avoid a difficult intubation later.
Breathing
- Chest excursion—Burn injuries may compromise mechanical excursion of chest wall.
- JVD
- Tracheal position
Intervention:
- Ventilate as needed
- O2
- Escarotomy of chest wall burns
Circulation
Fluid and Burn Shock Resuscitation
The priority of treatment in burn trauma is initial resuscitation to correct life-threatening compromises. Assure airway clearance, adequate ventilation, and good circulation, which may include fluid replacement. Following burn injury there is massive capillary leakage of circulating fluid into the surrounding tissues. Within minutes of a major burn, all of the capillaries in the circulatory system are affected, not only capillaries in the area of the burn. Capillaries lose their capillary seal, resulting in leakage of intravascular fluid into the interstitial space. Due to the fluid shift, there will be an elevated erythrocyte and leukocyte count. Burn shock continues for approximately 24 hours, at which time the capillary seal is restored.
Therapy for burn shock is aimed at supporting the patient through the period of hypovolemic shock until capillary integrity is restored. Many formulas are used as guidelines for fluid resuscitation, the most common being the Parkland Formula.
Parkland Formula for Fluid Resuscitation in Burn Shock Treatment
- Use 2 to 4 cc Ringer’s lactate solution per percentage of total body surface area (TBSA) burned per kilogram of body weight.
- Administer 50% of the total in the first 8 hours post burn. The timing is calculated retroactively beginning when the burn actually occurred, not when the patient arrived at the ED.
- Administer 25% in the second 8 hours post burn.
- Administer 25% of the total in the third 8 hours post burn.
- Criteria for successful burn shock fluid resuscitation are based on an hourly urine output of 50 mL/h in adults and 1 mL/kg/h in children.
Example of Use
of Parkland Formula
70 kg patient with a 50% TSBA
Burn injury occurred at 6:00 AM
4 mL X 70 kg X 50% TBSA burn=14 000 mL lactate Ringer’s solution
Administer
7000 mL in the first 8 hours post burn—fluid will be infused by 2:00 PM
3500 mL in second 8 hour post burn—2:00 PM-10:00 PM
3500 mL in third 8 hours post burn—10:00PM-6:00 AM
Fluid replacement is the primary objective of initial burn treatment. Ringer’s lactate is the fluid of choice because it most closely approximates the composition of the extracellular fluid being lost. The fluid replacement is based on the time of injury, not on the time when the patient is first seen in the ED. Fluids are administered at a rate such that half the volume is given during the first 8 hours after injury and the remaining amount over the following 16 hours. Fluid is administered through 2 large-bore intravenous catheters. Intravenous sites should be limited to unaffected areas. The Parkland Formula and other formulas are guidelines, and individual patients may require more or less than 4 mL/kg and TBSA burn during the first 24 hours after the burn. Adjust the infusion rate to maintain an hourly urine output of 50 mL in adults or (PEDS) 1 mL/kg in children weighing 30 kg.
Assessment of adequacy of fluid resuscitation:
- Urine output
- BP
- Pulse
- Mental status
- Hematocrit
- Osmolality
Situations when patients require fluid in excess of calculations:
- Underestimation of extent of burn
- Pulmonary injury—sequesters fluid in lung
- Electrical injury—greater tissue destruction than is visible
- Extremely deep injury
- Delayed start of fluid resuscitation
- Multiple trauma with burns
Information about the burn incident:
- Source of burn—scald, flame, chemical, electrical.
- Potential of smoke inhalation
- Time of burn injury
- Circumstances of injury
- Associated trauma
Specific Treatment Plans for Different Types of Burns
Thermal Burns
- The most common type of burn
- Assess for depth and extent of injury
- Assess for the potential of inhalation injury
Electrical Burn
Electrical
injury is usually deeper than full-thickness injury. The extent of
injury varies greatly depending on the voltage and the length of time
the patient was in contact with the source. Electricity follows paths
of least resistance, which are blood vessels, nerves, tendons, and
bone. Entrance and exit wounds are usually the sites of maximum
destruction. Three common early complications of electrical injury
follow:
- Cardiac Arrest or
Dysrhythmia
Treatment:- Cardiac Arrest—ACLS Protocol
- Dysrhythmia—ACLS protocol and ECG monitoring for a minimum of 24 hours
- Myoglobinuria
Treatment: - Infusion of Ringer’s lactate to maintain urine output:
- Adults—100 mL/h
- Pediatric—2 mL/kg body
- Mannitol—Dosage:
Initial dose of 25 g IV push.
Follow by infusion of 12.5 to 25 g of mannitol/L of Ringer’s lactate maintenance solution given. - Metabolic Acidosis: Occurs as a result of the
release of cellular contents into the
systemic circulation.
Treatment:- Sodium bicarbonate IV push followed by addition of 50 mEq sodium bicarbonate to each liter of Ringer’s lactate until the condition resolves (about 24 hours after injury).
Special Care Areas:
| Eyes: |
In the presence of facial burns that involve the eyes:
|
| Hands: | Wrap fingers individually. |
| Genitalia: | Potential for contamination, swelling. Foley catheter |
Estimation of Burn Areas
- Rule of Palm—the patient’s palm (excluding fingers and thumb) represents 1% of the patient’s TBSA.
- Rule of Nines—determines the percentage of body surface area (BSA) affected by burns by dividing body surface areas into areas of 9%
- Lund-Browder Chart—uses a table of areas of body to percentage of TBSA
Estimate Severity of Burn
- Size of burn
- Age of patient
- Past medical history
- Concurrent injuries
Initial Treatment of Burns
- Remove all clothing, jewelry, and contact lenses.
- Stop the burning process.
- Immediate cooling of burn with
water or
saline:
- lessens pain
- decreases post-burn hyperthermia
- decreases depth of injury
- Cleanse wounds with saline.
- Dress wounds with loose gauze dressing.
- Elevate extremities.
- Cover with a clean sheet.
- Keep the patient warm.
Medications
- Pain control—morphine IV (2 to 5 mg IV prn)
- Tetanus prophylaxis, 0.5 mL IM
- Antibiotic IV as needed (not generally done prophylactically)
- Cimetidine IV 300 mg
Burn Transfers
If comprehensive burn treatment is not available at your facility, consider the following transfer guidelines:
- Partial-thickness and full-thickness burns are > 10% of TBSA (PEDS) in patients < 10 years and > 50 years of age.
- Full-thickness burns over 5% TBSA in any age group
- Partial-thickness and full-thickness burns > 20% TBSA in other age groups
- Patients with burns and multiple injuries
- Medical histories that might be complicated by a burn
- Significant electrical injury including lightning
- Partial-thickness and full-thickness burns of hands, feet, face, eyes, ears, or perineum
- Carbon monoxide > 10%
- Suspicion of abuse (child or adult) requiring special social service or long-term rehabilitation support
- Evidence of pulmonary or respiratory distress
Transfer of any patient must be coordinated with the burn center physician. In your transfer guidelines, have available the telephone number(s) for your Burn Referral Center(s). Document all pertinent information regarding tests, temperature, pulse, fluids administered, urinary output, and treatments. Send these with the patient.
Modified Lund Browder Chart1
| Burned
Area |
Age, years | |||||
1 |
1 to
4 |
5 to
9 |
10
to 14 |
15 |
Adult |
|
| Head | 19% |
17% |
13% |
11% |
9% |
7% |
| Neck | 2 |
2 |
2 |
2 |
2 |
2 |
| Anterior trunk | 13 |
13 |
13 |
13 |
13 |
13 |
| Posterior trunk | 13 |
13 |
13 |
13 |
13 |
13 |
| Right buttock | 2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
| Left buttock | 2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
| Genitalia | 1 |
1 |
1 |
1 |
1 |
1 |
| R.U. arm | 4 |
4 |
4 |
4 |
4 |
4 |
| L.U. arm | 4 |
4 |
4 |
4 |
4 |
4 |
| Right hand | 2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
| Left hand | 2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
2.5 |
| Right thigh | 5.5 |
6.5 |
8 |
8.5 |
9 |
9.5 |
| Left thigh | 5.5 |
6.5 |
8 |
8.5 |
9 |
9.5 |
| Right leg | 5 |
5 |
5.5 |
6 |
6.5 |
7 |
| Left leg | 5 |
5 |
5.5 |
6 |
6.5 |
7 |
| Right foot | 3.5 |
3.5 |
3.5 |
3.5 |
3.5 |
3.5 |
| Left foot | 3.5 |
3.5 |
3.5 |
3.5 |
3.5 |
3.5 |
Reference
- Trauma Nursing Core Course Provider Manual. 6th ed. Chicago, IL: Emergency Nurses Association; 2007.