11/17/23, 8:30 AM Managment of Burns - Brunner and Suddarth's Textbook of Medical-Surgic…
Burns
Chapter 62 pg. 1845-1873
Management of Burn Injury
Categorized into three phases of care: emergent/resuscitative, acute/intermediate, and rehabilitation
Emergent/Resuscitative Phase
On the Scene Care
First step is to remove patient from source of injury and stop the burning process
Rescue worker’s priorities include establishing an airway, supplying 02, inserting @ least one large bore IV line, covering the
wound with clean, dry cloth or gauze
Immediate survey to assess ABCDE:
o Airway: protect cervical spine
o Breathing
o Circulatory or Cardiac status
o Disability: neurologic deficit
o Expose and Examine: maintain warm environment
Safety: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed
toward establishing airway and giving 100% humidified 02. If needed, they may insert a endotracheal tube and initiate mechanical
ventilation
Safety: No food or fluid is given PO, the patient is placed in a position to prevent aspiration of vomitus, because N/V may pccur and
protection of airway is also important priority.
The secondary survey focuses on obtaining history, the completion of the totally body system assessment, initial fluid
resuscitation, and provision of psychosocial support of the conscious patient
Medical Management
Initially the patient is referred to the ED so that life saving measures can be initiated and early burn center referral can be
made
For mild pulmonary injury, 100% humidified 02 is given and patient needs to cough to remove secretions by suctioning
For more severe situations, it may be needed to remove secretions by bronchial suctioning and give bronchodilators and
mucolytic agents
A once secure airway may become compromised with edema and toxic effects of smoke inhalation
In burns with over 20% TBSA fluid resuscitation is initiated to maintain organ perfusion
Under (shock, ischemia, multiple organ dysfunction syndrome MODS) and over (HF and pulmonary edema) resuscitation are
linked to poorer outcomes
In large burns central venous access is recommended due to large volume required
TBSA is calculated and fluids such as LR should be initiated using ABA fluid resuscitation formula
LR is indicated crystalloid of choice because its pH and osmolality most closely resemble human plasma
Formulas:
o 2 mL LR x kg x TBSA %
o Electrical burns use 4 mL
Starting point for fluids is at the time of injury, ½ of total calculated volume is given in the first 8 hours post-burn injury ->
then the next ½ is given over the next 16 hours
These formulas are just parameters and on going assessment should guide titration of rate of infusion
Goal for urine output:
o Thermal and chemical burns: 0.5-1 mL/kg/h
o Electrical: 75-100 mL/h is the goal
After respiratory function and cardiovascular status have been established the patient is assessed for cervical spine and or
head injuries if involved in a traumatic or electrical injury
All clothing and jewelry is removed
Chemical burns flushing of the exposed areas with amounts of clean water is continued
Eyes are examined and contacts are removed
Patient’s temperature must be monitored because hypothermia may develop rapidly and manipulation of environment may
be needed -> temp less than 95 F causes vasoconstriction may increase ischemia and necrosis
about:blank 1/6
, 11/17/23, 8:30 AM Managment of Burns - Brunner and Suddarth's Textbook of Medical-Surgic…
Burns
Chapter 62 pg. 1845-1873
Validating information with first responders includes: time and source of injury, scene on injury, length of exposure, prior
treatment, and any history of concomitant traumatic injury
Moderate to severe burns will have urinary catheter
If burn is over 20-25% TBSA then NG tube may be indicated with low intermittent suctioning
Those that are intubated need NG tube to decompress stomach and prevent vomiting and aspiration
Clean sheets are placed under and over patient to prevent wound from infection, maintain body temperature, and reduce
pain caused by air currents passing over exposed nerve endings
B/c poor tissue perfusion accompanies burns only IV analgesia is given in small repeated doses
W/ electrical burns ECG and cardiac monitoring is continuous
Tetanus prophylaxis is given if patient’s immunization status is no current or unknown
Safety: If needed a BP cuff is placed around extremity, needs to be correct size with accommodations for edema.
Nurse must consider psychological responses of family and patient as well, anxiety being very high
Nursing Management
Burn wound is secondary consideration to stabilization of airway, breathing, and circulation
Respiratory status is monitored closely and pulses are evaluated
Tachycardia and tachypnea may be apparent
Apply clean dressing over wound when applying BP cuff if all extremities are burnt
Edema may make BP difficult to assess -> Doppler device or noninvasive electronic BP device may be helpful
Severe burns an arterial catheter is used for BP measurement and collection of specimens
TO decrease edema, elevate extremity that is burnt above the level of the heart
Hourly assessment of intake and output
Red-colored urine indicate damage to RBC and myoglobin resulting from muscular damage
Glycosuria is common finding in early post-burns results from release of liver glycogen in response to stress
Nursing Responsibilities:
o Administration of fluids
o Strict I&O
o Monitoring patient response
o Notifying treatment team of abnormal labs and responses
Acute/Intermediate Phase
Occurs 48-72 hours after the burn injury
Medical Management
Pulmonary complications are common
Airway edema can take up to 48 hours to develop
Dx is based on Hx, clinical presentation, monitoring of arterial blood gases with carboxyhemoglobin levels and direct
observation of the airway by fiberoptic bronchoscopy
Elevate HOB to lessen effects of edema
Stridor and dyspnea are late signals to of impending airway obstruction
Best practice is to remove endotracheal tube ASAP so that infection risk is decreased
Late pulmonary complications secondary to inhalation injuries include mucosal sloughing of the airway and casts formed
from cellular debris, which can lead to obstruction, increased secretions, inflammation, atelectasis, airway ulceration,
pulmonary edema, and tissue hypoxia (Snell et al., 2013). Pneumonia, acute lung injury (ALI), and ARDS may also occur.
VAP is of concern as well
As capillaries regain integrity, 48 hours or more after the burn, fluid moves from the interstitial to the intravascular
compartment and intrinsic diuresis begins
Fluids are continued cautiously during this phase of burn care due to fluid shifts, evaporative fluid loss from large burn
wounds and patient response to burn injury
Blood products may be given for surgical procedures and anemia
Hyperthermia is common after burn shock resolves, which can be compounded by increased temperature due to sepsis
Early excision is needed for better outcomes -> necrotic tissue is removed and viable tissue is preserved
about:blank 2/6
Burns
Chapter 62 pg. 1845-1873
Management of Burn Injury
Categorized into three phases of care: emergent/resuscitative, acute/intermediate, and rehabilitation
Emergent/Resuscitative Phase
On the Scene Care
First step is to remove patient from source of injury and stop the burning process
Rescue worker’s priorities include establishing an airway, supplying 02, inserting @ least one large bore IV line, covering the
wound with clean, dry cloth or gauze
Immediate survey to assess ABCDE:
o Airway: protect cervical spine
o Breathing
o Circulatory or Cardiac status
o Disability: neurologic deficit
o Expose and Examine: maintain warm environment
Safety: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed
toward establishing airway and giving 100% humidified 02. If needed, they may insert a endotracheal tube and initiate mechanical
ventilation
Safety: No food or fluid is given PO, the patient is placed in a position to prevent aspiration of vomitus, because N/V may pccur and
protection of airway is also important priority.
The secondary survey focuses on obtaining history, the completion of the totally body system assessment, initial fluid
resuscitation, and provision of psychosocial support of the conscious patient
Medical Management
Initially the patient is referred to the ED so that life saving measures can be initiated and early burn center referral can be
made
For mild pulmonary injury, 100% humidified 02 is given and patient needs to cough to remove secretions by suctioning
For more severe situations, it may be needed to remove secretions by bronchial suctioning and give bronchodilators and
mucolytic agents
A once secure airway may become compromised with edema and toxic effects of smoke inhalation
In burns with over 20% TBSA fluid resuscitation is initiated to maintain organ perfusion
Under (shock, ischemia, multiple organ dysfunction syndrome MODS) and over (HF and pulmonary edema) resuscitation are
linked to poorer outcomes
In large burns central venous access is recommended due to large volume required
TBSA is calculated and fluids such as LR should be initiated using ABA fluid resuscitation formula
LR is indicated crystalloid of choice because its pH and osmolality most closely resemble human plasma
Formulas:
o 2 mL LR x kg x TBSA %
o Electrical burns use 4 mL
Starting point for fluids is at the time of injury, ½ of total calculated volume is given in the first 8 hours post-burn injury ->
then the next ½ is given over the next 16 hours
These formulas are just parameters and on going assessment should guide titration of rate of infusion
Goal for urine output:
o Thermal and chemical burns: 0.5-1 mL/kg/h
o Electrical: 75-100 mL/h is the goal
After respiratory function and cardiovascular status have been established the patient is assessed for cervical spine and or
head injuries if involved in a traumatic or electrical injury
All clothing and jewelry is removed
Chemical burns flushing of the exposed areas with amounts of clean water is continued
Eyes are examined and contacts are removed
Patient’s temperature must be monitored because hypothermia may develop rapidly and manipulation of environment may
be needed -> temp less than 95 F causes vasoconstriction may increase ischemia and necrosis
about:blank 1/6
, 11/17/23, 8:30 AM Managment of Burns - Brunner and Suddarth's Textbook of Medical-Surgic…
Burns
Chapter 62 pg. 1845-1873
Validating information with first responders includes: time and source of injury, scene on injury, length of exposure, prior
treatment, and any history of concomitant traumatic injury
Moderate to severe burns will have urinary catheter
If burn is over 20-25% TBSA then NG tube may be indicated with low intermittent suctioning
Those that are intubated need NG tube to decompress stomach and prevent vomiting and aspiration
Clean sheets are placed under and over patient to prevent wound from infection, maintain body temperature, and reduce
pain caused by air currents passing over exposed nerve endings
B/c poor tissue perfusion accompanies burns only IV analgesia is given in small repeated doses
W/ electrical burns ECG and cardiac monitoring is continuous
Tetanus prophylaxis is given if patient’s immunization status is no current or unknown
Safety: If needed a BP cuff is placed around extremity, needs to be correct size with accommodations for edema.
Nurse must consider psychological responses of family and patient as well, anxiety being very high
Nursing Management
Burn wound is secondary consideration to stabilization of airway, breathing, and circulation
Respiratory status is monitored closely and pulses are evaluated
Tachycardia and tachypnea may be apparent
Apply clean dressing over wound when applying BP cuff if all extremities are burnt
Edema may make BP difficult to assess -> Doppler device or noninvasive electronic BP device may be helpful
Severe burns an arterial catheter is used for BP measurement and collection of specimens
TO decrease edema, elevate extremity that is burnt above the level of the heart
Hourly assessment of intake and output
Red-colored urine indicate damage to RBC and myoglobin resulting from muscular damage
Glycosuria is common finding in early post-burns results from release of liver glycogen in response to stress
Nursing Responsibilities:
o Administration of fluids
o Strict I&O
o Monitoring patient response
o Notifying treatment team of abnormal labs and responses
Acute/Intermediate Phase
Occurs 48-72 hours after the burn injury
Medical Management
Pulmonary complications are common
Airway edema can take up to 48 hours to develop
Dx is based on Hx, clinical presentation, monitoring of arterial blood gases with carboxyhemoglobin levels and direct
observation of the airway by fiberoptic bronchoscopy
Elevate HOB to lessen effects of edema
Stridor and dyspnea are late signals to of impending airway obstruction
Best practice is to remove endotracheal tube ASAP so that infection risk is decreased
Late pulmonary complications secondary to inhalation injuries include mucosal sloughing of the airway and casts formed
from cellular debris, which can lead to obstruction, increased secretions, inflammation, atelectasis, airway ulceration,
pulmonary edema, and tissue hypoxia (Snell et al., 2013). Pneumonia, acute lung injury (ALI), and ARDS may also occur.
VAP is of concern as well
As capillaries regain integrity, 48 hours or more after the burn, fluid moves from the interstitial to the intravascular
compartment and intrinsic diuresis begins
Fluids are continued cautiously during this phase of burn care due to fluid shifts, evaporative fluid loss from large burn
wounds and patient response to burn injury
Blood products may be given for surgical procedures and anemia
Hyperthermia is common after burn shock resolves, which can be compounded by increased temperature due to sepsis
Early excision is needed for better outcomes -> necrotic tissue is removed and viable tissue is preserved
about:blank 2/6
