King Saud University College of Nursing

BurnHatem Alsrour

King Saud UniversityCollege of Nursing

Layers of the Skin

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

EpidermisOutermost layer, composed of cornified epithelial cells.

Outer surface cells are dead and sloughed off.

DermisMiddle layer, composed primarily of connective

tissue .

Contains capillaries that nourish the skin, nerve endings and hair follices

HypodermisLayer of adipose and connective tissue

between the skin and underlying tissues.

Function of SkinFunction of Skin

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

What is a BurnWhat 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 InjuryThermalOpen flame, steam, hot liquids

ChemicalAcids, strong alkalis, organic compounds

ElectricalDirect or alternating current, lightning

RadiationRadioactive agents

Pathophysiology of Burn InjuryPathophysiology of Burn Injury Zone of Coagulation:

Irreversible damage Zone of Stasis:

Impairment of blood flow Recovery variable

Zone of Hyperemia: Prominent vasodilation Usually recovers

Severity of a BurnSeverity 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 Partial thickness (second-degree) (second-degree)

burnsburns

Superficial (first-Superficial (first-degree) burnsdegree) burns

Third degree burn

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) burnsFull thickness (third-degree) burns

Depth of burn injuryDepth of burn injury

Depth of a BurnDepth of a Burn

First DegreeFirst Degree

SuperficialSuperficial SecondSecond

Deep SecondDeep Second

Third DegreeThird Degree

Extent of a BurnExtent of a Burn “Rule of Nines”

Most universal guide for initial estimate

Deviates in children due to larger head surface area

Rule of NineRule of Nine

““RobynRobyn’’s Rule of 4ss Rule of 4s””

Carbon Monoxide PoisoningCarbon 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 PoisoningCarbon Monoxide PoisoningSigns & Symptoms of Carbon Monoxide ToxicitySigns & Symptoms of Carbon Monoxide Toxicity

Carboxyhemoglobin (%)Carboxyhemoglobin (%) Signs/SymptomsSigns/Symptoms

0-100-10 NoneNone

10-3010-30 HeadacheHeadache

30-5030-50 Headache, nausea, Headache, nausea, dizziness, tachycardiadizziness, tachycardia

50-6050-60 CNS dysfunction, CNS dysfunction, comacoma

60+60+ DeathDeath

CO Poisoning: TreatmentCO Poisoning: Treatment 100% oxygen until carboxyhemoglobin levels

less than 15

Shock & Fluid ResuscitationShock & Fluid ResuscitationGoal:

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

Resuscitation Fluid NeedsResuscitation 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 ResuscitationMonitoring 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 Eyes are particularly vulnerable. Fumes can cause burns. To prevent exposure, wear appropriate gloves

and eye protection.

Care for Chemical Burns Remove the chemical from the patient. If it is a powder chemical, brush off first. Remove all contaminated clothing. 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. There will be two wounds (an entrance and an

exit wound) to bandage. Arrange for prompt transport and be prepared

to administer CPR.

Pre-hospital CareStop the burning processThermal – smother; stop, drop, and rollChemical – remove clothing and flush / irrigate skin / eyesElectrical – shut off electrical current or separate person from source with a nonconducting implement (such as wooden broomstick)Radiation – limit exposure

1-Stop the burning process, if still active

2 -Remove all clothing and jewelry, rings, in anticipation of edema formation.

3 -Ensure patent airway. Prepare for early intubation

4 -Administer oxygen via a mask at flow rate sufficient enough to keep reservoir bag inflated;

usually requires 12 to 15L\minute

5-Assist Ventilation, if needed

Emerncy impelementation : Emerncy impelementation :

6 -Cannulate two veins with large-bore, 14- or 16-gauge catheters, and initiate infusion of an IV solution

7 -Infuse a crystalloid solution such as lactated Ringer's solution according to a pre established fluid protocol.

8 -Fluid resuscitation is based on the individual patient's 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

9 -Administer analgesic medications, e.g., morphine, IV

10 -Insert a gastric tube. If patient has TBSA more than 25%, nausea & vomiting are present

11 -Apply cool, saline-moistened, sterile dressings to 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)

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

Rapid or delayed progression Decision to intubate: individualized

B: Breathing 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

Required for definitive diagnosis of CO Baseline chest x-ray

C: Circulation Who needs fluid resuscitation?

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

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

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 ConsiderationsGoals:Correct fluid and electrolyte imbalancePromote wound healingSupport nutritionControl painPrevent complications of immobilitySupport patient

QuestionsWhich 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 30ºB – Administer six liters of oxygen via nasal

cannulaC – Medicate the patient prior to repositioning

the patient in bedD – 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

cannulaC – Medicate the patient prior to repositioning

the patient in bedD – Prevent moving the skin around the burn

site

QuestionsWhat 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

sourceB. 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

sourceB. 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.