Burns

The World Health Organization (WHO, 2022) describes burns as injuries to the skin or other tissues caused by heat, friction, radiation, or chemicals. There are six classifications of burn wounds based on injury mechanism: scalds (by liquids, grease, or steam), contact burns, fire (flash or flame), chemical (caustic acids and bases, chemicals such as bleach, or vesicants such as blistering gases), electrical (high and low voltages, lightning), and radiation (ionizing or ultraviolet). Thermal burns (scalds, contact, fire), which are the most common type, occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Burns have a devastating effect on people's quality of life, finances, and relationships as well as create significant suffering and disability. Burns are the third leading cause of accidental death in the United States; approximately 4,000 people die each year from burns. The American Burn Association (ABA) estimates that approximately 500,000 Americans experience burns severe enough to seek medical care each year. Most burn care is delivered in the emergency department, although approximately 40,000 people require hospitalization each year in the United States. The most common place of occurrence for burns is in the home (73%), with less common locations including the workplace (8%), streets or highways (5%), and during recreation or sports (5%). The physiological responses to moderate and major burns are outlined in Table 1. Complications of burns include infection, hypovolemia, hypothermia, respiratory distress and acute respiratory distress syndrome, scarring, and joint contractures. The ABA reports that the survival rate after burns is 96.8%.

Table 1 System Impact of Moderate or Major Burns

SYSTEM	PHYSIOLOGICAL CHANGES
Cardiovascular	Fluid shifts from the vascular to the interstitial space occur because of increased permeability related to the inflammatory response. Hypovolemic shock may result or it may be overcorrected by overzealous fluid replacement, which can lead to hypervolemia. Hypertension occurs in about one-third of all children with burns, possibly caused by stress.	Pulmonary	Pulmonary edema brought about by primary cellular damage or circumferential chest burns limiting chest excursion can occur. Trauma may lead to release of cytokines that damage lung tissue. By-products of combustion may lead to carbon monoxide poisoning. Inhalation of noxious gases (smoke inhalation) may cause primary pulmonary damage or airway edema and upper airway obstructions.
Genitourinary	Potential for renal shutdown brought about by hypovolemia or acute renal failure exists. Massive diuresis from fluid returning to the vascular space marks the end of the emergent phase. Patients may develop hemomyoglobinuria because of massive full-thickness burns or electric injury. These injuries cause the release of muscle protein (myoglobin) and hemoglobin, which can clog the renal tubules and cause acute renal failure.	Gastrointestinal	Paralytic ileus can result from hypovolemia and last 2 or 3 days. Children are particularly susceptible to Curling ulcer, a stress ulcer, because of the overwhelming systemic injury.
Musculoskeletal	Potential exists for the development of compartment syndrome because of edema. Escharatomy (cutting of a thick burn) may be needed to improve circulation. Scarring and contractures are a potential problem if prevention is not started on admission.	Neurological	Personality changes are common throughout recovery because of stress, electrolyte disturbance, hypoxemia, or medications. Children are particularly at risk for postburn seizures during the acute phase.

Causes ⬆ ⬇

Most burns result from preventable accidents. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. The percentage of burns caused by abuse is estimated at approximately 10%, but they are some of the most difficult to manage because the causes are complex. Burns occur primarily in the home (73%), followed by occupational burns (8%), burns that occur on the street or highway (7%), and recreational burns (9%). Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop, Drop, and Roll program have decreased the number and severity of injuries.

Genetic Considerations ⬆ ⬇

No clear genetic contributions to susceptibility have been defined.

Sex and Life Span Considerations ⬆ ⬇

Preschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart for children (Lund-Browder chart) that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and, in particular, young adult males ages 20 to 29 years, followed by children under age 9 years. Individuals older than 50 years sustain the fewest number of serious burn injuries. In developed countries, burns occur in males at twice the rate that they occur in females. In developing countries, women have higher rates of burn injury than men, likely because of open fire cooking or unsafe cookstoves.

A young child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of carelessness or risk-taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets. Most adults are victims of house fires or work-related accidents that involve chemicals or electricity. Older adults are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat.

Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

The ABA reports that 59% of burns occur in White persons, 20% in Black persons, 14% in Hispanic persons, and 7% in other races and ethnicities. Native American and Black children are more than two and three times more likely than White children to die in a fire. Factors that are associated with increased burn risk include low income and residential overcrowding. Sexual and gender minority status has no known effect on the risk for burns.

Global Health Considerations ⬆ ⬇

Many developing countries do not track burn rates, but the WHO notes that the majority of burns worldwide occur in low- and middle-income countries in Africa and Southeast Asia. Around the world, an estimated 254,000 deaths occur each year from fires alone. Poverty, overcrowding, lack of water supply, and the lack of a living room in the home are global risks for burn injury. The World Fire Statistics Center reported that the countries with the lowest incidences of fire deaths per 100,000 persons include Singapore, Vietnam, Switzerland, and New Zealand. Those with the highest include Russia, Ukraine, Belarus, and Lithuania. Research in Ireland and Greece suggests that the incidence of burns increases during holidays that feature the use of celebratory fireworks.

Assessment ⬆ ⬇

ASSESSMENT

History

The initial triage is done according to ABCDE principles of the primary survey: airway maintenance with stabilization of the cervical spine, breathing and ventilation, circulation with control of hemorrhage, disability assessment and neurological examination, and exposure along with environmental control. The secondary survey is a complete head-to-toe assessment that occurs later as part of the physical assessment. Sometime during the first 48 hours, a tertiary survey is performed to discover any subtle injuries that may have been missed during the initial assessment. Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important because any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the injury because closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking healthcare, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members.

Physical Examination

The most common symptoms are thermal injury to the skin and signs of smoke inhalation (carbonaceous sputum, singed facial or nasal hairs, facial burns, oropharyngeal edema, vocal changes). Although the wounds of a serious burn injury may be dramatic, a basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine the severity of injury. The ABA establishes the severity of injury by calculating the total body surface area (TBSA) of partial- and full-thickness injury along with the age of the patient and other special factors (Table 2).

Table 2 Characteristics of Burns

SUPERFICIAL EPIDERMAL (FIRST DEGREE)	SUPERFICIAL AND DEEP PARTIAL THICKNESS (SECOND DEGREE)	FULL THICKNESS (THIRD AND FOURTH DEGREE)
Erythema, blanching on pressure, mild to moderate pain, no blister (typical of sunburn). Only structure involved is the epidermis.	Superficial: Papillary dermis is affected with blisters, redness, and severe pain because of exposed nerve endings Deep: Reticular dermis affected with blisters, pale white or yellow color, absent pain sensation	Third degree: All levels of the dermis along with subcutaneous fat. Blisters may be absent with leathery, wrinkled skin without capillary refill. Thrombosed blood vessels are visible, insensitive to pain because of nerve destruction. Fourth degree: Involvement of all levels of dermis as well as fascia, muscle, and bone

The “rule of nines” is a practical technique used to estimate the extent of TBSA involved in a burn. The technique divides the major anatomic areas of the body into percentages: In adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portion of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient's palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient's response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and output monitoring are essential to ensure that the patient is responding appropriately to treatment.

Psychosocial

Even small burns temporarily change the appearance of the skin. Major burns will have a permanent effect on the family unit. A complete assessment of the family's psychological health before the injury is essential. Expect preexisting issues to magnify during this crisis, and identify previous ways of coping in order to facilitate dealing with the crisis. Guilt, blame, anxiety, fear, and depression are commonly experienced emotions. Health providers are mandated by state laws to recognize and report suspected abuse. It is important to understand and implement reporting statutes based on the state of residence.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Fiberoptic bronchoscopy	Normal larynx, trachea, and bronchi	Thermal injury and edema to oropharynx and glottis	Used to investigate suspected smoke inhalation and damage from noxious gases
Carboxyhemoglobin levels	8%–10% in smokers; < 2% in nonsmokers	10%–20% indicates potential inhalation injury; 20%–30% disturbed judgment, headache, dizziness; 30%–40% dizziness, muscle weakness, visual problems, confusion; 50%–60% loss of consciousness; > 60% death	Carbon monoxide binds to hemoglobin with an affinity 240 times greater than that of oxygen

Other Tests: Because burns are the result of trauma, there are no tests needed to make the diagnosis. Some of the more common tests to monitor the patient's response to injury and treatment are complete blood count, arterial blood gases, serum electrolytes, blood and wound cultures and sensitivities, chest x-rays, urinalysis, and nutritional profiles.

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to exposure to smoke and airway edema as evidenced by shortness of breath, cough, and/or production of carbonaceous sputum

Outcomes

OutcomesRespiratory status: Airway patency, ventilation, and gas exchange; Symptom control; Mechanical management response; Comfort level: Physical

Interventions

InterventionsAirway insertion and stabilization; Airway management; Oxygen therapy; Anxiety reduction; Airway suctioning; Cough enhancement; Mechanical ventilation management; Positioning; Respiratory monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Minor Burn Care.

Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water two or three times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and all burn patients need to receive tetanus toxoid to prevent infection.

Major Burn Care.

For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. If the patient cannot be transported immediately to a hospital, remove charred clothing and immerse the burn wound in cold (not ice) water for 30 minutes. Note that cooling has no therapeutic value if delayed more than 30 minutes after injury. The cold temperature is thought to be related to reduced lactate production, reduced acidosis, and reduced histamine and other mediator release. In addition to ABCs management, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition. Fluid resuscitation is generally intravenously initiated with lactated Ringer solution based on the Parkland formula (4 mL/kg/% TBSA burned) during the first 24 hours. Patients are monitored carefully for over- and underhydration. Wounds are cleansed with chlorhexidine gluconate, and care consists of silver sulfadiazine or mafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze. The nutritional needs of the patient are extensive and complex. Initially metabolic rate is low because of decreased cardiac output, but a severe burn can double the metabolic rate and cause the release of large amounts of amino acids from the muscles. Nutritional assessment and support occur within the first 24 hours after the burn, and feedings are initiated enterally by feeding tube if possible. A nutritional consult is needed to determine exact caloric and nutrient needs.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Topical antimicrobial agents	Silver sulfadiazine	Cream that lowers bacterial counts, minimizes water evaporation, and decreases heat loss	Antimicrobial agent that is not irritating and has the fewest adverse effects
	Mafenide acetate	Bacterial coverage for gram-negative and anaerobic coverage; deep eschar penetration	Painful but readily absorbed and can lead to metabolic acidosis

Other Drugs: Tetanus prophylaxis, analgesia to manage the severe pain that accompanies thermal injury, other topical applications such as polymyxin B or Acticoat (dressings that release silver ions), H₂ blockers

Independent

The nursing care of the patient with a burn is complex and collaborative, with overlapping interventions among the nurse, the physician, and a variety of therapists. However, independent nursing interventions are also an important focus for the nurse. The highest priority for the burn patient is to maintain the ABCs. The airway can be maintained in some patients by an oral or nasal airway or by the jaw lift–chin thrust maneuver. Patency of the airway is maintained by endotracheal suctioning, the frequency of which is dictated by the character and amount of secretions. If the patient is apneic, maintain breathing with a manual resuscitator bag before intubation and mechanical ventilation.

If the patient is bleeding from burn sites, apply pressure until the bleeding can be controlled surgically. Remove all constricting clothing and jewelry to allow for adequate circulation to the extremities. Implement fluid resuscitation protocols as appropriate to support the patient's circulation. If any clothing is still smoldering and adhering to the patient, soak the area with normal saline solution and remove the material. Wound care includes collaborative management and other strategies. Cover wounds with clean, dry, sterile sheets. Do not cover large burn wounds with saline-soaked dressings, which lower the patient's temperature. If the patient has ineffective thermoregulation, use warming or cooling blankets as needed and control the room temperature to support the patient's optimum temperature. If the patient is hypothermic, limit traffic into the room to decrease drafts and keep the patient covered with sterile sheets. Help the patient manage pain and distress by providing careful explanations and teaching distraction and relaxation techniques.

Depending on the type and extent of injury, dressing changes are generally performed daily; twice-a-day dressing changes may be indicated for infected wounds or those with large amounts of drainage. While dressing protocols vary, one method is to cleanse the wound with sponges saturated with a wound cleanser such as poloxamer 188 to remove the topical antibiotics. Then cover the wound with antibiotic cream. As the wounds heal, use strategies such as tubbing, débridement, and dressing changes to limit infection, promote wound healing, and limit physical impairment. If impaired physical mobility is a risk, place the patient in antideformity positions at all times. Implement active and passive range of motion as needed. Get the patient out of bed on a regular basis to limit physical debilitation and decrease the risk of infection. Implement strategies to limit stress and anxiety.

Evidence-Based Practice and Health Policy

Govender, R., Hornsby, N., Kimemia, D., & Van Niekerk, A. (2020). The role of concomitant alcohol and drug use in increased risk for burn mortality outcomes. Burns, 46, 58–64.

Burn injuries are a major cause of mortality and morbidity in low- and middle-income countries, and the risk may be increased with alcohol and drug use. The authors used a national data set in low- and middle-income countries in Sub-Saharan Africa to explore the risk for burn injuries in adults 18 years and older (N = 918).
Burn victims with full-thickness and partial-thickness burns over more than 30% of TBSA had a risk of mortality 10 times higher when alcohol and drugs were involved as compared to when alcohol and drugs were not involved. The authors concluded that alcohol and drugs may predispose toward more severe burns and a higher risk for sepsis and death.

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DRG Information ⬇

Introduction ⬆ ⬇