Category: Critical Care Nursing

A burn injury happens when the skin comes into contact with something hot, causing disruption within the skin’s cell structure, resulting in skin cell death.

NOTE: Throughout this blogpost, the various burns listed are classified into burn degrees, however, this method of classification does not indicate the injury depth, and so, focus should be on the type of burn eg. superficial burn, and the percentage of skin area affected using the Lund and Browder Chart (featured further down).

The Zone of Stasis

The Zone of Stasis is the surrounding area of the burn. It is characterised by decreased tissue perfusion. Nonetheless, the skin within this zone is potentially salvageable:

1. the burn injury dressing should be chosen with the aim of promoting wound moisture
2. burnt area should be elevated so as to minimise oedema
3. smoking should be avoided by the patient since it puts the patient at increased risk of poor outcomes and complications
4. systemic diseases eg. diabetes should be managed; blood sugar levels should be kept stable

Assessing Burn Injury Surface Area

Prior to assessing a burn injury and its depth, DO NOT apply any silver sulfadiazine or any other topical agents, since doing so gives an inaccurate indication of the wound’s depth.

Superficial Burn Injury

A superficial burn, also called a 1st degree burn, is characterised by the following features:

• painful
• no blisters are present
• only the epidermis layer is involved
• erythema (redness) present due to vasodilation
• complete healing typically takes up to 7 days due to re-epithelialisation

Care of Superficial Burn

• superficial burns require no dressings
• patient should be advised to apply emollient cream
• patient should be advised to apply sunblock and to avoid the sun

Superficial Partial Thickness Burn Injury

A superficial partial thickness burn, also called a 2nd degree burn, is characterised by the following features:

• very painful
• pink or red
• blisters present
• wet and weepy
• complete healing with relatively little scarring

Care of Superficial Partial thickness Burn

• if available apply Aquacel (silver dressing) in the 1st 24 hours following injury
• de-roof and debride the blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
• assess wound depth
• apply silver sulfadiazine and cover with non-adherent dressing for the first 3 days following burn injury
• advise patient that a lot of exudate is expected to come out from the wound
• advise patient to take regular analgesia for pain management

Deep Partial Thickness Burn Injury

A deep partial thickness burn, also called a 3rd degree burn, is characterised by the following features:

• usually lacks physical sensation
• red with overlying eschar
• scarring expected
• delayed healing potential

Care of Deep Partial thickness Burn

• de-roof and debride blisters (if any) UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
• assess wound depth
• apply silver sulfadiazine and cover with light dry dressing
• inform patient that some exudate should be expected
• advise patient to take regular analgesia for pain management

Full Thickness Burn Injury

A full thickness burn, also called a 3rd or 4th degree burn, is characterised by the following features:

• lacks physical sensation
• white, brown, tan, or black
• dry and leathery
• firm non-blanche
• scarring expected
• no healing potential

Care of Full Thickness Burn

• following diagnosis of burn wound stage, refer patient to the Burns Unit
• apply aquacel
• elaborate surgical debridement, reconstruction, or amputation, may be indicated, depending on the case

Thermal Burns

The WHO estimates that thermal burns account for around 6.6 million injuries and 300,000 deaths yearly, worldwide. A thermal burn can be experienced through the following:

• scalding (commonly caused by hot drinks in children)
• direct contact with hot materials
• flash and flame burns
• can be a 1st, 2nd, 3rd or 4th degree burn (most full thickness burns are classified under thermal burns)

Chemical Burns

Chemical burns can be caused by direct contact with, or fumes of a chemical, usually an alkali or a strong acidic substance. Such burns can happen within various settings, including homes, work, or during an assault.

One such commonly used chemical is hydrofluoric acid – a colourless highly corrosive solution containing hydrogen fluoride in water. It is stored in a plastic container and is commonly used in industrial chemistry, glass finishing, and cleaning. Liquid hydrofluoric acid has the potential to interfere with calcium metabolism. It can cause deep skin burns, which though initially painless, may lead to a cardiac arrest and subsequent death, whilst in gas form, it can cause immediate and permanent lung damage, as well as damage to the eyes’ corneas.

care of a chemical burn

A chemical burn requires special care and attention so as to stop the substance from spreading within the skin. When caring for a chemical burn:

• obtain information as to what caused the chemical burn
• obtain information on how long the area was exposed to the chemical
• remove any contaminated clothing that the patient may still be wearing
• wash area to dilute or remove the substance
• keep the wound under running water for 20 minutes

Smoke Inhalation

Smoke inhalation, which includes inhalation of heat, chemicals, and soot, can lead to a burn injury to the airway. To confirm smoke inhalation, it is important to assess for:

• burns in mouth area
• sooty sputum
• voice change
• difficult cough

If in doubt one should still provide oxygen therapy following intubation whilst protecting the cervical spine.

TREATMENT

Based on the inhalation severity:

• patient may be intubated for minimal upper airway swelling
• if soot is present in large amounts, patient’s airway may need suctioning
• if the respiratory tract requires support, an aggressive approach should be taken…
• chest physiotherapy
• bacteriological surveillance – prophylactic antibiotic is administered
• administration of The Galvenstone Protocol: inhaled H1 blockers, inhaled heparin, and nebulised acetyl cysteine

Electrical Burns

Electrical burns are caused by exposure to an electric source. They typically have both an entry and an exit site. The extent of such an injury ranges from minimal injury to severe multi-organ involvement.

An electrical burn needs to be evaluated by a medical professional despite the patient’s condition, be it stable or not.

Radiological Burns

Radiological burns are caused by the exposure to radiation. Whilst the most common cause of a radiation burn is through UV radiation as sunburn, patients undergoing radiation may present with radiation ulcers following radiotherapy, which unfortunately increases cancer risk and causes cell death.

Burn Injury Nursing Care

A patient with burns is ideally kept in a positive-pressure room when hospitalised. Positive-pressure rooms have higher air pressure than the adjoining areas, preventing airborne pathogens from entering the room to avoid the air inside becoming contaminated. This reduces the risk of burn patients acquiring infection and causing further complications in their healing process.

Shock and Fluid management

In patients with critical burns, shock causes progressive failure of the circulation, leading to a decrease in oxygen perfusion within the vital organs. Fluid resuscitation aims to:

• maintain vital organ function especially when it comes to renal function
• replace fluid lost within the first 8 hours following burn infliction

Fluid Resuscitation Formula – Hartmann’s

4ml x weight x affected Total Body Surface Area (TBSA)

to be administered over the first 24 hrs

(Half of the prescribed volume should be administered over the first 8 hours from burn infliction, with the rest over the following 16 hours)

CRYSTALLOIDS VS COLLOIDS

The most commonly used resuscitation fluid for initial resuscitation is the Ringer’s Lactate (Hartmann’s) or other crystalloids. Crystalloids make up a balanced solution which helps balance electrolytes in large fluid replacements.

When compared to colloids, crystalloids have a less prominent affect of volume expansion, however colloids tend to exacerbate third space losses. In burn patients, colloids (commonly used being albumin) are added to decrease the total volume of resuscitation fluid needed, since these reduce capillary leakage. Albumin is however commonly used as a rescue approach since it increases mortality in critically ill patients. Albumin:

• reduces fluid creep (fluid overload)
• tends to cause haemodynamic instability – hypotension, oliguria, and increasing haematocrit

If Albumin is indicated as an adjunct to the fluid resuscitation protocol, it should replace HALF of the crystalloid amount.

URINE OUTPUT

Urine output is vital for indicating successful fluid resuscitation. A urine catheter should be inserted whenever fluid resuscitation is being performed, since in burn patients, the nurse needs to monitor:

• urine output
• heart rate
• blood pressure
• ABGs
• pH (patient may experience lactic acidosis)

Expected Urine Output in Patients Undergoing Fluid Resuscitation:

Adults: 0.5ml/kg/hr

Children: 1.0ml/kg/hr

NOTE: fluid resuscitation increases oedema. Fluid formulae should only be used as guidelines, and fluid calculations need to be calculated from the time at which the burn was inflicted. Ideal fluid resuscitation should include the LEAST amount of fluid necessary to maintain tissue perfusion, maintain vital physiological functions, and return physiology to normal as soon as possible.

THE GASTROINTESTINAL SYSTEM OF A PATIENT WITH BURNS

In burn patients, the liver’s function forms part of the systemic response to the burn injury, excreting glucagon and inflammatory markers.

Secondary Abdominal Compartment Syndrome (SACS) is a common crystalloid resuscitation complication caused by increased intra-abdominal pressure which may cause a secondary organ infarction if ignored. Typically, a patient with SACS has reduced urinary output which may also be bloody.

To avoid SACS, the patient’s intra-abdominal pressure should be measured, either via the patient’s bladder, or by measuring the intra-vesical pressure.

cleaning the burn Injury

• a new burn is considered to be sterile, thus, it is important to attempt to keep it that way
• clean thoroughly with an antibacterial wash eg. betadine surgical scrub
• antibiotics should not be prescribed as prophylaxis, but only if infection is noted (a temperature of up to 38.5°C is considered to be normal in patients with burn injuries)
• de-roof and debride large blisters UNLESS they are located on the palms or soles of the feet due to excessive pain as well as superficial nerves, to which debridement may cause irreparable problems
• debride any dead skin to promote healing

Change of Dressings

• in the initial stage, dressings should be changed daily, especially since at this stage these are usually found soaked
• once healing starts to progress, change of dressing should be performed every 3-5 days, however, if the wound becomes painful, smelly, or soaked at any time, it should be immediately changed

Further care

• encourage daily moisturiser application eg. aqueous cream
• encourage sunblock use over healed areas for 6-12 months
• advise patient that pruritus is a common problem following burn injury, and that advise should be sought if this becomes problematic
• provide patient with support and reassurance, without any false hopes

NOTE: unhealed burns lasting 3 weeks should be referred to the Burns Unit.

Renal Failure

Renal failure in a patient with burns is usually a late septic complication, especially since within the acute stage the patient would be receiving aggressive fluid resuscitation. To avoid such complication, haemofiltration is commonly considered in large burn injuries. Renal failure signs include:

• oliguria of <4o0ml per day
• a decline in the GFR
• a rise in Urea and Creatinine

A patient needing kidney relief may be put on the PrismaFlex System.

Patient Education on Burns First Aid Care

• always aim to stop the burning process by removing the heat source and any affected clothing
• if clothes catch on fire, “STOP, DROP & ROLL”
• put burn wound under running water for 20 minutes following a burn injury
• protect the burn by covering it with a sterile non-adhesive bandage
• manage pain through analgesia eg. paracetamol
• DO NOT use ice water since this causes vasoconstriction, leading to burn progression
• DO NOT apply any creams or ointments to burn injuries since these may cause further complications

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