Burns Seminar

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Anatomy of Integumentary System

The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from
microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold.

Albinism: Genetic disorder that affects the skin, in which there is no melanin production

Basal cell: Type of stem cell found in the stratum basale and in the hair matrix that continually undergoes cell
division, producing the keratinocytes of the epidermis

Dermal papilla: (plural = dermal papillae) extension of the papillary layer of the dermis that increases surface
contact between the epidermis and dermis

Dermis: Layer of skin between the epidermis and hypodermis, composed mainly of connective tissue and
containing blood vessels, hair follicles, sweat glands, and other structures

Desmosome: Structure that forms an impermeable junction between cellsfibers made of the protein elastin that
increase the elasticity of the dermis

Eleiden: Clear protein-bound lipid found in the stratum lucidum that is derived from keratohyalin and helps to
prevent water loss

Epidermis: Outermost tissue layer of the skin

Hypodermis: Connective tissue connecting the integument to the underlying bone and muscle

Integumentary system: Skin and its accessory structures

Keratin: Type of structural protein that gives skin, hair, and nails its hard, water-resistant properties

Keratinocyte: Cell that produces keratin and is the most predominant type of cell found in the epidermis

Keratohyalin: Granulated protein found in the stratum granulosum

Langerhans cell: Specialized dendritic cell found in the stratum spinosum that functions as a macrophage

Melanin: Pigment that determines the color of hair and skin

Melanocyte: Cell found in the stratum basale of the epidermis that produces the pigment melanin

Melanosome: Intercellular vesicle that transfers melanin from melanocytes into keratinocytes of the epidermis

Merkel cell: Receptor cell in the stratum basale of the epidermis that responds to the sense of touch

Papillary layer: Superficial layer of the dermis, made of loose, areolar connective tissue
Reticular layer: Deeper layer of the dermis; it has a reticulated appearance due to the presence of abundant
collagen and elastin fibers

Stratum basale: Deepest layer of the epidermis, made of epidermal stem cells

Stratum corneum: Most superficial layer of the epidermis

Stratum granulosum: Layer of the epidermis superficial to the stratum spinosum

Stratum lucidum: Layer of the epidermis between the stratum granulosum and stratum corneum, found only in
thick skin covering the palms, soles of the feet, and digits

Stratum spinosum: Layer of the epidermis superficial to the stratum basale, characterized by the presence of
desmosomes

Vitiligo: Skin condition in which melanocytes in certain areas lose the ability to produce melanin, possibly due
an autoimmune reaction that leads to loss of color in patches.

The skin and its accessory structures make up the integumentary system, which provides the body with overall
protection. The skin is made of multiple layers of cells and tissues, which are held to underlying structures by
connective tissue. The deeper layer of skin is well vascularized (has numerous blood vessels). It also has
numerous sensory, and autonomic and sympathetic nerve fibers ensuring communication to and from the brain.

Figure 1. Layers of Skin.

The skin consists of two main layers and a closely associated layer:
The Epidermis

The Dermis

The Hypodermis

The Epidermis:

The epidermis is composed of keratinized, stratified squamous epithelium.

It is made of four or five layers of epithelial cells, depending on its location in the body. It does not have any
blood vessels within it (i.e., it is avascular).

Skin that has four layers of cells is referred to as “thin skin.”

From deep to superficial, these layers are the stratum basale, stratum spinosum, stratum granulosum, and
stratum corneum. Most of the skin can be classified as thin skin. “Thick skin” is found only on the palms of the
hands and the soles of the feet. It has a fifth layer, called the stratum lucidum, located between the stratum
corneum and the stratum granulosum.

Figure 2. (a) Thin and (b) Thick skin(the Regents of University of Michigan Medical School © 2012)

The cells in all of the layers except the stratum basale are called keratinocytes.

A keratinocyte is a cell that manufactures and stores the protein keratin. Keratin is an intracellular fibrous
protein that gives hair, nails, and skin their hardness and water-resistant properties. The keratinocytes in the
stratum corneum are dead and regularly slough away, being replaced by cells from the deeper layers.
Figure 3. Epidermis (the Regents of University of Michigan Medical School © 2012)

Stratum Basale:

The stratum basale (also called the stratum germinativum) is the deepest epidermal layer and attaches the
epidermis to the basal lamina, below which lie the layers of the dermis. The cells in the stratum basale bond to
the dermis via intertwining collagen fibers, referred to as the basement membrane. A finger-like projection, or
fold, known as the dermal papilla (plural = dermal papillae) is found in the superficial portion of the dermis.
Dermal papillae increase the strength of the connection between the epidermis and dermis; the greater the
folding, the stronger the connections made.

Figure 4. Layers of the Epidermis.

The epidermis of thick skin has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum
lucidum, and stratum corneum.

A basal cell is a cuboidal-shaped stem cell that is a precursor of the keratinocytes of the epidermis. All of the
keratinocytes are produced from this single layer of cells, which are constantly going through mitosis to
produce new cells. As new cells are formed, the existing cells are pushed superficially away from the stratum
basale.

Two other cell types are found dispersed among the basal cells in the stratum basale.

Merkel cell, which functions as a receptor and is responsible for stimulating sensory nerves that the brain
perceives as touch. These cells are especially abundant on the surfaces of the hands and feet.

Melanocyte, a cell that produces the pigment melanin. Melanin gives hair and skin its color, and also helps
protect the living cells of the epidermis from ultraviolet (UV) radiation damage.

In a growing fetus, fingerprints form where the cells of the stratum basale meet the papillae of the underlying
dermal layer (papillary layer), resulting in the formation of the ridges on your fingers that you recognize as
fingerprints. Fingerprints are unique to each individual and are used for forensic analyses because the patterns
do not change with the growth and aging processes.

Stratum Spinosum:

Stratum Spinosum is spiny in appearance due to the protruding cell processes that join the cells via a structure
called a desmosome. The desmosomes interlock with each other and strengthen the bond between the cells.

The stratum spinosum is composed of eight to 10 layers of keratinocytes, formed as a result of cell division in
the stratum basale. Interspersed among the keratinocytes of this layer is a type of dendritic cell called
the Langerhans cell, which functions as a macrophage by engulfing bacteria, foreign particles, and damaged
cells that occur in this layer.

The keratinocytes in the stratum spinosum begin the synthesis of keratin and release a water-repelling
glycolipid that helps prevent water loss from the body, making the skin relatively waterproof.

As new keratinocytes are produced atop the stratum basale, the keratinocytes of the stratum spinosum are
pushed into the stratum granulosum.

Stratum Granulosum:

The stratum granulosum has a grainy appearance due to further changes to the keratinocytes as they are
pushed from the stratum spinosum.
The cells (three to five layers deep) become flatter, their cell membranes thicken, and they generate large
amounts of the proteins keratin, which is fibrous, and keratohyalin, which accumulates as lamellar granules
within the cells.

The nuclei and other cell organelles disintegrate as the cells die, leaving behind the keratin, keratohyalin, and
cell membranes that will form the stratum lucidum, the stratum corneum, and the accessory structures of hair
and nails.

Stratum Lucidum:

Stratum lucidum is a smooth, seemingly translucent layer of the epidermis located just above the stratum
granulosum and below the stratum corneum. This thin layer of cells is found only in the thick skin of the palms,
soles, and digits. The keratinocytes that compose the stratum lucidum are dead and flattened.

These cells are densely packed with eleiden, a clear protein rich in lipids, derived from keratohyalin, which
gives these cells their transparent (i.e., lucid) appearance and provides a barrier to water.

Stratum Corneum:

The stratum corneum is the most superficial layer of the epidermis and is the layer exposed to the outside
environment. The increased keratinization (also called cornification) of the cells in this layer gives it its name.
There are usually 15 to 30 layers of cells in the stratum corneum. This dry, dead layer helps prevent the
penetration of microbes and the dehydration of underlying tissues, and provides a mechanical protection against
abrasion for the more delicate, underlying layers.

Cells in this layer are shed periodically and are replaced by cells pushed up from the stratum granulosum (or
stratum lucidum in the case of the palms and soles of feet).

The entire layer is replaced during a period of about 4 weeks.

Cosmetic procedures, such as microdermabrasion, help remove some of the dry, upper layer and aim to keep the
skin looking “fresh” and healthy.

Dermis:

The dermis might be considered the “core” of the integumentary system (derma- = “skin”), as distinct from the
epidermis (epi- = “upon” or “over”) and hypodermis (hypo- = “below”). It contains blood and lymph vessels,
nerves, and other structures, such as hair follicles and sweat glands. The dermis is made of two layers of
connective tissue that compose an interconnected mesh of elastin and collagenous fibers, produced by
fibroblasts.
Figure 6. Layers of the Dermis.

Papillary Layer

The papillary layer is made of loose, areolar connective tissue, which means the collagen and elastin fibers of
this layer form a loose mesh. This superficial layer of the dermis projects into the stratum basale of the
epidermis to form finger-like dermal papillae.

Within the papillary layer are fibroblasts, a small number of fat cells (adipocytes), and an abundance of small
blood vessels.

The papillary layer contains phagocytes, defensive cells that help fight bacteria or other infections that have
breached the skin. This layer also contains lymphatic capillaries, nerve fibers, and touch receptors called the
Meissner corpuscles.

Reticular Layer

Underlying the papillary layer is the much thicker reticular layer, composed of dense, irregular connective
tissue. This layer is well vascularized and has a rich sensory and sympathetic nerve supply.

The reticular layer appears reticulated (net-like) due to a tight meshwork of fibers. Elastin fibers provide some
elasticity to the skin, enabling movement. Collagen fibers provide structure and tensile strength, with strands of
collagen extending into both the papillary layer and the hypodermis.

In addition, collagen binds water to keep the skin hydrated. Collagen injections and Retin-A creams help restore
skin turgor by either introducing collagen externally or stimulating blood flow and repair of the dermis,
respectively.
Hypodermis:

The hypodermis (also called the subcutaneous layer or superficial fascia) is a layer directly below the dermis
and serves to connect the skin to the underlying fascia (fibrous tissue) of the bones and muscles.

It is not strictly a part of the skin, although the border between the hypodermis and dermis can be difficult to
distinguish.

The hypodermis consists of well-vascularized, loose, areolar connective tissue and adipose tissue, which
functions as a mode of fat storage and provides insulation and cushioning for the integument.

Burns
Introduction:
Burns are commonly thought of as injury to the skin caused by excessive heat. More broadly, burns result from
traumatic injuries to the skin or other tissues primarily caused by thermal or other acute exposures. Burns occur
when some or all of the cells in the skin or other tissues are destroyed by heat, electrical discharge, friction,
chemicals, or radiation. Burns are acute wounds caused by an isolated, non-recurring insult, and healing ideally
progresses rapidly through an orderly series of steps.
Definition:
Burns are a form of traumatic injury to the skin and underlying tissue caused by thermal, electrical, chemical
and radioactive agents.
In other words, injuries that results from direct contact with the exposure to any thermal, chemical or radiation
source are termed as burns.
Epidemiology:
Burns are the fourth most common type of trauma worldwide, following traffic accidents, falls, and
interpersonal violence. Approximately 90 percent of burns occur in low- to middle-income countries, regions
that generally lack the necessary infrastructure to reduce the incidence and severity of burns.
Incidence:
The worldwide incidence of fire-related injuries in 2004 was estimated to be 1.1 per 100,000 population.
The incidence of burns in low- and middle-income countries is 1.3 per 100,000 population compared with an
incidence of 0.14 per 100,000 population in high-income countries.
According to WHO report; 1, 80, 000 deaths every year are caused by burns – the vast majority occur in low-
and middle-income countries. India, over 1 0, 00,000 people are moderately or severely burnt every year.
90,000 women suffer burn due to no accident.
Prevalence:
Estimated prevalence of fire-related burn injuries* in 2004, by World Health Organization region
  Africa The EMR¶ Europe SEARΔ WPR◊ World
America
s
Population (000) 737,536 874,380 519,688 883,311 1,671,90 1,738,457 6,436,826
4
Burns (000) 17,733 7850 14,919 15,668 44,344 15,531 116,284
Prevalence rate 2.4 0.9 2.87 1.77 2.65 8.93 1.81
* Includes only burns covering 20 percent or more of total body surface area.
¶ Eastern Mediterranean region.
Δ Southeast Asia region.
◊ Western Pacific region.
Risk Factors:
- Young children
- Age >60 years
- Male gender
- Women
- Cooking
- Low socioeconomic status
- Occupation
- Poverty, overcrowding and lack of proper safety measures
- Underlying medical conditions, including epilepsy, peripheral neuropathy, and physical and
cognitive disabilities
- Alcohol abuse and smoking
- Easy access to chemicals used for assault (such as in acid violence attacks)
- Use of kerosene (paraffin) as a fuel source for non-electric domestic appliances.
- Inadequate safety measures for liquefied petroleum gas and electricity
- Etiological factors:
- Dry heat
- Flame
- Electric contact
- Chemical
- Frostbite
- Ionizing radiation
- Friction
Classification of burn:
Burn injuries are classified on the basis of:
- Depth of injury
- Causes of injury
- Percentage of injury
By depth of burn:
The depth of the burn largely determines the healing potential and the need for surgical grafting. Traditionally
burn is classified as first, second, third, or fourth degree which is now replaced by a system reflecting the need
for surgical intervention.
The term fourth degree is still used to describe the most severe burns, burns that extend beyond the skin into the
subcutaneous soft tissue and can involve underlying vessels, nerves, muscle, bone, and joints.

Depth Appearance Sensation Healing time


Superficial Dry, red Painful 3 to 6 days without
(epidermal) Blanches with pressure scarring.
Superficial partial- Blisters Painful to 7 to 21 days with
thickness Moist, red, weeping temperature and air pigment changes.
Blanches with pressure
Deep partial- Blisters (easily unroofed) Perceptive of pain >21 days, usually
thickness Wet or waxy dry with pressure only requires surgical
(Deep dermis, hair Variable color (patchy to treatment
follicles, glandular cheesy white to red)
tissues) Does not blanch with
pressure
Full-thickness Waxy white to leathery gray Deep pressure only Rare, unless
(Underlying to charred and black surgically treated
subcutaneous Dry and inelastic skin
tissues) No blanching with pressure
Deeper injury (ie, Extends into fascia and/or Deep pressure Never, unless
fourth degree)  muscle surgically treated
Depending on the percentage of burns/ severity:
Mild:
- Partial thickness burns <15% in adults and <10%
- In children
- Full thickness <2%
- Can be treated on outpatient department
Moderate:
- Second degree burn of 15-25% burns
- Third degree burn between 2-10% burns
- Burns which are not involving eyes, ears Face, hand, feet and perineum
Severe:
- Second degree burns more than 25% in adults and More than 20% in children
- All third degree burns more than 10%
- All electrical burns and inhalation burns
- Burns with fracture
- Burns involving eyes, ears, feet, hands and perineum
On the basis of etiological factors:
 Thermal burn: Thermal injury is related to contact temperature, duration of contact of the external heat
source, and the thickness of the skin. Because the thermal conductivity of skin is low, most thermal
burns involve the epidermis and part of the dermis. It most commonly occur on exposure to flames, hot
liquids, hot solid objects, and steam.
 Chemical burn:The duration of exposure, the nature of the agent also determine injury severity.
Contact with acid causes coagulation necrosis of the tissue, while alkaline burns generate liquefaction
necrosis.Injury is caused by caustic reactions, including alteration of pH, disruption of cellular
membranes, and direct toxic effects on metabolic processes.
Classes of chemicals and their mechanisms of tissue injury
Class of chemical Mechanism of tissue injury
Acid Coagulation necrosis
Alkali Liquefaction necrosis – deeper penetration and more severe burns
Organic solutions Dissolve lipid membranes
Inorganic solutions Direct binding and salt formation

 Inhalational burn: Injury is caused by inhalation of toxic gases, causes including alteration of pH,
disruption of mucous membranes, and direct toxic effects on metabolic processes.
 Electrical burn:The magnitude of the injury depends on the pathway of the current, the resistance to the
current flow through the tissues, and the strength and duration of the current flow.
These injuries are divided into high voltage (>1,000 V) and low voltage(<1,000 V), and their severity is
based on:
Voltage (E)
Current (amperage – I)
Current type (AC vs. DC)
Contact time
Joule’s law de fines the amount of tissue damage:
Power(J) = Current(I)2 × Resistance(R) . The higher the resistance of tissue to currentflow, the greater heat
generated which results in greater tissue damage.
The types of electrical injury:
Electrical contact Electrical injury caused by current flow against tissue resistance
 Arc Thermal burn caused by arcing of electrical current passing through the air
 Flash Thermal burn from ignition of clothing or surroundings
 Friction burn: Injury from friction can occur due to a combination of mechanical disruption of tissues
as well as heat generated by friction.
 Radiation: Radio frequency energy or ionizing radiation can cause damage to skin and tissues. The
most common type of radiation burn is the sunburn. Radiation burns are most commonly seen today
following therapeutic radiation therapy and are also seen in patients who receive excessive radiation
from diagnostic procedures.
Local damage varies, depending upon:
(a) Temperature of the burning agent
(b) Duration of contact time
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(c) Type of tissue involved
Zones of tissue damage:
• Inner zone of coagulation (full-thickness injury) – irreversible cell death, skin grafting needed for permanent
coverage
• Middle zone of stasis (deep, partial-thickness injury) – some skin-reproducing cells present in the dermal
appendages with circulation partially intact, healing generally within 14–21 days
• Outer zone of hyperemia(superficial, partial-thickness injury) – minimal cell involvement and spontaneous
healing within 7–10 days
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same
location.

Pathophysiology:

Clinical manifestations:
-
-
-
-
-
Low cardiac index and profound vasoconstriction
Tachycardia and increased resting energy expenditure
Hyperglycemia
Weakness
Impairs wound healing
- Decreased glomerular filtration rate
- Acute kidney injury
- Multiple organ dysfunction
- Reduced chest wall compliance
- Decreased diaphragm strength
- Alveolar airspace enlargement
- Impairs neurosensory perception
- Increases permeability
- Impair cell-mediated immunity with atrophy of the thymus
- Reduced naïve T-cells
- Decreased T-cell memory
Assessment of burn
Extent of burn injury:An accurate estimation of burn size is essential to help therapy and to determine when to
transfer a patient to a burn center. It is expressed as the total percentage of body surface area (ie, TBSA).
Superficial (first-degree) burns are not included in percentage TBSA burn assessment.
Methods of estimation: The two commonly used methods of assessing percentage TBSA in adults are the
Lund-Browder chart and "Rule of Nines."
The Lund-Browder chart is the recommended method in children because it considers the relative percentage of
body surface area affected by growth. If the burn is irregular and/or patchy, the palm method may be more
useful.
●Lund-Browder – This is the most accurate method for estimating TBSA for both adults and children.
Children have proportionally larger heads and smaller lower extremities, so the percentage TBSA is more
accurately estimated using the Lund-Browder

●Rule of Nines – It is the most efficient method to estimate TBSA in adults.


•The head represents 9 percent TBSA
•Each arm represents 9 percent TBSA
•Each leg represents 18 percent TBSA
•The anterior and posterior trunk each represent 18 percent TBSA
●Palm method – Small or patchy burns can be approximated by using the surface area of the patient's palm.
The palm of the patient's hand, excluding the fingers, is approximately 0.5 percent of total body surface area,
and the entire palmar surface including fingers is 1 percent in children and adults.
Assessing depth from the history:
Burning of human skin is temperature and time dependent
It takes 6 hours for skin maintained at 44c* for irreversible changes
A surface temperature of 70c* for 1 second produce epidermal destruction
Example of Exposure to hot water at 65c*
45 second exposure produce full thickness burn
15 second exposure produce deep partial thickness burn
7 second exposure produce superficial partial thickness burn
Anatomical location of burn injury: The location of a burn often directs treatment. Burns on the face, hands,
feet, and genitalia as well as large burns in other areas of the body and those associated with inhalational injury
are often referred to burn centers for specialized expertise.
Age
• For patients less than 2 years of age and greater than 50, there is a higher incidence of morbidity and mortality.
• Sadly, the infant, toddler and elderly are at increased risk for abuse by burning.
Part of the body burned
• Patients with burns to the face, neck, hands, feet or perineum have greater challenges to overcome and require
the specialized care offered by a burn centre.
Past medical history
• Pre-existing cardiovascular, pulmonary or renal disease will be exacerbated by the burn injury.
• Persons with diabetes or peripheral vascular disease have a more difficult time with wound healing, especially
on the legs and feet.
Diagnostic evaluation:
- Complete blood count
- Biochemistry
- Coagulation profile
- Carboxyhemoglobin
- Arterial blood gases
- CT scan
- Wound biopsy
- Viral markers
- Cultures and sensitivity
Techniques used for assessment of burn depth

Technique Advantage Disadvantage

Radioactive isotopes Radioactive phosphorus ( 32 P) taken Invasive, too cumbersome, poorly


up by the skin reproducible

Non fluorescent dyes Differentiate necrotic from living No determination of depth of necrosis;
tissue on the surface many dyes not approved for clinical use.

Fluorescent dyes Approved for clinical use Invasive; marks necrosis at a fixed distance
in millimeters, not accounting for thickness
of the skin;large variability.

Many false positives and false negatives


Thermography Noninvasive, fast assessment
based on evaporative cooling and presence
of blisters; each center needs to validate its
own values

Single-institution experience; Expensive?


Photometry Portable, noninvasive, fast assessment,
validated against senior burn surgeons,
and color palette was developed.

Contact with tissue required, unreliable


Liquid crystal film Inexpensive
readings

In vitro assessment only, expensive, time-


Nuclear magnetic Water content in tissue differentiates
consuming
Resonance partial from full-thickness wounds

Nuclear imaging 99 mTc shows areas of deeper injury


Expensive, very time-consuming, not
readily available, and invasive
Pulse-echo Noninvasive, easily available
ultrasound Underestimates depth of injury, operator-
dependent, and requires contact with tissue
Doppler ultrasound Noncontact technology available,
provides morphologic and flow Operator-dependent, not as reliable as laser
information Doppler

Laser Doppler Noninvasive and noncontact


imaging technology, fast assessment, large Readings affected by temperature, distance
body of experience in multiple centers, from wound, wound humidity, angle of
and very accurate prediction in small recordings, extent of tissue edema, and
wounds in stable patients presence of shock; different versions of the
technology available make extrapolation of
results difficult
- Jaskille AD, Ramella-Roman JC, Shupp JW, Jordan MH, Jeng JC (2010) Critical review of burn depth assessment
techniques: part II. Review of laser Doppler technology. J Burn Care Res 31:151–157

Prognosis:Older age is a strong predictor for in-hospital mortality. Diminished functional reserve and social
support help explain their great morbidity and mortality. Age, along with gender, sex, percentage total body
surface area (TBSA), and concomitant inhalation injury, has consistently been shown to influence morbidity
and mortality following burn injury. Older adults who survive their injuries are at greater risk for long-term
disability and loss of independence.
Older burn patients are also at high risk for repeat hospitalization and late deaths, particularly if they are
discharged to skilled nursing facilities. Older age is also associated with reduced long-term survival for up to
two years after the initial burn injury.
Management of burn:
Combination of the burn mechanism, burn depth, extent, and anatomic location determine the overall severity of
the burn injury, which provides general guidance for the preferred disposition and care of these patients.
Prehospital care:
First Aid Management at the Scene
Steps Action
Step 1: Stop the burning process – remove patient from heat source
Step 2:Maintain airway – resuscitation measures may be necessary
Step 3: Assess for other injuries and check for any bleeding
Step 4: Flush chemical burns copiously with cool water
Step 5: Flush other burns with cool water to comfort
Step 6: Protect wounds from further trauma
Step 7: Provide emotional support and have someone to remain with patient to explain help is on the way
Step 8: Transport the patient as soon as possible to nearby emergency department

Treatment of the Severely Burned Patient on Admission


Step 1: Stop the burning process
Step 2: Establish and maintain an airway; inspect face and neck for singed nasal hair, soot in the mouth or nose,
stridor or hoarseness
Step 3: Administer 100 % high- flow humidified oxygen by non-rebreather mask. Be prepared to intubate if
respiratory distress increases
Step 4: Establish intravenous line(s) with large bore cannula (e) and initiate fluid replacement using Lactated
Ringer’s solution
Step 5: Insert an indwelling urinary catheter
Step 6: Insert a nasogastric tube
Step 7: Monitor vital signs including level of consciousness and oxygen saturation
Step 8: Assess and control pain
Step 9: Gently remove clothing and jewellery
Step 10: Examine and treat other associated injuries
Step 11: Assess extremities for pulses, especially with circumferential burns
Step 12: Determine depth and extent of the burn
Step 13: Provide initial wound care – cool the burn and cover with large, dry gauze dressings
Step 14: Prepare to transport to a burn centre as soon as possible
As per WHO
- In addition, there are a number of specific recommendations for individuals, communities and public
health officials to reduce burn risk.
- Enclose fires and limit the height of open flames in domestic environments.
- Promote safer cook stoves and less hazardous fuels, and educate regarding loose clothing.
- Apply safety regulations to housing designs and materials, and encourage home inspections.
- Improve the design of cook stoves, particularly with regard to stability and prevention of access by
children.
- Lower the temperature in hot water taps.
- Promote fire safety education and the use of smoke detectors, fire sprinklers, and fire-escape systems in
homes.
- Promote the introduction of and compliance with industrial safety regulations, and the use of fire-
retardant fabrics for children’s sleepwear.
- Avoid smoking in bed and encourage the use of child-resistant lighters.
- Promote legislation mandating the production of fire-safe cigarettes.
- Improve treatment of epilepsy, particularly in developing countries.
- Encourage further development of burn-care systems, including the training of health-care providers in
the appropriate triage and management of people with burns.
- Support the development and distribution of fire-retardant aprons to be used while cooking around an
open flame or kerosene stove.
- First aid
- Basic guidance for first Aid is as follows:
What to do?
- Stop the burning process by removing clothing and irrigating the burns.
- Extinguish flames by allowing the patient to roll on the ground, or by applying a blanket, or by using
water or other fire-extinguishing liquids.
- Use cool running water to reduce the temperature of the burn.
- In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water.
- Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate facility for medical
care.
What not to do
- Do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for
chemicals etc.)
- Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn.
- Do not apply ice because it deepens the injury.
- Avoid prolonged cooling with water because it will lead to hypothermia.
- Do not open blisters until topical antimicrobials can be applied, such as by a health-care provider.
- Do not apply any material directly to the wound as it might become infected.
- Avoid application of topical medication until the patient has been placed under appropriate medical care.
Burn center referral criteria:
- Partial-thickness burns greater than 10% of TBSA
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints
- Third-degree burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalation injury
- Burn injury in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality
- Any patient with burns and concomitant trauma (such as fractures) in which the burn
injury poses the greatest risk for morbidity or mortality. In such cases, if the trauma
poses the greater immediate risk, the patient may be stabilized initially in a trauma
center before being transferred to a burn unit. Physician judgment will be necessary in
such situations and should be in concert with the regional medical control plan and
triage protocols.
- Burned children in hospitals without qualified personnel or equipment for the care of
children
- Burn injury in patients who will require special social, emotional, or rehabilitative
intervention
At Hospital/ Inpatient care:
It includes:
- Improved resuscitation
- Enhanced wound coverage
- Infection control
- Management of inhalation injuries
- Prevention of secondary injuries include systemic, psychologic, and social consequences.
Management of burn occurs in three phases:
- Resuscitation/ emergent phase
- Acute phase
- Rehabilitation phase
Resuscitation/ emergent phase: (24-48 hours)
 Primary survey (ABCDE)
 Initial stabilization for myocardial depression and increased capillary permeability resulting in large
fluid shifts and depletion of intravascular volume.
- Airway management:
Secure airway with an endotracheal tube until swelling subsided which is usually 48 hours
Delayed diagnosis of airway burn make difficult to intubate the patient in presence of laryngeal edema so
cricothyroidectomy should be done.
Early intubation of suspected airway burn is the treatment of choice in such patients.
Indication for intubation:
Criteria Value
PaO2 (mmHg) <60
PaCO2 (mmHg) >50 (acutely)
P/F ratio <200
Respiratory/ventilatory failure Impending
Upper airway edema Severe
Severe facial burn
Burns over 40 % TBSA
Clinical signs of severe inhalation injury

Extubation criteria:
In general, early as possible
Criteria Value
PaO2 /FiO2 (P/F) ratio >250
Maximum inspiratory pressure (MIP) (cmH 2 O) >60
Spontaneous tidal volume (ml/kg) >5–7
Spontaneous vital capacity (ml/kg) >15–20
Maximum voluntary ventilation >Twice the minute volume
Audible leak around the ET tube with cuff deflated

- Breathing:
Ensure proper placement of ETT by auscultation/x-ray
Bronchoscopic assessment for inhalation injury
Physiotherapy
Nebulization
Warm humidified oxygen
- Circulatory management:
Establish adequate IV access (large bore IV placed peripherally in non-burnt tissue if possible, central
access would be required but can wait)
Begin resuscitation based on the Parkland formula
Fluid resuscitation
- Parkland formula = 4ml X %burn X (kg) body weight in 24 hours
E.g., 4ml X 50% X 60kg =12000ml in 24 hours
Half this volume is given in the first 8 hours
Second half is given in the subsequent 16 hours
- Other: Evan’s Muir and Barclay Formula
Colloid resuscitation
Plasma proteins are responsible for the inward oncotic Pressure that counteracts the outward capillary
hydrostatic Pressure, without proteins there will be edema
Proteins should be given after first 12 hours of burn before this time proteins will leak out of cells
Common colloid-based - Muir and Barclay formula
0.5 X %age BSA burn X weight (kg) =one portion
Periods of 4/4/4, 6/6, 12 hours respectively
One portion to be given in each period.
Blood and blood product transfusion.
- Brook’s formula: for crystalloid; 1.5ml X weight (kg) X %age BSA
For colloid; 0.5ml X weight (kg) X %age BSA
Free water 2000 ml should be given to the client.
- Galveston Formula: For pediatric burn patients = 5000ml X m2 BSA + 1500ml X m2 BSA
- Monitoring of Fluid resuscitation:
- Monitoring urinary output (0.5ml and 1.0ml/kg/hour)
- If urine output is below this infusion rate should increase By 50%
- If still output is inadequate then a bolus of 10ml/kg given
- 2ml/kg/hr urinary output signals decrease in the rate of Perfusion
- Hematocrit measurement is a useful tool in confirming
- Suspected under or over hydration.
- Disability: It can be prevented by infection control measures that are followed in Burn Unit.
- Immediate burn care and cooling:
- Any hot or burned clothing, jewelry, and obvious debris should immediately be removed.
- Cooling tissue to around 12°C (54°F) for 15-30 min.
- Early wound closure and wound care.
- Pain and anxiety management:
- IV morphine or other opioids
- Benzodiazepine
- Chemoprophylaxis; Tetanus, silver sulfadiazine dressing
Pain management:
- There are three dimensions of pain: pain intensity, behavioral reactions, and physiologic reactions.
- The most common tools used for adults and children with burn pain include verbal adjective scales,
numeric written or visual analog scales, pain assessment in dementia scales, FACES, and FLACC (Face,
Legs, Activity, Cry, consolability).
- The Wong-Baker FACES Pain Scale is designed for children three years and older. This pain scale uses
drawings of faces displaying varying degrees of pain and discomfort. Each face communicates a level of
pain intensity, and the child is asked to choose the face that most accurately describes their pain level.
- The OUCHER scale includes a picture scale for very young children and a numerical scale that can be
used in children over five years old.
Pharmacologic treatment: It includes:
- Opioid analgesics
- Nonopioid analgesics
- Anxiolytics
- Anesthetics.
- The type of medication used is determined by the severity of pain, the anticipated duration of pain, and
intravenous (IV) access.
- There is always we found "background pain" associated with acute burn wounds, long-acting oral opioid
e.g., methadone helps to maintain constant plasma level of analgesia.
- Nonopioid analgesics eg, acetaminophen
- Continuous IV opioid infusion eg, morphine and regularly scheduled benzodiazepines e.g., lorazepam in
patients unable to take oral medications.
Opioid analgesics — Opioid analgesics, the most common type of medication used for acute pain relief,
are potent and provide a dose-dependent degree of sedation important during burn wound care
procedures.
- Route of administration: Intravenously, Orally.
- Other methods includes: Patient-controlled analgesia (PCA) with IV opioids offers the burn patient a
safe and efficient method of achieving more flexible analgesia, provided the patient is alert and
competent enough to use the device.
- Oral or gastrointestinal administration of opioids via an enteral tube provides potent pain relief with
rapid onset and short duration of action and requires minimal monitoring. Oral transmucosal
administration is particularly helpful for performing burn dressing changes in children.
Nonopioid analgesics:
- Dexmedetomidine provides sedation, anxiolysis, and analgesia for burned children, with less respiratory
depression than other sedatives.
- Ketamine has a long history of use in burn-injured patients, particularly for procedural wound care pain.
Studies suggest it is both an effective and safe analgesic in adult and pediatric patients with burns.
- Other nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs
(NSAIDs), provide mild analgesia and can supplement opiates. They are most commonly used to treat
minor burn pain in the outpatient settings.
Anxiolytics:
- Anxiety in burn patients is mostly related to surgical procedures and future consequences of the burn
injuries. To relieve the anxiety patients need anxiolytics:
- First-generation antipsychotics e.g., haloperidol are used adjunctively for treatment or prevention of
hyperactive delirium and agitation in critically ill patients.
- Second-generation antipsychotics e.g., quetiapine are increasingly used for treating various anxiety
disorders and may be useful in combination with a benzodiazepine for managing anxiety and improving
sleep in burn patients.
Anesthetics:
- It includes: general anesthesia, peripheral nerve block, neuraxial anesthesia for management of burn
pain in various clinical settings.
- General anesthesia or deep sedation — A general anesthetic or deep sedation provides relief of
relatively brief, intense pain that would be experienced during a procedure, such as extensive wound
debridement, or dressing changes that occur outside of the operating room. While the risks of
complications following a general anesthetic are typically low in healthy individuals, burn patients have
metabolic, physiologic, and thermoregulatory abnormalities as well as possible inhalation injuries that
are associated with increased risk of complications of perioperative hypothermia, hypoxemia, and
abnormal responses to some anesthetic agents and to both depolarizing and non-depolarizing muscle
relaxants. Example, propofol clearance and volume of distribution are increased in patients with major
burns and may require larger bolus and/or infusion doses to maintain therapeutic plasma drug
concentrations.
- Inhaled nitrous oxide is an anesthetic agent that can be safely administered and provides effective
analgesia without loss of consciousness (ie, moderate sedation) for moderately painful procedures. It can
be used for the treatment of burn pain, typically as a 50 percent mixture in 50 percent oxygen, and self-
administered by an awake, cooperative, and spontaneously breathing patient via a mouthpiece or mask.
- Peripheral nerve block — Regional anesthesia is achieved by injecting a local anesthetic agent
(e.g., bupivacaine, lidocaine) around a nerve to block the sensory stimulation from that area innervated
by the nerve. These are particularly useful for procedures and burn pain relief involving the extremities.
- The most common nerve groups accessible for a nerve block include the brachial plexus (interscalene
block, infraclavicular block, and axillary block), the sciatic nerve, and the femoral nerve. Other nerve
blocks include the fascia iliaca compartment blockade (FICB) and lateral femoral cutaneous nerve
block, which can be used for lower extremity analgesia following skin graft harvesting.
- Neuraxial anesthesia: Neuraxial anesthesia is the administration of an anesthetic agent
(e.g., bupivacaine, lidocaine) and/or opioid analgesics via a spinal or epidural catheter with the goal of
providing background, procedural, and postoperative pain relief. This procedure has only been
anecdotally used in burn patients. A major drawback to the use of neuraxial anesthesia is the potential
colonization of the indwelling catheter, particularly if inserted through burned skin, and the associated
risks of meningitis and epidural abscess formation.
Local treatment of pruritus:
- Pruritus tends to present early during wound healing and continues well after reepithelialization and scar
maturation and can significantly impact quality of life of patient.
- Systemic and topical application, have been used for the treatment of post-burn pruritus.
- Systemic first-line treatment for post-burn pruritus consists of H1 and H2 antihistamines
(eg, diphenhydramine, cetirizine, cimetidine), but none has provided complete relief. Other systemic
agents that may prove helpful include cyproheptadine, hydroxyzine, gabapentin, and tricyclic
antidepressants (e.g., doxepin).
- Topical treatments, which may provide relief of pruritus, include:
- Aloe Vera
- Vaseline-based creams
- Cocoa butter
- Mineral oil
- Hydrogel sheets (e.g., Tegagel, Vigilon, Flexi Gel)
- Topical glucocorticoids
- Colloidal oatmeal in liquid paraffin
- UNNS boot (glycerin, zinc oxide, and calamine lotion)
- EMLA, which is a mixture of local anesthetics
- Topical doxepin
- Silicone gel sheeting
- Compression garments
- Massage therapy
- The role of topical glucocorticoids (e.g., hydrocortisone, triamcinolone) varies importantly with the
stage of the burn. These agents can be applied to re-epithelialized wounds. In contrast, topical
glucocorticoids are not used on unhealed burns, since they can lead to thinning of the healing skin,
infection, and systemic absorption.
- Topical agents high in lanolin should be avoided, since they can worsen pruritus.
- Other therapies that have been evaluated for the treatment of pruritus in burn patients include pulsed dye
laser and transcutaneous electrical nerve stimulation (TENS), which remains predominantly
experimental.
Nonpharmacological treatment:
- These are complementary to pharmacologic approaches when treating pain, anxiety, and pruritus in the
burn patient.
- Examples illustrate the types of coping styles to burn and procedural pain:
- Avoidance – Those burn patients who wish to give up control to the health care professional have a
tendency toward cognitive avoidance, or an "avoidant" style of coping mechanism. They will likely use
various types of distraction techniques to avoid the painful stimuli.
- Approach – Those burn patients who seek out information about the procedure and attempt to participate
and not relinquish control have an "approach" style of coping mechanism. These patients often find
distraction techniques distressing as trying to ignore a procedure may serve to relinquish too much
control.
- It is best for the burn care team to support an individual's coping style rather than try to change the
natural response. Patients may also change their coping style depending on the procedure. As an
example, a patient may find it is easier to use distraction techniques for short procedures such as
receiving injections, whereas they are more comfortable attending to details of their long wound care
sessions and participating when possible. Patients may also change their coping style as they become
more familiar and comfortable with the environment.
Avoidance techniques: Avoidance interventions are designed to psychologically distract or distance the
patient from the pain. The Multiple Resource Theory of Attention suggests that diverting attention
toward a nonpainful stimulus may lessen the intensity of perceived pain. The four interventions in the
avoidance category include distraction, guided imagery, hypnotic analgesia, and virtual reality.
Distraction: Distraction is the most common intervention activated by patients or the provider as an
adjunct for pain management in burned children. The types of distraction techniques available to reduce
burn pain are limited only by the creativity of patients and health care professionals. Common
distraction techniques used with children include bubble blowing, singing songs, reading a story, and
counting. For adults it include engaging in enjoyable conversation during the procedure, listening to
music, or playing a video game.
Guided imagery: Imagery is an integrative therapy that incorporates imagined pictures, sounds, or
sensations for specific therapeutic goals, such as the reduction of burn pain. While the patient is engaged
in the imagery scene, less attention is available for the painful stimuli.
Patients using imagery simply create or recreate an image in their mind, presumably one that they find
pleasant and engaging. Prior to a painful procedure, we often have the patient elicit a "safe" or "favorite"
place to go. This can be a place where they have been before (eg, a favorite vacation spot) or simply a
place that they imagine to be relaxing and safe. The clinician then simply cues the patient with the
details that they have provided and we encourage them to imagine this place during their subsequent
wound care.
Hypnotic analgesia: Hypnosis is an altered state of consciousness characterized by an increased
receptivity to suggestion, ability to alter perceptions and sensations, and an increased capacity for
dissociation. Hypnotic analgesia should only be used by trained clinicians who can assess the risks and
benefits of this powerful technique.
Hypnosis involves several stages including:
Building clinician-patient rapport
Enhancing relaxation through deep breathing
Suggestions for deepening the hypnotic state
Narrowing the patient's attention
Providing posthypnotic suggestions
Alerting stage
Burn patients are good candidates for hypnotic analgesia because:
- The intense nature and severity of burn pain motivates patients to engage in hypnosis.
- The behavioral regression that often occurs after a traumatic injury makes patients more willing to be
taken care of by others.
- Patients with burn injuries often experience a dissociative response as a means of coping that may
moderate hypnotizability.
- Procedures, which cause the most intense pain, can be scheduled and thus allow hypnosis to be
performed in advance of the painful stimulus.
Virtual reality: Virtual reality diverts attention away from the painful sensations by immersing patients
in a computer-generated environment. Burn patients can interact with the computer while painful
procedures, such as dressing changes, and range-of-motion therapy are performed.
Approach technique: The most commonly used approach technique is information provision.
Information provision: Information provision assists the patient's understanding of the issues,
alternatives, and solutions. This process provides information on how his/her input will affect the end
result, and sharing information can build trust and mutual understanding. This helps to create a sense of
control over one's environment.
- Relaxation techniques: Relaxation techniques are used to lower arousal, including unnecessary muscle
tension that can increase pain.
The techniques include:
Deep breathing exercises
Progressive muscle relaxation exercises
Cognitive behavioral techniques.
Deep breathing: When a person becomes anxious and/or experiences pain, breathing can become
shallow and irregular due to the increased muscle tension, known as thoracic breathing, Deep breathing
techniques allow patients to become aware of shallow irregular breathing and leads to relaxation that
may alleviate some pain. Children can be taught bubble blowing or blowing on a pinwheel to encourage
deep breathing. Adults can be taught to place a hand on their stomach and to take a breath deep enough
that it passes through their chest and fills their stomach (shallow breathing is more in the chest and will
not cause as much hand movement on the stomach.
Progressive muscle relaxation: Muscle tension increases as patients experience stress and pain; hence,
the focused effort on sequentially relaxing and tensing muscles in a controlled manner diverts the
attention away from the pain. Progressive muscle relaxation is a technique used to reduce anxiety
associated with painful stimuli, such as burn dressing changes, by alternately tensing then relaxing
muscles. Muscles are sequentially tensed (10 seconds) and relaxed (20 seconds) through various parts of
the body, and the technique can be performed during dressing changes.
Cognitive behavioral techniques: Cognitive behavioral therapy (CBT) is used to treat multiple
conditions by changing thoughts and behaviors. For treatment of burn patients, CBT includes diversion,
information provision, coping skills, and relaxation techniques to modify the patient's thought process
about the painful experience.
Expectations of a bad outcome, such as intense pain, are associated with higher levels of perceived pain.
This is known as catastrophizing. CBT can be used adjunctively to manage these expectations and
associated pain in the following manner
Recognize that the procedure will cause pain (anticipatory pain or distress).
Stop the thought that the procedure will cause pain by active efforts to reduce catastrophic thinking.
Distract from the pain by diverting attention to another thought.
Mind fullness meditation: Mindful meditation is another Nonpharmacological strategy that combines
attention, cognitive restructuring, and relaxation.
It involves purposeful attention on the present moment in a nonjudgmental and accepting manner. It
includes:
- Meditation is to clear the mind and self-regulate the body to achieve a state of relaxation. It should be
done for 20 min prior procedure.
The organ system sequelae of electrical injury and proposed management
System Sequelae Management
Neurologic/sensory: Loss of consciousness Need to monitor patients and have
Motor and sensory deficits (can be closefollow-up for possible delayed
delayed) presentation.
Traumatic brain injury
Tympanic membrane rupture
Delayed cataracts

Cardiovascular Arrhythmias,dysrhythmias Initial ECG, followed by cardiac


Myocardial infarction monitoring for up to 24–48 h based on
Vascular injury (thrombosis) presence of:
ECG abnormalities, Cardiac arrest
Loss of consciousness, Role of markers of
cardiac damage such as troponin, CK, CK-
MB unknown

Respiratory/ Pneumothorax Treat with chest tube. Treat with chest tube
Abdominal Pneumothorax Treat in accordance to the priority of injury
Blunt abdominal injury Treat in as per ATLS and trauma center guidelines.
accordance to the priority of injury
Evisceration as per ATLS and trauma
center guidelines
Ileus, gastroparesis

Renal Myoglobinuria Increase fluid resuscitation to maintain a


Acute tubular necrosis urine output of 1 ml/kg/h
Some controversy regarding alkalinization
(with sodium bicarbonate infusion) of urine
and forced diuresis (with mannitol)

Musculoskeletal Muscle necrosis Compartment decompression as necessary:


Compartment syndrome  Progressive neurologic dysfunction
Rhabdomyolysis  Increased compartment pressure
Fracture  Vascular compromise
 Clinical deterioration from
myonecrosis
Excision of all nonviable tissue
Might require amputation
Manage orthopedic injuries with
appropriate
Consultation

Management principles for chemical burns


Removal of chemical agent:
Removal of involved clothing
Thorough and copious irrigation with water except for:
Phenol: Wipe off with 50 % polyethylene glycol sponges
Dry lime: Dust off prior to lavage.
Muriatic acid, sulfuric acid: Neutralize with soap or lime water.
Systemic toxicity:
HF acid: Hypocalcemia and ventricular fibrillation.
Formic acid: Intravascular hemolysis, renal failure, pancreatitis
Organic solutions and hydrocarbures: Liver failure
Respiratory injury: Can occur with all inhaled agents and must be treated in same manner as inhalation injury.
Antidotes:
Hydrofluoric acid: Inject 10 % calcium gluconate sub-eschar
White phosphorus: Lavage with 1–2 % copper sulfate
Wound care:
Wound dressing as for thermal burns
Early excision of nonviable tissue
Ophthalmology consult for ocular involvement in addition to copious irrigation.
General Principles in Treatment of Frostbite:
1. Admit patient to specialized unit if possible.
2. On admission, rapidly rewarm the affected areas in warm water at 40–42 °C for 15–30 min or until thawing is
complete.
3. On completion of rewarming, treat the affected parts as follows:
(a) Debride white blisters and institute topical treatment with aloe vera every 6 h.
(b) Leave hemorrhagic blisters intact and institute topical aloe vera every 6 h.
(c) Elevate the affected part(s) with splinting as indicated.
(d) Administer anti-tetanus prophylaxis.
(e) Antibiotics as indicated.
(f) Analgesia: opiates as indicated.
(g) Administer ibuprofen 400 mg orally every 12 h.
4. Prohibit smoking.
5. Treat wounds expectantly, allow for demarcation, and treat surgically as indicated.
Murphy JV, Banwell PE, Roberts AH, McGrouther DA (2000) Frostbite: pathogenesis and treatment. J Trauma 48(1):171–178

Acute phase:
Secondary survey and management:
Complete head to toe assessment of patient
Obtain information about the patient’s past medical history, mediations, allergies, tetanus status
Determine the circumstances/mechanism of injury
Entrapment in closed space
Loss of consciousness
Time since injury
Flame, scald, grease, chemical, electrical
Examination should include a thorough neurological assessment
All extremities should be examined to determine possible neurovascular compromise (i.e., possible
compartment syndrome) and need for escharotomies
Burn size and depth should be determined at the end of the survey
Laboratory studies and monitoring.
Wound management:
- Thorough wound cleaning and irrigation
- Hydrotherapy
- Wound dressing and amputation
- Escharotomy
- Wound debridement; Natural Debridement
Mechanical Debridement
Surgical Debridement
Grafting
Local burn wound care:
Goals: This aims to:
- Protect the wound surface
- Maintain a moist environment
- Promote burn wound healing
- Limit burn wound progression while.
- Burn wound surfaces are prone to rapid bacterial colonization with the potential for invasive infection.
To reduce the likelihood of infection include:
- Good infection control practices
- Topical antimicrobial therapy
- Burn wound debridement/excision
- Closed dressing management is often advocated to minimize cross-contamination by pathogens (eg,
methicillin-resistant Staphylococcus aureus) that can cause burn wound infection, delayed wound
healing, and loss of skin grafts.
- Wounds that become infected require systemic antimicrobial therapy.
Dressings:  A variety of antimicrobial agents can be applied to the burn wound surface, which is then covered
with one of several dressing materials (eg, gauze, non-adherent films).
- Dry gauze promotes scab formation. However, pain can be significant when the gauze is removed.
- Non-adherent films or fine mesh gauze (in combination with topical antimicrobials) are common
dressings used to cover the burn wound, and films, foams, alginates, hydrocolloids, and hydrogels can
also be used depending on the specific qualities of the dressing (eg, silver containing) and the specific
needs of the burn wound.
- Partial-thickness burns: It have moderate-to-high amounts of exudate, foams and alginates are used.
- Flap or a graft donor site that has minimal-to-moderate exudate, the use of polyurethane, hydrocolloids,
or hydrogels may be adequate.
- Coverage of clean, uninfected burn wounds can also be accomplished using biologic dressings or skin
substitutes. These are applied once and adhere to the wound, separating spontaneously as healing
progresses.
- Dressing changes should be frequent enough to control exudate but not so frequent that they interfere
with wound reepithelialization. The frequency ranges from twice daily to weekly depending upon the
amount of exudate and choice of dressing material.
- Topical antimicrobials should be gently removed with dressing changes. Excessive scrubbing and sharp
debridement is not necessary and may hinder healing.
- Superficial burn wound: Superficial burns do not require antimicrobial therapy, but for extensive
superficial burns:
- Topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing
environment.
- Deep burn wounds: It includes (deep partial thickness, full thickness, and deeper) and require burn
wound excision and graft/flap coverage.
The deep burn wound site may often constitute a mixed pattern of injury with differing permeability and
compromised barrier function.
- Prior to definitive care and burn wound excision, a preliminary gauze dressing is often first applied.
Excising full-thickness eschar removes the biologic and bacterial burden.
- Fine mesh gauze in combination with topical antimicrobials, typically silver-containing agents or
dressings (eg, Silvadene, Sulfamylon, Acticoat), is used to provide a moist and minimally adherent
provisional dressing until definitive debridement or surgical excision can be performed following eschar
debridement untill flap reconstruction take place
- Provisional coverage with allograft, biologics, and biosynthetic is applicable when the wound bed is
optimized.
- Colonized/contaminated/infected burn wounds: When contamination with methicillin-
resistant Staphylococcus aureus (MRSA) is suspected/confirmed, directed topical antimicrobial
treatment e.g., mupirocin and mafenide should be added as a treatment.
Dressings are also used after surgery to cover and protect skin grafts and skin graft donor sites.
Antimicrobial agents:
Commonly used agents: Commonly used topical agents for partial-thickness burns include: Antimicrobial
ointments
Silver-containing agents
Bismuth-impregnated petroleum gauze
Chlorhexidine
Mafenide.
Antimicrobial ointments: Topical antimicrobial ointments, as single agents or combination agents, are
commonly used for superficial burn wounds.
Polysporin is a combination of bacitracin zinc and polymyxin B sulfate. It can be used to treat partial-thickness
burns, particularly those that involve the face and perineum
For uncomplicated wounds, many clinicians apply Polysporin ointment covered by a nonadherent dressing.
Areas near the eyes are generally managed with ophthalmic derivatives, such
as neomycin or erythromycin ophthalmic ointment.
Criteria for Burn Wound Coverings
• Absence of antigenicity
• Tissue compatibility
• Absence of local and systemic toxicity
• Water vapor transmission similar to normal skin
• Impermeability to exogenous microorganisms
• Rapid and sustained adherence to wound surface
• Inner surface structure that permits ingrowth of fibro vascular tissue
• Flexibility and pliability to permit conformation to irregular wound surface, elasticity to permit motion of
underlying body tissue
• Resistance to linear and shear stresses
• Prevention of proliferation of wound surface flora and reduction of bacterial density of the wound
• Tensile strength to resist fragmentation and retention of membrane fragments when removed
• Biodegradability (important for “permanently” implanted membranes)
• Low cost
• Indefinite shelf life
• Minimal storage requirements and easy delivery
Topical therapy for treatment of cutaneous burns

Agent Description
Bacitracin/polymyxin B Ointment for superficial burns

Mupirocin 2 % Ointment for superficial burns. Activity against MRSA

Artificial skin substitute bilayer – silicone film with a nylon fabric outer layer and
Biobrane a trifilament thread with collagen bound inner layer
For treatment of superficial dermal burns, Biobrane can be left intact until wound
fully healed, Reduces pain and evaporative losses

Aquacel Ag Methylcellulose dressing with ionic silver for superficial dermal burns
Can be left intact until wound fully healed. Wound base needs to be clean for
dressing Adherence

Silver sulfadiazine 1 % cream for deep dermal and full-thickness burns. Has broad spectrum of
activity. Intermediate eschar penetration

Mafenide acetate Available as 11 % water-soluble cream or 5 % solution for deep dermal and full-
thickness burns. Has broad spectrum of activity, however, minimal activity against
staphylococcus species. Excellent eschar penetration

Acticoat Sheet of thin, flexible rayon/polyester bonded with silver crystal-embedded


polyethylene mesh. Can be left on the wound for 3–7 days. Has broad-spectrum
activity

Escharotomy: All deep circumferential burns to the extremity have the potential to cause neurovascular
compromise and therefore benefit from escharotomies. The typical clinical signs of impaired perfusion in the
burned extremity/hand include cool temperature, decreased or absent capillary refill, tense compartments, with
the hand held in the claw position, and absence of pulses is a late sign.
For the hand, the Escharotomy is performed along the second and fourth metacarpals, and for the fingers, care is
taken to prevent any neurovascular damage; therefore, escharotomies are typically not performed along the
ulnar aspect of the thumb or the radial aspect of the index finger.
Negative-Pressure Wound Therapy (Vacuum-Assisted Closure):
Negative-pressure wound therapy or vacuum-assisted closure (VAC ®) can be used the local therapy in STSG
receiver regions of inferior take and allowed for early mobilisation in functionally important zones.
Fluidized Microsphere Beads-Bed:
Fluidized microsphere beads-beds can be used for wound preconditioning but also for postoperative wound
care. This method allows the removal of moisture in order to keep wounds dry and to permit maintenance of
constant temperature levels in areas in direct contact with the bed’s superficial fabric. Only thin sterile covers
are employed to shield dorsal burned areas while in these beds, and no extra ointments are applied. For wound
coverage of freshly operated areas, we prefer to use fat gauzes and dry sterile compresses.
Patients with arising difficulties in respiratory management or temperature control while in fluidized
microsphere beads-beds were temporarily transferred to standard intensive care beds
Temporary burn wound coverage:
Biologic grafts: Biologic graft materials that can be used for temporary coverage of burn wounds include
allografts, xenografts, and others (eg, human amnion). These help promote healing or can serve as a bridge to
definitive burn wound coverage.
Biologic grafts can be used on clean burn wounds, and they protect the wound from desiccation while
promoting reepithelialization. The graft separates from the wound once it has re-epithelialized. Biologic grafts
are especially useful in children as they are applied only once, decreasing the pain that typically accompanies
wound dressing changes.
- Allografts:Transient physiologic coverage can be achieved by allogeneic skin grafts (eg, from a non-
genetically identical donor from the same species, also called homograft). Allografts are distributed as
either fresh or cryopreserved after glycerol preservation from cadavers. The application of an allograft
over superficial partial-thickness wounds can minimize pain and facilitate reepithelialization. Allogeneic
skin is generally used only in burn centers.
- Xenografts: Xenografts are generally readily available but may not be as effective as allografts. Skin
xenografts, obtained from an unrelated species (heterograft), are used as temporary skin coverage,
especially for large burn wounds. Various animal skins have been used in the past, but only porcine
grafts are currently used. Porcine-derived xenografts do not vascularize but will adhere to a clean
superficial wound, accelerate reepithelialization, and reduce pain. Xenografts are easier and cheaper to
produce, and more readily available, but are not as effective as allografts. Large-dimensional sheets can
be processed, facilitating coverage.
- Human amnion: Human amniotic membrane has been successfully used as a biologic dressing for
partial-thickness wounds. However, concerns regarding pathogenic transmission have limited its use. An
allograft consists of sterilized, dehydrated human amnion/chorion membrane (dHACM). dHACM
contains growth factors that promote wound healing, including platelet-derived growth factor A and B,
basic fibroblastic growth factor, and transforming growth factor beta 1, and it is stable at ambient
temperatures for five years.
- Semi biologic skin substitutes: Semi biologic skin substitutes are temporary biosynthetic dressings that
are meant to reduce the number of dressing changes and facilitate healing. The semipermeable nature of
these dressings allows wound exudate to be absorbed by the external bulky dressing. The type of skin
substitute chosen depends upon the appearance of the wound, desired outcome, clinician experience,
availability, cost, and cultural preferences, as some are porcine derived.
- Biobrane and Biobrane-like: Biobrane is used to cover donor sites and aid in coverage of large surface
area burns, including hands, feet, and joints. Biobrane is sometimes used on full-thickness excisions as a
temporary covering to protect the excised wound site in a staged fashion prior to subsequent stage skin
grafting.
Biobrane is a bilaminate membrane that contains a thin semipermeable silicone membrane bonded to a
layer of nylon fabric mesh and coated with a monomolecular layer of type 1 porcine collagen. The
porcine collagen provides a hydrophilic coating for fibrin growth that promotes wound adherence.
Biobrane has no inherent antimicrobial activity, but the membrane is porous, allowing absorption of
topical antimicrobial agents and drainage of exudate. Biobrane is versatile and has additional properties
of flexibility, elasticity, and transparency for wound observation.
Some biosynthetic dressings incorporate Biobrane or are of a similar nature, including Transcyte
(neonatal fibroblast incorporated into Biobrane), Suprathel (resorbable caprolactone-based materials),
and Omiderm (hydrophilized polyurethane membrane). AWBAT, a derivative of Biobrane, is a porous
silicone-nylon membrane coated with porcine type 1 collagen.
Biobrane is applied by gently stretching the fabric over the burn surface to avoid wrinkles and is secured
to nonburned skin with paper strips.
Dry gauze is used to cover the Biobrane, and the dressings are secured with an elastic bandage. The
external dressings are changed every 24 hours, and any fluid accumulating under the Biobrane is
aspirated. Biobrane can be left in place for up to 14 days, then removed in a warm bath or trimmed.
Healed wounds are treated with topical agents or creams. If there is evidence of a wound infection, the
Biobrane is removed and the burn treated with topical antimicrobials.
- Nutritional and metabolic support:
Goal: To provide an adequate energy supply and the nutrients necessary to maintain organ function and
survival.
- The preferred route to administer nutrition is oral/NG or NJ tubers.
- Other routes are total parenteral nutrition, peripheral parenteral nutrition.
- Enteral nutrition (EN) decreases bacteremia, reduces sepsis, maintains motility of the gut, and
preserves“first pass” nutrient supply to the liver. In cases where enteral feeding is not applicable (e.g.,
prolonged ileus or intolerance to enteral feeding), parenteral nutrition should be used to maintain
appropriate macro- and micronutrient intake
- Healthy individuals require approximately 1 g/kg/day of protein intake.
- At least 1.5–2.0 g/kg/day protein should be given to burn patients.
- Critically ill, burned patients have caloric requirements that far exceed the body’s ability to assimilate
glucose, which has been reported to be 5 mg/kg/min or approximately 7 g/kg/day (2,240 kcal for an 80
kg man)
- Early provision of nutritional support, maintenance of warm ambient temperatures, and control of
infection are important strategies to mitigate the hyper metabolic response to burn injury that results in a
catabolic state.
Oxandrolone: Itpromote anabolism in both older men and women after only two weeks of therapy. For
older adults is lower (5 mg/day). It is effective in restoring lean body mass and reducing length of stay in
older burn patients.
Nonselective beta blocker propranolol reduces tachycardia, energy expenditure
Insulin: Mostly used in older adults.
Stem cell based therapies:Other than transplantation, recruiting endogenous stem cells to the site of injury
presents an alternative for the treatment of cutaneous wounds. However, several issues need to be considered
before administering stem cells to wound patients:
Functionality of stem cells decreases with age, thus older patients may not present the perfect population as
donors.
The risk of immunological rejection upon transplant or transfusion must be considered if using stem cells from
allogeneic sources.
Infection control:
Infections remain a leading cause of death in burn patients. This is as a result of loss of the environmental
barrier function of the skin predisposing these patients to microbial colonization leading to invasion.
The pathophysiological progression of burn wound infection runs the spectrum from bacterial wound
colonization to infection to invasive wound infection. The characteristics of each are as follows:
• Bacterial colonization
- Bacterial levels <105
- Does not necessarily prevent wound healing
• Bacterial infection
- Bacterial levels >105
- Can result in impaired wound healing and graft failure
- Can lead to systemic infection
• Invasive wound infection
- Clinically can have separation of the eschar from wound bed
- Appearance of focal dark brown, black, or violaceous discoloration of the wound
- Presence of pyocyanin (green pigment) in subcutaneous fat
- Erythema, edema, pain, and warmth of the surrounding skin
- Associated with signs of systemic infection/sepsis and positive blood cultures
Infection control management:
The treatment of burn wound infections involves both local and systemic therapy.
Local:
• Early excision of burn eschar (for un-excised burns)
• Aggressive excision of necrotic/infected tissue
• Topical agents to minimize bacterial colonization.
The use of any particular topical agent should be based on suspected organism in the wound but is at times
guided by the availability of the agent on hospital formulary.
These are not substitute for aggressive surgical management of wound infections.
Systemic
• Use of antibiotics and antifungals should be reserved for patients demonstrating systemic signs of sepsis (see
ABA criteria for definition of sepsis.
• Use of systemic prophylaxis can reduce the rate of surgical wound infections but can increase bacterial
antimicrobial resistance.
• The choice of antimicrobials needs to be based on each institution’s antibiogram and tailored specifically to
the organism, i.e., narrow the coverage as soon as sensitivities become available.
Ross Tilley Burn Centre guidelines for empiric antibiotic therapy
Early phase (<5 days)
The most common pathogens (from any source) in the early phase of a patient’s admission are:
Gram-positive Staphylococcus aureus (~90 % susceptible to cloxacillin)
Gram-negatives (95 % susceptibility to ceftriaxone)
H. influenza
E. coli
Klebsiella spp.
Based on this data, septic patients admitted within the past 5 days should be started on an empiric
regimen of:
Ceftriaxone 1 g IV q24 h
+/− Cloxacilliin 1–2 g IV q4–6 h (renal dosing required)
Penicillin allergy
Levofloxacin 750 mg IV/PO q24 h
Late phase (>5 days)
The most common pathogens (from any source) in the late phase of a patient’s admission are:
Gram-positive
Staphylococcus aureus (only ~60 % susceptible to cloxacillin)
Gram-negative (generally more predominant in the late phase)
Pseudomonas aeruginosa (>80 % susceptible to piperacillin/tazobactam)
Based on this data, septic patients admitted 5 days or more should be started on an empiric regimen of:
Piperacillin/tazobactam 4.5 g IV q6 h (renal dosing required)
+ Vancomycin 1 g IV q12 h (with pre- and post-levels around the third dose)
Or
Meropenem 500 mg IV q6 h (renal dosing required)
ABA Criteria for Definition of Sepsis
Includes at least three of the following:
Temperature >39° or <36.5 °C
Progressive tachycardia
• Adults >110 bpm
• Children >2 SD above age-specific norms (85 % age-adjusted max heart rate)
Progressive tachypnea
• Adults >25 bpm not ventilated. Minute ventilation >12 L/min ventilated
• Children >2 SD above age-specific norms (85 % age-adjusted max respiratory rate)
Thrombocytopenia (will not apply until 3 days after initial resuscitation)
• Adults <100,000/mcl
• Children >2 SD below age-specific norms
Hyperglycemia (in the absence of preexisting diabetes mellitus)
• Untreated plasma glucose >200 mg/dL or equivalent mM/L
• Insulin resistance—examples include:
– >7 units of insulin/h intravenous drip (adults)
– Significant resistance to insulin (>25 % increase in insulin requirements over 24 h)
Inability to continue enteral feedings >24 h
• Abdominal distension
• Enteral feeding intolerance (residual >150 mL/h in children or two times feeding rate in adults)
• Uncontrollable diarrhea (>2,500 mL/day for adults or >400 mL/day in children)
In addition, it is required that a documented infection (defined below) is identified:
• Culture-positive infection
• Pathologic tissue source identified
• Clinical response to antimicrobials
American Burn Association Practice Guidelines for Prevention, Diagnosis, and Treatment of Ventilator-
Associated Pneumonia (VAP) in Burn Patients:
• Mechanically ventilated burn patients are at high risk for developing VAP, with the presence of inhalation
injury as a unique risk factor in this patient group.
• VAP prevention strategies should be used in mechanically ventilated burn patients.
• Clinical diagnosis of VAP can be challenging in mechanically ventilated burn patients where systemic
inflammation and acute lung injury are prevalent. Therefore, a quantitative strategy, when available, is the
preferable method to confirm the diagnosis of VAP.
• An 8-day course of targeted antibiotic therapy is generally sufficient to treat VAP; however, resistant
Staphylococcus aureus and Gram-negative bacilli may require longer treatment duration.
Catheter-related infection
Type of infection Criteria
Catheter colonization: A significant growth of a microorganism from the catheter tip, subcutaneous segment,
or catheter hub in the absence of clinical signs of infection
Exit-site infection: Microbiologically documented exudates at catheter exit site yield a microorganism with or
without concomitant bloodstream infection.
Clinically documented erythema or induration within 2 cm of the catheter exit site in the absence of associated
bloodstream infection and
Without concomitant purulence
Positive blood culture: Microorganism, potentially pathogenic, cultured from one or more blood culture
Bloodstream infection: Positive blood culture with a clinical sepsis.
Clinical sepsis: Requires one of the following with no other recognized cause:
Fever (>38 °C), hypotension (SBP <90 mmHg), oliguria, paired quantitative blood
cultures with a >5:1 ratio catheter versus
Peripheral, differential time to positivity (blood culture obtained from a CVC is positive
at least 2 h earlier than a peripheral
Blood culture)

Guidelines for management of sepsis and septic shock


Initial resuscitation: (first 6 h)
- Begin resuscitation immediately in patients with hypotension or elevated serum lactate >4 mmol/L; do
not delay pending ICU admission
- Resuscitation goals:
- CVP 8–12 mmHg
- Mean arterial pressure ³ 65 mmHg
- Urine output ³ 0.5 mL/kg/h
- Central venous (superior vena cava) oxygen saturation>70 % or mixed venous>65 %
Diagnosis:
- Obtain appropriate cultures before starting antibiotics provided this does not significantly delay
antimicrobial administration
- Obtain two or more BCs
- One or more BCs should be percutaneous
- One BC from each vascular access device in place >48 h
- Culture other sites as clinically indicated
- Perform imaging studies promptly to con firm and sample any source of infection, if safe to do so
Antibiotic therapy:
- Begin intravenous antibiotics as early as possible and always within the first hour of recognizing severe
sepsis and septic shock
- Broad-spectrum: one or more agents active against likely bacterial/fungal pathogens and with good
penetration into presumed source
- Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity, and
minimize costs
- Consider combination therapy in Pseudomonas infections
- Consider combination empiric therapy in neutropenic patients
- Combination therapy £ 3–5 days and de-escalation following susceptibilities
- Duration of therapy typically limited to 7–10 days; longer if response is slow or there are undrainable
foci of infection or immunologic deficiencies
- Stop antimicrobial therapy if cause is found to be noninfectious
Source identification and control:
- A specific anatomic site of infection should be established as rapidly as possible and within first 6 h of
presentation
- Formally evaluate patient for a focus of infection amenable to source control measures (e.g., abscess
drainage, tissue debridement)
- Implement source control measures as soon as possible following successful initial resuscitation
(exception: infected pancreatic necrosis, where surgical intervention is best delayed)
- Choose source control measure with maximum efficacy and minimal physiologic upset. Remove
intravascular access devices if potentially infected.
Fluid therapy:
- Fluid-resuscitate using crystalloids or colloids
- Target a CVP of >8 mmHg (>12 mmHg if mechanically ventilated)
- Use a fluid challenge technique while associated with a hemodynamic improvement
- Give fluid challenges of 1,000 mL of crystalloids or 300–500 mL ofcolloids over 30 min. More rapid
and larger volumes may be required insepsis-induced tissue hypoperfusion
- Rate of fluid administration should be reduced if cardiac filling pressures increase without concurrent
hemodynamic improvement
Vasopressors:
- Maintain MAP> 65 mmHg
- Norepinephrine and dopamine centrally administered are the initial vasopressors of choice
- Do not use low-dose dopamine for renal protection
- In patients requiring vasopressors, insert an arterial catheter as soon as practical
Inotropic therapy:
- Use dobutamine in patients with myocardial dysfunction as supported by elevated cardiac filling
pressures and low cardiac output
- Do not increase cardiac index to predetermined supernormal levels
Steroids:
Do not use corticosteroids to treat sepsis in the absence of shock unless the patient’s endocrine or corticosteroid
history warrants it.
Recombinant human activated protein C:
- Adult patients with severe sepsis and low risk of death (typically,
- APACHE II <20 or one organ failure) should not receive rhAPC
Blood product administration:
Give red blood cells when hemoglobin decreases to <7.0 g/dL (<70 g/L) to target hemoglobin of 7.0–9.0 g/dL
in adults. A higher hemoglobin level may be required in special circumstances (e.g., myocardial ischemia,
severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis)
Do not use antithrombin therapy
Mechanical ventilation of sepsis-induced ALI/ARDS:
- Target a tidal volume of 6 mL/kg (predicted) body weight in patients with ALI/ARDS
- Target an initial upper limit plateau pressure £ 30 cm H 2 O. Consider chest wall compliance when
assessing plateau pressure
- Allow PaCO2 to increase above normal, if needed, to minimize plateau pressures and tidal volumes
- Set PEEP to avoid extensive lung collapse at end expiration
- Maintain mechanically ventilated patients in a semi-recumbent position (head of the bed raised to 45°)
unless contraindicated
- Use a weaning protocol and an SBT regularly to evaluate the potential for discontinuing mechanical
ventilation
- SBT options include a low level of pressure support with continuous positive airway pressure 5 cm H 2
O or a T piece
- Do not use a pulmonary artery catheter for the routine monitoring of patients with ALI/ARDS
- Use a conservative fluid strategy for patients with established ALI who do not have evidence of tissue
hypoperfusion
Sedation, analgesia, and neuromuscular blockade in sepsis:
- Use sedation protocols with a sedation goal for critically ill mechanically ventilated patients
- Use either intermittent bolus sedation or continuous infusion sedation to predetermined end points
(sedation scales), with daily interruption/lightening to produce awakening
- Avoid neuromuscular blockers where possible. Monitor depth of block with train-of-four when using
continuous infusions
- Glucose control Use intravenous insulin to control hyperglycemia in patients with severe sepsis
following stabilization in the ICU
- Aim to keep blood glucose <150 mg/dL (8.3 mmol/L) using a validated protocol for insulin dose
adjustment
- Provide a glucose calorie source and monitor blood glucose values every 1–2 h (4 h when stable) in
patients receiving intravenous insulin
- Interpret with caution low glucose levels obtained with point of care testing, as these techniques may
overestimate arterial blood or plasma glucose values
Bicarbonate therapy:
Do not use bicarbonate therapy for the purpose of improving hemodynamics or reducing vasopressor
requirements when treating hypoperfusion-induced lactic acidemia with pH ³ 7.15
DVT prophylaxis:
Use a mechanical prophylactic device, such as compression stockings or an intermittent compression device,
when heparin is contraindicated
Use either low-dose UFH or LMWH, unless contraindicated
Stress ulcer prophylaxis:
- Provide stress ulcer prophylaxis using H2 blocker or proton pump inhibitor
- Consideration for limitation of support
- Discuss advance care planning with patients and families. Describe likely outcomes and set realistic
expectations.
Dellinger RP, International Surviving Sepsis Campaign Guidelines Committee et al (2008) Surviving sepsis campaign: international guidelines for
management of severe sepsis and septicshock: 2008. Crit Care Med 36(1):296–327

Rehabilitation Phase:
Rehabilitation:
Burns can leave a patient with severely debilitating and deforming contractures, which can lead to significant
disability when left untreated. The aims of burn rehabilitation are to minimize the adverse effects caused by the
injury
Rehabilitative Phase Priorities: maintaining wound closure, scar management, rebuilding strength, transitioning
to a rehabilitation facility and/or home
Rehabilitative Phase Goal of Care: returning the burn survivor to a state of optimal physical and psychosocial
functioning
Rehabilitation Phase Assessment
• The clinical focus in on ensuring all open wounds eventually close, observing and responding to the
development of scars and contractures and ensuring that there is a plan for future reconstructive surgical care if
the need exists.
- Collaboration between the burn and inpatient rehabilitation teams is essential to improve functional
outcomes.
Short-term goal:
 To maintain and gradually increase the range of motion (ROM) in the uninjured and injured areas, to
reduce edema and pain
 To improve muscle strength and endurance
 To prevent contracture, and to minimize scar formation.
Long-term goal:
 To improve ROM and muscle strength, to further enhance exercise capacity, flexibility and
coordination, and to restore the ability of ambulation.
 Criteria for discharge: Patients are able to transfer, ambulate, eat, use the toilet, and perform other
activities of daily living without or with some assistance.
The ultimate goal: Patients can restore their abilities
 To their pre-injury condition, return to family and society:
1) Independent ADL, studying and working; 2) better
- aesthetic appearances; and 3) better psychological adaptation
There are two phases of rehabilitation:
Early stages rehabilitation:
Last from a few days to several months.
Depends upon severity of injury, age and co-morbidity.
Other rehabilitative modalities:
Physical therapy: Postural management of the patient by elevating the head and chest helps with chest
clearance and reduces swelling of the head, neck and upper airway.
 Elevation of all limbs affected is necessary in order to quickly reduce edema; hands should be splinted
or positioned and feet kept at 90 degree.
Legs should be positioned in a neutral position ensuring that patient is not externally rotating at the hips
Patients who are unable to move should have passive movements completed to maintain range of
movement (ROM) and prevent stiffness developing.
Psychological impact: It is important that the patient is given comfort and reassurance that they are
safe. Taking the time to listen to the patient’s concerns, demonstrating genuine empathy and
compassion, providing adequate information and answering their questions can often go a long way to
alleviating fears, which in turn can ease the treatment process for both patient and professional.
Anti-contracture positioning: It must be given from day one and may continue for many months
 Position of flexion and also the position of contracture
Early compliance is essential.
Common post burn contractures and the respective anti contracture position of nursing

Area burnt Contracture/ difficulty experienced Anti-contracture position

Front of neck Neck flexion. The chin is pulled towards Neck in extension. No pillow behind head, roll
the chest reducing neck movement. behind neck. Head tilted back in sitting.
Contours of the neck are lost.

Posterior neck Neck extension and other neck Sitting with head in flexion. Lying with pillows
movements. behind the head.

Axillas or Limited abduction, protraction when Lying and sitting - arms abducted to 90 degrees
anterior and burns also to chest. supported by pillows or foam blocks between
posterior chest and arms. Figure of eight bandaging or
axilliary fold strapping to provide stretch across chest.

Front of elbows Elbow flexion Elbow extension

Back of hands Metacarpalphalangeal (MCP) Wrist - 30–40 degrees extended, MCPs 60-70
degrees flexion, IP joints in extension, thumb
mid-palmar radial abduction

Hyperextension, interphalangeal (IP)

Flexion

Adduction of thumb

Wrist flexed
Palm of hand Fingers adducted and flexed, palm pulled Wrist extended, minimal MCP flexion, fingers
inwards extended and abducted.

Groin (hip) Hip flexion Lie in prone with legs extended. Limit sitting and
side lying. Supine lying with legs extended, no
pillow under knees.

Hip adduction

Back of knee Knee flexion Legs extended in lying and sitting.

Feet Feet are complex structures and can be Ankles at 90 degrees – use pillows to maintain
pulled in different directions by healing position. Encourage sitting with feet flat on floor
tissues preventing normal mobility as long as no oedema present.

Face The face can be effected in various Regular change of facial expression and
different ways including inability to open stretching regime required. A well-padded tube
or closer mouth fully and inability to can be inserted into the mouth to combat mouth
close eyes fully contracture.

Indian J Plast Surg. 2010 Sep; 43(Suppl): S101–S113


Splinting:
Splints are a highly effective method of helping prevent and manage burn contractures and are an integral part
of a comprehensive rehabilitation programme.
Splinting helps maintain anti-contracture positioning particularly for those patients experiencing a great deal of
pain, difficulty with compliance or with burns in an area where positioning alone is insufficient.
Splinting can provide a stretched position, which also provides an easier starting point for exercise and
stretching regimes.
Material for splinting:
Plaster of Paris: This material is excellent in the early stages while a patient is immobile and has heavy
dressings applied; however, it tends to absorb exudate, is heavy and breaks easily. It is often applied following
surgery to immobilize and position a limb; however, once it is discarded it must be replaced by something else.
Cardboard: This material also makes an excellent early splint material and is particularly good for positioning
and stretching burns to children’s hands. Use of discarded dressing boxes to fabricate easy, lightweight,
disposable splints also minimises cost. A dorsal block can be applied over the digits to enhance stretch and a
firm.
Foam and blown polystyrene: These make excellent positioning tools particularly for maintaining position of
large joints while the patient is on bed rest, for example, axilla in abduction. They are useful to position patients
at night. They can also be used in conjunction with other materials to create splints for example with PVC to
create hand splints.
PVC piping: This material is easily made into lightweight, effective splints which can be comfortably worn by
patients. It can be cut with a saw and grossly shaped with heavy duty scissors to create knee arm and finger
extension splints and with addition of other materials such as foam and blown polystyrene, hand splints can be
created. PVC elbow pipes can be cut lengthways, padded and can be worn as very effective axilla splints.
Stretching and early mobilization:
Active and passive range of motion exercises are done by therapist and family members.
Games which incorporate therapy goals such as stretching to catch a ball, reaching and bilateral use of hands
depending on the site of injury and therapeutic needs should be encouraged.
Pain control is essential to make this process as easy as possible for the patient as it is common for patients to be
extremely reluctant and fearful to move if this will cause severe pain.
Splinting should be accompanied by regular exercise regimes as contractures can occur, as well, in desirable
positions if a patient is persistently splinted and restricted to that position.
Therapeutic exercise encompasses ambulation of joints, consideration of neurovascular integrity, improving
cardiovascular and respiratory capacity, coordination, balance, muscle strength and endurance, exercise
performance and functional capacity.
Encourage activity of daily living:
Activities of daily living play an extremely important role in a burn patient’s successful outcome.
Highest levels of independence should be encouraged in all activities of daily living from as early as possible.
Increased ability to perform activities of daily living leads to increase in self-esteem, self-worth and sense of
independence and leads to increased motivation levels and desire to improve. Bathing, toileting, feeding,
grooming, dressing and vocational skills also incorporate therapeutic goals, for example increased ROM and
strength, fine motor and balance. It is important to remember that a child’s vocation is play; children should be
encouraged to play and participate in their normal routines as part of their rehabilitation.
Late stages rehabilitation
Scar management: Hypertrophic scarring is common following a burn injury and may cause significant
functional and cosmetic impairment. Hypertrophic scars are an exaggerated response of the body’s healing
process; they have a high blood flow and increased levels of collagen and are extremely active becoming raised,
red and rigid.
Positioning: Anti-contracture positioning should continue to be encouraged for many months post-injury
whenever the individual is at rest.
Splinting: Splints prescribed are not only essential for positioning but also for stretching and lengthening the
contracted scar tissue.
Stretching and exercise: In the early stages, post-wound healing scars are extremely active and dynamic and
the contractile force is at its highest. If the burn is close to or over a joint, it must be stretched to avoid loss of
ROM and to prevent a post-burn contracture developing. 
Massage and moisturizing: Scar massage is widely advocated as an integral part of burn scar management;
while the exact mechanisms of its effects are not known, it appears to help in several ways:

 Application of a moisturizer - burn scars are often lacking in moisture depending on the depth of the
injury and the extent of the damage to the skin structures. They can become very dry and uncomfortable
and this can lead to cracking and breakdown of the scar. By massaging with an unperfumed moisturizer
or oil, the upper layer of the scar becomes softer and more pliable and therefore more comfortable; this
also helps to reduce itching which can also be a common problem.

Pressure therapy: Pressure therapy is a primary modality in burn scar management although the clinical
effectiveness has never been scientifically proven. Applying pressure to a burn is thought to reduce scarring by
hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as
opposed to the whorled pattern seen in untreated scars. Pressure garments appear to help

 reduce scar thickness/lumpiness


 reduce scar redness
 reduce swelling
 relieve itching
 protect newly healed skin/graft
 prevent contractures/ maintain contours

Pressure garments must be applied as early as possible for maximum effect and worn for 23 h removing only
for washing and creaming of scars. In hot climates, however, some patients experience difficulties due to heat
and humidity in which case the wearing regime may need to be adjusted in order to accommodate more regular
removal. If a patient has taken a long time to heal and if they have had skin grafting, they should be provided
with a pressure garment as soon as possible post-healing. If they have had an extensive burn and scattered small
unhealed areas remain, a pressure garment can be applied with small topical dressings applied beneath it.

Silicone: Silicone is another modality used to treat hypertrophic scarring. It appears to soften, flatten and blanch
the scar, making it comfortable and improving its appearance.

Activities of daily living: Individuals should be encouraged to return to their normal daily routines as soon as
possible and should re-establish themselves in their roles in life prior to their burn injury as much as they can.

Social rehabilitation: Following a burn injury some individuals can feel isolated and alone. They may find it
difficult to integrate back into society and take up life as they knew it prior to their injury.

They may feel like they are the only one who has suffered such an injury and they may not know how to re-
enter society, particularly if they have visible burns scars.

These individuals should be encouraged in order to re-establish themselves in their social and vocational lives
as soon as they are able to, and their family members should be encouraged to promote this behaviour.

For children this will mean re-entering school as soon as they are ready to do so, meeting up with friends and
participating in activities and sports which they enjoy.

Sometimes relatives can become very protective of the individual, fearing that something may happen again; in
their desire to care for and protect the individual to keep them safe, they can sometimes impede the
reintegration process. Life after a burn injury, particularly a major injury can take some significant adjusting to
however with the right support and rehabilitation, burn injured patients can lead a full life.

Other surgical management:


Reconstructive surgeries:
Successful reconstruction requires a profound understanding of skin anatomy and physiology, careful analysis
of the defect, and thoughtful considerations of different techniques suitable to execute the surgical plan.
Technique of reconstruction:
There are several techniques routinely used to reconstruct deformities and to close defects related to the burn
trauma.
Principally, they are:
• Excision techniques
• Serial excision and tissue expansion
• Skin grafting techniques with or without the use of dermal substitutes
• Local skin flaps
• Distant flaps
• Allotransplantation
• Tissue engineering
• Robotics and prosthesis
Excision Technique: A circumferential incision is made in the line previously marked and is carried through
the full thickness of the scar down to the subcutaneous fatty layer. In case of a keloid, an intralesional excision
might be better instead of an extralesional one in order to avoid recurrence. E.g, W-Plasty and Geometric
Broken Line Closure.
Z-Plasty
There are three purposes to perform a Z-plasty:
• To lengthen a scar or to release a contracture
• To disperse a scar
• To realign a scar within a relaxed skin tension line
Double Opposing Z-Plasty
Two Z-plasty incisions placed immediately adjacent to one another as mirror images will produce an incision
known as a double opposing Z-plasty.
The advantage of this technique is that significant lengthening can be achieved in areas of limited skin
availability.
¾ Z-plasty or half-Z
The ¾ Z-plasty or half-Z is used to refer the technique with one limb incision being perpendicular to the central
one. The incision is created on the scar side, which creates a fissure into the scar in which a triangular flap is
introduced. The length gained on the scar side is directly proportional to the width of the triangular flap.

Skin grafting
- Split-thickness autografting: A split-thickness autograft includes the epidermis and varying amounts of
dermis. The general principles of skin grafting, including the advantages and disadvantages of split-
thickness skin grafts, surgical techniques, and general postoperative care.
The split-thickness skin graft is the most frequently used donor tissue and is the workhorse resurfacing
technique in the management of acute burn wounds.
Characteristically, 1:1 mesh (mini mesh), 2:1 mesh, and 4:1 mesh (with overlying allograft) are used
depending on the availability of donor sites. The Meek technique is an alternative technique for
expanding autografts.
Sheet grafts (unmeshed) provide optimal coverage for burns of the face and hands and other anatomic
sites where cosmesis and function are important, but their use also depends upon the availability of
unburned skin.
Donor sites are chosen carefully with a mind toward the possibility of repeated harvesting. Convex,
easy-to-harvest areas such as the anterior and lateral surfaces of the thigh are preferred split-thickness
skin graft donor sites. When donor sites are plentiful, skin can be taken from an inconspicuous location
that is easily accessible for wound care. However, for large surface area burns, every available site may
need to be used. This may include the scalp and scrotum area.
We do not harvest split-thickness skin grafts thicker than 12/1000 of an inch in the burn-injured patient.
Harvesting thicker grafts requires a longer time for donor sites to heal and may preclude that site from
repeat harvesting.
The primary dressing (in direct contact with the graft) should be non-adherent (eg, Telfa, Mepitel). This
greatly facilitates skin graft inspection and minimizes graft shearing. A secondary dressing with
antimicrobial properties (eg, Povidone-iodine solution, silver-based topical agents) is placed overlying
the primary dressing. Tertiary dressings (bandages) that control exudate and keep the patient's
environment clean complete the dressing. Tie-over bolsters are helpful for the fixation and immobility of
the grafts.
Early graft inspection is recommended, especially in cosmetically sensitive areas, though the protocol
may vary according to the surgeon's preferences or level of experience. We generally inspect the grafts
and change the dressings every 48 hours with removal of staples or other suture material at day 6. The
aim of this close surveillance approach is early detection of graft shearing, hematomas, seromas, or any
other problem.
- Full-thickness autografting: A full-thickness autograft includes the entire thickness of skin, both
epidermis and dermis. The donor site is closed primarily. The general principles of skin grafting,
including the advantages and disadvantages of full-thickness skin grafts, surgical techniques, and
general postoperative care.
Full-thickness skin grafts are used in areas of special anatomic and functional importance (eg, head,
eyelids, perioral areas, neck, and hands. Full-thickness skin grafts provide better-appearing texture,
pliability, elasticity, and color match and contract less compared with split-thickness skin grafts.
Serial Excision and Tissue Expansion: In areas where tissue laxity is poor or the resulting defect would be too
big, tissue expansion and serial excision are useful techniques to overcome a lack of sufficient local tissue for
closure. Tissue expansion allows large areas of burn scar to be resurfaced by providing tissue of similar texture
and color to the defect.
Tissue expansion: Tissue expansion is a technique that gradually stretches an area of pliable skin
(taking advantage of the principles of creep and stress relaxation) in preparation for its use as coverage
of a burn defect or area of contracture release.
- Tissue expansion techniques are used in the reconstructive stage of scar management when the wounds
are fully healed and the scars resulting from the original burn injury need to be addressed.
- Tissue expansion provides tissue that best matches the affected skin in terms of function and cosmetic
appearance (color, consistency, elasticity, pliability, presence of hair, and sensation). However, suitable
tissue neighboring the burned region must be available.
- Tissue expansion has been used in multiple anatomic areas and is particularly useful in head and neck
reconstruction. Indications for tissue expansion include:
- Limited availability of tissue for reconstruction
- Reconstruction of specialized hair-bearing areas (eg, scalp)
- Reconstruction of sensitive cosmetic areas (eg, head and neck, breast)
- Reconstruction of sites requiring skin match for color, thickness, and/or texture
- The procedure is performed in stages. The first procedure creates a pocket in a subcutaneous plane
(subgaleal in the scalp) in which to insert the expander. Expansion requires repeated injections of saline
into the expander's port.
- Expansion is started once the burn wounds are healed and stopped once enough of the expander has
achieved the desired volume. Temporary cessation of expansion may be needed it there is excessive pain
or blanching of the expanded skin. A second procedure removes the expander and advances, rotates, or
transposes the expanded tissue into the defect, and the wounds are closed.
Flap reconstruction: Flaps represent the gold standard of reconstruction by providing like tissue for like tissue
in burn wound defects. The obvious limitation to their use in the burn patient is the availability of healthy,
pliable, well-vascularized tissue.
Free flap: It is used in the following situations:
- When less complex reconstructive methods (eg, skin grafting) have failed.
- When deep structures (eg, calvarium, frontal sinus, nasal pyramid, tibial crest, neurovascular structures,
tendons) are exposed.
- When there is an absolute need to combine reconstruction with cosmetic appearance, such as with the
facial structures or the female breast.
- Unsalvageable deep burns.
- Resurfacing following release of scar contractures.
Musculocutaneous (MC) or Fasciocutaneous (FC) Flap Technique:
- Inclusion of not only the skin but also the subcutaneous tissues and the fascia and the muscle is
necessary to fabricate a skin flap to reconstruct a tissue defect in individuals with deep burn injuries.
That is, fabricating a flap in a burned area is possible if the underlying muscle or the fascia is included in
the design.
Distant Flaps:
A distant flap involves a donor site, which is distant from the defect. The mode oftransfer might be
direct or microvascular. Direct flap, such as the forehead flap or the groin flap, involves direct
approximation of the recipient bed to the donor site.
These flaps all require a second operation to divide the pedicle.
Free Tissue Transfer
It has expanded the functional and aesthetic potential of reconstructive surgery. Due to
microvascularanastomoses, free transfer of single or compound tissues and replantation ofamputated
parts are possible.
Perforator Flaps
Based on the septocutaneous perforator vessels, the perforator flap was developed.Every perforator
contains a unique vasculatory territory, the perforasome. Thisknowledge will lead to new useable
pedicled and free flaps for reconstruction.
Composite Tissue Allotransplantation:
“Composite tissue allotransplantation” (CTA) of parts of the face or forearms and upper extremities is a
young area of transplantation medicine.
Regeneration: Tissue Engineering:
Thestem cell-associated fat cell transplantation in patients with a radioderma has led toimproved
healing. Moreover, fat cell transplantation is not only able to improvevolume and contour defects but
also skin quality.
Robotics/Prosthesis
If all reconstructive measures fail, myoelectric prostheses are a promising resort togo to. In recent years,
these have been improved tremendously by introducingtargeted muscle transfers (TMR) to the
armamentarium of reconstructive surgery.

Nursing management
Nursing assessment:
- History collection
- Physical examination includes primary and secondary survey.
- Assess the intensity, location and type of pain.
- Monitor vital signs and signs of shock in patient
- Monitor intake/ output of the client.
- Monitor nutritional intake of the client.
- Monitor client for psychological impact of the burn.
- Assess the client for impact/ complications of burn injury.

Nursing diagnosis:
Fluid volume deficit related to increased capillary permeability/ leak and large fluid shift from intravascular
space.
Expected outcome: The client will have improved fluid balance as evidenced by urine output 30-50 ml/hr,
clear sensorium, pulse rate< 120bpm without dysrhythmia and blood pressure within expected range for age and
medical history.
Nursing interventions:
- Observe vital signs and urine output every hourly for 36 hours and be alert for signs of hypovolemia or
fluid overload.
- Monitor urine output at least hourly and weigh patient daily.
- Maintain IV lines and regulate fluids at appropriate rates, as prescribed.
- Observe for symptom of deficiency or excess of serum sodium, potassium, calcium and bicarbonate.
- Elevate head of patient’s bed and elevate burn extremities to prevent edema.
Evaluation: With adequate fluid resuscitation expected fluid balance achieved within 24-36 hours.

Nursing diagnosis:Ineffective airway clearance related to laryngeal edema, airway epidermal sloughing and
depressed pulmonary ciliary action from inhalational injury.
Expected outcome: Client will have effective airway clearance as evidenced by clear bilateral breath sounds,
clear pulmonary secretions, effective mobilization of pulmonary secretions and unlabored respiration.
Nursing Intervention:
- Maintain patent airway through proper patient positioning, removal of secretions.
- Provide humidified oxygen.
- Encourage the patient to turn, cough and deep breathe every hourly.
- Encourage the patient to use incentive Spirometry.
- Perform endotracheal and nasotracheal suctioning as needed.
- Monitor the color and consistency of sputum
- Provide nebulization to client as prescribed.
Evaluation: If client is intubated, airway clearance problems remain well intubated and for several days after
extubation.

Nursing diagnosis:Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, heat
damage and upper airway obstruction.
Expected outcome: Client will have improved gases exchange as evidenced by unlabored respiration, 16-
24/min; PaO2 > 90 mm Hg; PaCO2 35-45 mmHg; SaO2 >95%; and clear bilateral breath sounds.
Nursing interventions:
- Assess for signs of respiratory distress as evidenced by restlessness, confusion, labored breathing,
tachypnea, dyspnea, diminished breath sounds, tachycardia, decreased in PaO2 and SaO2 levels and
cyanosis.
- Monitor arterial blood gas and Carboxyhemoglobin levelas per physician order.
- Monitor SaO2 level continuously.
- Administer oxygen therapy as prescribed.
- Instruct client to use incentive spirometer.
- Elevate head end of bed.
- Monitor the need of endotracheal intubation.
Evaluation: Problems with gases exchange may require several days to resolve. If the client develop respiratory
distress it may be much longer.

Nursing Diagnosis:Acute pain related to tissue injury, exposed nerve endings, treatment and emotional impact
of injury.
Expected outcome: The client will have more comfort as evidenced by verbalizing relief or control of pain or
discomfort.
Nursing Intervention:
- Assess the client’s response to pain with wound care, physical therapy and at rest by using pain intensity
scale to assess pain level.
- Medicate the client prior to painful procedures; 45 min for oral, 5-10 min for IV.
- Do not administer IM injections to client with major burns during the emergent phase of care.
- Explore relaxation techniques, music therapy, guided imagery, distraction.
- Explain all procedures to client and allow time for preparation.
- Talk to the client while providing care and performing procedures.
- Assess the need of anxiolytic medication.
- Administer intravenous opioids analgesics as prescribed.
- Observe for respiratory depression in the patient who is not mechanically ventilated.
- Assess response to analgesic and non-pharmacological treatment.
Evaluation: Expect level of pain to decrease as burn wounds heal. Use of various pain relief measures may be
needed for weeks to months.

Nursing diagnosis: Hypothermia related to epithelial tissue loss and fluctuating ambient air temperature.
Expected outcome: The client will remain normothermic as evidenced by core body temperature between 99.6
0
F to 101.0 0 F.
Nursing interventions:
- Monitor the client’s core body temperature hourly during emergent phase and post-surgery.
- Limit the amount of body surface area exposed during wound care.
- Limit Hydrotherapy treatment sessions to 30 min or less with water temperature 98 0 to 102 0 F.
- Use external heat shields/ radiant heat lamps.
- Keep procedure rooms and surgical suites warm.
- If air fluidized therapy bed is in use, monitor and maintain appropriate bed temperature and consider
reducing the flow of fluidization if hypothermia develops.
Evaluation: The risk of hypothermia remains a problem as long as there is > 155 to 20% ungrafted burn
wound.

Nursing diagnosis: Self-care deficit related to functional deficits resulting from the burn injury, pain, dressings,
splints and enforced immobility.
Expected Outcome: The client will have less self- care deficit and will demonstrate increased participation in
self-care.
Nursing Interventions:
- Assess the client’s ability to provide self-care.
- Consult with occupational therapist regarding the need of assistive devices.
- Encourage client to participate in self- care tasks.
- Ensure that the client has adequate time to accomplish tasks.
- Provide positive reinforcement when tasks are accomplished.
Evaluation: Self-care deficit may or may not resolve depending on the location and extent of burns and need
for splints.

Nursing Diagnosis: Impaired physical mobility related to edema, pain dressing, splints, surgical procedures and
wound contractures.
Expected Outcome: The client will have improved physical mobility as evidenced by returning to maximum
activities of daily living with minimal disability and disfigurement.
Nursing Interventions:
- Assess range of motion and muscle strength in burned areas prone to develop contractures every day.
- Maintain burned areas in position of physiological function within limits imposed by associated injuries,
grafting, and other therapeutic devices for positioning.
- Explain rational for positioning and activities to client and family.
- Consult physical and occupational therapist for individualized rehabilitation schedule.
- Wrap donor site on burned legs and unburned legs with Ace bandage wraps before placing in dependent
position; as healing progress, other elastic support bandages can be worn.
- Encourage range of motion exercises every 2-4 hours while awake unless contraindicated because of a
recent grafting procedure.
- Help client to ambulate to chair or to walking (unless contraindicated by a recent grafting procedures or
others injuries).
- Provide passive exercises and stretching if client is unable to actively participate.
Evaluation: Expect the client to begin ambulation early in the acute period. The problem should remain active
untill able to perform ADL and ambulate independently.
Nursing Diagnosis: Altered nutritional intake less than body requirement related to increased metabolic needs
for wound healing.
Expected Outcome: The client will have adequate nutrition as evidenced by maintaining 85% to 90% of pre-
burn weight and healing burn wounds, donor sites and skin grafts.
Nursing Interventions:
- Obtain accurate pre-burn weight.
- Consult dietitian
- Assess eating habits/patterns, food preferences, food allergies, within 72 hours of admission.
- Record calorie intake
- Weight client daily to follow weight trends untill unless operative procedure limits movement.
- Provide oral hygiene in every shift.
- Provide an aesthetically pleasing environment.
- Schedule treatments to provide for uninterrupted meal times.
- Allow a period of rest prior to meal time if the client has endured a painful procedure or treatment.
- Provide aids and devices for eating utensils.
- Encourage family members to bring the client’s favorite foods from home.
- Provide nutritious supplements between meals.
- Provide positive reinforcement for eating.
- Consider other methods to meet caloric needs, such as tube feeding, total parenteral nutrition.
Evaluation: The client remains at nutritional risk untill completely healed or grafted.

Nursing Diagnosis: Risk for paralytic ileus related to sympathetic nervous system response to injury.
Expected Outcome: The nurse will monitor for normoactive bowel sound absence of abdominal distension,
flatus production and normal bowel movements.
Nursing Interventions:
- Assess the need for placement of nasogastric tube.
- Assess the bowel functions.
- Auscultate bowel sounds every 4th hourly.
- Observe the client for abdominal distension.
- Monitor gastric output and amount, color, presence of blood and pH.
Evaluation: Expect bowel sounds to return once fluid volume is balanced.

Nursing diagnosis:Risk for renal failure related to presence of hemochromagens in the urine due to deep burn
and crush injuries.
Expected Outcome: The nurse will monitor for visible urinary hemochromagens and adequate urine output of
75-100ml/hour.
Nursing Interventions:
- Monitor and document urine output and color hourly.
- Insert urinary catheter for correct measurement of urinary output.
- Ensure patency of urinary catheter.
- Administer IV fluid as per physician’s order.
- Send urine samples for urine myoglobin/ hemoglobin level as per physician’s order.
Evaluation: Renal failure is a high priority problem for first 24-36 hours. Once client has diuresis, the risk
declines.

Nursing diagnosis: Risk for stress ulcer related to neurohormonal stress response from burn injury.
Expected Outcome: The nurse will monitor for gastrointestinal bleeding and will maintain gastric pH>5.
Nursing Interventions:
- Monitor and document gastric pH values and heme concentration every 2 hours while NG tubes is in
place.
- Administer antacids and H2 receptors antagonists per physician’s order.
- Monitor stools for occult blood.
Evaluation: Stress ulceration can occur at any time following a burn injury.

Nursing diagnosis:Risk of infection related to loss of skin barrier and impaired immune response, presence of
invasive catheters and invasive procedures.
Expected Outcomes: The client will have no burn wound microbial invasion, as evidenced by quantification
wound cultures <100000 organisms; core body temperature at 99.6 to 101.0degree F, no swelling, redness or
purulent discharge present at invasive line insertion sites; and blood, urine, and sputum cultures will be
negative.
Nursing Interventions:
- Administer tetanus prophylaxis.
- Maintain infection control technique.
- Instruct family/ significant other on infection control measures.
- Enforce strict hand washing.
- Assess for clinical signs of infection; discoloration of wound or drainage, odor, delayed wound healing;
headache, chills, anorexia, nausea, changes in vital signs, hyperglycemia and glycosuria; paralytic ileus,
confusion, restlessness, hallucinations.
- Before reapplying topical cream, cleanse and rinse the burn wound.
- Debride wound of loose, nonviable tissue.
- Shave or cut body hair in and around wound margins.
- Apply topical therapy.
- Assess for sign of infection at catheter insertion site in each shift.
Evaluation: Infection remains an active problem as long as the client has open tissue, or invasive lines.

Nursing Diagnosis:Risk for self-esteem disturbance related to threaten or actual change in body image,
physical loss, and loss of responsibilities.
Expected Outcome: The client will develop improved self-esteem as evidenced by making social contact with
others outside of immediate family, developing effective coping mechanism through the stages of recovery and
verbalizing feeling about self-concept.

Nursing Interventions:
- Determine the previous coping styles
- Provide an atmosphere of acceptance
- Explain projected appearance of burns and grafts during different phases of wound healing.
- Allow client to progress at his or her own pace through stages of denial, grief, and acceptance of injury
and recovery.
- Assess need for limit setting for maladaptive behavior consult with burn team members to establish
limits and treatment plan; explain and assist family/significant others to maintain same limits.
- Promote client’s self- confidence:
- Ensure continuity of care providers.
- Discuss all activities and procedure prior to initiation.
- Support client’s role in care and treatment.
- Keep client informed of progress.
- Provide honest, positive reinforcement.
- Help family/significant other to interact with client.
- Encourage interaction with other outside. Use family day passes.
- Help prepare client for social interaction after discharge by discussing potential situations and how client
might deal with them.
- Make home healthcare nurse or physical therapist referral as indicated.
Evaluation: Self-esteem problems may resolve over months or years. This problem is followed up after
discharge.
Nursing diagnosis: Risk for ineffective family coping related to emergent and critical nature of the injury and
separation from family/ friends.
Expected outcome: family will have improved coping strategies, as evidenced by verbalizing goals of
treatment regimen; emotional stressors, concerns, and behavior; and understanding and knowledge of available
stressors.
Nursing Interventions:
- Prior to initial visit of family/significant other:
- Communicate extent of burn and changes in client’s appearance.
- Provide family/significant other with information that meets their basic needs.
- Provide brief, simple explanations of procedures and equipment.
- Determine how the client and family/significant other have coped with past stresses.
- Allow for uninterrupted visitation during visiting hours if possible.
- Provide family/significant other with daily updates regarding changes in client’s condition.
- Consult with psychologist, psychiatrist, social workers, or psychiatric clinical nurse specialist.
- Encourage family/significant other attendance at support group meetings for family members.
- For impending client transfer, provide family/significant other with support services to assist with travel.
Evaluation: Family coping issues will vary during the course of recovery. Early concerns with survival are
replaced with worries over appearance and return to society. This problem may require long-term care to
resolve.

Assignment:
A patient 40 years old with 80kg weight admitted in emergency department with approximately 41% of burn
(BAS), Partial thickness burn of upper thigh (15%) & abdomen and anterior chest (18%), Circumferential burn
to left arm (8%)
How will you manage the patient?
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