BURNS

PRESENTED BY:
Suvetha.G
M.sc(N) 1st year
CON-PIMS.
 INTRODUCTION:
• Burns sustained by children are a commom
presentation to emergency departments and often
cause significant distress to both the child and the
parents and it is the leading cause of death in
children.
 DEFINITION:
ACCORDING TO INTERNATIONAL SOCIETY FOR
BURN INJURIES,
 A burns occurs when some or all of the
different layers of cells in the skin are
destroyed by a hot liquid( Scald)or a hot solid
(Contact burns) or a flame ( Flame burns).
 Skin injuries due to ultraviolet radiation,
radioactivity, electricity or chemicals as well
as respiratory damage resulting from smoke
inhalation are considered to be burns.
 INCIDENCE OF BURNS IN CHILDREN

 Children are at higher risk of burn injury than

adults. Approximately one fourth of burns
cases are below 10 years of age, and about
65% of burnt children are below 5 years of
age.
 Over 80% of burn accidents occur in the child’s own
home. Scalds from hot liquids constitute maximum
numbers and others are due to flame burns, electrical
or chemical burns.

 The incidence of burns increased during Diwali,

festivals and in winter seasons. The children of high risk
for burns include single parent, unsupervised,
neglected and less protected child especially of poor
socio-economic group.
 THE TYPES OF BURNS INJURY

TYPE OF INJURY
Scalds
 Scalds are important burn injury caused by hot
liquids (liquid hot food, hot water, tea, coffee,
milk) or steam. It is common in children below 3
years of age.
Electric burns
 It is common in toddlers and adolescents when
playing with electrical outlet, extension cord,
touching high tension wires, etc...
 Open flame burns
 Open flame burns are common during playing
with lighter or at kitchen near stove or over of
gasline. It may happen from open fire in winter
season or from fireworks during festivals or
Diwali.
Chemical burns
 Itis also common in children. Out of curiosity
they handle household cleansing chemicals,
acids, etc and get injured.
CLASSIFICATION OF BURNS
ACCORDING TO EXTENT OF BURN INJURY
ACCORDING TO SEVERITY OF BURN
INJURY

MINOR MODERATE MAJOR

INJURY INJURY INJURY
Minor burns
Minor burns are:
Age 10-50yrs: Partial-thickness burns <15% TBSA
Age <10 or >50: Partial thickness burns involving
<10% TBSA
Full thickness burns <2% TBSA without associated
injuries.
These burns usually do not require hospitalisation.
Moderate burns
 Moderate burns are defined as:
 Age 10-50yrs: Partial thickness burns involving 15-
25% TBSA
 Age <10 or >50: Partial thickness burns involving 10-
20% TBSA
 Full thickness burns involving 2-10% TBSA
 Persons suffering these burns often need to be
hospitalised for burn care.
Major burns
Major burns are defined as:
Age 10-50yrs: Partial thickness burns >25% TBSA
Age <10 or >50: Partial thickness burns >20% TBSA
Full thickness burns >10%
Burns involving the hands, face, feet or perineum
Burns that cross major joints
Circumferential burns to any extremity
Any burn associated with inhalational injury
Electrical burns
Burns associated with fractures or other trauma
Burns in infants and the elderly
Burns in persons at high-risk of developing
complications
These burns typically require referral to a
specialised burn treatment center.
THE ESTIMATION OF EXTENT OF BURNS
SURFACE AREA:

1. Rule of nine:
An estimation of the total Body Surface
Area (TBSA) burned by assigning percentage
in multiple of nine to major body surfaces.
Rule-of-9s Total Subdivision 
Head and neck 18% Anterior Head = 9%
Posterior Head = 9%

Anterior trunk 18% Chest = 9%

Abdomen = 9%

Posterior trunk 18% –

Each arm 9% Anterior Arm = 4.5%

Posterior Arm = 4.5%

Each Leg 13.5% Anterior Leg = 6.75%

Posterior Leg = 6.75%

Perineum 1% –
2.Lund and browder method:
A more precise methodof estimating the
extent of the burn; takes into account that the
percentage of the surtace area represented by
various anatomic parts change with growth.
3.Palmar method:
Used to estimate percentage of scattered
burns, using the size of the patienť's palm(about 1%
of body surface area) to assess the extentof burn
injury.
 PATHOPHYSIOLOGY OF BURNS
 Following a major burn injury, heart rate and
peripheral vascular resistance increase. This is due to the
release of catecholamines from injured tissues, and the
relative hypovolemia that occurs from fluid volume shifts.
Initially cardiac output decreases. At approximately 24 hours
after burn injuries, cardiac output returns to normal if
adequate fluid resuscitation has been given. Following this,
cardiac output increases to meet the hypermetabolic needs
of the body.
Circulatory changes:
There is loss of fluid and fluid shift from intravascular to
extravascular compartment due to increased capillary
permeability.
 
Hypovolemic shock due to fall in cardiac output

Swelling and edema of burnt area occur (local & systemic

inflammatory mediators also contribute to develop severe
edema)

Ischemia and necrosis occur due to vasoconstriction

Hematological alterations:
Heat energy destroys the cellular elements of blood (RBC)
Hemolysis (cause immediate or late anemia)
Hemoglobinuria
Higher the depth of burns, more the cellular damage occurs.
Burns injury leads to initial rise in WBC but leukotaxis and
phagocytosis are impaired.

Plasma proteins and immunoglobins are reduced

Resulting in increased vulnerability to infections and also fall in

platelet count and fibrinogen level
Leading to coagulation problems
Renal changes:
Hypovolemia and reduced cardiac output

Result in decreased renal blood flow reduced GFR

Leading to tubular necrosis and renal failure and finally

hemoglobinuria contribute to renal shut down
Respiratory changes:
 Extensive burn injury may cause fatal respiratory
complications due to damage of respiratory mucosa by heat
or due to severe hypoxia.
Pulmonary congestion, hypostatic pneumonia and
respiratory infections.
Immune response:
 Following burn injury several major
immunoglobulins, complement and serum albumin
are decreased with depressed cellular immunity.

 Hypoxia, acidosis and thrombosis of vessels in the

wound area impair host resistance to pathogenic
bacteria.

 These immunological disturbances make the patient

more susceptible to various infections and wound
sepsis.
CLINICAL MANIFESTATIONS:
It depends upon the degree of burns;

 The child may present with shock along with varied

depth and extent of body surface area burnt.
 Pallor
 Cyanosis
 Prostration
 Poormuscle tone and failure to recognize familiar
people
 Rapid pulse, low BP and subnormal temperature
CLINICAL MANIFESTATIONS
Inhalation injury causes;
 Edema of the glottis, vocal cords and upper trachea leading to
upper airway obstruction.
 Dyspnea
 Tachypnea
 Hoarseness
 Stridor
 Chest retractions
 Nasal flaring
 Restlessness, cough and drooling
MANAGEMENT OF BURNS IN CHILDREN:
FIRST AID MEASURES
 Stop the burning process
 Assess the victims condition
 Cover the burn
 Transport the child to medical aid
 Provide reassurance
 Stop the burning process
 The chief aim is to smother the fire, not fan it
 The injured child should be placed in a horizontal
position and rolled in a blanket, with care taken not
to cover the head and face.
 Major Burns with large amounts of denuded skin should
not be cooled.
 Heat is rapidly lost from burned areas and additional
cooling leads to a drop in core body temperature and
potential circulatory failure.
 Chemical burns require continuous flushing with large
amounts of water before transport to a medical
facility.

 Burnedclothing is removed to prevent further damage

from smoldering fabric and hot beads of melted
synthetic materials.

 Jewelryis removed to eliminate the transfer of heat

from the metal and constriction resulting from edema
formation.
 Assess the victims condition

 As soon as the flames are extinguished, the child is

assessed. Airway, breathing, and circulation are the
primary concerns.

 Cover the burn

 The burn wound should be covered with a clean cloth to

prevent contamination, decrease pain by eliminating air
contact and prevent hypothermia.
 Transport the child to medical aid

 The child is transported to the nearest medical

facility.
 If this cannot be achieved, IV access should be
established, 100% oxygen is administered.
A report of the initial assessment and any
interventions implemented is given to the medical
facility assuming care of the child.
 Provide reassurance
 Providing reassurance and psychological support to
both the family and the child helps immeasurably
during the period of postinjury crisis.
Fluid replacement therapy

The objectives of fluid therapy are to;

 Compensate for water and sodium lost to traumatized
areas and interstitial spaces
 Reestablish sodium balance
 Restore circulatory volume
 Provide adequate perfusion
 Correct acidosis
 Improve renal function
 Fluid replacement is required during the first 24hrs
because of fluid shifts that occur after the injury.
It is done promptly on the basis of TBSA burnt and
body weight of the child.
 Isotonicsaline solution like Ringer lactate (RL) in
5% dextrose or hypertonic saline solution can be
used to exapand plasma volume.
Brook’s Formula:
 For first 24 hours
-Colloids (blood, plasma, dextran) are given in dose of
0.5 ml/kg/TBSA.
-Saline 1.5 mL/kg/TBSA is given.
-Five percent dextrose may be administered according to
the age of patient.
 For next 24 hours
-Colloids are given in a dose of 0.25mL/kg/TBSA
- Saline is given in a dose of 0.75 mL/kg/TBSA
-Five percent dextrose may be given according to the
age of the patient.
 NUTRITION :
o High protein and high calorie diet
o Oral feeding are encouraged unless child is intubated or paralytic
ileus persisted.
o Burns excess 25% of TBSA require supplementation with tube
feeding.
o The nurse should monitor for any abdominal distension, diarrhoea
or electrolyte and metabolic deviations.
o To facilitate growth and proliferation of epithelial cells, administer
vitamin A and C is begun early in the post burn periods.
o Zinc is supplemented as it play important role.
 MEDICATION:
 Systemic antibiotics to control wound colonization
 Some form of sedation and analgesics is required in the care of
burns children- Morphine sulphate is DOC for severe injuries.
 COMBINED( Midazolam + Fentanyl) also provide excess IV
sedation and analgesics to control procedural pain.
 Propofol and nitrous oxide help in eliminating procedural pain.
 MANAGEMENT OF BURN WOUND:
 The objectives of wound management include prevention of
infection, removal of devitalized tissue and closure of the
wound.

1.Primary excision
 Early excision of deep partial-thickness and full-thickness
burns reduces the incidence of infection and the threat of
sepsis.

 
2.Debridement

 Partial-thickness wounds require debridement of

devitalized tissue to promote healing.
 Debridement is very painful and requires
analgesia and a sedative before the procedure.
 Atarax are often needed for itching that occurs
after whirlpool and debridement.
3.Topical antimicrobial agents

Common agents are Silver nitrate 0.5%, Silver

sulfadiazine 1%, Mafenide acetate 10% and
Bacitracin.
4.Bilogical skin covering:
Allograft (homograft)
Skin is obtained from human cadavers that are
screened for communicable diseases.
Xenograft
From a variety of species, most notably pigs is
commercially available.
Synthetic skin coverings
This dressing provide the properties of human
skin. These are composed of a variety of
5.Permanent skin coverings:
The graft consists of a epidermis and a portionof
dermis removed from the donor site of an intact area
of skin by a special instrument called a dermatome.
 Sheet graft
A sheet of skin, removed from the donor site, is
placed intact over the recipient site and sutured in
place.
 Mesh graft
A sheet of skin is removed from the donor site
and passed through a mesher, which produces tiny slits
in the skin
 Artificial skin
The two-layer membrane is made of collagen (a
fibrous protein from animal tendons and cartilage)
and silicone rubber (i.e., Silastic). The Silastic layer
is peeled off after the dermis is formed.

 Cultured epithelium
The child’s own skin is fractionated and
cultured in a porcine media to form a thin epithelial
layer that is applied to the burn wound.
 NURSING MANAGEMENT:
ACUTE PHASE:
 Monitor vital signs, output, fluid infusion and
respiratory parameter are ongoing activities in the
hours immediately after injury.
 IV infusion to maintain urinary output at least 1-2 ml/kg
in children less than 30 kg
 Requireconstant observation and assessment of
complications
 Monitor infection control procedure
 Psychological needs of the child and family.
 Physical needs of child has to be met.
MANAGEMENT PHASE:
 Extend from the completion of adequate resuscitation
through burn coverage.
REHABILITATIVE PHASE:
 Begins when the majority of the burns have heeled.
 Comfortable management
PREVENTION OF BURN INJURY

Following all safety measures

 Don’t allow children to play with electric cords.
 Don’t leave an electric iron switched on close to a child
 Don’t drink / pass hot tea/ coffee while holding the
infant.
 Don’t keep electric equipments plugged on when not in
use.
 Don’t allow the children to use matchboxes
 NURSING DIAGNOSIS:
 Impaired skin integrity related to thermal injury.
 Risk for altered tissue perfusion related to
circumferential burns.
 Pain related to skin trauma, therapies.
 Risk for infection related to denuded skin, presence
of pathogenic organisms or altered immune response.
 Risk for ineffective thermoregulation related to heat
loss and disruption of skin’s defense mechanism to
maintain body temperature.
 JOURNAL ABSTRACT:

Retrospective Epidemiological Study of Burn Injuries in 1717

Pediatric Patients: 10 Years Analysis of Hospital Data in Iran
-Jafar KAZEMZADEH and Rahman KHOSRAVY
ABSTRACT :
Background:
This study investigated the causes and severity of burns in
patients.
Methods:
This study was retrospective descriptive study of
children-burn injury
The subjects included 1717 consecutive patients with
various causes of burn injury. 
Conclusion:
Most patients were in the 2–4 yr age group, with most
of the injuries occurring in boys under the age of 5 yr old.
Most affected part of the body was trunk and 1256
patients (73.2%) suffered from hot liquid burns.
CONCLUSION:

 Itis important to prevent the child from burns

injury to decrease the death due to burns.
 Knowing what to do in case of burn can Help to
prevent serious injuries.
 As a nurse it is our duty to educate the parents
regarding the safety measures a d prevention
from burns injuries.
SUMMARY
ASSIGNMENT:

 Prepare a nursing care plan for a child with burns

injury.
REFERENCE:

BOOK REFERENCE:
 Wong’s, “ Essential of paediatric nursing”, 2nd edition, Arian Elsevier publishers, p.982-
1002
 OP Ghai,” Essential paediatrics”, 7th edition, CBS publishers, New Delhi, pp:435-439
 Dorothy R. MARLOW,” Textbook of paediatric nursing”, south Asian elseivr,pp:731-
735
 Rimple Sharma,” Essential of paediatric nursing”, Jaypee publishers, pp.: 343-348
NET REFERENCE
 http:// www. Burns management of child. Slideshare.net