BURN INJURIES: INITIAL EVALUATION AND EMERGENCY INTERVENTION

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

ABSTRACT

There are many different types of burn injuries, including those from fire, scalds, electricity, friction, contact with chemicals, and others. The one constant is that people who suffer burns have a desire for minimal scarring and impact to their lives. Emergency intervention is key in returning patients to their lives with minimal scarring and other lasting effects. This course primarily discusses the initial evaluation and emergency interventions associated with burn injuries.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Burn injuries involve acute physiological changes, pain and wound healing that require interventions from the beginning and long after the initial treatment. Health clinicians need to be knowledgeable of the potential and prevention of burn injury complications.

Course Purpose

To provide health clinicians with knowledge about burn conditions and treatments during the acute emergency setting and throughout a patient’s treatment.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. True or False: Airway edema is generally apparent in the initial burn injury patient and the emergency team must act immediately to stabilize a patient’s airway.

a. True b. False

2. During the secondary survey, the health team may uncover injuries not initially apparent in a burn patient, such as:

a. Fractures b. Dislocations c. Abdominal injuries d. All of the above

3. An escharotomy involves an incision

a. made outside the burned skin using a scalpel. b. deep enough to penetrate the subcutaneous fat. c. to release pressure in the burned area. d. used for debridement of eschar.

4. A Lund and Browder chart is used for:

a. estimating the burn extent in a patient. b. estimating fluid loss of a burn patient. c. estimating the range of motion of a burn patient. d. All of the above

5. True or False: Range-of-motion exercises are necessary on a regular basis to promote blood flow to the extremities and to prevent contractures in a burn patient.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction

Burns are a leading cause of injury in the United States. Over one million people seek medical care and treatment for burn-related injuries each year. Burns may range from minor burns, impacting only a small area, to major burns that require months of treatment and rehabilitation. Major burns are a significant cause of disability, morbidity, and mortality among burn victims.

The costs associated with caring for individuals with extensive burn injuries are high and the treatment of burns has become highly specialized. Consequently, regional burn centers have evolved into treatment for high-need patients who can be transported to the closest location where specialized care of the burn patient can occur. While regional care services are known to improve the outcome for burn patients, transporting patients to nearby centers that provide comprehensive burn care requires more staff training and understanding of burn injuries during initial patient care and emergency transport. Clinicians who are responsible for assessing, resuscitating, stabilizing, and transporting critical burn patients must be well trained to understand their complex needs and to get them safely to a regional center where their treatment will be continued.

Initial Assessment And Rapid Response

The initial assessment of a burn patient is a skill that should be learned by clinicians responding to an emergency in the field as well as in the receiving hospital where emergency staff will be working fast to stabilize the patient. Firstly, a patient still in contact with the source of the burn must be removed from that source. In the case of a thermal or electrical burn, the patient should be removed from the area where nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 the fluid or fire took place; if a chemical burn, the person first arriving to the scene should strive to remove as much of the chemical as possible from the patient in order to stop the burning process. This may involve brushing away powders or particles that continue to burn the skin, or flushing the skin or eyes to rinse away caustic chemicals that could still cause damage.1,2

It is important for clinicians to recognize that burn patients can deteriorate quickly, even if they initially seem stable. Clinicians in the emergency setting must assess the patient on a continuous basis and be familiar with the anticipated subtle changes indicating deterioration of the patient before it is too late.

Airway Stabilization and C-Spine Immobilization

The primary survey of a burn injury involves maintaining a patent airway to facilitate adequate air exchange for the patient. A burn patient may have suffered injuries that could cause the airway to swell and constrict, thereby impeding airflow. Edema formation and airway obstruction can occur quickly with certain types of injuries, such as inhalation injuries, or may develop slowly over time. Because airway edema may not be apparent immediately and develop over a period of time, the clinician must continue to assess and stabilize the airway while providing care for the patient.

A patient with burn injuries may have been exposed to some type of gas, smoke, or other materials that were combustible and that can be damaging to the airway and the lungs if inhaled. The heat from the burn source is also damaging to the respiratory tract. The body responds to this exposure with inflammation and swelling, which

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 constricts the size of the airway and can cause obstruction. The patient should be provided with 100% humidified oxygen right away to improve the distribution of oxygen to the tissues while the clinician continues to monitor for changes that suggest an obstructed airway.1

If the patient shows signs of breathing difficulties or obstruction related to airway damage from the burn, endotracheal intubation should be performed as quickly as possible.1 Responders at the scene of the burn or those providing initial care at the hospital should observe for signs of inhalation injury as well as determine from bystanders the nature of the burn potentially affecting the patient’s ability to maintain an open airway; for example, whether the burn injury occurred in an enclosed space. Airway intubation should be performed to support respiratory ventilation while the emergency clinician simultaneously addresses the extent of edema in the patient’s throat. Waiting to intubate a patient’s airway after signs of edema and an obstructed airway develops due to a burn injury may only lead to difficult intubation because in such situations the edema that develops often further constricts the throat and airway passages.1,10

There is a risk of spinal cord injury in situations where the patient was burned as a result of an accident or fall. The clinician should be aware that an injury to the cervical spine, although not common among burn patients, may have occurred if the burn was associated with an accident that would have resulted in an injury to the head or neck. Some of the most common types of burn injuries that would definitely require cervical spine immobilization include burns from explosions, burns that occur as a result of a motor vehicle collision, or burns that occur with exposure to high-voltage electricity. If there is any question

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 of whether the patient has an injury that could result in damage to the spinal cord, a cervical collar should be applied to the neck and kept in place until the cervical spine is cleared of evidence of fracture.

A patient with cervical spine immobilization should be monitored until evidence determines that it is safe to remove the collar, such as through confirmation from radiological studies. Also, a patient with a cervical collar should have the collar removed as soon as possible after the injury, rather than remaining with a cervical collar in place for a long period of time. Radiologic imaging to confirm that no injury exists is necessary in any patient where cervical spine injury is suspected, including those with pain and tenderness in the neck and shoulder area and with an altered mental status or neurological deficit. Alternatively, a patient who is awake, and alert, has no neurological deficits or penetrating injuries, and does not have pain in the neck and shoulder area, does not need an X-ray to clear the cervical spine. In such cases, the cervical collar can be removed.

Breathing Status and Interventions

An open airway does not necessarily mean a patient is breathing adequately. If a burn patient has not been intubated and the clinician is continuing to monitor for signs of airway obstruction, the patient’s nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 breathing patterns and attempts to breathe must continue to be evaluated. Administering humidified oxygen helps only if the patient is breathing the oxygen. If the patient needs further assistance to breathe because of airway damage, smoke inhalation, or carbon monoxide poisoning, he or she must be intubated or assisted to breathe through positive-pressure ventilation.

The clinician should look for signs of burn injury around or in the mouth that indicate that the patient has inhaled chemicals or particles that could cause lung damage and breathing difficulties. Signs of inhalation include particles or fine powder around the mouth and nose, singed hair around the mouth and nose, carbonaceous sputum with cough, or sores or blisters on the gums or roof of the mouth.3,4

Inhalation injuries are present in up to 50% of patients who are admitted to burn centers2 and are a leading cause of death among affected patients because of the damage such injuries can cause to lung tissue and subsequent oxygenation of the body. There is an increased risk of inhalation injury associated with a greater amount of body surface area affected by a burn. Inhalation injuries involve injuries to the airway and lungs when the patient inhales toxic chemicals and byproducts from the process of combustion. These types of injuries may be classified as being either above the glottis or below the glottis.1,2

Injuries above the glottis, or an upper airway injury, may result in dyspnea, stridor, a dry cough, or hoarse voice. The patient may develop edema in the upper airway that can cause blockage of the airway and subsequent apnea. Inhalation injury below the glottis, or a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 lower airway injury, causes damage to the lung tissue. This type of injury can quickly progress to acute respiratory distress syndrome and respiratory failure within the first several days of the burn injury. The patient may develop bronchial spasms that lead to airway constriction, and sloughing of the mucous membranes occurs as a response to the injury, causing a productive cough.1,10

Diagnosis of a lower airway injury must be done by a bronchoscopy to verify whether damage has occurred and to understand the extent of the injury to better predict the outcome. Those initially responding to a burn injury should continually assess for symptoms associated with an airway injury until an emergency clinician is able to recommend airway treatment based on an actual diagnosis.

Initial administration of 100% oxygen by mask at 15 L should be started right away, particularly if a patient has suffered from inhalation injuries or carbon monoxide poisoning as a result of the burn. Initial responders to a burn patient should remove the clothing as a potential source of continuous burning and to assess for conditions that could impair the patient’s ability to breathe. Circumferential burns around the chest can limit chest expansion, leading to shallow attempts at breathing and subsequent hypoxia. The clinician should assess breath sounds by not only auscultating the lung fields, but also assessing for depth and rate of respirations.

The health team should monitor a patient’s oxygen status by initially monitoring pulse oximetry to determine if administered oxygen is preventing hypoxia. An arterial blood gas (ABG) can provide insight into oxygenation or carbon dioxide buildup in the bloodstream. The

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 patient may also require a chest radiograph (XRAY) to assess for lung damage and expansion. In addition to oxygen administration, bronchodilator medications may be effective in opening airway passages and facilitating easier breathing. This may not be an initial part of the resuscitation process, and can be added if the patient is showing signs of dyspnea indicative of airway constriction. It should be raised that corticosteroids, used to minimize inflammation in the airways, has been shown to increase the patient’s risk of infection and 2-4 is not recommended.

As noted earlier, tracheal intubation should not be delayed if a patient is showing signs of breathing difficulties and there is evidence of inhalation injury. Because airway edema can develop rapidly, and can quickly occlude the airway, tracheal intubation should be performed sooner rather than later. It cannot be overemphasized that once the airway is obstructed due to edema, it can become very difficult to pass an endotracheal tube to ventilate the patient. A patient, who is unconscious, has burns on the face or the neck, or with worsening respiratory distress are all primary candidates for intubation.1 The clinician should continue to monitor for signs of worsening respiratory distress that indicate a need for intubation. Signs and symptoms to observe for include:1,30 • coughing, wheezing, and stridor with breathing • circumferential burns of the neck or face • hoarseness • hypoxia • hypercapnia • high levels of carbon monoxide in the body

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 If a patient must be intubated to assist with breathing, it may be difficult to secure the tube, particularly if burns to the head and neck are present. Swelling and edema that follow a burn injury may increase the risk of tube dislodgement, and there may be a lack of adequate tissue to secure the tube. Tape should be avoided on damaged skin and, if necessary, the tube should be secured with cloth or umbilical tape by tying it around the tube and securing it behind the patient’s ears or head. Continuous monitoring of the endotracheal tube is necessary to ensure the patient is maintaining adequate oxygenation with the ventilator and that the tube has not become dislodged.

A pediatric patient may require early intubation based on consideration of the size of the patient’s airway as well as the patient’s condition. Pediatric patients have smaller airways, which can be difficult to intubate even under normal conditions. The risk of airway occlusion because of edema following a burn may prompt more rapid intubation in the pediatric patient as compared to an adult. A clinician experienced with endotracheal tube placement in pediatric patients, particularly when airway damage has occurred, should be performing the intubation procedure.4,10

Respiratory ventilator settings when initiated are based on the individual’s needs and condition. For patients with inhalation injuries, the American College of Chest Physicians does not offer specific recommendations for ventilation parameters for all patients; however, guidelines are offered that suggest minimizing plateau pressures and the use of appropriate levels of positive-end expiratory pressure 1-3 (PEEP) in individual cases as required.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Circulation Status

Checking the heart rate and pulse typically is done during assessment of the patient’s circulation status. Auscultating heart sounds may reveal the rate and character of the heart rate. A heart rate of less than 110 beats per minute (bpm) indicates that the patient has adequate blood volume, while a heart rate greater than 120 bpm may point to low blood volume and demonstrates the body’s attempt to compensate. If the patient with a burn injury is hypotensive upon arrival to an acute care center, the emergency clinician should not assume that the low blood pressure is a direct result of the burn. It is important to understand the patient’s history and the events surrounding the burn before determining that blood pressure changes are caused only by the burn injury.1,30 For example, a patient may have been injured in a fall when trying to escape a burning building and could have low blood pressure because of internal bleeding.

Blood pressure readings may not be the most accurate sign of appropriate blood circulation in a burn victim. It can be difficult to take a blood pressure if the burns are so extensive that an appropriate location for a blood pressure cuff becomes hard to obtain. A more accurate method of measuring blood pressure is to place an arterial catheter for direct pressure measurement. The most common location is the radial artery of the wrist. Because of changes in the intravascular system, as a result of the body’s response to the burn, fluid will shift out of the intravascular space and into the surrounding tissues. As a result, a patient may have an increased pulse rate and low blood pressure; capillary refill is typically delayed and it may be difficult to detect peripheral pulses.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 A patient who has suffered an electrical burn may be at risk for cardiac abnormalities. In a patient with an electrical burn that has an entry and exit point cardiac arrhythmias may develop as a result of the electricity from the burn disrupting the cardiac electrical cycle. This can lead to heart arrhythmias or complete asystole.3 An electrocardiogram (ECG) is done to assess for cardiac arrhythmias, and continuous cardiac monitoring is important to measure hemodynamic status on a regular basis and to assess for changes in cardiac function.

While assessing circulation is an initial part of the primary survey and stabilization, a patient who has suffered an electrical burn should continue to receive cardiac monitoring for several hours after his or her condition has stabilized. Ultimately, all patients who have suffered burn injuries that require fluid resuscitation and initial stabilization should receive cardiac monitoring on a continuous basis to measure changes that could indicate a decline in patient status, even after the initial stabilization period.

Burn shock can develop quickly and involves a change in cardiovascular status. Burn shock involves a state at which the body receives inadequate perfusion of blood and nutrients; in this case, the condition develops as a result of severe burns.1 The patient develops hypotension and signs of perfusion diminish, as evidenced by delayed capillary refill.3 Pulse oximetry should be continuously checked to assess levels of oxygen in the bloodstream, although this method of observation is not always accurate when applied peripherally. The burn patient may have fewer areas on the body for which to place a pulse

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 oximeter; furthermore, the results of pulse oximetry may not be accurate if circulation is impaired as a result of injury.

It is important to note that standard pulse oximetry is not an adequate assessment when carbon monoxide poisoning has occurred and other measures should be assessed to rule out this condition, such as lab work to check carboxyhemoglobin levels. Some health care centers use specialized oximetry probes that can accurately detect oxygen concentrations in the blood when the possibility of carbon monoxide poisoning is present. Called CO-oximetry, monitoring probes use four wavelengths of light in comparison to standard pulse oximetry, which uses only two wavelengths.1,10

Standard pulse oximetry cannot necessarily detect carbon monoxide bound to hemoglobin because it can only detect hemoglobin that is either oxygenated or deoxygenated, and not any other forms. Alternatively, CO-oximetry has more light wavelengths that can detect hemoglobin, oxyhemoglobin, carboxyhemoglobin, and methemoglobin. This type of probe can specifically measure oxyhemoglobin levels that are the same as arterial oxygen saturations. If a facility has access to CO-oximetry, this form of monitoring can be utilized in inhalation injuries or in the possibility that carbon monoxide toxicity exists.1,16

The Secondary Survey

The secondary survey begins as soon as a patient’s airway, breathing abilities, and circulatory status have been assessed and stabilized. The secondary survey consists of a head-to-toe examination to look for other injuries and to assess the extent of the burns. During the secondary survey, the clinician continues to keep the patient stable, nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 provides intravenous fluid resuscitation, and controls other factors that may contribute to continued injury or illness for the patient.

The secondary survey includes several important components that are considered burn specific. Reviewing these factors about the burn will provide a comprehensive history of the incident, which may better prepare clinicians about how to manage the injuries involved. These considerations include the following:

• Mechanism of Injury:

The mechanism of injury and what happened that actually caused the burn.

• Time of the Injury:

This is exceedingly important information, as every minute following a burn injury can be crucial for providing life-saving treatment or preventing complications. Depending on the area where the burn occurred in relation to the treating facility, there could be considerable time that has elapsed between the injury and the beginning of treatment.

• Consideration of Abuse:

A patient who has used alcohol or illicit drugs prior to the burn injury may have more complications throughout treatment as compared with someone who has not used these substances.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 • Height and Weight:

Obtaining the patient’s height and weight information helps providers to calculate fluid requirements and other medications that may be administered during the treatment period.

• Inhalation Injury:

As stated, inhalation injuries can cause trauma to the airway that can result in an occlusion and need for intubation. Inhalation injuries can also cause significant lung damage and overall toxicity when the patient breathes in toxic particles or chemicals found in smoke.

• Facial Burns:

Burns to the face require specialized care and can place the patient at risk of airway occlusion, breathing difficulties, altered oral intake, and vision loss as well as other complications. Facial burns should be managed by an accredited burn care center and the patient should be transferred, according to the American Burn Association guidelines.

Evaluation of Associated Trauma

If it has not already been done, a patient’s clothing and jewelry should be removed as soon as possible to avoid further injury and burning of the skin. Items such as watches, rings, and belts should be removed as part of this process as well, as these items constrict the flow of blood and have the same effect as a tourniquet. This tourniquet effect can lead to edema and vascular damage.1

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 In most cases, patients brought to a health care facility have been stabilized in the field to a certain extent, and removed from the source of the burn. However, there may be times when clothing continues to burn a patient’s skin or there are still particles of chemicals from the initial burn present on the patient’s skin and continuing to burn the patient. These items must be removed to stop the burning process. A health team member removing the items, whether it is burned clothing, chemicals, or other substances causing the burn, must be very careful not to become injured in the process.

If chemicals have burned a patient, removing as much of the chemical as possible is essential to stopping the burn process. Research does not recommend attempting to neutralize chemicals by applying countermeasures through products that stop the effects of the burning. Not only can this process be complicated, but it could also cause further skin damage with the application. Additionally, neutralizing chemicals produces a certain amount of heat in the process itself, which would only add to burn damage.1 When removing chemicals from a burned patient, the provider should take measures to protect themselves by wearing a mask, gloves, and goggles to avoid getting any of the chemicals on his or her own skin and subsequently becoming burned as well.

During the secondary survey, the health team may uncover other injuries that have occurred that may not have been initially apparent when the burn injuries were first being managed. There are some types of injuries that could go unnoticed as compared to a severe burn and the clinician must assess for signs and symptoms of other existing problems in order to manage these as well. Some examples of injuries

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 include fractures, dislocations or abdominal injuries. Additionally, injuries to the head or face, including to the eyes and ears (such as corneal abrasions or tympanic membrane rupture) require careful evaluation as potential injuries associated with burns that may have been overlooked.3,4,21,24

A neurological exam should also be performed at this point to assess whether the patient suffered an injury that would have caused hypoxia to the brain. If smoke inhalation has occurred, the patient may have had a period of time of decreased oxygen to the brain. If the burn occurred as a result of an accident, such as a fall or an explosion, there is the potential of a head injury. A neurological exam can identify if deficits exist based on certain findings and by understanding the mechanism of injury and incidents surrounding the time of the burn.

A basic neurological exam can be performed on the patient to assess for deficits and changes in level of consciousness. If the patient is awake and able to answer basic questions, the clinician can ask the patient: “What is your name or birthday?” If the patient can answer these questions accurately and appears to be awake and alert, the clinician can continue to gain information about the patient’s history, including important information regarding past medical conditions and the circumstances associated with the burn injury.

A patient who has suffered a traumatic injury beyond the burn wounds and who is unable to answer basic questions, as part of a neurological exam, may need assessment through a trauma scoring system to determine the extent of neurological deficits that may exist. The Glasgow Coma Scale (GCS) is a scoring system that should be used for

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 any patient who presents with a burn wound as a result of an accident or traumatic injury. The GCS is a tool used to assess neurologic function in three different areas: best eye response (the eye opens), verbal response, and motor response. The clinician assesses each of these areas in the patient and then assigns a score based on the response.1-3

The highest level of the GCS is 15 points, which is the best response indicating very little to no neurological deficit. The lowest score is 3 points, which demonstrates that the patient has no motor or sensory response to stimulation and does not open the eyes. The lower the score on the GCS, the more severe the neurological deficit. The results of the GCS can help clinicians to better manage a patient’s total condition beyond the burn injury.

While stabilization of the burn is important during early assessment, neurological deficits must also be addressed as severe deficits can impact a patient’s ability to recover or even survive after a traumatic burn. For instance, a patient with a GCS score of less than 8 would most likely need to be intubated because he or she may have enough neurological impairment to cause an inability to breathe without assistance. The decision to intubate involves more than an initial assessment of the patient’s airway as a result of a burn; because even if the burned patient has no signs of inhalation injury or airway obstruction, there may still be a need to intubate as a result of a low GCS score.

During the process of checking the patient’s circulation and for the presence of other injuries, an additional assessment involves the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 presence of circumferential burns that can affect circulation. Circumferential burns are those that extend around a body part, such as one that is wrapped around an extremity. It has been noted that circumferential wounds in the chest can impact the patient’s ability to breathe and must be checked carefully. In the extremities, circumferential burns can impede blood flow from the damaged tissue. This tissue, called eschar, is inelastic and will not expand to allow for breathing or movement; consequently, it compresses the circulatory system, causing ischemia in the distal tissues.

If a circumferential burn has been identified, rapid treatment may be necessary to prevent continued injury. In this case, emergent escharotomy may be needed to allow for expansion and to promote breathing and circulation. An emergent escharotomy may be performed in the emergency room, but it is more commonly done in a surgical suite to allow for adequate sedation and/or anesthesia for the patient, as well as electrocautery to manage bleeding in the event of extensive blood loss.28 Although the operating room is the ideal location for emergent escharotomy, in significantly dangerous situations, escharotomy has been performed in the emergency room and in the field before patient transport to a hospital as a life-saving measure.

Escharotomy involves using a scalpel to cut into the burned skin; the incision is deep enough to reach but does not penetrate the subcutaneous fat underneath. This incision is done to release the pressure buildup that occurs in the affected area. The eschar incision is drawn along the length of the affected area to about 1 cm past each end of the burn. The goal of the procedure is to reduce the pressure in

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 the affected area and restore normal circulation to the site. The clinician can check for adequacy of the procedure by assessing distal pulses and checking capillary refill to determine if circulation has been 27 restored.

Although an emergent escharotomy is not always necessary, failure to relieve pressure that can occur from circumferential burns that impede blood flow to parts of the body can result in disastrous consequences for the patient. Some complications associated with failure to recognize the need for and perform an escharotomy, or with inadequate decompression from an escharotomy, include gangrene development in the affected area, respiratory insufficiency, destruction of muscle tissue, and nerve injury.27 While the process of performing an escharotomy may be somewhat complex and may cause anxiety for the patient, failure to perform this procedure when necessary produces more complications than managing the patient otherwise.

Total Body Surface Area (TBSA)

Burn management is dependent on the type of burn that has occurred, the depth of the burn, and the extent of the burn covering the body. The source of the burn can cause different types of complications between situations; two people may present for burn care with different manifestations and needed management of a burn area based on the source of a burn. For example, a patient who has suffered from an electrical burn may require different aspects of management than a patient who has suffered a thermal burn. The three main sources of burns are outlined below.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 Electrical Burns

Electrical burns occur with exposure to an electrical current. They may not always have the same appearance as a thermal burn in that the outer skin surface may not be significantly affected. However, electrical burns can cause significant internal damage, including broken bones, seizures, muscle contractures, and cardiac arrhythmias. The surface of the skin, including an entrance and/or exit wound, may appear to be only a minor injury, or it may cause extensive skin damage. Electrical burns may be caused by such situations as exposure to a home power supply, a child biting an electrical cord, or lightening.8

Chemical Burns

Chemical burns develop when a person comes in contact with a substance that is caustic to the skin and mucous membranes. They can affect the exterior of the body or they could cause internal burns, such as in the case of ingestion of caustic chemicals. The extent of the burn depends on several factors, including the amount of the chemical that caused the burn, the concentration of the chemical, and the duration of contact. The chemical burn will continue as long as the chemical remains in contact with the body.2,7 Chemical burns most often occur with exposure to substances in the workplace or in the home, such as cleaning solutions, car battery fluid, fertilizers, or bleach.

Thermal Burns

Thermal burns tend to be the main type of burn that people consider when they think of someone being burned. In fact, thermal burns

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 make up 90% of burns received.2 Thermal burns occur with exposure to a heat source, such as hot liquid or fire. These types of burns can cause extensive damage to the skin and mucous membranes. The most common types of thermal burns occur in the home from cooking fires and hot bath water.3 Older adults may be at higher risk of severe burn injuries because of thinner skin that contains less collagen; similarly, young children are also at higher risk because they often cannot control their circumstances or prevent injuries.

Once the source of the burn has been identified, the clinician must assess the depth of the burn. Burns are classified according to the depth of skin tissue that is impacted. Superficial, or first-degree burns are considered partial-thickness burns that typically affect the epidermis and part of the dermis. First-degree burns appear as reddened skin that may peel as part of the healing process. There may be blisters on the surface of the skin. These types of burns heal quickly as compared to second-degree or full-thickness burns. Most people heal from first-degree burns within one week with minimal long-term damage.3

Second-degree or deep partial-thickness burns are those involving the epidermis and lower layers of the dermis but not the structures underneath. These types of burns can be extremely painful for the involved patient and often require frequent administration of medications for analgesia. The skin is reddened and may have weeping blisters; edema also may develop. A patient with a second-degree burn may have an increased sensitivity to touch or even surrounding air.3 These types of burns may take up to a month to heal.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 Third degree or full-thickness burns are those that involve the epidermis and the dermis, as well as underlying subcutaneous tissue, muscle, tendons, and bone. The skin of a full-thickness burn may not appear similar to skin at all, but instead may be blackened, charred, or leathery; alternatively, it may also appear white, dry, or crusty. The patient may have less pain with a full-thickness burn as compared to a second-degree burn, because the nerve endings may have been 3 destroyed with a third-degree burn, resulting in less pain. Treatment of full-thickness burns is complex and healing may take weeks to months in length, followed by rehabilitation to restore some functioning.

The extent of the burn determines the amount of tissue involved. This is referred to as the total body surface area (TBSA) of the burn. There are several methods of determining TBSA, depending on the situation, including time constraints for estimating the client’s needs and the age and condition of the patient. Because treatment parameters will be based on the source and depth of the burn, as well as the total body surface area of the burn, it is important to accurately determine the extent of injury in order to best manage injuries associated with severe burns.

Determining TBSA

One of the most common methods of determining TBSA is the Rule of Nines. This method is typically used among adults (and may be modified for children) who are burned and provides a rough estimate of TBSA. The Rule of Nines breaks down major areas of the body into percentages divisible by nine. The clinician can determine the approximate amount of area on the body burned by remembering the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 percentage and adding the total together. The head and neck constitute 9%, the chest and abdomen accounts for 18% in the front and 18% in the back, each leg is 18%, each arm is 9%, and the perineum is 1%.3 If the patient is a child, the Rule of Nines estimation can still be used, but the percentages are modified to account for body surface area of the child and the size of the head in relation to the rest of the body. According to the Rule of Nines, a child’s head and neck are 18%, the chest and abdomen is 18% in front and 18% in back, each leg is 14%, and each arm is 9%.6

When using the Rule of Nines to determine TBSA, if the clinician encounters an area that does not fit with the pre-determined percentages, the palm method of estimating burn size can be used. This assumes that the palm of the hand is approximately 1% of body size.6 This method can be used in situations where there are patches of burned areas or burns that do not fit the typical size associated with the Rule of Nines, but that still must be estimated quickly. For example, a patient may have a burned area on the front of the upper part of the leg on the thigh, which would not warrant classifying this burn as 18% TBSA since it does not involve the entire leg. Instead, the clinician can quickly use the palm method to estimate how much surface area is burned by estimating the size of the burn according to the size of the patient’s palm.

Although the Rule of Nines is helpful and can be instituted quickly, the Lund and Browder method is another more comprehensive and accurate approach to estimate burn injuries. The Lund and Browder chart considers age-related proportions and may be used more among children who receive burn injuries. This method also involves a scoring

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 system, but the body parts assessed are grouped in smaller segments. These smaller groups provide more accurate assessment when compared to the Rule of Nines, particularly if a burn affects a smaller body area.

Often, a Lund and Browder chart is kept at emergency facilities for use to estimate burn extent in a patient. A facility that receives a burn victim may use the chart, which shows a body outline with percentages broken down into smaller components to compare to a patient’s body. Because this method provides a more accurate assessment of TBSA in a burn patient, it may be more likely to be used when calculating fluid requirements for resuscitation.2,9

Burns are further classified as minor, moderate, or major injuries. The following classifications categorize types of burns:2,3,9,10

• Minor Burns:

Minor burns are considered to be burns that are superficial or partial-thickness burns covering less than 15% of TBSA in adults and less than 10% of TBSA in children. Minor burns do not involve the eyes, face, ears, hands, feet, or perineum in affected patients. A full-thickness burn may also be classified as a minor burn if it affects less than 2% of TBSA in an adult or child.

• Moderate Burns:

Moderate burns are partial-thickness burns that constitute 15 to 25 % of TBSA in adults or between 10 and 20% TBSA in children. Moderate burns do not involve the face, eyes, ears,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 hands, feet, or perineum. A full-thickness burn may also be classified as a moderate burn if it affects less than 10% TBSA.

• Major Burns:

Major burns are partial-thickness burns, which affect more than 25% TBSA in adults and more than 20% TBSA in children. These burns involve particular areas such as the face, eyes, ears, hands, feet, and perineum. Full-thickness burns that cover more than 10% of TBSA are also classified as major burns.

Edema Formation

The body’s initial response to the burn results in the release of several chemicals that affect circulation and can cause edema. The initial, or local response involves activation of complement, release of free radicals, increased histamine production, and coagulation of proteins.2,9,10 These responses all affect circulation by increasing capillary permeability, in which fluid starts to leak out of the intravascular space and into the interstitial space, resulting in edema. Marked edema may be noted throughout the body, including edema of the extremities, which places the patient at risk of limb ischemia and compartment syndrome. Increased edema also leads to pulmonary congestion and ultimate airway obstruction if it is not managed properly.2,9,10,26

A significant burn injury may cause changes to the cardiovascular system that are the same as what occurs with a severe hemorrhage, as intravascular volume can drop significantly. In these instances, the patient has decreased cardiac output and decreased urine output. Alternatively, instead of blood flow leaving the body as is seen with nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 hemorrhage, the fluid causes extensive edema, which must be managed and minimized to prevent complications. The patient is at risk of tissue ischemia and although it may seem counterproductive to administer more fluid when excess edema is present, the patient needs high volumes of fluid to replace what was lost from intravascular volume.

Edema formation initially occurs in burned and damaged skin and then moves to affect non-burned skin within the first 24 hours after injury. Herndon (2012) Total Burn Care states that edema formation in burned skin can occur extremely rapidly, and water content in the tissues has been shown to double within the first hour after a burn injury.1 The total amount of edema often peaks about 24 hours after the initial burn injury. After about 48 hours, edema formation slows and begins to resolve; most edema has completely resolved by 10 days after the burn injury.4 In the meantime, it is essential to provide care to the patient that will minimize edema and control the condition to prevent complications.1,23,24

Extremities that have been burned should be elevated in order to promote blood flow back to the heart and to reduce the risk of such excessive edema that compartment syndrome develops in the distal tissues. Range-of-motion exercises are also necessary on a regular basis to promote blood flow to the extremities and to prevent contractures. Range-of-motion exercise is performed as the patient tolerates, and can be very helpful in managing extremity edema. The type and amount of fluid given during the fluid resuscitation period may also help to control edema formation.10,27

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 Administration of hypertonic saline solutions may be helpful in reducing instances of burn shock by reducing fluid shifts from the intravascular space to the interstitial space when the blood serum contains more than enough sodium. Administration of hypertonic saline solutions has been shown to reduce edema formation and to reduce the need for emergent procedures to control excessive edema, such as escharotomies.1 However, hypertonic saline administration is typically not common during standard fluid resuscitation with a burn injury. Diuretics are not recommended for use to control edema in burn patients, except for in cases of myoglobinuria and hyperpigmentation of the urine associated with kidney damage.

One dangerous complication of excess edema is compartment syndrome. The muscles of the body are arranged into compartments that are surrounded by fascia, a tough, inelastic membrane that protects the space. With excess fluid accumulation following a burn injury, there is risk for compartment syndrome, which is an increase in pressure within a compartment in the body. The increased volume of fluid from edema raises the intracompartmental pressure, leading to pain and the potential for severe complications, including ischemia and tissue loss.

A burn patient is at risk of compartment syndrome not only because of the large amounts of fluid being administered during the fluid resuscitation period, but also as a result of massive edema that may develop following a burn injury when fluid leaks out of the intravascular system. Compartment syndrome may develop in a number of areas of the body, including the extremities, the abdomen, and even the periorbital areas. As pressure increases within the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 compartment, blood flow is decreased and venous pressure rises. The fascia overlying the area is unyielding and typically does not stretch to accommodate the increase in fluid volume in the area. Eventually, the blood vessels are compressed to the point of collapse and ischemia develops in the surrounding tissue when oxygen in the bloodstream cannot reach the area.23,27

Symptoms of compartment syndrome may include weakness, numbness, and tingling of the area distal to the site. Additionally, the patient may experience severe pain at the site that is proportionately greater than the pain associated with his injuries; the pain is often described as a deep ache or a burning pain. The area is tight and musculature is tense at the site, and passive stretching of the muscles causes severe pain for the patient. The skin may appear pale and cool due to decreased circulation to the area, but this is an uncommon finding.23,27

It may be difficult to properly identify the development of compartment syndrome when pain is a clinical indicator. Often, burned patients are already in pain and may not be able to identify the difference between the pain caused from burn wounds compared to an increase in pressure in a certain body compartment. Additionally, a critically ill burn patient who requires mechanical ventilation and who may be sedated will not necessarily be able to tell the provider about increased pain in certain areas of the body. Furthermore, if the burn patient is a child, he or she may not be able to pinpoint what is going on and may not be able to explain exactly where the pain is or if there are other symptoms. It is therefore up to the health team to regularly monitor for signs and symptoms of compartment syndrome and to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 consider the effects of increased fluid administration associated with burn treatment, as well as to take measures to minimize edema to prevent compartment syndrome.22

Compartment syndrome has been associated with severe and sometimes life-threatening complications for the affected patient. Infection, contractures, paralysis, limb amputation, and kidney failure as a result of myoglobinemia have all been seen with severe compartment syndrome.27 If the emergency clinician suspects compartment syndrome in a burned patient, arrangements should be made for a surgical consult as soon as possible for further examination of the situation and potential treatment.

Some clinicians may measure pressures within the compartment to determine a diagnosis; however, compartment pressures are not necessarily mandated in all situations and the clinician may choose to treat the situation based on the patient’s presentation and the treatment team’s report. Measurement of pressure inside a compartment involves use of a manometer, which is a catheter-type instrument through which a small amount of fluid can be injected into the compartment to measure for resistance. This may not be warranted in a patient who has been burned and, although the reading of intracompartmental pressures is important when considering treatment, the surgeon will decide what is most appropriate for the patient by checking pressures or proceeding to treatment without knowing the exact amount of pressure measurement.

Treatment of compartment syndrome involves a fasciotomy to release the pressure within the compartment.27 Ideally, fasciotomy should be

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 performed within six hours of onset of compartment syndrome to minimize potential complications associated with the condition. Fasciotomy involves creating a linear incision along the area where the compartment syndrome has developed. The incision must be deep enough to cut through the tough fascia overlying the compartment that is contributing to increased pressure.27 Fasciotomy differs from escharotomy in that a fasciotomy incision is deeper and cuts through the fascia, whereas an escharotomy incision is only deep enough to reach the subcutaneous fat and tissue and not penetrate it.

Fasciotomy may be performed after an escharotomy if the original procedure did not relieve the pressure in the area. A fasciotomy is typically performed in a surgical suite and should be done by a surgeon experienced in the treatment of burn injuries. Ideally, the procedure releases the built up pressure within a compartment and restores blood flow to the area. Following a fasciotomy, the patient should be monitored closely. If the procedure was performed on an extremity, it should be elevated for 24 to 48 hours to reduce fluid buildup distal to the site. The fasciotomy causes an open wound that should be kept clean and monitored as any other wound, particularly in a burn patient who may be at higher risk of infection.27

The surgeon may choose to close the fasciotomy wound later; this is often done after several days. The swelling in the affected area needs to go down first and there must be no evidence of a repeat occurrence of increased pressure in the area or further development of compartment syndrome. The patient may require a wound vacuum to provide negative pressure for a period of time following the fasciotomy to avoid further buildup of fluid.27

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 Abdominal compartment syndrome can be extremely challenging to control and may be associated with increased levels of fluid administration during the fluid resuscitation period. Abdominal compartment syndrome develops through what is known as abdominal hypertension, when pressures in the abdominal cavity increase to dangerous levels. Abdominal compartment syndrome is considered when intra-abdominal pressure exceeds 20 mmHg and the patient develops organ dysfunction that was not present at the time of the injury. Abdominal hypertension may be more likely to develop when crystalloid administration reaches 250 to 350 mL/kg during the resuscitation phase. Abdominal compartment syndrome has been shown to result in over 97% mortality among patients with burns of over 60% TBSA.29

Abdominal compartment syndrome (ACS) may cause severe complications, including impaired renal function, tissue ischemia in the gastrointestinal tract, and poor perfusion to the cardiac and respiratory systems. Monitoring urine output, while valid and applicable when assessing the results of fluid resuscitation, will not serve as a method of determining ACS development. The health team must instead be acutely aware of fluid administration rates and monitor for the subtle signs and symptoms that can indicate increased intraabdominal pressures.29

Signs and symptoms of developing abdominal compartment syndrome include a tense and firm abdomen, hypercapnia, decreased pulmonary compliance, and poor urine output. If ACS is suspected, the emergency clinician should intervene right away with further evaluation and treatment as necessary. Nothing should be placed on

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 the patient’s abdomen, and blankets or constricting clothing should be removed.10,29

One of the fastest methods of reducing intraabdominal pressure is through paracentesis of the abdomen to reduce excess fluid from edema development. Paracentesis is performed to decompress the abdomen and to restore normal pressure. It is a minimally invasive process that is appropriate for recovering burn patients because of the decreased risk of infection as compared to a larger incision that would be warranted through laparotomy or an open incision to reduce pressure. Abdominal paracentesis also has a much lower incidence of mortality as compared to laparotomy for abdominal decompression.

The process of paracentesis involves inserting a needle into the abdomen and drawing out excess fluid from the space. The patient should be carefully monitored during and after the procedure for possible complications, including bleeding and washout of lactic acid, which can be toxic and damaging to the tissues. Some medications may also be used to control intraabdominal pressure, the most common includes diuretic therapy such as mannitol. However, because burn patients are a special population, use of diuretics is not typically recommended and abdominal compartment syndrome among this group requires specialized management in comparison to other causes of ACS, such as ascites.3,4,29

Continuous Monitoring

Continuous and thorough monitoring is necessary, particularly during the acute phase after burn injury but on an ongoing basis to ensure the patient remains in stable condition. If a large amount of TBSA is

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 burned (greater than 20%) the patient will most likely need intensive care during the initial recovery. In addition to fluid resuscitation, this also requires hemodynamic monitoring of heart rate and blood oxygen saturations, as well as arterial blood pressure measurements.1-4

The intensively monitored patient should also have an indwelling urinary catheter, as urine output is one of the most important indicators of response to fluid resuscitation. A nasogastric tube is typically also placed to decompress the stomach, particularly among patients with over greater than 20% total body surface area burned. This patient population may be at greater risk of vomiting with the further potential for aspiration of stomach contents that can lead to infection and pneumonia in lung tissue. A nasogastric tube may be placed at low or intermittent suction to keep excess air out of the stomach and to prevent a gastric ileus. Additionally, the patient may receive enteral nutrition during this time.1-3,28,30

Nutrition Status

Often, patients with extensive burns are unable to maintain adequate oral intake; further, a patient who requires mechanical ventilation for breathing assistance will not be able to take in any nutrition by mouth. Enteral feedings are necessary to provide enough nutrition for wound healing and should be started early in the burn recovery process. Part of the monitoring process is administration of enteral nutrition to stimulate the gastrointestinal tract and provide nutrition for the patient as well as to determine the patient’s response.16,17

The role of early enteral nutrition in the burn patient is to prevent gastric ileus and to promote wound healing through adequate protein nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 and proper nutrient intake. However, the health team must continue to monitor the patient’s status through nutrition intake to determine how well he or she tolerates it and for whether there are any signs of delayed stomach emptying or other gastrointestinal complications. Although nothing by mouth (NPO) status is typically not warranted the patient will need to be monitored carefully to prevent the development of potential problems that could further complicate the healing process.

Pain Management

Pain management is critical for the patient who has been burned. Superficial and partial thickness burns can be extremely painful, to the point that elevated pain levels cause changes in vital signs and may make management of breathing and circulation difficult. While third- degree burns may be less painful if the burn has destroyed the nerve endings under the skin, the patient may still have significant pain through the healing process. Pain must also be managed for necessary surgical procedures associated with needed burn injury interventions, including the placement of central or arterial catheters, and for any other injuries co-occurring with the burn, such as fractures.1,10

Often a burned patient is extremely anxious about his or her injuries, and anxiety, restlessness, and agitation may be present during the initial stages of burn care. Alternatively, some patients have decreased levels of consciousness and are unable to express pain; likewise, young children cannot always express their pain or explain where it hurts the most. In all of these situations, pain control and sedation is important and remains a top priority in pain management of a patient with burns. The health team should assess for signs that the patient is

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 in pain regardless of whether the patient is able to express in words or otherwise demonstrate pain. Similarly, the anxious patient may need intravenous sedation to assist with feeling calm during the early process of stabilization in order to complete required tasks and obtain information about the patient’s history.

Morphine sulfate, given intravenously at 1 to 4 mg per dose, is one of the most common methods of pain management when a burn patient has moderate to severe pain from their wounds. This dose may be given every 2 to 4 hours as needed for pain control. Morphine is an opioid analgesic used for the treatment of moderate to severe pain and, when given intravenously, can have a fairly rapid onset for pain control. Meperidine (Demerol) is another opioid analgesic that may be used for pain control; a typical dose would be between 10 and 40 mg 1 intravenously every 2 to 4 hours for severe pain.

Since morphine and meperidine are opioids there are side effects that both can cause, such as constipation and delayed gastric emptying, particularly when given incrementally over a long period of time for pain control. This should be noted in the burn patient, as gastric ileus and decreased intestinal peristalsis are complications of which the patient may already be predisposed. Pain medications should never be given intramuscularly, as this method is painful for the patient and could cause further skin and tissue damage.1

Patient History

Evaluating the patient’s history and determining if there is information pertinent to the current situation is an important part of the patient evaluation. The patient history may not be immediately available if the nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 patient is unconscious and there are no family members present who can provide the information. If the patient is able to answer questions, or if there is someone with the patient who can provide appropriate information about the patient’s history, the information can be gathered once the patient has been stabilized. If life-threatening circumstances are still present, it may be best to wait until the patient is stable before attempting to gather data about the patient’s history, unless some of the medical information directly affects the patient’s current status.1

The best source of the patient history is directly from the patient, as he or she can attest to what happened as the burn victim and is most aware of their background information and health history. However, there are times when this is inappropriate, such as if the patient is unconscious, as mentioned, but also if the patient has consumed alcohol or other substances that may have had a role in the injury and impede the patient’s ability to answer questions.

Other patient circumstances may require that the clinician obtain collateral information, such as when the patient experiences elevated anxiety or pain levels leading to impairment of concentration or mental cognition necessary to provide background information. If the patient has a mental illness or other cognitive deficit, he or she may not be able to provide accurate health information to the health team. Children and infants who are burned are usually not reliable sources of information about their history and events leading to the burn injury and would require a parent or caregiver to provide information.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 Allergies

Assessment of patient allergies is an important part of the medical history. A patient who has been burned will often need a number of different types of fluids and medications as part of treatment and it is essential to initially know of the existing allergies. The clinician should learn of the patient’s allergies to avoid administering drugs or fluids that could cause an allergic reaction, which would worsen the situation for the patient.

Some common types of allergies encountered with patients that could affect burn management include allergy to latex and to certain kinds of antibiotics. While many healthcare facilities have become latex free in their practices as a result of the increasing amounts of latex allergies encountered, it is still important to document whether the patient has a latex sensitivity or allergy. This is especially important if the health team was to use any materials or equipment that could cause a latex reaction or if the patient were to be transferred to another facility.

Since the risk of infection is high after a burn, topical antibiotics are typically necessary. It is very important to determine if the patient has any allergies to medications that could be given during the treatment of burns, including antibiotics. The nurse should find out not only what medication caused the reaction, but also the type of reaction that occurred as well. As an example, silver sulfadiazine is a topical ointment that is used to prevent infection in some patients with second- or third-degree burns. Silver sulfadiazine is derived from sulfonamides and should not be used in patients who have an allergy to sulfa because of the possibility of a reaction.13

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 Once the clinician has determined that allergies exist, the allergies should be documented and well marked to avoid accidentally administering medications or substances that would cause a reaction. Since some reactions can be life threatening, it is essential to be aware of allergies and to find out as much information about the patient’s background as possible. It is easier to prevent an allergic reaction than it is to manage a reaction once it has started.

Medication Reconciliation

Once the clinician finds out what type of medication the patient is taking, he or she must decide whether or not to continue the medication while the patient is receiving care for their burns. Through medication reconciliation the clinician determines what medications a patient is taking, decides whether to continue the same medications at the same doses normally taken; and, then makes arrangements for how the patient will take medication. The clinician will determine whether medication will be provided by the facility pharmacy or through the patient’s own medications.1,7

The emergency clinician should find out whether the patient is taking any medications and the reason for taking them during the medical history intake. This information may be gathered when learning more about the patient’s past history. It is important to know what kinds of medications the patient is taking, including prescription and over-the- counter preparations, as well as any herbal supplements. Since the patient will likely receive medications as part of the burn treatment, the clinician needs to know of any medications that the patient is already taking in order to avoid negative drug interactions and to prevent overdosing.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 The types of medications that the patient is taking provide helpful information and clues about the patient’s medical history. Certain medications have obvious purposes and knowing what medications a patient is taking can help the clinician to better manage the patient’s condition. For instance, if the clinician finds out that the patient normally has a prescription for atenolol (a beta blocker medication), he or she can know that the patient may have high blood pressure or may have had a heart attack. Likewise, a patient who normally takes insulin may be assumed to be diabetic even if that specific information is not available right away.

Past Medical History

Information about the patient’s past medical history is necessary during the treatment of burn injuries, as there could be components of the medical history that impact the patient’s healing process. Chronic diseases such as diabetes, kidney disease, or coronary heart disease can impact the patient’s response to the burn and may worsen the patient’s condition because of impaired circulation after the burn. Learning the patient’s past medical history determines what acute or chronic conditions exist, as well as a history of surgical procedures, hospitalizations, and other conditions requiring medical interventions and medications.

Understanding the patient’s history can help the medical clinician to better deliver care and treatment of burn injuries. For example, some conditions can further impact circulation after the initial vascular changes have stabilized, which contributes to poor or delayed wound healing. A patient with diabetes may have slowed wound healing while

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 recovering from a burn injury; additionally, glucose levels and insulin response must be managed throughout the recovery process.

Another aspect to consider when asking about the past medical history is the patient’s immunization status. Although this information may not be readily available or may not be at the forefront of the patient’s mind after a burn injury, it is important to know if the patient has had certain immunizations to better protect against some types of infections.

Burn patients may be at higher risk of infection with tetanus, so it is important to determine if the patient has had a tetanus vaccination in the last ten years. Tetanus is a toxin created by bacteria that could infect burn wounds, causing significant illness including muscle pain and stiffness, seizures, and hypertension, as well as respiratory difficulties. If a patient does not know when their last tetanus vaccination occurred or is sure that one has not been received within ten years, a vaccination with tetanus toxoid should be administered as 1 prophylaxis.

Other factors about the patient’s medical history that would be important to know include whether or not the patient: • is a smoker or uses alcohol or other substances. • has a history of infectious diseases, such as hepatitis or HIV. • would already be in an immunocompromised state, such as with a cancer diagnosis or a recent organ transplant. • has a history of major illnesses or chronic diseases that may impact the healing process, including diabetes, heart disease, anemia, kidney problems, or lung disease.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 Many medical conditions can impact how well the patient is able to recover from a traumatic burn injury and must be considered while the health team is providing treatment.

Events Preceding the Injury

Knowledge of the events preceding the injury helps the health team to understand the circumstances under which the patient became burned. This may involve a description of an accident or event that led to the patient becoming injured and burned; some patients may describe events and a timeline of how they became injured as well as how they sought help. When asking for a description of events that led to the injury, the clinician should question whether there were other factors present that could complicate the injury.1 For example, a burn patient may have become injured as a result of an explosion in a grain elevator, in which case exposure to noxious chemicals, such as fumigant gases and nitrogen tetroxide, could have occurred.

Burns are often accompanied by inhalation of smoke or other substances that can cause internal injuries to the respiratory tract and mucous membranes, as well as external injuries to the skin and subcutaneous tissues. Internal damage from carbon monoxide, smoke, or other toxic chemicals can cause breathing difficulties and possible airway obstruction in the burned patient.1 Exposure could also lead to long-term lung damage when the lungs become injured as a result of chemical exposure. For example, significant smoke exposure has been associated with the development of acute respiratory distress syndrome (ARDS) and eventual pulmonary fibrosis from scarring.1,20 It is therefore a very important component of the patient’s history to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 determine if he or she was exposed to chemicals or fumes that would have been inhaled or caused internal damage to the respiratory tract.

The emergency clinician must critically assess children who are burned to not only care for their wounds and fluid needs but also to find out the cause and nature of the injury.25 Children may be burned unintentionally from such circumstances as scalds after contact with hot food or tub water, or through injuries associated with unsafe behavior, such as playing with matches. Alternatively, children may arrive at a health care center after having been burned by their caregiver as a means of punishment. A child who has been deliberately burned may show a pattern of burns that indicates intentional injury. The history of how the burn occurred and the pattern of the burn injuries may not align.

A child who has been deliberately burned may be brought in for care long after the injury occurred if the caregiver is negligent or does not 25 want hospital personnel involved. If the clinician involved in evaluating a child suspects a deliberate burn injury was caused, he or she should contact the proper authorities and social services for follow up of the situation. It is also important to document information appropriately, as it could be used at a later time during investigation.

A description of the events preceding the burn injury can also determine whether other types of injuries occurred. The burn may not be the only physical injury present and while management of the burn is very important, other injuries could be present that is life threatening or that also need to be managed concurrently with burn care. Even a minor wound in comparison to an extensive burn, such as

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 involving a broken bone, must still be managed relatively quickly, as these conditions can cause further pain for the patient. Other important data to obtain when learning about the events preceding the burn include the type of burn that occurred and the substance (i.e., liquid, flame, electricity), object, or situation that caused the burn.

The health team may also find out the environment of where the burn took place. It is important to know whether the patient was in an enclosed space, such as a garage, or in an open area when the burn occurred; and, the source of the burn injury such as fire or electricity. It is also important to note if any bystanders or family members stepped in to help the patient, and their actions. For example, with a chemical burn in a place of business, a co-worker may have helped the patient by offering assistance to flush the skin after contact with caustic products.

Risk of Gastrointestinal Dysfunction

The risk of gastrointestinal dysfunction is increased after a severe burn. Depending on how long it has been since the last meal, there could be a greater potential for gastrointestinal problems if the patient is still trying to digest food and fluids just after a burn injury. The time of the patient’s last meal is important to know during resuscitation for several reasons. If the patient ate a meal just prior to a burn injury, there is an increased chance that food is still in the stomach and is being processed in the gastrointestinal tract.1-4

Additionally, the patient with carbon monoxide poisoning as a result of smoke inhalation is at greater risk of hypoxia and of infection in the gastrointestinal tract. When hypoxia occurs as a result of carbon nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 monoxide replacing oxygen bound to hemoglobin in the red blood cells, the gastrointestinal tract can be adversely affected. Hypoxia causes vasoconstriction of the intestinal tract and decreased amounts of oxygenated blood reaching the area. As a result, food may move more slowly through the process of digestion. There is also an increased risk of infection when ischemic tissue does not have adequate blood flow as a defense against bacteria proliferation.1

Finding out about the last meal a patient had prior to a burn injury is also helpful to determine if the patient is on a special diet due to a health condition. While some of this information may be garnered while discussing the patient’s medical history, dietary interventions may not be considered until the patient is asked to remember the time and type of meal last consumed. There may also be special dietary practices that the patient follows that are important for the health team to know. For example, a patient may be on a gluten-free diet for celiac disease, which provides information for the health team about the client’s gastrointestinal health; it would also alert the clinician about the need for a specialized diet before starting the patient on enteral nutrition. Although it may not seem immediately important to know the type of diet and time of the last meal consumed by a patient, this information helps in the overall determination of medications, treatments, and nutritional plan required to promote healing of a burn injury.

Laboratory Work-up

Initial laboratory work-up following the burn injury can help the medical clinician to better understand some of the internal mechanisms occurring in the body because of the injury. Laboratory nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 tests, reviewed in this section, can pinpoint many physiological responses as a result of the injury and can help the clinician to treat underlying issues that may be taking place but that are not outwardly prominent.1,5,11-19

Complete Blood Count

A complete blood count (CBC) checks the status of blood cells, in particular the red blood cells (RBC), white blood cells (WBC), and platelets. Each of these types of cells has important functions that may be altered by burn injuries. Red blood cells are produced in the bone marrow and carry hemoglobin, which binds to oxygen molecules. The red blood cells carry this oxygen throughout the body through the bloodstream in order to provide oxygenation to the tissues and organs. Hemoglobin levels are another component of the CBC, as well as the hematocrit, which measures how much space the red blood cells take up in the blood. After a burn injury, red blood cells, hematocrit, and hemoglobin can be impacted in a number of ways. Hemoglobin may become connected to carcinogens found in smoke associated with an inhalation injury. These products, such as carbon monoxide, can bind to hemoglobin and take the place of oxygen.

Red blood cell loss also occurs with a burn injury when thrombi develop in the capillaries as the body responds to the burn by activating the complement cascade and causing coagulation. Oxygen free radicals are also released after the burn injury, which are destructive to red blood cell membranes. Finally, multiple laboratory draws and surgical procedures, as part of treatment for burn wounds, can cause a loss of blood and, ultimately, lower levels of red blood cells.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 Hematocrit levels are often increased in the early period after a burn. The normal level of hematocrit is about 40% to 50% in men and 36% to 44% in women. Following a burn injury, it is not uncommon for hematocrit levels to rise to 55% to 60%. This suggests the need for more fluid in the bloodstream, and is usually corrected with adequate fluid resuscitation. However, following correction of hematocrit levels with fluid administration, anemia may then develop in the patient. This can occur because of the excess fluid administration, the breakdown of red blood cells, or the inability of the body to produce more red blood cells right away in the bone marrow. The patient most likely will need blood transfusions, and anemia can be corrected with infusion of packed red blood cells, which will provide less fluid than whole blood. While it is important to monitor hematocrit levels to determine hemoconcentration, the clinician should not set a certain hematocrit level as a goal and attempt to transfuse to get the patient to that point. Instead, transfusion should be based on the patient’s condition and response, which is identified closely by monitoring the complete blood count.

White blood cells, which are also measured in the CBC, are part of the immune system and work to protect the body from infection. The number of WBC in the blood is lower than the RBC count, but WBC levels may rise quickly after an infection develops. There are several major types of white blood cells, which would show up on a laboratory test of a CBC that includes a differential. The major types are neutrophils, lymphocytes, monocytes, eosinophils, and basophils. It is essential that these cells remain in balance in order to fully protect the body from infection. Alterations in levels of WBCs could lead to systemic responses such as inflammation or cell destruction, which is

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 ultimately detrimental to the burn patient. Platelets are essential for blood clotting and are measured in the CBC; platelet counts often drop after a burn injury as a result of the body’s response. The normal amount of platelets ranges between 150,000 µ/L and 400,000 µ/L, but low platelet counts under 100,000 µ/L are common for the first several days following a burn injury.

Disorders of coagulation, including disseminated intravascular coagulation (DIC), may be more likely to occur in burn patients due to changes in proteins found in blood that control clotting. Systemic small thrombi that occur in the capillaries take up extra platelets, which result in low overall levels in the bloodstream. Small thrombi may appear in the capillaries, which suggest an excess amount of coagulation in the body, and these microthrombi actually inhibit blood flow to essential organs and cause organ damage and failure. Low platelets are also associated with infection and although initial platelet counts may be low after the burn injury, consistently low platelet levels several days after the injury can indicate a severe infection that includes septicemia. A burn patient who has extensive wounds and who develops sepsis following injury has a high rate of mortality and sepsis, and this type of patient is associated with a low chance of survival.

As the patient continues to recover, platelet levels may increase to the point that the patient is at risk of blood clots and deep vein thrombosis. The health team must provide prophylaxis in the form of antiembolism stockings applied to nonburned areas and other methods of maintaining adequate circulation to decrease the risk of embolism associated with immobility. While all of CBC measures are important,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 regular checking of the patient’s platelet levels may be included in the continuing vigilance to prevent blood-related complications following a burn injury.

Comprehensive Metabolic Panel

The comprehensive metabolic panel (CMP) is a measure of body electrolytes that can guide the health team as to the patient’s fluid response, kidney and liver functions. The CMP contains several components that are affected by burn injuries. Some of the main components include sodium, potassium, and chloride levels, total protein, calcium, and albumin; as well as liver function tests (LFT) such as the aspartate aminotransferase (AST), alanine aminotranferease (ALT), and total bilirubin.

Sodium levels change after burn injury with the shift of fluid from the intravascular space into the interstitial space. As the fluid moves out of circulation and into tissues, sodium particles move as well. This decreases sodium levels in the bloodstream and causes hyponatremia. This can be corrected in part with electrolytes found in intravenous fluid; Lactated Ringer’s (LR) solution contains a certain amount of sodium chloride that may be used as part of treatment and replacement of sodium loss. Additionally, administration of Normal Saline (NS) is a method of correcting sodium levels through intravenous measures.

In contrast to sodium, high levels of potassium can develop in the bloodstream as a result of muscle and tissue breakdown with burn injuries. If kidney damage occurs because of increased myoglobin in the bloodstream, the kidneys may be unable to excrete excess

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 potassium and it can build up. This hyperkalemia can be very dangerous and can lead to cardiac arrhythmias, some of which may be fatal. Treatment of hyperkalemia may involve infusion of calcium gluconate and insulin. It is very important to monitor the patient’s potassium levels through the CMP to avoid these life-threatening complications.

The liver can also sustain damage with a burn injury, which may be demonstrated with altered levels of AST and ALT on the comprehensive metabolic panel. AST and ALT are two types of enzymes found in the liver. Measurement of the levels of these two substances can indicate whether damage has occurred in the liver. If the liver becomes damaged, ALT and AST may become elevated when they leak into circulation. Edema that occurs in other parts of the body can also develop in the liver, causing damage to the structure. These enzymes may also be found in other structures, including the heart and skeletal muscles; however, ALT seems to be specific to liver injury, so when this level is elevated on the CMP blood test, it is evidence that some level of injury to the liver has occurred. High levels of ALT and AST may appear in blood tests as early as the first day after the injury, and levels have been known to be as much as 200 percent higher than normal with burn injuries, indicating that liver injury as a result of burns is rapid and can be extensive.

Albumin is a type of protein created by the liver that is necessary for tissue repair in the body. Hypoalbuminemia may develop in burn patients when albumin in the bloodstream leaks into the interstitial space when capillary permeability occurs after the injury. Levels of albumin are measured on the CMP lab test. The normal levels are

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 typically between 3.4 and 5.4 g/dL. Low levels of albumin have been shown to increase mortality among burn patients. An albumin level of less than 2 g/dL is associated with more than 80% mortality risk in burned patients. Because albumin is so necessary for growth and repair of tissues, extremely low levels can significantly affect the body’s ability to recover following a burn injury. Therefore, it is important to continue to monitor albumin as one of the components of the CMP blood test.

Blood Urea Nitrogen and Creatinine

Some measures of kidney function may also be determined through the comprehensive metabolic panel lab test. The two most prominent measures are the blood urea nitrogen (BUN) and creatinine levels. The body creates urea as a byproduct of the breakdown of protein; urea is normally removed from the body through the urine. If the kidneys are not working properly, urea levels can build up in the body, causing an elevated BUN level. Likewise, creatinine is created from the breakdown of creatine, a substance that is made during food metabolism. Once creatinine is formed from creatine, it is excreted from the body through the urine. Similar to measurement of the BUN, elevated levels of creatinine in the body can indicate that the kidneys are not filtering this substance properly and it is building up in the bloodstream.

Creatinine may also be measured through a laboratory test known as creatinine clearance. Checking the blood or a urine sample can be done to perform this type of test. The creatinine clearance tests how well the kidneys are able to excrete creatinine into the urine and the results are typically more specific, as compared to a serum creatinine level, to how well the kidneys are functioning. Another test, called the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 BUN-to-creatinine ratio, compares the levels of BUN and creatinine; normally, the BUN is higher than creatinine and the ratios are between 10:1 and 20:1 in comparison. If both the BUN and the creatinine are high, it can indicate kidney damage because the kidneys are not properly filtering these substances from the blood. Alternatively, if the BUN rises but the creatinine does not rise proportionately, it may indicate that the problem is not kidney damage but, rather, the kidney is not getting enough blood.

Blood urea nitrogen and creatinine levels are both important measurements to consider when checking laboratory tests on a patient who has been burned. Both levels are typically elevated after a burn injury. If the patient does not receive enough fluids with resuscitation, there may have low urine output, in which case the levels of BUN and creatinine will be elevated because they are not being excreted in the urine. Additionally, if the kidneys become damaged and are unable to appropriately filter products into the urine, they may allow excess BUN and creatinine to build up, causing elevated levels. By checking the BUN/creatinine ratio, the provider can also better understand if the kidneys are damaged or if they are not getting enough blood to function. Along with urine output, the BUN/creatinine ratio measurement can guide fluid resuscitation parameters and better help providers to understand the patient’s fluid needs based on circulation and urine production.

Glucose

Following a burn injury, the affected patient’s body begins to demand high levels of energy for such processes as the inflammatory response and wound healing. Burn patients typically develop hyperglycemia, a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 state in which there is too much glucose circulating in the bloodstream. Glucose levels may be checked as part of the comprehensive metabolic panel laboratory test, or they may be evaluated as a separate blood test. The body responds to a burn by increasing glucose production to meet increased energy needs. Glucocorticoids are hormones in the body that impact the metabolism of carbohydrates; glucocorticoids are responsible for increasing production of glucose in the liver, which may be further elevated after a burn injury. However, although the body may create high levels of glucose it does not necessarily require or use all of the glucose, and the result is sustained elevated levels of glucose circulating in the bloodstream.

A significant burn injury is a condition that would precipitate what researchers have termed stress-induced hyperglycemia (SIH). Stress- induced hyperglycemia occurs as a result of critical illness in which the body causes a state of hypermetabolism in response to secretion of various hormones and substances that occur internally when a major injury or illness has occurred. During extreme stress, such as a burn injury, the body secretes higher levels of epinephrine, norepinephrine, pro-inflammatory cytokines, growth hormone, and cortisol. The body’s response to the injury and secretion of these types of substances results in an increase in glucose production as well.

Under normal conditions, the body would respond to increased levels of glucose in the bloodstream by secreting insulin from the pancreas, in order to get the cells to take up insulin to use for energy and to reduce levels of circulating glucose in the bloodstream. However, these effects are typically not seen in burn patients due to physiological

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 factors related to the injury, such as the break down of muscle tissue leading to a loss of lean body mass. The result is impaired glucose tolerance and insulin resistance whereby the cells do not respond to insulin efficiently and therefore do not use glucose in the bloodstream. The result is hyperglycemia.

Elevated levels of blood glucose can be detrimental to burn patients. Studies have shown that glucose should be maintained within normal parameters in order to avoid certain risks. The burn patient with hyperglycemia is at higher risk of wound infection, sepsis, fungal infections, and pneumonia; and, continued hyperglycemia is associated with poor outcome and increased morbidity. Blood glucose levels tend to rise quickly in the acute phase following a burn injury, but they must continue to be managed over time with regular care and treatment of the patient.

One exact target level for blood glucose levels has not been found to be the most beneficial and appropriate goal for burn patients. A number of studies have shown various target glucose results to be appropriate in response to insulin therapy. The suggested range was from 110 mg/dL to 200 mg/dL for burn patients as appropriate outcomes; although consistently higher levels of glucose, such as maintaining levels at or above 200 mg/dL, has been shown to increase mortality among burn patients.

The treatment of high blood glucose is typically intravenous administration of insulin, which is used in conjunction with intravenous fluids. The amount of insulin to administer is based on glucose levels, which require frequent monitoring in the patient; the results may then

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 be used to titrate the insulin dose as the body responds. Intensive insulin therapy, which involves the administration of large amounts of insulin in order to keep blood glucose levels below 110 mg/dL in the burn patient, have not been shown to improve mortality in this population.

Each institution caring for burn patients should have protocols in place that outline the process of checking blood glucose levels, the regularity with which this test must be performed, and the target goals of glucose levels in this group of patients. Additionally, medical clinicians are expected to prescribe the amount of insulin required to respond to altered glucose levels and to set parameters according to facility policy and research underpinning best practice guidelines at their institution of practice. Clinicians caring for the burn patient have an important role in the management of hyperglycemia through routine glucose level checks and addressing the insulin requirements of the burn patient during treatment.

Arterial Blood Gas

Blood gas analysis (ABG) is used in critically ill patients to assess for levels of oxygenation in the bloodstream, to determine acid-base balance of blood, and to assess for respiratory sufficiency. The normal pH of blood is 7.35 to 7.45; the pH of the blood measures the level of acidity. A blood pH below 7.35 is considered acidotic and a pH higher than 7.45 is considered alkalotic. The carbon dioxide levels of the blood gas results, if they are within normal range, should be 35 to 45 mmHg.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 Carbon dioxide (CO2) measures how much is in the bloodstream and how well the body is able to expel it through breathing. In contrast to the pH, a CO2 level below 35 mmHg is considered alkalotic and a CO2 level above 45 mmHg is considered acidic. The partial pressure of oxygen (PaO2) is how much oxygen is dissolved in the bloodstream. This level indicates how well the body is able to maintain gas exchange at the level of the alveoli when oxygen passes from the lung tissue into the bloodstream. The normal level of PaO2 in blood is typically 75 to 100 mmHg. A blood gas result may also show an oxygen saturation, which indicates how much hemoglobin in the blood is saturated with oxygen molecules. Finally, bicarbonate (HCO3) levels are measured as part of the blood gas. Normal levels for HCO3 are between 22 and 26 mEq/L. Low levels of bicarbonate indicate acidosis, and high levels indicate alkalosis.

The blood gas can be obtained through either an arterial sample of blood or a venous sample. If the patient has an arterial catheter, it may be relatively easy to obtain a sample of blood to use for blood gas analysis. Arterial blood gases are typically more common than venous blood gases, but venous samples may also be used particularly when arterial blood is not available. After blood collection, the blood sample is tested through a blood gas analyzer to measure the pH, carbon dioxide, oxygen, and bicarbonate levels.

The outcomes of the blood gas analysis can give the health team an idea of how well the patient is breathing and exchanging carbon dioxide and oxygen through gas exchange in the lung tissue. If the patient requires a mechanical ventilator, the results of the blood gas analysis may be used to determine changes needed on the ventilator

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 settings. It may not always be obvious how well the patient is tolerating supplemental oxygen and ventilation, but a blood gas analysis can give an indication of the patient’s internal needs, to better identify the level of adequacy for carbon dioxide and oxygen in the bloodstream.

Blood gas analysis is useful in determining if the patient is developing respiratory insufficiency or is retaining carbon dioxide in the body. If a patient has a smoke inhalation injury, the arterial PaO2 may not be accurate. The PaO2 shows how much oxygen is dissolved in the blood but this may be only a small portion of arterial oxygen content. If a patient has been exposed to carbon monoxide, such as through inhalation injury, the carbon monoxide will bind to hemoglobin instead of oxygen, but this is not necessarily reflected in the blood gas analysis.

A burn patient may be more likely to develop metabolic acidosis, particularly when fluid resuscitation is inadequate. Metabolic acidosis develops when the blood becomes too acidic and there is a reduction in sodium bicarbonate, which is alkalotic. In other cases of metabolic acidosis, administration of sodium bicarbonate is part of standard treatment to regulate the blood pH and bring it back into normal parameters. However, with the burn patient, administration of sodium bicarbonate is not always necessary. The acidosis may be a sign that fluid resuscitation is inadequate and that fluid must be administered at a faster rate. Often, the acidosis is corrected when fluid administration is corrected.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 Alkalosis, on the other hand, is more likely to develop later during the course of treatment for burn injuries, particularly after the patient has undergone surgical procedures and has received quantities of blood products for transfusion. In situations where a patient is receiving diuretics for fluid management, alkalosis may be more likely to develop as well. The most common form of treatment of alkalosis is to regulate the factors that are most likely causing the condition in the first place, rather than administering medications or substances to correct pH in the bloodstream. Regular monitoring of venous blood gases is part of continued control of the state of pH in the blood, as even small changes in pH on the venous gas results can be reflective of a symptomatic state.

Carboxyhemoglobin and Lactate

Inhalation of noxious chemicals can cause changes in oxygen and carbon dioxide levels in the bloodstream. If a patient is exposed to large amounts of carbon monoxide because of smoke from a fire, he or she may develop carbon monoxide poisoning. The carbon monoxide binds to hemoglobin in the red blood cells much more readily than oxygen; the binding of carbon monoxide with hemoglobin results in carboxyhemoglobin and a decreased amount of oxygen reaching the brain and other organs. A carboxyhemoglobin level should be drawn as part of laboratory work, particularly in patients where increased levels of carbon monoxide may be present, including any patient who has suffered a moderate or major burn. A carboxyhemoglobin level is a blood test that can be performed to measure the amount of carbon monoxide and hemoglobin in the blood. Because carbon monoxide has an affinity for hemoglobin that is 240 times that of oxygen, carbon monoxide poisoning will demonstrate increased binding of carbon

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 monoxide to hemoglobin in the blood, resulting in decreased oxygen binding and resultant hypoxia.

Normal values for carboxyhemoglobin are less than 2.0% of total hemoglobin. This number may be slightly elevated if the patient is a smoker, and reference ranges are between 4.0% and 8.0% of total hemoglobin, depending on how much the patient smokes. Values of up to 20% may cause no symptoms in the patient, but as levels increase, there is potential for symptoms of confusion, nausea, vomiting, hypotension, and ultimately coma and death. Initial treatment of carbon monoxide poisoning is administration of 100% oxygen, which may be necessary for several hours until symptoms of toxicity resolve and carboxyhemoglobin levels return to normal.

Smoke inhalation that occurs as part of a thermal burn injury may also lead to acute cyanide poisoning, particularly when the patient is exposed to fire in an enclosed area. The breakdown of certain components produces cyanide gas, which can then be inhaled with smoke exposure by the injured patient. Cyanide is considered a poison that, upon entering the bloodstream, impacts important enzymatic processes in the body, resulting in impaired functioning of the central nervous and cardiovascular systems. The tissues and organs may still receive oxygen in the bloodstream but they are unable to extract it and use it effectively. Consequently, the patient may develop symptoms such as confusion, decreased level of consciousness, and seizures, which could ultimately lead to coma and death. In the cardiovascular and respiratory systems, the effects of cyanide exposure lead to hypotension, tachycardia, and possible ventricular

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 fibrillation. The patient’s respiratory rate becomes dampened and may lead to hypoventilation and ultimate apnea.

Serum lactate levels may be checked as part of laboratory testing when a patient presents with smoke inhalation after a burn injury. Increased levels of lactate may be associated with exposure to cyanide. Normal levels of lactate are 0.5 - 2.2 mmol/L, but levels above 8 mmol/L have been correlated with cyanide poisoning. Increased lactic acid levels may develop in the bloodstream during times of hypoxia. Lactic acid is a by-product of the breakdown of skeletal muscle cells and red blood cells. Elevated levels of serum lactate may occur as a result of hypoxia associated with cyanide exposure.

It may be difficult to determine if the patient is suffering from symptoms related to the burn injury or another injury associated with the burn, such as a head injury from an accident that resulted in a burn. Certain injuries can lead to similar symptoms that may also be associated with carbon monoxide or cyanide poisoning, such as altered level of consciousness, tachycardia, and hypotension. If carbon monoxide or cyanide poisoning is a possibility in any patient, carboxyhemoglobin and serum lactate levels should be drawn as part of lab work to determine if toxicity is present.

Blood Type and Crossmatch

Blood type and crossmatch is most likely necessary in order to provide appropriate blood products for the patient when needed. Blood typing refers to determining whether the patient is type A, B, AB, or O and to determine if the patient is Rh negative or positive. The crossmatch nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 involves mixing a small amount of the patient’s blood with a small amount of donor blood to determine if the samples are compatible or if there would be a transfusion reaction.

The blood type and crossmatch is performed in case the patient needs blood products, even if the need is not necessary right away. It will be necessary to monitor the patient’s lab work, including the hemoglobin and hematocrit levels, to determine if the patient needs blood products. Consideration should be made between whole blood and packed red blood cells, as whole blood contributes more to fluid levels in the bloodstream as compared to packed red cells. A patient already receiving large amounts of crystalloids may not tolerate further fluid through whole blood if their condition can otherwise be corrected with packed red blood cells. Although it is common that burn patients typically need transfusion of blood products at some point during hospitalization, the decision at what point to transfuse depends upon the patient’s condition and status, as well as the provider’s understanding of the situation and the facility guidelines.

Summary

Appropriate burn care requires an initial period of rapid response to stabilize the patient and prevent complications that could be life threatening. Following the initial response and the acute period after the burn, ongoing care and vigilance is essential to ensure that the patient receives proper treatment and does not develop further problems associated with the traumatic injury. While it is essential to provide initial care through management of the patient’s airway,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 breathing, and circulation, other measures are also necessary after these initial components of stabilization are complete.

Fluid resuscitation, enteral nutrition, infection prevention, and monitoring of laboratory values, as well as maintaining patient comfort, are just some of the measures implemented in providing total burn care during the initial period after injury. Continued monitoring and response to changes can ensure that a burn patient moves toward recovery in as safe a manner as possible.

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nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 1. True or False: Airway edema is generally apparent in the initial phases of a burn injury requiring immediate airway stabilization.

a. True b. *False

2. During the secondary survey, the health team may uncover injuries not initially apparent in a burn patient, such as:

a. Fractures b. Dislocations c. Abdominal injuries d. *All of the above

3. An escharotomy involves an incision

a. made outside the burned skin using a scalpel. b. deep enough to penetrate the subcutaneous fat. c. *to release pressure in the burned area. d. used for debridement of eschar.

4. A Lund and Browder chart is used for

a. *estimating the burn extent in a patient. b. estimating fluid loss of a burn patient. c. estimating the range of motion of a burn patient. d. All of the above

5. True or False: Range-of-motion exercises are necessary to promote blood flow to the extremities and prevent contractures in a burn patient.

a. *True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 6. While providing care for a burn patient, which of the following best expresses a provider’s care for a patient with potential edema formation and airway obstruction?

a. Provider must assess and stabilize the airway for inhalation injuries only b. Provider must assess airway obstruction only if patient has difficulty breathing c. *Provider must continually assess and stabilize the airway d. Provider must stabilize airway immediately after injury

7. Morphine sulfate may be administered to a burn patient as follows:

a. *Intravenously, 1 to 4 mg per dose every 2 to 4 hours b. Intramuscularly, 10 mg per dose every 6 hours c. Mild narcotic analgesia needed for pain control d. Intravenously, 0.5 to 1 mg per dose every hour

8. The comprehensive metabolic panel (CMP) is used to help guide treatment of the burn patient but does not include:

a. potassium level b. sodium level c. liver function tests d. *neutrophil count

9. True or False: A nurse who suspects deliberate burns to a child by a caregiver should contact the proper authorities and social services for follow up of the situation.

a. *True b. False

10. Blood gas analysis (ABG), used to assess for levels of oxygenation in the bloodstream, have normal values of:

a. pH of 7.35 to 7.45 b. CO2 of 35 to 45 mmHg c. PaO2 of 75 to 100 mmHg d. *All of the above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 11. Airway intubation should be performed to support respiratory ventilation

a. for inhalation injuries only. b. after signs of edema or an obstructed airway are present. c. *while the provider assesses the extent of edema formation in the patient’s throat. d. if the throat and airway passages are constricted.

12. A patient who is awake and alert, and who has no neurological deficits or penetrating injuries, and does not have pain in the neck and shoulder area, ______to clear the cervical spine and for removal of a cervical collar.

a. must have a GCS score of 15 points b. must have an x-ray c. *does not need an x-ray d. must have airway intubation

13. True or False: Serum lactate is checked for all electrical burns.

a. True b. *False

14. In a patient with an ______that has an entry and exit point, cardiac arrhythmias may develop.

a. burn shock b. pulse oximetry c. impaired circulation d. *electrical burn

15. A patient with burns that extend around a body part or wrap around an extremity is said to have

a. *circumferential burns. b. burn shock. c. superficial burns. d. impaired circulation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 16. Burn management is dependent on the following factor(s):

a. superficial versus deep burns. b. *type, depth and extent of burns. c. formation, obstruction and neurology. d. resuscitation, nutrition, and infection prevention.

17. Which of the following burn types involves the epidermis and lower layers of the dermis but not the structures underneath?

a. First-degree burns b. Circumferential burns c. Third-degree burns d. *Second-degree burns

18. With a burn patient, administration of sodium bicarbonate is part of standard treatment

a. *to regulate the blood pH. b. in all cases. c. for alkalosis. d. for electrical burns.

19. As the fluid moves out of circulation and into tissues, sodium particles move as well. This decreases sodium levels in the bloodstream and causes

a. hypercapnia. b. hypoxia. c. *hyponatremia. d. hypoalbuminemia.

20. True or False: With burn patients, a provider should set a certain hematocrit level as a goal and attempt to transfuse to get the patient to that point.

a. True b. *False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 Correct Answers:

1. True or False: Airway edema is generally apparent in the initial phases of a burn injury requiring immediate airway stabilization.

b. False

“Because airway edema may not be apparent immediately and develop over a period of time, the clinician must continue to assess and stabilize the airway while providing care for the patient.”

2. During the secondary survey, the health team may uncover injuries not initially apparent in a burn patient, such as:

a. Fractures b. Dislocations c. Abdominal injuries d. *All of the above

“During the secondary survey, the health team may uncover other injuries that have occurred that may not have been initially apparent when the burn injuries were first being managed…. Some examples of injuries include fractures, dislocations or abdominal injuries.”

3. An escharotomy involves an incision

c. to release pressure in the burned area.

“Escharotomy involves using a scalpel to cut into the burned skin; the incision is deep enough to reach but does not penetrate the subcutaneous fat underneath. This incision is done to release the pressure buildup that occurs in the affected area. The eschar incision is drawn along the length of the affected area to about 1 cm past each end of the burn. The goal of the procedure is to reduce the pressure in the affected area and restore normal circulation to the site.

“Fasciotomy differs from escharotomy in that a fasciotomy incision is deeper and cuts through the fascia, whereas an escharotomy incision is only deep enough to reach the subcutaneous fat and tissue and not penetrate it.” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 4. A Lund and Browder chart is used for

a. estimating the burn extent in a patient.

“Although the Rule of Nines is helpful and can be instituted quickly, the Lund and Browder method is another more comprehensive and accurate approach to estimate burn injuries… This method also involves a scoring system, but the body parts assessed are grouped in smaller segments. These smaller groups provide more accurate assessment when compared to the Rule of Nines, particularly if a burn affects a smaller body area.”

5. True or False: Range-of-motion exercises are necessary to promote blood flow to the extremities and prevent contractures in a burn patient.

a. True

“Range-of-motion exercises are also necessary on a regular basis to promote blood flow to the extremities and to prevent contractures.”

6. While providing care for a burn patient, which of the following best expresses a provider’s care for a patient with potential edema formation and airway obstruction?

c. Provider must continually assess and stabilize the airway

“A burn patient may have suffered injuries that could cause the airway to swell and constrict, thereby impeding airflow. Edema formation and airway obstruction can occur quickly with certain types of injuries, such as inhalation injuries, or may develop slowly over time. Because airway edema may not be apparent immediately and develop over a period of time, the clinician must continue to assess and stabilize the airway while providing care for the patient.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 7. Morphine sulfate may be administered to a burn patient as follows:

a. Intravenously, 1 to 4 mg per dose every 2 to 4 hours

“Morphine sulfate, given intravenously at 1 to 4 mg per dose, is one of the most common methods of pain management when a burn patient has moderate to severe pain from their wounds. This dose may be given every 2 to 4 hours as needed for pain control.”

8. The comprehensive metabolic panel (CMP) is used to help guide treatment of the burn patient and does not include:

d. neutrophil count

“The comprehensive metabolic panel (CMP) is a measure of body electrolytes that can guide the health team as to the patient’s fluid response, kidney and liver functions. The CMP contains several components that are affected by burn injuries. Some of the main components include sodium, potassium, and chloride levels, total protein, calcium, and albumin; as well as liver function tests (LFT) such as the aspartate aminotransferase (AST), alanine aminotranferease (ALT), and total bilirubin.”

9. True or False: A nurse who suspects deliberate burns to a child by a caregiver should contact the proper authorities and social services for follow up of the situation.

a. True

“If the medical provider or nurse involved in evaluating a child suspects a deliberate burn injury was caused, he or she should contact the proper authorities and social services for follow up of the situation.”

10. Blood gas analysis (ABG), used to assess for levels of oxygenation in the bloodstream, have normal values of:

a. pH of 7.35 to 7.45 b. CO2 of 35 to 45 mmHg c. PaO2 of 75 to 100 mmHg d. *All of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71

“Blood gas analysis (ABG) is used in critically ill patients to assess for levels of oxygenation in the bloodstream, to determine acid-base balance of blood, and to assess for respiratory sufficiency. The normal pH of blood is 7.35 to 7.45; …. The carbon dioxide levels of the blood gas results, if they are within normal range, should be 35 to 45 mmHg … The normal level of PaO2 in blood is typically 75 to 100 mmHg.”

11. Airway intubation should be performed to support respiratory ventilation

c. while the provider assesses the extent of edema formation in the patient’s throat.

“Airway intubation should be performed to support respiratory ventilation while the emergency provider simultaneously addresses the extent of edema formation in the patient’s throat.”

12. A patient who is awake and alert, and who has no neurological deficits or penetrating injuries, and does not have pain in the neck and shoulder area, ______to clear the cervical spine and for removal of a cervical collar.

c. does not need an x-ray

“Alternatively, a patient who is awake, and alert, has no neurological deficits or penetrating injuries, and does not have pain in the neck and shoulder area, does not need an x- ray to clear the cervical spine. In such cases, the cervical collar can be removed.”

13. True or False: Serum lactate is checked for all electrical burns.

b. False

“Serum lactate levels may be checked as part of laboratory testing when a patient presents with smoke inhalation after a burn injury…. If carbon monoxide or cyanide poisoning is a possibility in any patient, carboxyhemoglobin and serum nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 lactate levels should be drawn as part of lab work to determine if toxicity is present.”

14. In a patient with an ______that has an entry and exit point, cardiac arrhythmias may develop.

d. electrical burn

“A patient who has suffered an electrical burn may be at risk for cardiac abnormalities. In a patient with an electrical burn that has an entry and exit point cardiac arrhythmias may develop as a result of the electricity from the burn disrupting the cardiac electrical cycle.”

15. A patient with burns that extend around a body part or wrap around an extremity is said to have

a. circumferential burns.

“Circumferential burns are those that extend around a body part, such as one that is wrapped around an extremity.”

16. Burn management is dependent on the following factor(s):

b. type, depth and extent of burns.

“Burn management is dependent on the type of burn that has occurred, the depth of the burn, and the extent of the burn covering the body.”

17. Which of the following burn types involves the epidermis and lower layers of the dermis but not the structures underneath?

d. Second-degree burns

“Second-degree or deep partial-thickness burns are those involving the epidermis and lower layers of the dermis but not the structures underneath.”

18. With a burn patient, administration of sodium bicarbonate is part of standard treatment

a. to regulate the blood pH nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73

“In other cases of metabolic acidosis, administration of sodium bicarbonate is part of standard treatment to regulate the blood pH and bring it back into normal parameters. However, with the burn patient, administration of sodium bicarbonate is not always necessary.”

19. As the fluid moves out of circulation and into tissues, sodium particles move as well. This decreases sodium levels in the bloodstream and causes

c. hyponatremia.

“As the fluid moves out of circulation and into tissues, sodium particles move as well. This decreases sodium levels in the bloodstream and causes hyponatremia.”

20. True or False: With burn patients, a provider should set a certain hematocrit level as a goal and attempt to transfuse to get the patient to that point.

b. False

“While it is important to monitor hematocrit levels to determine hemoconcentration, the provider should not set a certain hematocrit level as a goal and attempt to transfuse to get the patient to that point.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Herndon, D. N. (2012). Total burn care: Expert consult. Philadelphia, PA: Elsevier Saunders 2. Baldwin-Rodriguez, B. (n.d.). Burn trauma injuries. Retrieved from http://dynamicnursingeducation.com/class_more.php?class_id=1 26&more=91 3. Rice, P. L., Orgill, D. P. (2014, Apr). Emergency care of moderate and severe thermal burns in adults. Retrieved from http://www.uptodate.com/contents/emergency-care-of- moderate-and-severe-thermal-burns-in-adults 4. Bacomo, F. K., Chung, K. K. (2011). A primer on burn resuscitation. Journal of Emergencies, Trauma and Shock 4(1): 109-113. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097558/#!po=36 .6667 5. University of Michigan Trauma Burn Center. (2014). Fluid resuscitation. Retrieved from http://www.traumaburn.org/referring/fluid.shtml 6. University of Wisconsin (2016). Assessing Burns and Planning Resuscitation: Rule of Nines. Emergency Medicine. Retrieved online at http://www.uwhealth.org/emergency-room/assessing- burns-and-planning-resuscitation-the-rule-of-nines/12698. 7. Nurse Labs. (2012, Mar.). Burn injury. Retrieved from http://nurseslabs.com/burn-injury-nursing-management/ 8. Kirchheimer, S. (2013, Dec.). Electrical burns. Retrieved from http://www.med.nyu.edu/content?ChunkIID=163347 9. Rice, P., et al. (2016). Classification of burns. Up To Date. Retrieved online at http://www.uptodate.com/contents/classification-of-burns. 10. Gauglitz, G. and Williams, F. (2016). Overview of the management of the severely burned patient. Up To Date. Retrieved from https://www.uptodate.com/contents/overview-of- the-management-of-the-severely-burned- patient?source=search_result&search=burn%20injuries&selected Title=3~150. 11. Hamel, J. (2011, Feb.). A review of acute cyanide poisoning with a treatment update. Critical Care Nurse 31(1): 72-81. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 12. Fazal, N. (2012). T-cell suppression in burn and septic injuries. Retrieved from http://cdn.intechopen.com/pdfs-wm/29072.pdf 13. Wiktor, A. and Richards, D. (2016). Treatment of Minor Thermal Burns. Up To Date. Retrieved online at https://www.uptodate.com/contents/treatment-of-minor-thermal- burns?source=search_result&search=silvadene&selectedTitle=6~ 34. 14. American Burn Association. (n.d.). Burn center referral criteria. Retrieved from http://www.ameriburn.org/BurnCenterReferralCriteria.pdf 15. Hall, K. L., Shahrohki, S., Jeschke, M. G. (2012, Nov.). Enteral nutrition support in burn care: A review of current recommendations as instituted in the Ross Tilley Burn Centre. Nutrients 4(1): 1554-1565. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509506/ 16. Parrillo, J. E., Dellinger, R. P. (2014). Critical care medicine: Principles of diagnosis and management in the adult (4th ed.). Philadelphia, PA: Elsevier Saunders 17. Aguayo-Becerra, O. A., Torres-Garibay, C., González-Ojeda, A. (2013, Jul.). Serum albumin level as a risk factor for mortality in burn patients. Clinics (Sao Paulo) 68(7): 940-945. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714858/ 18. Davita.com. (2014). What is creatinine? Retrieved from http://www.davita.com/kidney-disease/overview/symptoms-and- diagnosis/what-is-creatinine?/e/4726 19. Mecott, G. A., Al-Mousawi, A. M., Gauglitz, G. G., Herndon, D. N., Jeschke, M. G. (2010, Jan.). The role of hyperglycemia in burned patients: Evidence-based studies. Shock 33(1): 5-13. Retrieved from http://journals.lww.com/shockjournal/Fulltext/2010/01000/The_R ole_of_Hyperglycemia_in_Burned_Patients_.3.aspx 20. Micak, R. (2016). Inhalation injury from heat, smoke or chemical irritants. Up To Date. Retrieved online at https://www.uptodate.com/contents/inhalation-injury-from-heat- smoke-or-chemical- irritants?source=search_result&search=smoke%20inhalation&sele ctedTitle=1~90. 21. U.S. Army Medical Department. (2013). Emergency war surgery (4th ed.). Fort Sam Houston, TX: Borden Institute 22. Sharar, S. and Olivar, H. (2016). Anesthesia for burn patients. Up To Date. Retrieved online at https://www.uptodate.com/contents/anesthesia-for-burn- patients?source=search_result&search=burn%20and%20fluid%2 0administration&selectedTitle=2~150. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 23. Henry, M. C., Stapleton, E. R. (2012). EMT prehospital care (4th ed.). Burlington, MA: Jones & Bartlett Learning 24. Alharbi, Z., Piatkowski, A., Dembinski, R., Reckort, S., Grieb, G., Kauczok, J., Pallua, N. (2012). Treatment of burns in the first 24 hours: Simple and practical guide by answering 10 questions in a step-by-step form. World Journal of Emergency Surgery 7(13). 25. Joffe, M. (2016). Emergency care of moderate and severe thermal burns in children. Up To Date. Retrieved online at https://www.uptodate.com/contents/emergency-care-of- moderate-and-severe-thermal-burns-in- children?source=search_result&search=pediatric%20burn%20car e&selectedTitle=3~150. 26. Aityeh, B. S., Zgheib, E. R. (2012, Jun.). Acute burn resuscitation and fluid creep: It is time for colloid rehabilitation. Annals of Burn and Fire Disasters 25(2): 59-65. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506208/ 27. Stracciolini, A., Hammerberg, E. M. (2014, Jul.). Acute compartment syndrome of the extremities. Retrieved from http://www.uptodate.com/contents/acute-compartment- syndrome-of-the-extremities 28. Boffard, K. D. (Ed.). (2011). Manual of definitive surgical trauma care (3rd ed.). Boca Raton, FL: CRC Press 29. Gestrig, M. (2016). Abdominal Compartment Syndrome. Up To Date. Retrieved online at https://www.uptodate.com/contents/abdominal-compartment- syndrome-in- adults?source=search_result&search=abdominal%20compartmen t%20syndrome&selectedTitle=1~60. 30. Pollack, A. N. (Ed.). (2011). Critical care transport. Sudbury, MA: Jones and Bartlett Publishers. 31. Armstrong, D. and Meyr, A. (2016). Clinical assessment of wounds. Up To Date. Retrieved online at https://www.uptodate.com/contents/clinical-assessment-of- wounds?source=search_result&search=eschar&selectedTitle=2~9 5. 32. Wolf, S. (2016). Overview and management strategies for the combined burned trauma patient. Up To Date. Retrieved online at https://www.uptodate.com/contents/overview-and-management- strategies-for-the-combined-burn-trauma- patient?source=search_result&search=eschar&selectedTitle=3~9 5.

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