Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Caring for patients with burn injuries Refresh your knowledge of burn types and initial management. By Alicia L. Culleiton, DNP, RN, CNE, and Lynn M. Simko, PhD, RN, CCRN Caring for a patient with severe burn injuries offers functions including acting as a protective barrier many challenges for critical care nurses. This article against injury and infection, thermoregulatory con- reviews various types of burns and what you need trol, regulation of fluid loss, synthesis of vitamin D, to know to provide initial resuscitative care for a and sensory contact with the environment. When patient if treatment in a designated burn center the skin is damaged or destroyed by a burn, it may facility or burn ICU isn’t possible. result in or lead to compromised immunity, hypo- Although burn incidence has decreased slightly thermia, increased fluid loss, infection, changes in over the years, burn injuries still occur too frequent- appearance, function, and body image. ly, with an estimated 3,500 fire and burn deaths The skin is divided into three layers: the epider- Ceach year (this figure includes deaths from smoke mis, dermis, and subcutaneous tissue. Burn injuries inhalation and poisoning).1 In addition, about 45,000 are described by the causative agent, depth, and patients who sustain burn injuries require medical severity. In the past, burn injuries were classified as treatment or hospitalization yearly. According to the first, second, third, and occasionally fourth degree. American Burn Association (ABA), hospital admis- In recent years, the ABA has recommended a more sion based on the type of burn include: 44% due to precise definition of first-, second-, and third-degree fire or burn injury, 33% due to scald injury, 9% due burns, categorizing them according to depth of skin to contact burn injuries, 4% due to electrical burns, destruction: epidermal or superficial (first-degree), 3% due to chemical burns, and 7% due to miscel- partial-thickness (second-degree), which may also laneous causes of burns.1 Burn injuries are one of be classified as superficial or deep partial-thickness) the most expensive catastrophic injuries to treat. and full-thickness (third-degree) burns (may also be For instance, a burn injury of 30% of total body classified as a deep full-thickness).4 (See The skin surface area (TBSA) can cost as much as $200,000 in and degrees of burns.) initial hospitalization costs; furthermore, for more extensive burns there are significant additional costs Size matters related to reconstructive surgery and rehabilitation The size of the burn is expressed as the percentage efforts.2 Lastly, mortalities are higher for children of TBSA. A partial-thickness burn of more than younger than age 4 (especially for children from 10% TBSA is serious and needs referral to a burn birth to age 1), and for adults over age 65.3 center (see Should my patient go to a burn center?). You can estimate the TBSA burned on an adult Why is the skin important? by using 9 or multiples of 9, known as the Rule of Burn injuries involve the partial or complete Nines. The Rule of Nines varies between infants and destruction of the integumentary system: the skin. adults because infants’ heads are proportionally larg- The layers of the skin are destroyed and this results er compared to adults (see Rule of Nines: Estimating in local and systemic disturbances. The skin is one burn size in adults). Although the Rule of Nines ILLUSTRATION BY STEVE OH, M.S./PHOTOTAKE © of the largest organs of the body and has many provides a rapid method for calculating the size of www.nursingcriticalcare.com January l Nursing2013CriticalCare l 15 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Caring for patients with burn injuries the injury, it can overestimate the TBSA burned, such as grease and scald burns. Often, the rule of so follow your facility’s protocol for estimating the palms will be completed first as a quick assess- extent of a burn injury. Most burn centers repeat the ment until the Lund and Browder assessment can estimation of TBSA burned in 72 hours, when burns be completed. The patient’s palm (not including the and their depth are more clearly demarcated and the fingers or wrist area) equals 1% TBSA. burned area can be more easily quantified.5 Other common methods for measuring burn Types of burns size include the Lund and Browder chart and the A burn injury is described based on its cause: “rule of palms.” The Lund and Browder method thermal, chemical, electrical, radiation, smoke or is highly recommended because it corrects for the inhalation, or frostbite. large head-to-body ratio of infants and children.6 • Thermal burns result from contact with hot The rule of palms is used for small scattered burns substances that cause cell injury by coagulation, The skin and degrees of burns6,8,9,15 The epidermis is the nonvascular outer layer of • Depths of burns the skin and is as thick as a sheet of paper. The Epidermis epidermis is a protective barrier for the skin, Superficial holding in fl uids and electrolytes and aiding in (1st degree) Partial body temperature regulation. thickness • The dermis lies beneath the epidermis and is 30 to (2nd degree) 45 times thicker than the epidermis. Connective Full tissues with blood vessels, hair follicles, nerve thickness endings, and sweat glands are found in the dermis. (3rd degree) Dermis • Under the epidermis is the subcutaneous tissue, which contains major vascular networks, nerves, fat, and lymphatics. The subcutaneous tissue Subcutaneous acts as a heat insulator for underlying structures, tissue including the muscles and internal organs. • Superfi cial burns caused by the sun or low-intensity heat fl ashes damage only the epidermis. These part of the dermis, and 2 to 6 weeks for deep partial- fi rst-degree burns cause erythema, skin blanching on thickness burns, which involve more of the dermis. pressure, mild pain and swelling, and no blisters or • Full-thickness burns may extend into the subcutaneous vesicles, although after 24 hours the skin may blister tissue, meaning the skin can’t heal on its own. These and peel. Symptoms include hyperesthesia, mild pain, burns, classifi ed as third- and fourth-degree burns, are and tingling. Healing typically takes 3 to 6 days. caused by prolonged exposure to chemicals, electrical • Partial-thickness burns caused by chemicals, fl ame, current, fl ame, hot liquids, or tar. The skin appears dry, or hot liquids damage the epidermis and part of waxy, white, leathery, or hard. Thrombosed vessels the dermis. These second-degree burns appear as will be visible, and muscles, tendons, and bones may fl uid-fi lled vesicles that be involved. Signs and are red and shiny (and symptoms include lack wet if the vesicles have of pain, possible hema- ruptured). Symptoms turia, possible entrance include edema, hyper- and exit wounds from esthesia, pain caused an electrical burn, and by nerve injury, and shock. Skin grafting sensitivity to cold air. is often required for Healing typically takes healing, and patients 10 to 21 days for super- may lose function of fi cial partial-thickness Deep partial-thickness (second extremities or digits, or A full-thickness (third degree) burns, which involve degree) burns of the hands. need amputation. burn of the foot. 16 l Nursing2013CriticalCare l Volume 8, Number 1 www.nursingcriticalcare.com Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. including flame, hot liquids, hot solid objects, and Should my patient go to a burn steam.7 The longer the skin is in contact with these center?19 hot substances the deeper the wound. Oil-based liquids such as grease and cooking oil have higher Patients who should be referred to a burn center boiling points, and cause deeper burns than scalds include: with water or other liquids.8 Burns from hot solid • All burn patients under age 1. objects such as solid metal, hot plastic, glass, or • All burn patients ages 1 to 2 with burns over 5% or stone are all considered thermal burns. more of TBSA. • Chemical burns destroy tissue and continue • Patients of any age with full-thickness burns of to do damage up to 72 hours unless neutralized. any size. Causes of chemical burns are strong acids, alkalis, • Patients over age 2 with partial-thickness burns and organic compounds.9 Acids are commonly greater than 10% of TBSA. found in household cleaners such as rust removers • Patients with burns of special areas such as the face, hands, feet, genitalia, perineum, or major joints. and bathroom cleaners, and cause protein coagula- • Patients with electrical burns, including lightning tion, which results in less extensive injuries. Alkalis injuries. such as oven cleaners and fertilizers cause deeper • Patients with chemical burns. burns due to liquefaction necrosis of tissue, which • Patients with inhalation injury resulting from a fi re lets the chemical penetrate deeper into tissues.9 or hot liquid burn. Organic compounds that cause chemical burns • Patients with circumferential burns of the limbs include gasoline and chemical disinfectants, which or chest. can cause severe coagulation necrosis and produce • Patients with preexisting medical conditions a layer of thick, nonviable tissue called eschar, that could complicate burn management, prolong 9 which is normally present in full-thickness burns. recovery, or affect mortality. • Electrical burns are classified as low voltage • Patients with burns and concomitant trauma. (under 1,000 volts) or high voltage (1,000 volts or • Children with burns who are suspected to be victims higher).9 Electrical injuries can cause death by of child abuse.