Burns:

Definition/Etiology:

I think we all know this, but the actual definition of a burn is an injury caused by heat or flame. That being said, the definition isn’t as important as the etiology. Most burns are thermal, from hot liquids, fire, flames, flash (like electricity) and contact with a hot object. The severity of the burn depends on the intensity, exposure time and source temperature.

Electrical burns are when a current passes through the body and meets the resistance of body tissues.

Chemical burns are just that, burns that result from exposure to caustic chemicals.

Pathophysiology:

Damage to burned tissue causes an inflammatory response.

In the first 24 hours following burn injury:

• Coagulation necrosis of soft tissue ->
• Release of vasoactive substances ->
• Increased capillary permeability and vasodilation ->
• Formation of tissue edema. Increased fluid loss ->
• Hypovolemic shock, decreased cardiac output, cellular shock

The next 18-24 hours:

• Capillary permeability returns to normal
• Third spacing resolves.

Clinical Presentations:

This can get tricky. I mean if you have a conscious patient who walks in and says, “I burned myself when a pot of hot water landed on my leg”, that’s easy. The presentation becomes more tricky with trauma, or a patient from an actual fire scene. You also have to consider internal burns in addition to the burns to the skin you might see. For instance, inhalation burns are extremely lethal if not recognized.

It’s during the initial presentation and assessment that we determine the severity and type of burn. We want to determine if it’s superficial, partial thickness, or full thickness. This is where the old terms of 1st, 2nd, and 3rd degree burns used to be used, but we have put them aside for the actual thickness descriptions.

It is also during our assessment that we will use….The Rule of Nines!. I know it sounds daunting, but you should have all learned about this in the past. To our left here, we see the value for each part of the body. When we document, we need to document the severity of the burn and the total surface area percentage it is affecting.

Collaborative Management:

First things first, as always, ABCs…and very specifically Airway. You want to look for signs of an inhalation injury like soot around the mouth, or an intractable cough. If you suspect any inhalation injury….prepare for early intubation, even if they are breathing and oxygenating. Do you know why we rush to intubate these patients?……… Right, those inhalation injuries are just like any other injury, they swell. And what happens if the trachea continues to swell??? That’s right, no more breathing! So we try to prevent that.

When it comes to labs, there are some things that we might not normally draw, in addition to the basic CBC, CMP and coags. You want to get a carboxyhemoglobin level. For those that don’t know what carboxyhemoglobin is….time for a quick lesson.

We all know that hemoglobin is the O2 carrying portion of the blood. Blood likes hemoglobin. Problem is that carboxyhemoglobin is a form of hemoglobin that carries no O2, but instead carbon monoxide. Here’s the best part…. The body likes carboxyhemoglobin more than oxygen carrying hemoglobin. So it will push out the O2 for the Co2. This is why with inhalation injuries, we can’t really trust our O2 saturation. The blood will have a form of hemoglobin present, which is what the O2 Sat measures. The problem is that it’s not the right kind. That’s why we draw the level.

Ok….moving on…these patients need fluids. How much…well kids, it’s math time. When it comes to determining the amount of fluid a burn patient requires, we use The Parkland Formula, which is:

The Parkland Formula = 4 mL x %TBSA x weight (kg).

We give the first half of the total volume calculated in the first 8 hours and the remaining volume over the following 16 hours

I highly recommend you remember this piece of information as you may see it again.

OK. with our more severe burns, you want to prevent the possibility of infection. Remember, these full thickness burns are open wounds and very susceptible to infections so when dealing with them, we try to be as clean or sterile as possible.

Make sure we remove all clothing. We also need to ensure that the burn is not continuing. I’m really talking specifically about chemical burns, but this could occur with thermal as well. If there is still a heat or chemical source on the skin, make sure we remove it. With thermal, we are flushing with water. With dry chemicals, we brush the visible chemical off first and then flush.

Oh, and one final thing I’ll say here (i mean we could be here a while), but do not forget pain management. Just think of the level of pain these patients will be in. And don’t trust the old wive’s tale…well they burned off all their nerve endings, so they don’t feel it. That’s crap. Burns hurt, period. Treat their pain!

Evaluation | Patient Monitoring | Education:

The most important aspect of our evaluation of these patients is ABCs. Are they maintaining their airway? Are their hemodynamics maintained? Large surface burn patients can lose large amounts of fluid quickly so we need to keep an eye on BP and HR.

For the simple burns, we need to make sure they are keeping them clean and providing education to that end.

Linchpins: (Key Points)

• Stop the burn
• Replace fluids
• Maintain airway
• Pain control