Care of the Patient with Burns

Incidence and Causes

• 500,000 burns per year in the U.S.A.
• 40,000 hospitalizations; 25,000 admitted to Burn Centers
• 4,000 fire and burn deaths per year: 3,500 from residential fires; 500 from motor vehicle and aircraft crashes
• Major causes: flames; scalds; hot objects; chemicals and electricity
• Under age 6, major cause is scalding
• 75% of burns could be avoided

Classification of Burns

• First-degree or superficial burns involving only the epidermis: burned area is red
• Appearance: no blisters
• Second-degree or partial thickness burns involve all the epidermis and varying depths of the dermis
• Appearance: blisters, pink, moist. These burns are painful.
• Third-degree or full thickness burns involve epidermis, the entire dermis, skin appendages and possible deeper tissue such as muscle and bone
• Appearance: area appears white and dry. May be free of pain. Requires skin grafting.

Estimate Burn Size of % Total Body Surface Area (TBSA)

The percentage of the body burned is used to determine the need for hospitalization, the prognosis, and the calculation of early fluid and nutrition requirements.

Important Aspects of Care of the Burn Patient

• Fluid Resuscitation Following thermal injury the blood vessels in the body undergo a functional change leading to an increase in capillary permeability causing great fluid and plasma losses. Rapid infusion of electrolyte fluids is given in the first 24 hours post burn to replace volume loss and maintain vital organ function. The formula to replace fluids in our unit is 3 cc Lactated Ringers' solution, times the percent of burns, times the weight in kilograms. This volume is given in the first 24 hours, 1/2 during the first 8 hours and 1/2 during the next 16 hours. Urine output is monitored closely to evaluate the effectiveness of the fluid resuscitation. Hourly output should be 1.0 - 1.5 cc/kg/hour for children and 30-50 cc/hr for adults.
• Nutritional Support Because the burn patient is hypermetabolic following the injury, energy and protein requirements are increased. These requirements are usually met with a high calorie, high protein diet and often also requires enteral feedings via a small tube placed in the stomach. In our unit, the patient is assessed by the dietitian on admission and a feeding tube placed shortly after admission. In addition to feedings, the patient receives daily vitamins and supplements. Patients are weighed daily.
• Wound Care The goal of wound care is preventing infection and consists of daily observation and hydrotherapy to remove bacteria, necrotic tissue. After the wounds are cleansed we apply topical antibacterial agents and a light dressings.
• Grafting Early surgical excision and grafting of deep partial thickness and full thickness wounds is proven to promote healing and increase patients survival rate and shorten hospital stay. Skin is taken from the patient for grafting by using a dermatome, which removes a very thin layer of skin from an unburned area. The skin may be meshed to allow stretching for greater wound coverage. Our procedure for the post-op care of grafts is determined by the type and location of the graft.
• Pain Control Pain management is a major challenge. The nursing staff and therapist are supportive and assist the patient with relaxation techniques and breathing exercises. Opiates (e.g oxycodone, hydromorphone, and fentanyl) are our pain medications.
• Infection Control It is important to remember that the skin is the body's first line of defense. The burn wounds become colonized by the patient's own bacterial flora by the third day following a burn injury. If untreated, this can lead to sepsis and death. Manifestations of sepsis include an elevated temperature, increased pulse rate and respiratory rate, decreased blood pressure and urinary output. When sepsis is suspected, cultures are obtained and appropriate antibiotics begun.
• Rehabilitation The goals of rehabilitation are to accomplish functional and cosmetic recovery and to assist the patient in resuming a productive role in society. The formation of scar tissue may be minimized by the use of custom made compression garments. These garments are worn 24 hours a day for up to one-to-two years after the burn. The patient will experience itching and dry skin as the healing process continues. The use of emollient creams and anti-itching medications serve to keep the skin supple and control itching. Positioning, splinting, and exercises continue until the skin matures. Major joints can become contracted without continued therapy.