Last updated: August 2022 Show
Burns are cutaneous lesions caused by exposure to heat, electricity, chemicals or radiation. They cause significant pain and may threaten survival and/or compromise function. Classification of burnsSevere burns: one or more of the following parameters:
Minor burns: involving less than 10% of the BSA in children and 15% in adults, in the absence of other risk factors Evaluation of burnsExtent of burnsLund-Browder table – Percentage of body surface area according to age
This table helps to accurately calculate the % of BSA involved according to patient’s age: e.g. burn of the face, anterior trunk, inner surface of the lower arm and circumferential burn of left upper arm in a child 2 years of age: 8.5 + 13 + 1.5 + 4 = 27% BSA. Depth of burnsApart from first-degree burns (painful erythema of the skin and absence of blisters) and very deep burns (third-degree burns, carbonization), it is not possible, upon initial examination, to determine the depth of burns. Differentiation is possible after D8-D10.
Evaluation for the presence of inhalation injuryDyspnoea with chest wall indrawing, bronchospasm, soot in the nares or mouth, productive cough, carbonaceous sputum, hoarseness, etc. Treatment of severe burnsI. Initial managementOn admission
Once the patient is stabilized
II. General measures during the first 48 hoursResuscitative measuresIntravenous replacement fluid to correct hypovolaemia: Fluid and electrolyte requirements during the first 48 hours according to age
Note: increase replacement volumes by 50% (3 ml/kg x % BSA for the first 8 hours) in the event of inhalation injury or electrical burn. For burns > 50% BSA, limit the calculation to 50% BSA. This formula provides a guide only and should be adjusted according to systolic arterial pressure (SAP) and urine output. Avoid fluid overload. Reduce replacement fluid volumes if urine output exceeds the upper limit. Target endpoints for IV replacement fluids
In patients with oliguria despite adequate fluid replacement: Respiratory care
AnalgesiaSee Pain management NutritionStart feeding early, beginning at H8:
Patients at risk of rhabdomyolysisIn the event of deep and extensive burns, electrical burns, crush injuries to the extremities:
Infection controlPrecautions against infection are of paramount importance until healing is complete. Infection is one of the most frequent and serious complications of burns:
Other treatments
III. Local treatmentRegular dressing changes a prevent infection, decrease heat and fluid losses, reduce energy loss, and promote patient comfort. Dressings should be occlusive, assist in relieving pain, permit mobilisation, and prevent contractures. Basic principles
Technique
Frequency
Monitoring
IV. Surgical careEmergency surgical interventions
Burn surgery
V. Pain managementAll burns require analgesic treatment. Pain intensity is not always predictable and regular assessment is paramount: use a simple verbal scale (SVS) in children > 5 years and adults and NFCS or FLACC scales in children < 5 years (see Pain, Chapter 1). Morphine is the treatment of choice for moderate to severe pain. Development of tolerance is common in burn patients and requires dose augmentation. Adjuvant treatment may complement analgesic medication (e.g. massage therapy, psychotherapy). Continuous pain (experienced at rest)
Acute pain experienced during careAnalgesics are given in addition to those given for continuous pain.
Note: these doses of morphine are for adults, dosing is the same in children > 1 year, should be halved in children less than 1 year, and quartered in infants less than 3 months.
Chronic pain (during the rehabilitation period)
Minor burns
How do you suspect inhalation injury?Inhalation injury should be suspected in the context of smoke inhalation and with any of the following: closed-space fire, loss of consciousness, burns to the face or neck, changes in voice, respiratory symptoms, soot in the mouth or airway, or singed nasal hairs.
What are the clinical manifestations of a lower airway lung injury associated with burns?Symptoms of lower respiratory tract injury may include shortness of breath and productive cough. Physical findings include burns to the face, singed nasal vibrissae, soot in the oropharynx, nasal passages, proximal airways, and carbonaceous sputum [9,25,36,37].
Which part of the respiratory anatomy will most likely be injured in a burn patient exposed to flames?Thermal injury often affects only to the level of the larynx. Chemical toxin/irritants may cause damage to just the airways, just the alveoli, or both.
Which of the following burn locations would lead the nurse to assess for inhalation injury?The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury.
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