1. Connie Handel RN University of Wisconsin Hospital and Clinics
Initial Care of Burns
Connie Handel RN
University of Wisconsin Hospital and Clinics

2. Objectives Discover who’s getting burned?
Discuss Burn pathophysiology.
Understand why some treatments are better than others.
Review treatment options.

3. Skin Structures Epidermis – outermost layer of keratinized cells
Dermis – contains skin appendages, vascular supply and nerve endings
Subcutaneous Tissue

4. Functions of the Skin Barrier to infection
Protection from external injury
Temperature control
Control of body fluids
Sensory organ
Determines identity

6. What is a burn?
Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

7. Burn Depth

8. First Degree Burns Epidermis affected only
Red or pink, dry, painful, blanches to touch
Epidermis is intact
Spontaneous healing within 7 days. Outer injured epithelial cells peel
Seldom clinically significant

9. Superficial Partial Thickness
Entire epidermis & portion of dermis (Papillary dermis)
Homogenous pink
Painful
Blisters
Blanches
Hair usually intact
Does not scar, may pigment differently

10. Sup 2nd degree

11. Deep partial thickness
Reticular dermis
Mottled red and white
Not painful to pinprick or pressure
Does not blanch
Heals > 3 weeks
Usually scars
Need to excise and graft

12. Deep Partial Thicknessx

13. Deep dermal

14. Full Thickness: 3rd degree
May go into fat or deeper
Red, white, brown, black
Inelastic and leathery
painless or numb
Heals only from the periphery
Always excise and graft

15. Full-thickness

16. Etiology

17. Types of burns

18. Circumstances of injury

19. Where do burns occur

20. Admissions by age

21. % of admissions vs. burn size

22. Inhalation Injury Exposure to heat and toxic products of combustion
50% of fire deaths are related to inhalation injuries
Asphyxia/Carbon Monoxide displacement of oxygen

23. Inhalation injury diagnosis
Closed-space fire
Face burns

24. Terminology Inhalation injury “nonspecific” Thermal injury
Upper airway
Heat and toxic fumes
Local chemical irritation
Throughout airway
Primarily toxic fumes
Systemic toxicity CO

25. Signs and symptoms Lacrimation Cough Hoarseness Dyspnea Disorientation
Anxiety
Wheezing
Conjunctivitis
Carbonaceous sputum
Singed hairs
Stridor
Bronchorrhea

26. Pathophysiology
The main factor responsible for mortality in thermally injured patients
Carbon monoxide the most common toxin
200 times greater affinity
Competitive inhibition with cytochrome P-450

28. Poison management = CO 500 unintentional deaths each year
Persistent Neurologic Sequelae
May improve over time
Delayed Neurologic Sequelae
Relapse later

29. Carbon Monoxide Poisoning
10% COHb – asymptomatic, seen most often in smokers, truck drivers, traffic police
20% COHb - headache, nausea, vomiting, loss of dexterity
30% COHb - confusion & lethargy, possible ECG changes
40-60% COHb - coma
60% + - usually fatal

30. Poison management = CO Treatment
CO level means nothing to predict outcome
Length of hypoxia is the determining factor
Oxygen
HBO
No studies show benefit in treatment

31. Reduction of CO

32. Determine Burn Severity
% BSA involved
Depth of injury
Age
Associated/pre-existing disease or illness
Burns to face, hands, genitalia xx

33. Difficulties with accurate initial assessment of burn size & depth
Soot, blisters, adherent clothing or debris obscure wound
Burns are dynamic…Progression is always a risk

34. Burn Extent Total Body Surface Area (TBSA)? Rule of nines
Lund and Browder chart
Patients palm = about 1% TBSA

35. Extent of Burn :“Rule of Nines”
Adult anatomical areas = 9% BSA (or multiple)
Not accurate for infants or children due to larger BSA of head & smaller BSA legs.
Burn diagrams illustrate adult – child differences

36. Lund & Browder Chart

37. Extent of Burns
Patient’s palmar surface (hand + fingers) = 1% TBSA

38. Burn Depth Factors Temperature Duration of contact Dermal thickness
Blood supply
Special Consideration: Very young and very old have thinner skin

39. Burns begin at 44 degrees C
6 hours for burns to occur at
111 degrees F (44 C)
1 second of burns to occur at
140 degrees F (60 C)

40. Time For Full Thickness Burns To Occur In Scalds
5 seconds in 140 F (60 C)
30 seconds in 130 F (55 C)
5 minutes in 120 F (49 C)

41. Pain control

42. Ice Pack-----DO NOT USE EVER
DOES NOT
Reverse temperature
Inhibit destruction
Prevent edema
DOES
Delay edema
Reduce pain

43. Non-medication methods
Cover burns with plastic wrap
Wet dressings will stick and cause more pain
Other burn dressings are expensive and not necessary
Quik Clot is expensive and will not provide any patient benefit

44. Medication
Medications
Opioids
Narcotics
Pain medications
IV Analgesia

45. Resuscitation

46. IV access < 15% TBSA – oral resuscitation
15 – 40% TBSA – one large bore IV
> 40% -- two large bore IV’s
IV’s should be in the upper extremities
Suture IV’s started through burns

47. Field resuscitation Start IV with LR, through burn OK
< 6 years = 125mL/hr
6-13 years = 250mL/hr
>13 years = 500mL/hr

48. Contact

49. Contact Burn

50. Scald Burn

51. Flame Burn

52. Grease Burn

54. ABA Burn Referral Criteria
The ABA identifies the following as injuries requiring a Burn Center referral:
2nd degree burns > 10% TBSA
Burns to face, hands, feet, genitalia, perineum, major joints
3rd degree burns
Electrical injury
Chemical burns
Inhalation injuries
Burns accompanied by pre-existing medical conditions
Burns accompanied by trauma, where burn injury poses greatest risk of morbidity or mortality.
Burns to children in hospitals without pediatric services.
Patients with special social, emotional or rehabilitative needs.

55. UWHC Burn Center Verified by the American Burn Association
7 ICU beds
General care bed expansion available as needed
Open to all burns, all ages, all times
Capability of providing specialized care for all patients, from pediatrics to geriatrics
Full time Surgical
Staff, House Staff, Nursing, Respiratory, Occupational and Physical Therapists, Social Worker, Nutritionist, Health Psychologist, Child Life and Pharmacist

56. UWHC Burn Center Verified by the American Burn Association
Closely integrated inpatient, rehabilitation and outpatient services
Outreach programs
Burn Support Group
Burn Camp
Burn Buddies
Juvenile Fire Starters Program
School Reintegration
Burn Education to School and Community Groups