1. Burns
Basic Trauma Course

2. Mechanism of Injury
Thermal burns can be caused by flames, flash, scalds, and contact with burning substances or objects.
Chemical burns can be caused from acid and alkali materials, both dry and wet.
Electrical burns are caused by electrical sources of AC/DC power, including lightening.
Radiation burns can occur from ultraviolet or ionizing radiation.
Thermal-Most common type of burn , High incidence in children and elderly, scalds are the highest in this population
Electrical energy is converted to heat. This type of burn: Usually has an entry and exit wound , Follows the path of least resistance (e.g. blood vessels or nerves) , High risk for cardiac arrhythmias

3. Inhalation Injury
In burn patients, the skin is usually the first injury observed, but the potential for injury to the pulmonary system requires immediate assessment and observation.
To treat an inhalation injury:
High flow O2, open and support airway
Intubate
Exam: c/o headaches, tachycardia, irritability, confusion, vomiting, incontinence, dilated pupils, cyanosis, pallor
Physical Findings: facial burns, singed facial hair, mouth blisters, carbonaceous sputum, visible soot, wheezing, stridor, hoarseness, labored and rapid breathing

4. Pathophysiology of Burns
A burn injury will cause a release of vasoactive inflammatory mediators.
These mediators alter capillary permeability.
The smaller the burn the more local the trauma and edema.
A burn >20-25% TBSA will result in a systemic response and generalized edema.
The burned skin is divided into three zones: zone of coagulation, zone of stasis and zone of hyperemia.
The zone of coagulation is the most seriously affected and the tissue cannot regenerate.
The zone of stasis surrounds the zone of coagulation. There is capillary occlusion with diminished perfusion and edema during the first 24 to 48 hours. This area has the potential to be salvaged.
The zone of hyperemia has increased blood flow as a consequence of the inflammatory response.
Refer to page 207 Figure 12-3 Zones of the Burn Wound.

5. Assessment of Burn Mechanism of Injury, Depth, Extent, and Location
The severity of a burn injury is dependent upon the total burn surface area, TBSA, the depth of the burn injury and accompanying inhalation injury.
Minor factors that effect the severity of the burn injury are age of the patient, associated trauma and co-morbid conditions such as diabetes and renal failure, and the location of the burn.
The Rule of Nines is a quick way to assign percentage of body surface area affected.
Depth of injury: Superficial, Partial thickness, Full thickness , Fourth-degree burn
Extent-Refer to page 212 Figure 12-4 for The Rules of Nines
Location- Perineum, face, hands- high risk areas
Question Tetanus Status
Ask Questions About Event
Did the accident occur indoors or outdoors
Was it a flash from the fire or was the patient actually on fire?
Did the patient's clothes catch on fire?
How long was the patient on fire and/or exposed to smoke?
How was the fire extinguished?
Did the patient fall?
Were there any other concomitant injuries?
What was the strength of the current and voltage if it was an electrical burn
?Is there a possibility that the injury is intentional or a result of drug abuse?
Does the patient have a psychiatric history of illness?

6. Resuscitation Phase
The initial phase of burn injury requires early interventions to ensure adequate fluid resuscitation.
The goal of fluid resuscitation is early restoration of intravascular volume to ensure adequate organ and tissue perfusion.
Determine fluid resuscitation volumes: Calculate 2 to 4 ml/kg × % of TBSA burned and give within the first 24 hours
Give 1/2 of the total amount in the first 8 hours postburn and the remainder over the next 16 hours
The TBSA can predict the changes in capillary permeability.
The burns that have a large TBSA > 25% result in generalized permeability and a greater degree of intravascular fluid loss.
The burns with TBSA < 25% tend to have a more localized effect limiting the changes in capillary permeability to the injured area.

7. Acute Phase
IVF should be a crystalloid solution-Normal Saline or Lactated Ringer’s-warmed.
Urine out put is the key measurement in monitoring for adequacy of fluid intake. The output goal for an adults is 30cc/hr .
Maintain normothermia.
Cover burns with clean sterile dressings and dry blankets .(no application of topical agents- burn center will treat the wounds) .
Insert a foley and NGT if indicated
Remove all clothing and jewelry
A burn patient is at greater risk for hypothermia due to skin loss.
Infection is a major source of mortality and morbidity with burn patients.
Administering analgesic medications
Inserting an indwelling urinary catheter and a gastric tube
Applying cool, saline-moistened, sterile dressings to TBSA burns < 10%
Covering burns > 10% TBSA with a clean, dry sheet
Keeping the patient warm
Elevate burned extremities
Prepare for transfer Refer to page 216 Table 12-8