Burn injuries in the ICU: A case scenario approach

Simko, Lynn Coletta PhD, RN, CCRN; Culleiton, Alicia L. DNP, RN, CNE

Nursing Critical Care:
doi: 10.1097/01.CCN.0000511826.04099.6e

Abstract: Severe burn injuries offer many unique challenges for critical care nurses. This article uses a case scenario to review various types of burn injuries, burn pathophysiology, and what nurses need to know to provide comprehensive assessment and resuscitative care to patients with this type of injury.

In Brief

This article uses a case scenario to review various types of burn injuries, burn pathophysiology, and what nurses need to know to provide comprehensive assessment and resuscitative care to patients with this type of injury.

Author Information

Lynn Coletta Simko is a clinical associate professor at the Duquesne University School of Nursing, Pittsburgh, Pa.

Alicia L. Culleiton is an RN at MedExpress, Pittsburgh, Pa.

The authors have disclosed that they have no financial relationships related to this article.

Article Outline

Caring for a patient with severe burn injuries offers many unique challenges for critical care nurses. The following case study, about a young male patient named Abe, illustrates a common situation. This article reviews various types of burn injuries and what you need to know to provide initial resuscitative care for patients with severe burn injuries. A future article will be based on Abe's unfolding case scenario and will describe various treatment modalities necessary to manage the extended care of patients with burn injuries in the ICU, including what nurses need to know about skin grafting and in-hospital rehabilitation.

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Abe's story

The helicopter transport system notified their local Burn ICU (BICU) at 2400 that they were flying to a site in central Pennsylvania, and would be arriving within the hour. The transport was for a 14-year-old Amish boy who had stoked the fire in a wood-burning stove and an explosion occurred. As a result, the patient, Abe, had sustained an 82% total body surface area (TBSA) thermal burn (calculated using the Lund-Browder chart). Abe had sustained bilateral full-thickness circumferential burns to his legs and feet, arms and hands, genitalia, and deep partial-thickness burns to his head, neck, and anterior trunk. Abe's mother flew with him from his home to the hospital and remained in the BICU during his initial care.

Before Abe's arrival to the BICU, the flight nurse and flight team stabilized Abe by initiating cervical spine precautions, endotracheally intubating him, and providing sedation/analgesia with I.V. propofol and morphine via two large-bore peripheral venous catheters. In anticipation of Abe's arrival, the nursing staff readied the trauma room. They prepared for an arterial line placement, primed tubing for fluid replacement with lactated Ringer (LR) solution, obtained a pediatric-size urinary catheter and tetanus vaccine, readied a ketamine drip, and notified their respiratory therapy department that they would need a mechanical ventilator.

Upon initial assessment, Abe's right and left pedal pulses were not palpable, but were audible with a hand-held Doppler device. Radial pulses were 1+/0-3+ bilaterally. A right brachial arterial line and a right interior jugular central venous catheter were inserted and Abe's team began burn wound care. On reassessment, the nursing staff noted that both his pedal and radial pulses were absent bilaterally. Considering these findings, emergent bilateral upper and lower extremity escharotomies were performed. At this point of care, Abe's clinical status was critical, but stable.

As the nursing staff provided care for Abe, they became aware that there were many cultural, societal, and religious issues that would need to be considered in Abe's multidisciplinary plan of care. For example, following Abe's arrival, his father called the BICU and requested to speak to Abe's mother. Neither parent had a mobile telephone, and their house did not have a landline, so her husband was calling from a nearby hardware store. The nursing team called on their facility's social worker to determine appropriate ways to keep the patient's family updated, and also in an effort to anticipate any further needs the parents might have.

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Although burn incidence has decreased slightly over the years, burn injuries still occur frequently, with an estimated 3,275 fire and burn deaths occurring in the United States each year (this figure includes deaths from smoke inhalation and poisoning).1 In addition, about 40,000 patients who sustain burn injuries require medical treatment or hospitalization yearly. According to the American Burn Association (ABA), 43% of burn-related hospital admissions are due to fire or flame injury, 34% are due to scald injury, 9% are due to contact burn injuries, 4% are due to electrical burns, 3% are due to chemical burns, and 7% are due to miscellaneous causes.1

According to the National Burn Repository, pediatric burn injuries typically occur between ages 1 and 15 years and comprise 30% of all burns.2 Abe, for example, falls into this category. The majority of adult burn injuries occur between ages 20 and 59, accounting for 54% of burns, and are most likely to affect patients between ages 20 and 30.2

Burn injuries are some of the most expensive catastrophic injuries to treat. For instance, when treating a burn injury of greater than 10% TBSA, total hospital charges for surviving patients average $257,582 and $340,474 for nonsurvivors.2

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Defining burn injuries

Burn injuries involve the partial or complete destruction of the integumentary system: the skin. The skin is divided into three layers: the epidermis, dermis, and subcutaneous tissue (see Three-dimensional view of the skin). The skin is one of the largest organs in the body and has many functions, including protection against injury and infection, thermoregulation, regulation of fluid losses, vitamin D synthesis, and sensory contact with the environment. When the skin is damaged or destroyed by a burn, it can lead to local and systemic disturbances such as compromised immunity, hypothermia, increased fluid losses, infection, and changes in appearance, function, and body image.3

Burn injuries are described by the causative agent, depth, and severity.

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Types of burns

A burn injury is described by its cause: thermal, chemical, electrical, radiation, inhalation, or cold exposure (frostbite). Children most often suffer from scalds, whereas adults often suffer from flame burns.4,5

* Thermal burns result from contact with hot substances that cause cell injury by coagulation, including flames, hot solid objects, hot liquids, and steam.5 The time the skin is in contact with hot substances and the thickness of the patient's skin determine the depth of the wound. Oil-based liquids such as cooking oil and grease have higher boiling points and cause deeper burns than scalds with water or other liquids.3 Burns from hot solid objects such as metal (a curling iron), heated glass, plastic, or stone are all considered thermal burns; this includes Abe's burn from the explosion of the wood-burning stove heating his family's home.

* Chemical burns destroy tissue and continue to do damage for up to 72 hours unless neutralized. Further, systemic absorption of some chemicals can be life-threatening.5 Causes of chemical burns are strong acids, alkali agents, and organic compounds.6 Acids are commonly found in household cleaners such as rust removers, acidification for home swimming pools, and bathroom cleaners. These cause protein coagulation, which results in less extensive injuries. Alkali agents such as wet cement, oven cleaners, and fertilizers cause deeper burns due to liquefaction necrosis, which lets the chemical penetrate deeper into tissues.6 Organic compounds that cause chemical burns include gasoline and chemical disinfectants, which can cause severe coagulation necrosis and produce a layer of thick, nonviable tissue called eschar, which is normally present in full-thickness burns.6

* Electrical burns are classified as low voltage (under 1,000 volts) or high voltage (1,000 volts or higher).6 Electrical injuries can cause death from ventricular fibrillation or paralysis of the respiratory muscles; dysrhythmias can occur with low voltage, but are more commonly seen in high-voltage injuries. The extent of damage from an electrical burn may initially appear minor and the patient may only have small entry and exit wounds. Extensive damage can appear within several days to weeks—a phenomenon known as the iceberg effect—because the skin surface shows little injury and hides massive injury beneath.6 Instead of conducting the electricity, bones, muscle, tendons, and fat respond to electrical injury by producing heat. Most injuries occur to muscles surrounding the long bones.6 The magnitude of the electrical damage depends on the duration and strength of the current flow as well as the pathway of the current and the resistance to the current flow through the tissue.5

* Radiation burns result from exposure to sunlight, tanning booths, X-rays, or nuclear emissions or explosions. Ionizing radiation can produce tissue damage and be directly associated with cancer by striking a vital molecule such as DNA.3,5 Sunburn is usually a superficial burn, but radiation can also cause full-thickness burns.

* Inhalation burns can occur concurrently with thermal or chemical burns. If the patient has thermal burns, the signs and symptoms of inhalation burns include facial burns, hoarseness, soot in the nose or mouth, carbon in the sputum, lip edema, and singed eyebrows, eyelashes, and/or nasal hair.6 Hot smoke usually burns the pharynx and steam can also burn the smaller airways below the glottis. Many toxic chemicals produced in fires injure the smaller airways with chemical burns.5 Manufacturing of illegal methamphetamine can cause thermal and chemical burns and associated inhalation burns.6 Regardless of the cause of the inhalation injury, the patient needs immediate respiratory interventions such as endotracheal intubation and mechanical ventilation, and measurement of carboxyhemoglobin (COHgb) cyanide and lactic acid levels.6

* Frostbite (cold exposure) is temporary or permanent tissue damage resulting from exposure to very cold temperatures. Any area left uncovered in very cold temperatures can become frostbitten, but the most commonly affected areas are the fingers, toes, chin, earlobes, cheeks, and nose.7 Blood flow to the skin's outer layer is reduced and the skin tissue freezes and begins to die. Without treatment, frostbite can progress to necrosis, gangrene, hypothermia, and cardiac arrest. Because frostbite causes damage to the skin, some patients are treated in the BICU as burn patients, although initial treatment for frostbite is different than that for burns. Salvage of digits increases with rapid rewarming, early surgical consultation, and possible administration of fibrinolytics.7

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Burn depth

In the past, burn injuries were classified as first-, second-, third-, and occasionally fourth-degree burns. In recent years, the ABA has recommended a more precise definition of burns, categorizing them according to depth of tissue injury:8

* epidermal or superficial burns (first-degree)

* partial-thickness burns, when the epithelium is burnt but the dermis is spared (second-degree; these may also be classified as superficial or deep partial thickness)

* full-thickness burns, when the full thickness of the skin including superficial and deep dermis is destroyed (third-degree)

* deep full thickness, or exposure of fascia, muscles, and/or bone (fourth-degree).

See Classification of burns by depth of injury for more information.

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Size matters

Burn size is expressed as a percentage of TBSA. For example, a partial-thickness burn of more than 10% TBSA is serious and needs referral to a burn center (although there are many reasons why a patient with a burn injury might require referral; see Should the patient go to a burn center?).9

Initially, assessing the extent of a burn injury is necessary to guide therapy. Nurses can estimate the TBSA burned on an adult using the rule of nines.6 The rule is based on dividing the adult body into anatomical regions by factors of nine. The rule of nines varies between infants and adults because infants' heads are proportionally larger compared with adults (see Rule of nines: Estimating burn size in adults). Although the rule of nines provides a rapid method for calculating the size of the injury, it can overestimate the TBSA burned, so nurses must follow their facility's protocol for estimating the extent of a burn injury.6

Other common methods for measuring burn size include the Lund-Browder chart and the Palm Method.6 The Lund-Browder chart is highly recommended because it corrects for the large head-to-body ratio of infants and children; once Abe arrived to the BICU, this method was used to estimate the extent of his burn injuries.

The Palm Method is used for small scattered burns such as grease and scald burns. The patient's palm, including the fingers, equals 1% TBSA in children and adults.6 Often, the Palm Method will be completed first as a quick assessment until the Lund-Browder chart can be completed.

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Location matters

The location of a burn injury can predispose a patient to both early and late complications.10 Based on this knowledge, Abe's nurses were vigilant for complications as outlined in this section.

Circumferential burns of the extremities (see Ring of fire) can lead to vascular compromise resulting in compartment syndrome, and circumferential burns to the thorax can impair chest wall expansion, causing respiratory distress or failure. Burns of the chest, head, and neck are also associated with pulmonary complications. Facial burns are associated with corneal abrasions, burns of the ears with auricular chondritis, and burns of the perineal area are prone to autocontamination by urine and feces.10

Lastly, burns over the joints immediately affect the patient's range of motion, which may be exacerbated later by hypertrophic scarring (see Troublesome scars). Intensive therapy to prevent permanent disability is crucial.3

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Understanding the pathophysiology of a burn injury is vital for effective management and optimal patient outcomes. Different causes lead to different burn injury patterns, which require specific interventions.

The body's compensatory mechanisms start with the inflammatory response, which is initiated by cellular injury. The most important activator of the inflammatory response is the mast cell, which releases biochemical mediators, such as histamine and chemotactic factors, and synthesizes other mediators, such as leukotrienes and prostaglandins.11 Histamine, the major vasoactive amine released by the mast cells, causes increased capillary permeability and exudation resulting in edema, decreased intravascular volume, hypotension, tachycardia, oliguria, tachypnea, and shock.11 The sympathetic nervous system (SNS) is stimulated and the fight-or-flight response is activated. This causes gastrointestinal hypomotility (ileus), thirst, adrenal stimulation (causing increased catecholamine release, increased metabolic rate, and increased aldosterone secretion), hepatic stimulation (causing release of glycogen stores), increased blood glucose levels, and vasoconstriction.11

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Systems breakdown

Burns negatively affect every system in the patient's body. Respiratory system effects include direct airway injury, inhalation injury, carbon monoxide poisoning, smoke inhalation (damage to epithelial cells in the lower respiratory tract secondary to inhaling oxides, the products of combustion), pulmonary edema, alveolar damage, and decreased oxygen diffusion.3

Cardiovascular system effects include fluid volume deficit, decreased mean arterial pressure, decreased cardiac output, hypovolemic shock (secondary to extensive fluid shifts), and decreased myocardial contractility (impaired cardiac function improves 24 to 30 hours postinjury).6 For example, in Abe's situation, although he had received several liters of LR during helicopter transport, on presentation he demonstrated a fluid volume deficit and was experiencing episodes of hypotension. Further, electrical burns can cause myocardial infarction, ECG changes, ventricular fibrillation, and cardiac arrest.6

Renal system effects are indirect. Decreased cardiac output leads to decreased renal perfusion and oliguria that can culminate in acute kidney injury (AKI). In addition, after a burn injury, damaged red blood cells release hemoglobin and potassium, and skeletal muscle cells release myoglobin. Both hemoglobin and myoglobin are filtered by the glomerulus and degraded, releasing heme pigment. Heme pigment, especially in the setting of fluid volume deficit, can cause AKI.12 Marked release of hemoglobin or myoglobin usually causes red or brown urine, otherwise known as myoglobinuria. Abe's nurses saw some of these effects when they initially inserted an indwelling urinary catheter, because he only produced 30 cc of dark brown urine.

Gastrointestinal system effects include ileus secondary to SNS activation.3,6 Abe presented with no audible bowel sounds and was diagnosed with an ileus. Other effects include Curling ulcer (stress ulcer). Curling ulcer formation is triggered by the stress response and the histamine released in the inflammatory response. Intra-abdominal hypertension and abdominal compartment syndrome can be caused by circumferential eschar formation and the inflammatory response, which will damage the gut, kidneys, and liver.3,6

Neuroendocrine system effects include an increased metabolic rate to compensate for the initial low core body temperature because of loss of skin. The increased metabolic demand increases caloric needs and leads to a negative nitrogen balance and catabolism that slows tissue building and healing.6 Increased cortisol levels can cause insulin resistance and hyperglycemia.11

Musculoskeletal system effects include contractures and complications secondary to immobility and the healing process.

Immune system effects include immunosuppression secondary to the immediate, prolonged, and severe immunologic and inflammatory responses to a major burn injury.11

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Assessment and initial management

The emergency management of a patient with a burn injury begins with the initial assessment and treatment of life-threatening injuries. For Abe, many, if not all, of the following assessments and treatment modalities were initially completed by the flight team. However, it does not matter whether a burn patient's initial acute care starts in an ED or a specialized BICU; it is the nursing and medical staff's responsibility to ensure the following have been completed.

Stabilize the patient's cervical spine if this has not already been done. The true mechanism of injury may not be clear (for example, as with Abe, the patient may have been both burned and propelled in an explosion).

Follow the specific aspects of the primary survey during initial evaluation of every patient with a burn injury:13,14

* Airway. The airway is the primary concern, especially if a patient has an inhalation injury. Assess for stridor (an ominous sign that suggests the patient's upper airway is at least 85% narrowed), increased work of breathing, facial burns, soot in the nares or mouth, singed facial hair or nasal hair, edema of the lips and oral cavity, coughing, hoarseness, inability to tolerate secretions, and circumferential neck burns.13,15

* Ventilation. Determine adequacy of ventilation by assessing the patient's respiratory rate, depth, and work of breathing, auscultating bilateral breath sounds, and observing for dyspnea. Obtain an SpO2 (remembering that it may be inaccurate in the presence of carbon monoxide), and a co-oximetry reading (which can detect COHgb) if indicated and available. Rapid identification of circumferential burns of the trunk and neck are key, as a bedside escharotomy may be warranted.15

* Cardiovascular status. Every patient with a major burn should be placed on a cardiac monitor, with continuous pulse oximetry and vital sign evaluation at frequent intervals. Assess for the presence of peripheral pulses and grade their amplitude; evaluate capillary refill time, skin color, and temperature (in both burned and unburned skin), and observe for obvious arterial bleeding. Fluid management based on the patient's age, weight, burn severity, associated injuries, and comorbidities should be initiated once the extent of the burn injury is established.16

During this stage of the primary assessment, remember that a complete cardiovascular assessment includes evaluation of perfusion to all extremities (noting any circumferentially burned extremities). Vascular compromise must be addressed immediately and ideally prior to loss of distal pulses (which is a late clinical finding).

If decreased or absent peripheral pulses are noted, an escharotomy is indicated.16 Abe presented with unpalpable pedal pulses, which were audible with a Doppler; on further assessment, both his pedal pulses and radial pulses were absent. Bilateral upper and lower escharotomies needed to be performed to ensure that his extremities were adequately perfused.

* Disability, deficit, and deformity. Use the Alert, Verbal, Pain stimuli, Unresponsive Scale (AVPU; see A look at the AVPU scale) to quickly determine the patient's level of consciousness and carefully evaluate for any abnormalities. In addition, in the stable environment of an acute care setting, obtain a Glasgow Coma Scale (GCS) score, assessing best eye, verbal, and motor responses to establish baseline mental status.15 Assess for associated injuries, substance abuse, hypoxemia, decreased cerebral perfusion related to hypovolemia, and brain injury resulting from head trauma.

* Exposure/environmental control. Gently remove the patient's nonadherent clothing and jewelry to prevent continued tissue damage. If the patient's face is burned, remove glasses or contact lenses. Cover the patient with a clean blanket and ensure a warmed environment to prevent further contamination of the burn wounds and to provide warmth.15

As you complete the primary survey, obtain vital signs and establish I.V. access (this may include the initiation of two large-bore peripheral venous catheters if the patient has burns over 15% or more of TBSA and/or central venous catheter placement). Elevate burned extremities above heart level to decrease edema. Administer I.V. analgesia as prescribed and assess its effectiveness often, using a valid and reliable pain intensity rating scale.15

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Next steps

After the initial focused assessment is completed and the patient is stabilized, obtain a history of events while performing a comprehensive physical assessment (secondary survey). The main priorities are to determine the potential for an inhalation injury, presence of concomitant injuries or trauma, and any preexisting comorbidities that may influence the physical assessment findings or patient outcomes.

A simple way to initially accomplish this is to use the SAMPLE mnemonic: Signs and symptoms, Allergies, current Medications (including illegal substances or alcohol), Pertinent/Past history, Last oral intake, and Events leading up to the injury.17 This can only be accomplished if the patient is alert. If the patient is unable to answer these questions, question family members or witnesses to the burn injury.17 In Abe's case, he was not alert or speaking because he had been endotracheally intubated and sedated. The only source of information and patient history was his mother.

Determine the extent and depth of the burn, and ask the following questions:18

* What is the patient's chief complaint (for example, dyspnea or pain)?

* Did the burn occur in an enclosed space?

* Were explosives or chemicals involved?

* What was the source of the burning agent (for example, electrical, hot liquids, flame)?

* What is the status of the patient's tetanus immunization?

At the completion of the secondary survey, the following should be determined: indicated imaging studies, lab analysis, and adjunctive measures not limited to indwelling urinary catheters and nasogastric tube placement.

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About fluid resuscitation

Fluid resuscitation efforts should begin as soon as possible for patients with burns of 15% of TBSA or more; otherwise, the patient may experience hypovolemic shock.6 Nurses should insert an indwelling urinary catheter to assist in monitoring fluid balance.

Several fluid resuscitation formulas are available, and a formula usually is prescribed by the burn trauma surgeon. All formulas are based on the TBSA burned, the patient's weight in kilograms (kg), and the patient's age. Half of the fluid volume is administered in the first 8 hours postburn, and the remainder is given over the next 16 hours. The ABA recommends titrating the fluids to maintain a urine output of 0.5 to 1.0 mL/kg/hour in adults and 1 to 1.5 mL/kg/hour in children weighing less than 30 kg.6

Using the Parkland formula, which was created to help calculate fluid replacements for burn patients, and Abe's weight of 36 kg, the following equation was used to determine his fluid resuscitation requirements over 24 hours: %TBSA × weight in kg × 4, or 82% × 36 kg × 4 mL = 11,808 mL in 24 hours, half of that in the first 8 hours (5,904 mL), or 738 mL/hour.6

In the case of a patient who has sustained a high-voltage electrical burn, the target range for urine output is 75 to 100 mL/hour in adults and 1 mL/kg/hour in children until their urine becomes clear to prevent renal tubular obstruction from heme pigment. Avoid administering diuretics, which may aggravate dehydration.6 The patient's mental status, vital signs, hourly urine output, and urine specific gravity are valuable indicators of the patient's response to fluid resuscitation.

Because of the massive volumes of I.V. fluids administered to patients with burn injuries (rates of 1,000 mL/hour are common), diligently assess the patient's hemodynamic status to avoid inducing fluid overload. Complications of “fluid creep,” or excess fluid resuscitation, include abdominal compartment syndrome, peripheral compartment syndrome, and acute respiratory distress syndrome.19,20

Fluid resuscitation after the first 24 hours is accomplished by using isotonic crystalloids as well as colloids. Dextrose solutions and electrolyte replacement (especially potassium replacement) is initiated. LR solution is isotonic and does not increase intravascular oncotic pressure. Because of increased capillary permeability in patients with burns, only 25% of the LR solution infused in the initial fluid resuscitation will actually stay in the intravascular space. This is one reason for the large fluid volumes needed in fluid replacement.6

Once the increased capillary permeability has decreased (8 to 12 hours after the burn injury), colloids such as albumin may be given to help restore intravascular volume. Colloids increase the oncotic pressure in the vascular space, pulling interstitial fluid into the intravascular space. This helps decrease the edema associated with burn injuries. Newer guidelines suggest administering colloids earlier than in the past.20 Albumin and/or fresh frozen plasma is sometimes recommended earlier in the fluid resuscitation period, and may decrease the large volumes of crystalloids that are needed, thus decreasing fluid creep.19,20

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For all burn patients, it is imperative that you continually monitor vital signs, level of consciousness, respiratory status, and cardiac rate and rhythm. Continue to identify and treat other associated injuries (such as head injury, pneumothorax, or fractures). Remember specific interventions for common types of burns:

* Thermal. Assess the patient for inhalation injuries. For adults with burns of more than 15% TBSA, begin fluid replacement as prescribed and insert an indwelling urinary catheter.21 Knowing that Abe would require very aggressive fluid resuscitation, a pediatric indwelling urinary catheter was inserted upon admission to the BICU.

* Chemical. Assess the patient's ABCs before starting decontamination procedures. Endotracheal intubation and mechanical ventilation may be needed for patients with significant inhalation injuries or circumferential full-thickness burns to the neck or chest. Remove dry chemicals from the patient's skin (utilize protective garments when indicated), then use saline or tap water to flush chemicals from the burn (for 30 minutes, or up to 2 hours). Contact the poison control center for more information on handling chemicals, and protect yourself from potential exposure. Chemical burns to the eyes should be continuously irrigated. If only one eye is affected, be careful not to contaminate the unaffected eye. If contact lenses are in place, remove with a clean gloved hand. Irrigate the eye by running normal saline through I.V. tubing when both eyes are affected.22

* Electrical. Assess pulses distal to the burn. Monitor the patient for myoglobinuria (myoglobin released from injured muscle tissue and hemoglobin from damaged red blood cells). Initiate fluid resuscitation and insert an indwelling urinary catheter. Be prepared to administer I.V. mannitol, an osmotic diuretic, to maintain urine output, and I.V. sodium bicarbonate to alkalinize the urine.21,22

* Inhalation. Obtain an arterial blood gas analysis, COHgb level, and chest X-ray. Be prepared if fiber-optic bronchoscopy or endotracheal intubation is needed.21

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A good start

As you can see, Abe's initial care faithfully mirrored the information contained in this manuscript. Abe's story and progress will continue to unfold in a second article, discussing his care in the BICU, skin grafting, and in-hospital rehabilitation.

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Classification of burns by depth of injury

* Superficial or epidermal burns caused by the sun or low-intensity heat flashes damage only the epidermis. These burns cause erythema, skin blanching on pressure, mild pain and edema, and no blisters or vesicles, although after 24 hours the skin may blister and peel. Symptoms include hyperesthesia, mild pain, and tingling. Healing typically takes 3 to 6 days without scarring.

* Partial-thickness burns caused by chemicals, flame, or hot liquids damage the epidermis and part of the dermis. They are characterized as either superficial or deep. These burns appear as fluid-filled vesicles that are red and shiny (and wet if the vesicles have ruptured). Symptoms include edema, hyperesthesia, pain caused by nerve injury, and sensitivity to cold air. Healing typically takes 10 to 21 days for superficial partial-thickness burns, which involve part of the dermis, and 2 to 6 weeks for deep partial-thickness burns, which involve more of the dermis.

* Full-thickness burns are caused by prolonged exposure to chemicals, electrical current, flame, hot liquids, or tar. Full-thickness burns will expose adipose tissue beneath the dermis layer of skin. The skin appears dry, waxy, white, leathery, or hard. Signs and symptoms include anesthesia, possible hematuria, possible entrance and exit wounds from an electrical burn, and shock. Skin grafting is often required for healing, and patients may lose function of extremities or digits, or need amputation.

* Deep full-thickness burns are deep and potentially life-threatening injuries that extend through the skin into underlying tissues such as fascia, muscle, and/or bone. Deep full-thickness burns are typically caused by prolonged exposure to fire, hot liquids, chemicals, or exposure to a burst of intense electricity or ultraviolet rays.

Sources: Coffee T. Care of patients with burns. In: Ignatavicius DD, Workman ML, eds. Medical-Surgical Nursing: Patient-Centered Collaborative Care. 8th ed. St. Louis, MO: Saunders Elsevier; 2016.

Rice PL, Orgill DP. Classification of burns. UptoDate. 2016. www.uptodate.com.

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Should the patient go to a burn center?1

Patients who should be referred to a burn center include:

* All burn patients under age 1 year.

* All burn patients ages 1 to 2 years with burns over 5% or more of TBSA.

* Patients of any age with full-thickness burns of any size.

* Patients over age 2 years with partial-thickness burns greater than 10% of TBSA.

* Patients with burns of special areas such as the face, hands, feet, genitalia, perineum, or major joints.

* Patients with electrical burns, including lightning injuries.

* Patients with chemical burns.

* Patients with inhalation injury resulting from a fire or hot liquid burn.

* Patients with circumferential burns of the limbs or chest.

* Patients with preexisting medical disorders that could complicate burn management, prolong recovery, or affect mortality.

* Patients with burns and concomitant trauma.

* Children with burns who are suspected to be victims of child abuse.

* Patients whose burns require treatment that exceeds the capabilities of the referring facility.

* Patients with septic burn wounds.

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A look at the AVPU scale

This scale, a shortened form of the GCS, can be used to determine a patient's level of consciousness.

Alert: patient is alert, awake, responds to voice, and/or is oriented to time, place, and person. Nurses can obtain subjective information from the patient.

Verbal: The patient opens his or her eyes to verbal stimuli, but is not fully oriented to time, place, or person; or only becomes aroused after verbal stimuli.

Painful: The patient responds to painful or noxious stimuli, such as nailbed pressure, but does not respond to verbal stimuli; patient difficult to arouse.

Unresponsive: The patient is nonverbal and does not respond to painful stimuli; unconscious.

Source: Emergency Medical Paramedic. AVPU. 2013. www.emergencymedicalparamedic.com/avpu.

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burns; ICU; nursing assessment; severe burn injuries; trauma

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