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
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
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.
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
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
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.
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.
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.
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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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved
burns; ICU; nursing assessment; severe burn injuries; trauma