Nursing assessment and care of major burn injuries : Nursing made Incredibly Easy

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Nursing assessment and care of major burn injuries

Miller, Nichole DNP, AGACNP-BC

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Nursing Made Incredibly Easy! 21(1):p 6-13, January/February 2023. | DOI: 10.1097/01.NME.0000899380.81703.82

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Figure

Major burn injuries are one of the worst insults the body can endure and require intense specialty care. Whereas burns are traditionally thought of as a skin injury, a major burn can impact every system in the body within minutes of injury. In the US, a burn injury requires medical intervention every 30 minutes and between 4,000 and 6,000 people die from burn-related injuries each year.1 There are approximately 120 burn centers in the US and only half of these hold certification by the American Burn Association.2 This means that most people don't have direct access to a burn center and need to be stabilized at a local hospital after their initial injury. Therefore, it's important that everyone working in the acute setting, especially the nurse who's the first point of care, has some basic understanding of burn assessment and treatment.

Factors such as geographic location, gender, and extremes of age increase the risk of sustaining a burn injury.1 It's a common misconception that most major burn injuries are the result of house fires; these incidents only account for approximately 4% of all burn admissions.1 The Southeastern US has the highest incidence of major burn injuries. Men are twice more likely than women to sustain a major burn injury. Common causes of adult burn injuries include electrical injuries, work-related accidents, automobile fires, or burning trash or yard debris.2 At-risk populations such as children, older adults, and persons with a disability are more likely to suffer burn injuries due to mobility restrictions and decreased coordination.

Burn classifications

Burns are classified in several different ways. To treat a burn injury appropriately, you'll need to know the cause of the injury, the depth of the burn, and the total skin involvement. Burn causes include thermal, chemical, and electrical contact. The depth of a burn is measured by the depth that the burn extends. Depth is separated into partial-thickness and full-thickness burns. Burns can also be classified in degree of injury from first through fourth. Partial-thickness burns include first- and second-degree burns, and full-thickness burns include third- and fourth-degree burns.3

Partial-thickness burns

First-degree burns are superficial burns that only involve the epidermis. First-degree burns appear red without any blistering. The skin may feel tight, irritated, and painful. The skin will blanche when pressure is applied.3 Sunburn is the most common example of a first-degree burn injury. First-degree burns are often uncomfortable but are self-limiting and generally don't require medical intervention unless there are additional complications, such as dehydration, or they encompass a large surface area.

Second-degree burns involve the epidermis and the dermis. Second-degree burns can be superficial or extend deeper into the dermis. Skin with second-degree burns can appear red with fluid-filled or open blisters. Deep second-degree burns may appear red, pale pink, or yellow in color.3 The wound bed may be wet or dry. Deep second-degree burns are often difficult to distinguish from third-degree burns and often take an extended period to heal without surgical intervention.

Full-thickness burns

Third-degree or full-thickness burns extend through the dermis and into the subcutaneous tissue. In full-thickness burns, the entire skin surface has been damaged. These types of burns appear pale white, gray, yellow, dark red, or even charred.3 The skin is often tight, appears “leathery,” and provides little flexibility. The areas don't blanche with pressure and likely won't heal without surgical intervention.

Fourth-degree burns aren't often discussed but are an important classification for nurses to distinguish. Fourth-degree burns include any burn that involves damage to the deeper structures such as tendon and bone.3 Fingers and toes are more susceptible to fourth-degree burns. Most fourth-degree burns will result in amputation due to bone injury.

Sizing of a burn injury

The size and depth of a burn injury directly impacts the level of care that the patient will require. Large burns require extensive specialized care for the best possible outcomes. Estimation of the total affected body surface area is one of the most important initial assessments when caring for a burn injury. Burn size will dictate many aspects of care, such as the fluid volume the patient will need for resuscitation and potential resources that'll be required to appropriately care for the patient. An accurate estimation of burn size is important but can often be difficult for nurses who don't frequently assess patients with burn injuries.4 Clinicians are more likely to overestimate the total body surface area (TBSA) of a burn injury than underestimate, but both can increase patient mortality.

There are several different methods of estimating the percentage of body surface area covered by burns, the most common being the rule of nines (see Rule of nines). This model divides the body into different sections and assigns each section with a percentage. In the rule of nines, the entire head is worth 9%, the torso is worth 36%, the arms through the hands are worth 9%, each leg is worth 18%, and the genitals are worth 1%. The percentage is assigned to the entire area. If only part of the area is burned, then only part of the percentage would be awarded. The rule of nines is also used with children; however, surface area percentage is calculated differently due to the difference in body ratios.

Initial burn management

The first 48 hours are the most critical period in the care of patients with burns. Nursing priorities in the initial management of patients with burns include airway protection, fluid resuscitation, warming measures, and evaluation of the burned tissue.1 Airway evaluation and protection are priorities for patients who may have sustained an inhalation injury or burns to the airways. Patients involved in structure fires, automobile fires, or fires in any enclosed spaces are at risk for inhalation injury.

Airway and inhalation injuries

Patients with inhalation injuries may present with respiratory symptoms such as shortness of breath, cough, and hypoxia. Other symptoms include hoarse voice, soot in the nose or mouth, or soot in airway secretions. Inhalation injuries often accompany facial burns. Patients with facial burns should be assessed immediately for potential inhalation injury and monitored closely for changes. Airway protection is important due to the risk of airway swelling. Patients with facial burns and inhalation injuries often require intubation and mechanical ventilation for airway protection.1

Patients involved in structure fires, especially in enclosed spaces, are also at risk for carbon monoxide and cyanide poisoning. When objects burn, they release carbon monoxide, which has a stronger bond than oxygen to the hemoglobin, leading to severe hypoxia and death. Carbon monoxide levels, otherwise known as carboxyhemoglobin, should be drawn as soon as poisoning is suspected. Spo2 isn't an accurate assessment in a patient with carbon monoxide poisoning and shouldn't be used to determine oxygenation.

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Figure:
Rule of nines

Patients with carbon monoxide poisoning or suspected poisoning should be placed on 100% Fio2 for 12 to 24 hours. Patients with elevated levels of carbon monoxide will likely require intubation due to inhalation injury, but all patients should be placed on 100% FiO2 even if not intubated.5 Repeat carboxyhemoglobin testing should be checked 5 to 8 hours after the initial test to ensure complete washout. In severe cases of carbon monoxide poisoning, hyperbaric oxygenation should be considered.

Another point for nurses to consider is cyanide. If a patient has carbon monoxide poisoning or was in a building for a prolonged time, it's important to consider the risk of cyanide poisoning.1 Cyanide is released when plastics and coated textiles burn. These are often present in burns involving mobile homes, RVs, and campers with plastic walls, or upholstery and rugs that contain plastic or coated fibers. Treatment should be given if the carbon monoxide level is significantly elevated or if there's a high suspicion of cyanide toxicity.

Burn shock and fluid resuscitation

Within minutes of a major burn injury, the permeability of the vascular changes causes a significant fluid shift from the intravascular space to the tissues. This shift leads to burn shock. Patients with burns require large amounts of I.V. fluids to prevent and manage burn shock. Rapid infusion of I.V. fluids is required to maintain perfusion to organs and prevent organ failure. The patient with burns can require several liters of fluid an hour in the first 24 to 48 hours. Lactated Ringer's solution is the most common fluid used in the resuscitation process.6,7

Burn resuscitation in the first 24 hours is key to decreasing mortality and morbidity. Too little or too much fluid can have a detrimental effect on patient outcome. There are many different tools to estimate the volume of fluid required to resuscitate a patient with burns.8 The Parkland Formula for Burns is considered the standard (see Parkland calculation example). The formula is based on burn size, TBSA, and patient weight to calculate the requirements. Half of the required fluid is administered to the patient within the first 8 hours. Time is calculated from the point of injury, not the time the patient presents to the hospital. This method requires accurate estimation of burn size.

Large burn injuries often require aggressive fluid resuscitation for the first 24 to 48 hours after the initial burn injury to prevent hypovolemic shock. Many patients will also require vasopressors for hemodynamic support.9 These should be used for shock management and shouldn't be used as a replacement for adequate fluid resuscitation. Norepinephrine is recommended as the first-line vasopressor in patients with burns. Vasopressin is often added as a second-line agent.

The nurse should monitor urine output hourly in any patient requiring fluid resuscitation. Place a urinary catheter to facilitate accurate measurements. Fluids may need to be adjusted in patients with shock symptoms or low urine output.4 If a patient's urine output doesn't respond to fluid resuscitation, they may require emergent renal replacement therapy.7,10 Most significant burn injuries will have some level of acute kidney injury.

Temperature management

Burn injuries cause significant injury to the skin, leading to loss of body heat and difficulty with temperature regulation.1 Patients with burns can develop hypothermia quickly; therefore, continuous temperature monitoring should be performed when possible. Significant hypothermia can lead to bradycardia, hypotension, and coagulopathy. Patients should be kept warm with regular blankets, shock blankets, airflow warming blankets such as a Bair Hugger device, and/or head covers. Any wet clothing should be removed immediately on initial presentation. If the patient doesn't respond to the conventional methods, of warming detailed above, other methods, such as esophageal warming probes or centrally placed warming catheters, may be required.

Pain management

Pain management is an important part of the initial care of large burns. Burn injuries are extremely painful and pain should be treated. Most large burn injuries will require intubation and mechanical ventilation to allow for continuous infusion of medications for pain control and sedation. Some patients may even require intubation for pain control and care.

As there are no standard recommendations for what medications to use for pain management in burn injuries, a multi-modality approach is often used to target multiple methods of pain control. Nonsteroidal anti-inflammatory drugs are often avoided in large burns because of the risk of acute kidney injury and bleeding. Propofol isn't recommended for sedation in burn injuries because it's been shown to cause fatty liver disease in patients with burns.

Fentanyl and versed infusions are often used in the first 24-48 hours for sedation and pain management, respectively.11,12 Dexmedetomidine can be used to treat pain in smaller burn injuries, nonintubated patients, or later in the clinical treatment when patients must be more alert and interactive. Enteral medications can be introduced 24 to 48 hours after the injury. Methadone or other long-acting narcotics can be added to the analgesic routine. Gabapentin or pregabalin are often used in combination with narcotics to target pain related to damaged nerves.

Initial wound management

The initial burn management depends on the size, depth, and location of the burns. Full-thickness, circumferential burns can lead to compartment syndrome due to restrictive burn tissue. Circumferential burns to the extremities can lead to loss of limbs if the pressure isn't released. Escharotomies are an emergent intervention that require a surgeon to make incisions in the tissue to release restrictive burn tissue.1 Escharotomies are commonly performed on the limbs but may also be performed on the chest and abdomen.

Patients with major burn injuries should be transferred to a certified burn center for the best outcome (see Burn center referral criteria). They will require multiple surgical interventions. Initial wound management can vary depending on the facility's capabilities. The priority is to keep the patient warm and to avoid hypothermia. If the patient is warm, they can be put into moist sterile dressings. Moisten dressings with saline or an antimicrobial such as Dakin solution. If the patient is hypothermic, you can cover the patient with sterile towels or a sterile sheet until the patient is warm.

Nonsurgical management

Minor burn injuries are superficial partial-thickness burns that total less than 10% of the body. Some minor burns may be treated with topical management alone. This usually involves topical antimicrobials such as silver sulfadiazine. Oral antibiotics aren't usually required for minor burn injuries unless the wound is infected or there's a delayed presentation. Patients should receive a tetanus vaccine if they haven't received one in the last 5 years.

Special consideration should be given to burns to the hands, face, genitals, over joints, and any circumferential burns. According to the American Burn Association, burns to these locations should be evaluated in a certified burn center. Even small burns to these areas should be referred because there's a substantial risk of complications, including scarring and loss of mobility.

Surgical management

Major burns will require multiple surgical procedures over weeks to months depending on size of the burn and comorbidities. Major burns are at risk for infection until the burned areas are healed. The goal for large burn injuries is to undergo initial surgical excision within 48 hours of injury. Removal of the burned tissue decreases the risk of infection and allows for the preservation of viable tissue.1 The wound bed is then usually covered in a temporary skin substitute called an allograft. This helps protect the wound bed and prepare it for a permanent autograft. Autograft will allow for healing of the burn injury. The sooner the skin closure is obtained, the better the outcome for the patient.

Allografts are temporary grafts that act as a skin substitute. This is often cadaver skin that's donated and sterilized. Because it's human skin, it provides an ideal environment for the wound bed to granulate and mature in order to receive an autograft. Allografts help maintain moisture that's lost through dressing application and prevent infection by providing a barrier. There are other types of allografts including porcine skin, also known as xenograft, and several types that use placental stem cells.1

Autografts are grafts that originate from the patient's own skin. These include full- and split-thickness grafts. This graft type is permanent and is used primarily in full-thickness burn injuries or burns that have failed other treatment attempts. During an autografting procedure, the surgeon will remove a layer of healthy skin and place it over the burned area to provide skin for that area to heal. The area the skin is taken from, called the donor site, must then be cared for as a new wound. The donor site should heal in approximately 2 weeks. In large burns, there may be no place to obtain donor sites. In these cases, a biopsy is obtained, and the patients' own skin is grown in a lab. These are called cultured epithelial autografts and are used in a similar manner as the patient's own skin.13

Quality care makes the difference

Patients with burn injuries are complex and have high mortality. Burns are traumatic injuries that cause profound shock within minutes and can affect every body system. Nurses must prioritize assessment of the airway, the cause of burn, depth, and TBSA during the initial screening. These assessments are important to appropriately resuscitate the patient and decrease the risk of burn shock. Patients with burns are at considerable risk for infection and hypothermia. Nurses should keep patients warm and transfer them to a certified burn center as soon as possible for the best outcomes. Providing early, quality nursing care to patients with burns will make all the difference in the outcome.

Parkland calculation example

A patient sustained a 55% burn. The patient weighs 72 kg.

(surface area) x (patient weight) x (mL)

55x72x4 = 15,840 mL

Total fluid required over first 24 hours

15,840 mL

Total fluid required over first 8 hours (half total volume)

15,840/2 = 7,920 mL

Infusion rate (first 8 hours)

7,920/8 = 990 mL/h

Infusion rate (second 16 hours)

7,920/16 = 495 mL/h

Burn center referral criteria

  • Second-degree burns (>10%)
  • Burns to the genitals or perineum
  • Burns to the face
  • Burns to major joints
  • Burns to hands or feet
  • Third-degree burns
  • Electrical burns
  • Trauma where the burn injury poses the greater risk to the patient
  • Patients with inhalation injuries
  • Patients with preexisting medical conditions that could increase the risk of death
  • Hospital doesn't have the capability to care for the burned patient

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REFERENCES

1. Herndon DN. Total Burn Care. 5th ed. Edinburgh: Elsevier; 2017:19–222.
2. American Burn Association. Find a Burn Center. https://ameriburn.org/resources/find-a-burn-center.
3. Simko LC, Culleiton AL. Burn injuries in the ICU. Nurs Crit Care. 2017;12(2):12–22.
4. Osborn K. Nursing burn injuries. Nurs Manage. 2003;34(5):49–56.
5. Rose JJ, Wang L, Xu Q, et al. Carbon monoxide poisoning: pathogenesis, management, and future directions of therapy. Am J Respir Crit Care Med. 2017;195(5):596–606.
6. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013;(2):CD000567.
7. Kao Y, Loh E-W, Hsu C-C, et al. Fluid resuscitation in patients with severe burns: a meta-analysis of randomized controlled trials. Acad Emerg Med. 2018;25(3):320–329.
8. Shah A, Pedraza I, Mitchell C, Kramer GC. Fluid volumes infused during burn resuscitation 1980-2015: a quantitative review. Burns. 2020;46(1):52–57.
9. Yeong E-K, O'Boyle CP, Huang H-F, et al. Response of a local hospital to a burn disaster: contributory factors leading to zero mortality outcomes. Burns. 2018;44(5):1083–1090.
10. Culnan DM, Farner K, Bitz GH, et al. Volume resuscitation in patients with high-voltage electrical injuries. Ann Plast Surg. 2018;80(3 suppl 2):S113–S118.
11. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825–e873.
12. Retrouvey H, Shahrokhi S. Pain and the thermally injured patient-a review of current therapies. J Burn Care Res. 2015;36(2):315–323.
13. Sood R, Roggy D, Zieger M, et al. Cultured epithelial autografts for coverage of large burn wounds in eighty-eight patients: the Indiana University experience. J Burn Care Res. 2010;31(4):559–568.
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