BURNS

MODULE 5; LESSON 2
Anatomy of the Skin
 First- degree burns
Include only the outer layer of skin, the epidermis
- Superficial and red
- Usually quite painful
- Dry in appearance
- Healing occurs in 3-5 days, injured epithelium peels away from the
healthy skin
- Hospitalization is for pain control and maybe fluid imbalance
 Second-degree burns
Include damage to the dermis, causing pain, and redness and
produce blisters
Partial thickness
- Blisters can be present
- Involve the entire epidermis and upper layers of the dermis
- Wound will be pink, red in color, painful and wet appearing
- Wound will blanch when pressure is applied
- Should heal in several weeks (10-21 days) without grafting, scarring
is usually minimal
 Second-degree burns
Full thickness
- Can be red or white in appearance, but will appear dry.
- Involves the destruction of the entire epidermis and most of the
dermis
- Sensation can be present, but diminished
- Blanching is sluggish or absent
- Full thickness will most likely need excision & skin grafting to heal
 Third-degree burns
Go deeper than the dermis, into the subcutaneous fat and tissues
- Produce dry, dead tissue.
- There is no pain because the nerve endings are destroyed.
- Areas can appear black or white and will be dry, can appear
leathery in texture.
- Will not blanch when pressure is applied.
 Fourth-degree burns
Extend through the skin and subcutaneous fat INTO the underlying
muscle and bone. Fourth degree burns are stiff and charred
 Burns: History taking
• Burns can be caused in different ways (e.g. heat, electricity, and
radiation or external chemicals such as acid).
• History is important to understand the material involved and to be
able, after the treatment, to teach prevention of this kind of injury.
• Ask, when the burn occurred
• Ask, how was the burn made and what was the source of the burn?
• Ask if the burn happened in an enclosed space, because the patient
may have experienced smoke inhalation.
• Pain assessment (OLDCARTS)
 Burns: History taking
- For children, ask questions to make sure that the story that the
parents give and the shape/size of the burn are consistent (be
suspicious for child abuse)

- Ask about the patient’s status with the tetanus vaccine (if not up to
date, the patient needs a tetanus vaccine today).

“Patients with burns are also at risk for tetanus. Tetanus vaccination
plus anti-tetanus immunoglobulin should be administered to patients
who have no history of vaccination” and booster injection given to
 Assessment of the Burn

A person’s level of pain is NOT a good indicator of the severity of the

burn; deep burns may have disabled the nerve endings to feel pain.

How do you determine severity of the burn?

The severity of a burn depends on how big of an area the burn covers
and how deep the burn is & if the patient has any other medical
issues that could affect the risk of delayed healing or infection (like
diabetes)
 “Rule of Palms”
How do you determine the surface area of a burn?

Best used on patchy areas

- Use the surface area of the PATIENT’s palm with fingers closed to
estimate 1% of their total body area, and estimate the total percent
of body area covered

- This can be used on children and adults

 Rule of Nines”
- Can also be used for adults (not as accurate in children)
- Each leg represents 18% total body surface area (TBSA)
- Each arm represents 9% TBSA
- The anterior & posterior trunk each represent 18% TBSA
- The head represents 9% TBSA
- Perineum represents 1% TBSA
Minor vs. Severe burn based on Body
Surface Area:
Minor burn:
- Involves less than 10% of the BSA in children and 15% in adults, in the
absence of other risk factors
Severe burn:
- The burn covers more than one body part or a large surface area (>10%
body surface area in children and 15% in adults)
- If the burn is located on the hands, face, neck, genitalia/perineum, joints
NOTE: “Morbidity and mortality rises with increasing burned surface area. It
also rises with increasing age so that even small burns may be fatal in elderly
people.”
 Immediate Care of the Burn
Early treatment of the burn itself focuses on stopping the burning process,
avoiding excess heat loss, determining the extent of the injury, cleaning and
debriding the wound, controlling infection with topical antibiotics, and
maintaining tissue perfusion.
- Immediately after a burn, remove the source of the burn and make sure that
no one else is at risk for being burned.
- Remove constricting clothes (jewelry) as the skin will begin swelling soon if
it has not already
- Wrap the patient to prevent hypothermia (burn victims have a difficult time
regulating heat/cold)
 Immediate Care of the Burn
• IF it has been less than 15 minutes since the burn was made,
immerse burned area in cool normal (no need for boiled) water for
at least 15minutes.
• This helps cool the temperature of the skin as well as to flush
substances such as chemicals or fluids away from the skin and
stops the burning.
• However, it is unlikely that you will encounter the patient within the
15 minutes of the burn. This is better done by the patient/patient’s
caregiver at the time of the burn.
• Teach this to the family so that next time they know what to
do!
 Immediate Care of the Burn
Never expose the blistered skin to ice water, as this will serve to
increase chances of skin infection.
Ice causes vasoconstriction and the burned tissues already have a
problem with blood supply.
You can apply soaked towels, sheets or other wet cloths to a burned
face or other areas that cannot be immersed. Do not (break) open the
blisters when first examining the patient.
NEVER: Soothe a burn by applying butter, mud, cow dung, honey, or
animal hair/skins
 Minor Burns: Outpatient
Treatment
• Wound care: Dressings with Silver sulfadiazine or petrolatum gauze
(except for first-degree superficial burns).

• A moist wound environment should be maintained for optimal

healing and the dressing should provide a barrier that reduces the
risk of infection.

• Silver sulfadiazine cream should not be used near the eyes, in

children younger than 2 months old, in pregnant women, or an
 Minor Burns: Outpatient
Treatment
- Pain: paracetamol ± tramadol
- Review signs and symptoms of infection with patient and emphasize
need for immediate follow up at clinic if any of these signs occur
- Have them come in every 2 days for a dressing change to review
signs/symptoms of the infection
- N.B. Silver nitrate (sometimes used when silver sulfadiazine is not
available) can discolor skin: do not use on the face
 Burns: When to Refer
• The patient must be referred to the hospital and doctor if:
• The patient has trouble breathing (may require oxygen or
ventilator)
• The burn is serious (may require grafting, surgical debridement, IV
morphine, sterile operating theatre)
• The burn covers more than one body part or a large surface area
(>10% body surface area in children and 15% in adults)
 Burns: When to Refer
Serious burns are:
- All 3rd degree burns
- Burns to the airway or inhalation injury (Look for singed nasal hair,
facial burns, carbonaceous (black/grey) sputum, progressive
hoarseness, or tachypnea)
- Burns to the Head, Neck, Hands, Feet, or Genitals
- Electric or lightening burns, Chemical burns
 Burns: When to Refer
Burns cause by an explosion
- Circumferential burns (burns around the body)
- Burns on a joint
- Child younger than 3 years old or an adult older than 60 years old
- Significant co-morbidities (Ex. epilepsy, diabetes)
NOTE: All patients referred to the hospital should be given 100%
oxygen through a face mask, if available
 Emergency Treatment of Severe
Burns
Severe burns should be referred to the hospital and should be taken
care of by a physician
- The first priority for a patient with a major burn is to stabilize the
patient. Managing life threatening breathing problems and stabilizing
hypovolemia are the first priority. The wound management comes
next.
 Emergency Treatment of Severe
Burns
-Initial rapid assessment (airway, breathing, circulation); look for signs of
respiratory distress.
- Look for significant associated injuries such as head injury or blunt
abdominal trauma.
- Care must be taken to consider whether or not the patient has been
exposed to an inhalation injury as well as an external burn.
Was the patient in a fire? Did the patient inhale smoke or chemicals? Look
for singed nasal hair, facial burns, carbonaceous (black/grey) sputum,
progressive
hoarseness, tachypnea, or productive cough
- Always give oxygen 100% with a face-mask for severe burns, if available
 Emergency Treatment of Severe
Burns
Protect the patient and keep him/her warm: clean/sterile sheet,
survival blanket
- Insert a urinary catheter if burns involve > 15% of BSA, and in the
case of electrical burns or burns of the perineum/genitalia
- Insert a nasogastric tube if burns involve > 20% of BSA (in the
operating room while carrying out dressing procedure)
- Calculate and initiate fluid and electrolyte requirements for the first
24 hours
 Emergency Treatment of Severe Burns

Adequate volume resuscitation- After the acute injury, the major fluid loss
is
water from the injured skin surface, which can no longer act as a barrier
to water evaporation.
- Rehydration should be done immediately using an isotonic crystalloid
for the first 24 hours—preferably Ringer’s Lactate (Normal Saline in large
amounts can lead to hyperchloremic metabolic acidosis, so it is not a
good choice, but ok if no other option is available).
- A volume of 4mL/kg is given for each percent of body surface burned
plus normal 24 hour maintenance fluid requirements.
 Emergency Treatment of Severe
Burns
• Add maintenance fluid with glucose for children under 5 years. The
first 50% should be given in the first 8 hours, the second 50%
should be given over 16 hours
• Intensive monitoring: level of consciousness, pulse, blood pressure,
pulse oximetry, respiratory rate (RR) hourly; temperature and urine
output every 4 hours
• Additional testing: hemoglobin, blood group, urine dipstick test
• Prepare the patient for the first dressing procedure in the operating
room (at hospital)
Fluid Resuscitation Dosing
• Maintenance fluid: Alternate RL and 5% glucose: 4 mL/kg/h for first
10 kg of body weight + 2 mL/kg/h for next 10 kg + 1 mL/kg/h for
each additional kg (over 20 kg, up to 30 kg).
• Fluid replacement should be adjusted based on urine output and
systolic blood pressure.

• Avoid fluid overload. **URINE OUTPUT is the most important

measure for determining adequate resuscitation after the initial 24
hours
 Nutrition:
• For a severe burn, 50% of total calories should be
carbohydrates/glucose, 30% fat, and 20% are protein.
• Multivitamins should also be given as it is recommended to provide
5-10 times the daily intake of vitamins/minerals.
• High energy foods (NRG5, Plumpy'nut, F100 milk) are necessary if
the BSA is > 20% (normal food is inadequate).
 Potential Complications of
Burns
• INFECTION—this is the most common and must be addressed
immediately and seriously
• Other complications include:
• Multiple organ dysfunction syndrome (organ damage or failure) -
risk increased with burn wounds greater than 20% TBSA
• Gastroduodenal ulcerations (major burns)
• Pneumonia
• Burn wound sepsis
 Potential Complications of
Burnsmobility with possibility of future flexion contractures
• Decreased
(depends on where burn is)

• Hypertrophic scarring (common)

• Psychological trauma

• Of note: “Burns alone do not alter the level of consciousness. In

the case of altered consciousness, consider head injury,
intoxication, postictal state in epileptic patients (after a seizure)
 Burn Infections: Definition and Treatment

Infection is a SERIOUS problem and must be treated immediately and

correctly.

NOTE: People who get burned are very susceptible to infection. It can
be hard to tell if a minor burn is infected because the skin
surrounding a burn is usually red and may become warm to the touch
- both are signs of infection.
 Risk factors for infection:
• TBSA greater than 20%; delays in burn wound excision; very young
child; impaired immunity
• A rapid change in the clinical condition of the burn patient may indicate
a burn wound infection, and potentially sepsis
• Infection is defined by the presence of at least 2 of 4 following signs:
• Temperature > 38.5°C or < 36°C
• Tachycardia, Tachypnea
• Elevation of white blood cell count by more than 100% (or substantial
decrease in the number of white blood cells)
 Treatment for infection:
- In the event of systemic infection, start antibiotic treatment in the
hospital/inpatient setting:
- Children > 1 month: Cefazolin IV: 75 mg/kg/day in 3 divided
injections + Ciprofloxacin PO: 30 mg/kg/day in 2 divided doses
- Adults: Cefazolin IV: 6 g/day in 3 injections + Ciprofloxacin PO: 1.5
g/day in 3 doses
Uganda MOH 2016 recommendation: Benzylpenicillin 3 MU every 6
hours +/- Gentamicin 5-7 mg/kg IV or IM once a day
- Local infection, with no of signs of systemic infection, requires
topical treatment with silver sulfadiazine
 Other treatments for burn:
- Omeprazole IV from day one:
• Children: 1 mg/kg once daily
• Adults: 40 mg once daily
- Tetanus immunization/prophylaxis
- Thromboprophylaxis: give an anticoagulant 48 to 72 hours post-
injury.
- Physiotherapy from day one (prevention of contractures), analgesia is
necessary.
- Intentional burns (suicide attempt, aggression): appropriate
psychological follow-up.
 Prevention of Burn Infections
• Precautions against infection are crucial until healing is complete -
Infection is one of the most frequent and serious complications of
burns:
• Follow hygiene precautions (e.g. clean/sterile gloves when handling
patients)
• Rigorous wound management (dressing changes, early excision)
• Separate “new” patients (< 7 days from burn) from patients with ≥
7 days from burn
• ALWAYS WEAR A FACE MASK AND CLEAN GLOVES WHEN ASSESSING
A PATIENT WITH A BURN to protect yourself as well as the patient
 Wound Care of Burns
Burns require frequent dressing changes: every 48 hours for most
burns, every day for superinfection and certain areas like the
perineum
- Regular dressing changes are necessary to: Prevent infection,
Decrease heat and fluid losses, & Promote patient comfort
- Dressings should be occlusive, assist in relieving pain, permit
mobilization, and prevent contractures. Aseptic technique is
essential
- Dressing changes can be very painful for patients so pain control is
important
- For severe burns (at the hospital level), the first dressing procedure
 Wound Care Technique:
• Cleanse the burn with Normal Saline or soapy water
• Scrub gently with compresses and try to avoid bleeding
• Blisters - there is much debate over the management of burn blisters,
but these are 3 common methods:
• Leave the blister intact
• Aspirate fluid from the blister, leaving the epidermis intact
• Deroof the blister, removing the epidermis
 Wound Care Technique:
Rinse with 0.9% sodium chloride or sterile water
- Dry the skin by gently dabbing with sterile compresses
- Apply silver sulfadiazine directly by hand (wear sterile
gloves) in a thin even layer of 3-5 mm to all burned areas
(except eyelids and lips) - this kills bacteria and helps to
prevent infection
- Apply a greasy dressing (petrolatum gauze) to keep the
wound bed moist
 Wound Care Technique:
- Cover with sterile compresses, unfolded into a single
layer (Never encircle a limb with a single compress)
- Loosely wrap
- Elevate extremities to prevent edema
- Immobilize in extension (to prevent contractures)
 Burns: Pain Management
• Pain management is important and should NOT be forgotten
• - Pain management is essential so that the burn can heal well and
to avoid adverse physiological and emotional effects, especially in
children
- Studies have shown that pain causes stress which delays wound
healing.

- All burns require analgesic treatment - Paracetamol alone may not

be sufficient treatment (tramadol, codeine, or other pain reducers
may be necessary to control the patient’s pain)
 Burns: Pain Management

- As with any medication, make sure that the dose and time of dosing
is correct for the patient (adult vs. child), and observe for any
adverse effects
Note: In severe burns, oral medications are not well absorbed in the
digestive tract; IV or subcutaneous routes (as indicated by the
medication) should be considered
- General anesthesia should be considered for dressing changes for
extensive burns (in hospitals)