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Introduction   

Severe burns often cause serious initial health problems and complications, ranging from life-threatening emergencies to death. Therefore, it’s imperative for healthcare providers and nurses to understand the initial severe burn management of these patients to improve health outcomes and potentially prevent mortality. This course reviews the classification, types of injuries, and risk factors for burns. It also discusses initial severe burn management strategies for healthcare providers and nurses.

Statistics

According to the National Burn Repository of the American Burn Association’s 2015 survey data, greater than 450,000 Americans each year suffer from a severe burn. Furthermore, the survey reported from 2005-2015 that it’s estimated around 73% of burns occur at home and 8% happen at work [2].

The World Health Organization (WHO) estimates that there are approximately 180,000 deaths annually from burn injuries worldwide, with the majority occurring in low to middle income countries [13]. Additionally, the mortality rates associated with burn injuries are high, especially for individuals with airway compromise as well. One small study of a hospital in Saudi Arabia from 2014 through 2020 reported a mortality rate of 72% for patients with inhalation injuries.

The study also concludes that patients without airway compromise or inhalation injury were 19 times more likely to survive than those with airway injuries [1]. Another study of a developing country, Cameroon, conducted from 2008 to 2015 found a 23.4% mortality rate of 440 patients with burn injuries [5]. Thus, it is essential for healthcare professionals to understand how they can potentially improve patient outcomes by effectively managing and delivering treatment for patients with burn injuries.

Risk Factors

The Centers for Disease Control and Prevention (CDC) regularly collects data regarding burn injuries in the United States. According to the CDC’s 2020 report released in April 2022, unintentional burn injuries were higher in rural than urban areas. More specifically, 1.4 per 100,000 females and 2.4 per 100,000 males in rural areas had unintentional burn injuries from fire or flames. In both rural and urban areas, males had higher burn injuries rates and higher death rates than females [4]. However, according to the WHO, females have an increased likelihood of death from burn injuries when compared to males worldwide [13]. Reviewing this data, males in the U.S. are more likely to suffer burn injuries, but worldwide, females have a higher risk.

The World Health Organization has also identified several other risk factors for potential burn injuries. First, children are at increased risk and the WHO reports burn injuries are the fifth most common non-fatal injury in children. This is mostly contributed to lack of proper adult supervision but can also be from child abuse and maltreatment. Furthermore, certain regions of the world have increased incidence of child burn injuries. For example, the burn injury rate in the WHO Western Pacific Region is 20 times greater than the WHO Regions of the Americas [13].

Additionally, burn injuries are more likely in low- and middle-income countries than in high income countries. However, regardless of a country’s income, an increased likelihood of burn injuries correlates with socioeconomic status. Additional risk factors reported by the WHO include places with poverty and overcrowding, and workplaces with exposure to fire. People with certain medical conditions, like seizures or neuropathy, and physical or cognitive disabilities are also at increased risk. Households with alcohol abuse, smoking, and easy access to chemicals used for violent attacks have a higher risk as well. Lack of safety measures also contributes to burn injuries [13].

Types of Burn Injuries

There are four main types of burn injuries, and each is named by the initial heat source. The most common type of burn is a thermal burn. It’s important for nurses and healthcare providers to be able to identify sources of burns since it can change treatment options. The type of burns, definitions, and examples are outlined in the table below [9, 10, 11, 13].

Table 1. Type, Definition, and Example of Burns [9, 10, 11, 13]

Zones of Injury

When a burn injury occurs, it affects the local and surrounding tissues. The site of injury is subdivided into three zones, which include [14]:

• Zone of coagulation: Central area where the maximum, irreversible tissue damaged occurred. The tissue in this area is necrotic, meaning its dead tissue.
• Zone of stasis: Area that surrounds the zone of coagulation. Tissue perfusion is decreased to this area and a local inflammatory reaction is present. Tissue in this area may still be viable.
• Zone of hyperemia: Outermost area of the burn injury. Tissue is most viable in this region since its blood flow is healthy and has less risk of becoming necrotic.

Burn Classification

Burns are classified by the type of burn, depth of affected tissue, appearance, pain, sensation, and if they are blanchable. Blanchable tissue is often healthy and viable, meaning it turns white when pressure is applied (blanches) [12].

The American Burn Association categorizes burns into four major classes based on severity and depth of tissue affected. Many individuals who do not work in the healthcare field call these “degree” burns. For example, a first-, second-, or third-degree burn [3].  The table below further details information regarding each type of burn [3, 12].  

Table 2. Burn Descriptions [3, 12]

The classification of a burn injury is meant to serve as a guideline or estimate, and not an absolute. For patients with severe burns or burn injuries covering a large portion of their body, it may be difficult to determine exact classification or severity [3, 12].

Initial Burn Management Strategies

Nurses and healthcare providers must take several strategies when initially assessing and managing severe burn injuries. Please note that many of these strategies below are completed concurrently by a healthcare team to quickly assess and stabilize patients with severe burns.

Initial Burn Assessment

Severe burn injuries can produce systemic and sometimes life-threatening effects. Systemic effects include fluid loss, systemic inflammation, and impaired glucose metabolism and liver function. Issues with thermoregulation and inadequate oxygenation and nutrient delivery may occur as well [6, 12, 14].

During the initial assessment, the healthcare team should work together to collect as much information as possible about the injury. They can consult with the patient (if conscious), family members, and emergency medical technicians to gather a thorough history. However, much of this information can be obtained prior to patient arrival to the hospital from emergency services in route.

Pertinent information includes source of the burn, possibility of smoke inhalation, the patient’s past medical history, and other additional injuries [6]. Once the emergency team is notified of a severe burn injury, they should prepare the triage room. This includes setting up equipment, supplies, increasing the room temperature, and calling appropriate emergency response providers (i.e. ER physicians, respiratory therapists, trauma nurses, etc.)

ABCDE Approach

Next, the healthcare team works together to initially take the patient’s vital signs and assess their overall health status. In the emergency or trauma room, the healthcare team typically uses the ABCDE, and trauma approaches to assess the patient’s status. ABCDE stands for airway, breathing, circulation, disability, and exposure. Following this ABCDE assessment, a patient’s airway is assessed and stabilized before moving towards breathing (oxygenation). Next, the patient’s circulatory system is assessed and stabilized, then disability (neurological status), and lastly, exposure [8].

When assessing the airway, there may be signs of a smoke inhalation injury, which include [8]:

• Coughing, wheezing, or voice hoarseness
• Singed facial or nasal hair
• Burns to the neck or blistering of mouth or throat
• Hypoxia, hypercapnia, or elevated carbon monoxide levels
• Respiratory distress (retractions, anxiety, labored breathing)

If the patient shows any signs of a potential inhalation injury, they should be intubated immediately since oftentimes delay in airway swelling can occur. If intubation is not necessary, the patient may be placed on supplemental oxygen. The patient’s oxygen saturation goal is to remain above 90%.

After addressing the airway and breathing, next is circulation. Fluid blood and hypovolemic shock are major concerns for patients with severe burns. Rapid fluid resuscitation is often necessary to stabilize the patient. Two large bore intravenous catheters (IVs) should be placed by the nurse, if not already completed. If IV placement is difficult to obtain due to the severity and extent of the burns, then the healthcare provider should insert a central venous catheter.

The nurse assists with setting up equipment and supplies for this procedure. Once IV access is obtained, isotonic solutions, like Lactated Ringers or Hartmann’s solution, are often administered. The goal is usually to administer around 2 mL/kg of body weight per each percent of total body surface area burned within the first 24 hours. There are specific formulas that healthcare providers use to calculate fluid resuscitation requirements, which can vary by provider or institutional policy [6, 8].

Next, the emergency team collaborates and assesses other potential life-threatening or traumatic injuries. It is still critical to use the ABCDE approach when triaging and providing patient care. Some penetrating wounds may need pressure to be applied or fractures to be stabilized. Next, the patient’s neurological status is evaluated and addresses (disability). The nurse and healthcare team typically make neurological assessments using the Glascow Coma Scale (GCS). Lastly, the patient’s exposure (temperature) is addressed [6, 8].

Initial Wound Care and Calculating Total Body Surface Area

After the patient is stabilized, the emergency team can begin to complete initial wound care and calculate the patient’s total body surface area (TBSA) covered in burns. By calculating the patient’s TBSA, this helps determine the next steps in patient care, like fluid resuscitation needs or if they require transfer to a burn care center [9].

First, initial burn wound care should be provided. If not already done so, the healthcare team should remove any clothing, jewelry, and other objects from the patient to prevent further injury. The burns areas are immediately cooled by using either cool water or gauze soaked in saline.

By cooling the burns, this prevents the spread of burn injury zones and can help with patient pain. Initial cooling of the burns can last for several minutes to upward of several hours. During this time, the nurse continuously monitors the patient’s core temperature. If the patient becomes hypothermic, the nurse may need to administer warmed IV fluids to increase the patient’s core temperature [8].

Depending on the patient’s pain levels and anxiety, the nurse may need to administer pain medications or anxiolytics before calculating the TBSA. There are several methods for determining the patient’s TBSA, which include the Rule of Nines, the Palmar Surface Method, and the Lund and Browder Chart. The most widely used is the Rule of Nines. However, some healthcare facilities may have policies and procedures that outline the preferred TBSA calculation method. Depending on the severity and extent of the patient’s burns, they may need to be transferred to a specialized burn center or hospital [8, 9].

Rule of Nines

The Rules of Nines is divided into calculating TBSA for adults and children [9]. When calculating TBSA using the Rules of Nines, superficial burns are not included for adults. Also, there are special rules when using this method for obese patients or infants. When using this method, each region of the body is assigned a specific percentage and anterior and posterior regions are separate, totaling 100%. Below is the Rule of Nines for adults [7]:

• Head: 4.5% anterior and 4.5% posterior, with entire head 9%
• Trunk: 18% anterior and 18% posterior, with entire trunk 36%. Sometimes the trunk is further subdivided into the chest and abdomen, which would each account for 9%.
• Upper Extremities: 9% each arm, both arms totaling 18%. Anterior and posterior arms can be subdivided into anterior and posterior, which would each account for 4.5%.
• Lower Extremities: 18% each leg, both legs totaling 36%. Anterior and posterior legs can be subdivided into anterior and posterior, which would each account for 9%.
• Groin: 1%

Children’s body proportions are slightly different than adults and are dependent on their age since they are growing. For children, the Rule of Nines is divided by age range, which includes [3,7]:

• Children 1 to 4 years old:
  • Entire Head: 19%
  • Entire Trunk: 32%
  • Upper Extremities: 19%
  • Lower Extremities: 30%
• Children 5 to 9 years old:
  • Entire Head: 15%
  • Entire Trunk: 32%
  • Upper Extremities: 19%
  • Lower Extremities: 34%
• Children 10 to 14 years old:
  • Entire Head: 13%
  • Entire Trunk: 32%
  • Upper Extremities: 19%
  • Lower Extremities: 36%
• For infants weighing less than 10kg, the Rule of Eights is used instead and includes:
  • Entire Head: 20%
  • Entire Trunk: 32%
  • Upper Extremities: 32%
  • Lower Extremities: 16%

Palmar Surface Method

The Palmar Surface Method is typically used for burns covering a small portion of the patient’s body. The nurse uses the patient’s palm size (excluding the fingers) to calculate the percentage area burned. Each patient’s palm size accounts for 0.5% of their TBSA. If the fingers are included for the palm size, this accounts for 1% of the patient’s TBSA [9].

Lund and Browder Chart

The Lund and Browder Chart is typically used to calculate TBSA in children, since it’s more accurate. The percentage varies for each age. Typically, each arm accounts for 10%, anterior trunk is 13%, posterior trunk is 13%, and the remaining regions vary by percentage [9].

When to Transfer to a Burn Center

After calculating the patient’s TBSA with burn injuries, the healthcare provider and team determine if the patient needs to be transferred to a burn center or a consultation is warranted. If the patient is not initially stabilized at a burn center, the American Burn Association has guidelines for determining whether referral, consultation, or transfer are necessary.

Consultation Guidelines [3]:

• Partial thickness burns covering less than 10% TBSA
• Any deep thickness burns of any size
• Signs or suspicion of an inhalation injury
• Low voltage electrical burn injury, typically less than 1,000 Volts

If a consultation is initiated, the healthcare provider should also consider continued follow-up care at a burn center.

Immediate Consultation with Potential Burn Center Referral or Transfer:

• Any full thickness burns or partial thickness covering greater than or equal to 10% TBSA
• Any full or partial thickness burns to the face, genitals, hands, feet, joints, or perineal region
• Patients with comorbidities than can affect care and treatment
• Patients with traumatic burn injuries
• Patients where pain is unable to be or poorly controlled
• Suspected or confirmed inhalation injuries
• Any chemical burn
• High voltage electrical burn injury, typically greater than 1,000 Volts
• Lightning strike injuries

Furthermore, all pediatric patients (14 years old or less) should be referred to a specialized burn center. Although these are guidelines, healthcare providers should consider transferring or referring patients to a burn center whenever possible to ensure the best patient care [3].

Initial Diagnostic Workup

If not already done so, initial diagnostic tests may be ordered after the patient is stabilized. This can help determine the severity of the patient’s injuries and overall health status. Please note that the following list is not all-inclusive. Additional diagnostics may be ordered by the healthcare provider. Some tests include [6, 8, 12]:

• Chest X-ray: typically ordered for suspicion of smoke inhalation injury and assess pulmonary function; can also screen for pulmonary edema, airway patency, and proper placement after the insertion of artificial airway.
• Arterial Blood Gas (ABG): Initial and ongoing assessment of pulmonary function and patient’s oxygenation.
• Carboxyhemoglobin levels: Obtained on all patients with severe burns to assess for carbon monoxide and/or cyanide poisoning.
• Peak Expiratory Flow Rate (PEFR): Initial and ongoing assessment of pulmonary function.
• Serum lactate levels: If concerns for potential cyanide poisoning or sepsis.
• Bronchoscopy or laryngoscopy: Initial assessment of airway injury.
• Electrocardiogram: Look for potential cardiac complications.
• End-Tidal CO2: Assess patient’s respiratory status and function
• Complete Blood Count (CBC): Determine white blood cell count, hemoglobin, and hematocrit levels.
• Basic or Complete Metabolic Panel (BMP or CMP): Determine patient’s kidney function, and serum electrolytes.
• Blood Type and Crossmatch: Required if the patient needs a blood transfusion.
• Creatinine Kinase levels: Assess for signs of muscle damage and potential complications, like rhabdomyolysis.
• Urine output with myoglobin: Initial and ongoing assessment of muscle injury or complications, like dehydration or compartment syndrome.

Patient Care and Monitoring

During the initial treatment of a patient who is severely burned, the nurse and healthcare team collaboratively provide a thorough patient assessment and deliver patient care. Below details further strategies the emergency care team and nurse may take during initial severe burn management.

Additional Wound Care

If it is determined that the patient needs to be transferred to a burn center, additional wound care beyond initial cooling and cleansing may not be necessary. However, this is typically determined by the healthcare team and how quickly the patient can be transferred. In some instances, the patient is wrapped in a clean, dry sheet before immediate transfer with dressings only over partial and full-thickness burns. While in other instances, full wound care is completed, and dressings are applied [8]. Regardless of patient transfer, additional wound care and dressing changes are necessary and part of routine care.

Burns are typically cleansed with a mild, antibacterial soap and ruptured blisters are removed. There is still controversial evidence of rupturing intact blisters since it can introduce infection. After the wounds are cleansed, topical ointments are applied. Polymyxin-C bacitracin zinc ointment is a common topical ointment used. Non-adherent gauze is then applied over the burn sites and dressings are held in place by non-stick tape to intact skin or lightly wrapping. Biosynthetic or bismuth-impregnated petroleum gauze may be used for deeper wounds [8].

Depending on the severity of the burn, sometimes eschar is present. If so, the nurse should anticipate an escharotomy, or surgery where the eschar is removed. This procedure helps prevent ischemia surrounding the burn site [8].

Monitoring Fluid Status and Urinary Output

As mentioned, initial fluid resuscitation requirements are calculated using the Parkland formula. The patient’s fluid status may be monitored using a variety of methods. If a central line was placed, sometimes central venous pressure (CVP) monitoring is initiated to assess the patient’s blood volume status. For patients with severe burns, typically an indwelling urinary catheter is inserted to monitor the patient’s urine output. Urine output is measured hourly, with a goal of maintaining output of at least 0.5 mL/kg/hour [8].

Continuous Assessment and Monitoring

The nurse will continuously assess and monitor the patient’s condition closely over the first 24 hours. Patients are placed on continuous monitoring devices to assess cardiac and respiratory status. Slight changes in the patient’s heart rate, blood pressure, oxygen saturation, and pulse pressure can indicate a decline in their volume status, shock, presence of infection developing, or other complications. Furthermore, the nurse will perform hourly neurovascular checks for the first 24 hours.

The nurses should check the patient’s capillary refill time, skin color, pulse strength, and skin turgor in all four extremities, and especially those sites distal to burn injuries If signs of compartment syndrome develop, such as diminished pulses or extremity edema, the nurse should contact the healthcare provider immediately. Sometimes acute compartment syndrome is treated with a procedure called a fasciotomy, where incision is made to the fascia layers to relieve pressure [8].

Additionally, the nurse should continuously monitor the patient’s temperature for signs of hypo- or hyperthermia. The nurse should plan to repeat ordered bloodwork every couple of hours. Blood transfusions, electrolytes, and other medications may be ordered depending on the patient’s recent bloodwork [8].

Gastrointestinal and Nutritional Interventions

For patients with severe burns, especially those covering greater than 20% TBSA, a nasogastric (NG) tube should be inserted. Although the emergency room nurse may not initially administer medications or enteral feedings, they must anticipate the future need for an NG tube [8].

Pain and Anxiety Management

Patients with severe burn injuries, especially those with partial-thickness burns, require medications to control pain. The nurse should assess the patient’s pain frequently. There are a variety of pain assessment tools that can be utilized to assess a patient’s pain level, including non-verbal and verbal methods. Opioids, like IV morphine or fentanyl, are commonly ordered to initially control a patient’s pain. Nurses should consider administering pain medications at least 30 minutes before performing wound care [8].

Sometimes patients are started on a patient-controlled analgesic (PCA) pump, where they can push a button and the machine delivers pain medication through their IV line. Severe burns can also cause patient anxiety. In this care, benzodiazepines may be ordered as well [8].

Ventilation and Sedation

As mentioned, most patients with suspected or confirmed inhalation injuries will require ventilatory support. After intubation, IV sedation and analgesia should be initiated and titrated to the patient’s needs using the healthcare facility’s required assessment tools. A common medication used to sedate patients with burn injuries is propofol. Fentanyl, dexmedetomidine, and midazolam are also commonly used to control anxiety, sedation, and pain. The nurse should monitor the patient for possible medication side effects, such as hypotension or hypertriglyceridemia (especially for patients sedated with propofol) [6, 8].

Ongoing Management of Burns

While the emergency care team and nurse provide the initial burn injury management, they should also be aware of ongoing patient care strategies. Some of these strategies are detailed below.

Additional Consults

The nurse should anticipate several consultations regarding patient care. First, if the patient is considered for or transferred to a burn center, the nurse typically initiates consultation with the burn specialist or transferring hospital. They will report the patient’s history and assessment to the transferring facility’s nurse.

Sometimes multi-disciplinary consultations are ordered before the patient is transferred to another unit within the hospital. To expedite patient care, the emergency room nurse may need to call or delegate responsibility for these consults. Some specialties that may be consulted are pulmonology, immunology, plastic surgery, wound care, infectious disease, and cardiology. Additionally, depending on which inpatient unit the patient is admitted to, a hospitalist or intensivist consult may be needed [6, 8].

Additional Pharmacological Treatments

Additional pharmacological treatments are often warranted for initial burn management. While prophylactic antibiotics are not typically ordered, the nurse may apply topical antibiotics, like bacitracin, to the patient’s burn injuries. If signs of infection develop, IV antibiotics may be needed. Wound cultures may be ordered to determine the underlying organism. Also, the nurse should check to make sure the patient’s tetanus vaccinate is up to date. If it’s not up to date, then they should request the healthcare provider order the vaccine [6, 8].

Additionally, the patient’s risk for developing blood clots increases with severe burn injuries. The nurse should anticipate beginning thrombophylactic treatment by either administering medications, applying sequential compression devices (SCDs), or early ambulation. Treatment selection is individualized for the patient and their specific needs and activity level. Sometimes hyperglycemia develops, where the nurse should anticipate the provider ordering insulin. If the patient shows signs of hypermetabolism, beta-blockers may be ordered [6].

Breathing treatments may be ordered for patients who require oxygen support or with inhalation injuries. Bronchodilators, like albuterol, are commonly administered. Depending on the healthcare facility, the nurse or respiratory therapist administers these treatments [8].

Potential Complications

Complications can arise at any time in patients with severe burn injuries. Therefore, it is imperative for nurses to understand the signs and symptoms of potential complications. Shock is the most common complication from burn injuries. Other potential complications include sepsis, acute kidney injury, and respiratory distress [5]. Rhabdomyolysis and compartment syndrome can also develop. Since severe burns cause systemic effects, it can exacerbate patient comorbidities. For example, a patient with diabetes mellitus may develop hyperglycemia or impaired wound healing. Similarly, a patient with asthma may be prone to respiratory complications [6, 8].

Conclusion

Nurses and the emergency care team must understand initial burn management strategies to provide quality patient care. They should also be aware of guidelines when caring for patients with severe burns and when to refer, consult, or transfer patients to a burn center. For nurses interested in burn care management and certifications, the American Burn Association offers the Advanced Burn Life Support (ABLS) certification. This program discusses management strategies for patients with burn injuries during the first 24 hours.

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