BURN

A burn is a type of injury that may be caused by heat, electricity, chemicals, light,
radiation, or friction. Burns can be highly variable in terms of the tissue affected, the
severity, and resultant complications. Muscle, bone, blood vessel, dermal and epidermal
tissue can all be damaged with subsequent pain due to injury to nerves. Depending on the
location affected and the degree of severity, a burn victim may experience a wide number
of potentially fatal complications including shock, infection, electrolyte imbalance and
respiratory distress. Beyond physical complications, burns can also result in severe
psychological and emotional distress due to scarring and deformity.

The anatomy of the skin is complex, and there are many structures within the layers of
the skin. There are three layers:

1. Epidermis, the outer layer of the skin

2. Dermis, made up of collagen and elastic fibers and where nerves, blood vessels,
sweat glands, and hair follicles reside.

3. Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are
located. This is the layer of tissue that is most important in temperature
regulation.

ANATOMY OF THE SKIN

Facts about the skin:
The skin is the body's largest organ, covering the entire outside of the body and weighing
approximately six pounds. In addition to serving as a protective shield against heat, light,
injury, and infection, the skin also:
• regulates body temperature.
• stores water, fat, and vitamin D.
• can sense painful and pleasant stimulation.
Throughout the body, the skin's characteristics vary (i.e., thickness, color, texture). For
instance, the head contains more hair follicles than anywhere else, while the soles of the
feet contain none. In addition, the soles of the feet and the palms of the hands have much
thicker layers.
The skin is made up of the following layers, with each layer performing specific functions:
• epidermis
 • dermis
• fat layer

The epidermis is the thin outer layer of the skin. The epidermis itself is made
up of three sub-layers:

• stratum corneum (horny layer)

This layer contains continually shedding, dead keratinocytes (the
primary cell type of the epidermis). The keratin, a protein formed from
the dead cells, protects the skin from harmful substances.
• keratinocytes (squamous cells)
epidermis
This layer contains living keratinocytes (squamous cells), which help
provide the skin with what it needs to protect the rest of the body.
• basal layer
The basal layer is the inner layer of the epidermis, containing basal
cells. Basal cells continually divide, forming new keratinocytes and
replacing the old ones that are shed from the skin's surface.
The epidermis also contains melanocytes, which are cells that produce melanin
(skin pigment).

The dermis is the middle layer of the skin. The dermis is made up of the
following:

• blood vessels
• lymph vessels
dermis
• hair follicles
• sweat glands
The dermis is held together by a protein called collagen, made by fibroblasts
(skin cells that give the skin its strength and resilience). This layer also
contains pain and touch receptors.

The subcutis is the deepest layer of skin and is also known as the subcutaneous
layer. The subcutis, consisting of a network of collagen and fat cells, helps
subcutis
conserve the body's heat while protecting other organs from injury by acting
as a "shock absorber."

How are burns classified?

Burns are classified based upon their depth.
A first degree burn is superficial and causes local inflammation of the skin. Sunburns
often are categorized as first degree burns. The inflammation is characterized by pain,
redness, and a mild amount of swelling. The skin may be very tender to touch.
Second degree burns are deeper and in addition to the pain, redness and inflammation,
there is also blistering of the skin.
Third degree burns are deeper still, involving all layers of the skin, in effect killing that
area of skin. Because the nerves and blood vessels are damaged, third degree burns appear
white and leathery and tend to be relatively painless.

What is the significance of the amount of body area burned?

In addition to the depth of the burn, the total area of the burn is significant. Burns are
measured as a percentage of total body area affected. The "rule of nines" is often used,
though this measurement is adjusted for infants and children. This calculation is based
upon the fact that the surface area of the following parts of an adult body each
correspond to approximately 9% of total (and the total body area of 100% is achieved):
• Head = 9%

• Chest (front) = 9%

• Abdomen (front) = 9%

• Upper/mid/low back and buttocks = 18%

• Each arm = 9%

• Each palm = 1%

• Groin = 1%
 • Each leg = 18% total (front = 9%, back = 9%) As an example, if both legs (18% x 2 =
36%), the groin (1%) and the front chest and abdomen were burned, this would

involve 55% of the body.

Only second and third degree burn areas are added together to measure total body burn
area. While first degree burns are painful, the skin integrity is intact and it is able to do
its job with fluid and temperature maintenance.
If more than15%-20% of the body is involved in a burn, significant fluid may be lost. Shock
may occur if inadequate fluid is not provided intravenously. The Parkland formula (named
for the trauma hospital in Dallas) estimates the amount of fluid required in the first few
hours of care following a burn:
• 4cc/ kg of weight/% burn = initial fluid requirement in the first 24 hours, with half
given in the first 8 hours.

• As an example: A 175lb (or 80kg) patient with 25% burn will need 4cc x 80kg x
25%, or 8000cc of fluid in the first 24 hours, or more than 7 pounds of fluid.
As the percentage of burn surface area increases, the risk of death increases as well.
Patients with burns involving less than 20% of their body should do well, but those with
burns involving greater than 50% have a significant mortality risk, depending upon a
variety of factors, including underlying medical conditions and age.

MEDICATIONS
Thermal Burn Medications
Analgesics
For thermal burns doctors will prescribe analgesics for pain control to ensure that the
patient is as comfortable as possible. Morphine sulfate, Demerol and Vicodin may be
prescribed. These analgesics are prescribed for severe pain.
Nonsteroidal Anti-inflammatory Agents
These are used for the relief of mild to moderate pain. Ibuprofen (Advil, Motrin) is usually
used for initial therapy, but other options such as Naproxen, Ansaid, and Anaprox may be
prescribed.
Topical Antibiotics
Topical antibiotics are used to prevent infections and bacteria growth. Neosporin is used
to treat minor infections and is applied to the skin 1 to 3 times a day to the affected
areas.
Silvadene is a topical cream that is used for more severe burns. Silvadene is a sulfa
medicine used to prevent and treat bacterial or fungus infections. Silvadene should be
applied using a sterile technique to affected areas and the areas should be washed before
applying. Avoid applying Silvaden to the face and it should not be use in newborns, infants
younger than 2 years or in late pregnancy.
Chemical Burn Medications
Though medications play a limited role in the treatment of most chemical burns topical
antibiotics, calcium and magnesium salts may be used. After decontamination is performed
a standard IV fluid and narcotic therapy is administered.
Antibiotics
Silvadene is used for dermal burns and is useful in the prevention of infections in second
or third degree burns. It should be applied to skin once or twice daily and all previous
medication must be removed before applying each new dose. Erythromycin ointment
(Bacitracin) is used to prevent infections following ocular burns.
Analgesics
Morphine, and Acetaminophen are prescribed for pain management and may be used for
sedation which beneficial for patients who have sustained injuries to their eyes.
Nonsteroidal Anti-inflammatory Agents
Advil, Motrin Ansaid, Naprosyn and Anaprox are anti-inflammatory agents used to control
mild to moderate pain.
Electrical Injuries
When treating electrical injuries hydration is the key to reducing morbidity. If muscle
damage is severe an osmotic diuretic will be administered.
Fluids
Lactated ringers are used for fluid resuscitation. It is an isotonic and has volume
restorative properties. They are administered using an IV and should be stopped if
pulmonary edema develops.
Osmotic Diuretics
Mannitol is an osmotic diuretic which is not significantly metabolized which passes to
through the glomerulus without being reabsorbed by the kidneys. It is used to restore and
maintain urinary output.
Scar Treatment Medications
Mederma is a topical gel used to reduce the visibility of scars. The gel should be rubbed
into the scar 3 to 4 times a day for 3 to 6 months for burn scars.
Cica-Care gel sheets are made of a silicone gel and they are designed to flatten and soften
scars. These sheets are self adhesive and one sheet can be for up to 28 days.

Management Of Burn Patient

First Aid -
(1) Stop the burning process, flames from burning clothing or from burning inflammable
substances on the skin surface should be extinguished by wrapping the patient in a fire
blanket. In electrical burn any live current is to be switched off.
(2) Cooling the burn surface - Immediate cooling of the part should continue for 20
minutes. Irrigation with cold water is useful in chemical burn. Hypothermia should be
avoided , do not use ice or ice water. Ideal temperature of cooling water is 15 o C. The
burn is wrapped in a clean linen and transported to hospital.
Emergency Treatment
1. A - Airway.
2. B - Breathing and ventilation.
3. C - Circulation.
4. D - Disability - neurological status.
5. E - Environmental control - keep warm.
6. F - Fluid resuscitation.
In severe facial and neck burn early endotracheal intubation or tracheostomy should be
considered. Early escharotomy is needed in circumferential chest and limb burns where
respiratory or circulatory disturbance is observed. Altered consciousness may due to
carbon monoxide poising.
For major burns (second and third degree burns)
1. Remove the victim from the burning area, remembering not to put the rescuer in
danger.

2. Remove any burning material from the patient.

3. Call 911 or activate the emergency response system in your area if needed.

4. Once the victim is in a safe place, keep them warm and still. Try to wrap the injured
areas in a clean sheet if available. DO NOT use cold water on the victim; this may
drop the body temperature and cause hypothermia.
Burns of the face, hands, and feet should always be considered a significant injury
(although this may exclude sunburn.
For minor burns (first degree burns or second degree burns involving a small area of
the body)
• Gently clean the wound with lukewarm water.

• Though butter has been used as a home remedy, it should NOT be used on any burn.

• Rings, bracelets, and other potentially constricting articles should be removed

(edema, or swelling from inflammation may occur and the item may cut into the
skin).

• The burn may be dressed with a topical antibiotic ointment like Bacitracin or
Neosporin.

• If there is concern that the burn is deeper and may be second or third degree in
nature, medical care should be accessed.

• Tetanus immunization should be updated if needed.

NURSING MANAGEMENT
• Soak the burned area in cold water for 10 minutes.
• Gently wash the burn with warm, soapy water. Pat it dry with a clean towel, and
cover it with a clean, dry bandage.
 • You will need to clean the burn and put on new bandages several times a day. Be
sure that everything that touches the burn is clean. Only use the burn medicine
prescribed by your doctor. When changing bandages:
○ Wash your hands well with soap and water. Dry them with a clean towel.
○ Remove the outer bandage by cutting it off with a pair of scissors. Do not
pull off the bandage if it is sticking to the burn. Instead, soak it in warm
water for a few minutes and then remove it slowly.
○ Gently wash the burn with warm, soapy water. Use a clean, soft washcloth to
help remove any old cream, blood, and loose skin. Do not break blisters. This
may increase the pain.
○ Rinse the burn with clear warm water. Pat dry with a clean towel.
○ With a clean tongue depressor, apply the antibiotic ointment prescribed by
your doctor to a gauze pad in a thin layer. Throw the tongue depressor away
when you're done. Do NOT put it back in the container of ointment.
○ Cover the burn with the gauze. Be careful not to touch the gauze that comes
in contact with the burn. Carefully rewrap the burn with a clean bandage as
directed by your doctor.
• Keep the bandage clean and dry. Change it if it gets wet.
• If the burn is on your arm or leg, keep it raised or propped up for the first 24
hours to help reduce swelling.
• You may use aspirin, acetaminophen, or ibuprofen for pain.
• Do not bump or overuse the burned area.
• Drink plenty of water or juice to prevent dehydration.
Call Your Doctor If...
• You have increasing pain and redness in the burned area or bad-smelling drainage
from the burn. These are signs of infection.
• You develop a high temperature.
Seek Care Immediately If...
• You develop swelling, numbness, or tingling below a burn on your arm or leg.