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Stabilization And Transfer Of
The Burn Patient To A Burn
Center
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and medical
author. He graduated from Ross University
School of Medicine and has completed his
clinical clerkship training in various teaching
hospitals throughout New York, including
King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has
passed all USMLE medical board exams, and
has served as a test prep tutor and instructor for Kaplan. He has developed several medical
courses and curricula for a variety of educational institutions. Dr. Jouria has also served on
multiple levels in the academic field including faculty member and Department Chair. Dr.
Jouria continues to serves as a Subject Matter Expert for several continuing education
organizations covering multiple basic medical sciences. He has also developed several
continuing medical education courses covering various topics in clinical medicine. Recently,
Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy &
Physiology.
ABSTRACT
There are many different types of burn injuries, including those from fire,
scalds, electricity, friction, contact with chemicals, and others. The one
constant is that people who suffer burns have a desire for minimal scarring
and impact to their lives. Emergency intervention is key in returning patients
to their lives with minimal scarring and other lasting effects. This course
discusses life-saving measures and burn wound treatment during the initial
stabilization and preparation of a burn patient for transfer to a regional burn
center according to established criteria.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
Burn injuries involve acute physiological changes, pain and wound healing
that require interventions from the beginning and long after the initial
treatment. Health clinicians need to be knowledgeable of the potential and
prevention of burn injury complications.
Course Purpose
To provide health clinicians with knowledge about burn conditions and
treatments during the acute emergency setting and throughout a patient’s
treatment.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1.
Fluid resuscitation of a burn victim should begin within _____
hours of the injury:
a.
b.
c.
d.
2.
4 hours
2 hours
6 hours
None of the above
True or False: The American Burn Association recommends fluid
resuscitation of any patient with more than 15% TBSA burned
through calculating the specific need of fluid for rapid infusion.
a. True
b. False
3.
The most common isotonic crystalloid solution administered to
increase intravascular volume and prevent burn shock is:
a.
b.
c.
d.
4.
Normal Saline
5% Dextrose
Lactated Ringer’s
Answers a., and b., above
True or False: The Modified Brooke Formula involves
administration of more total fluid in 24 hours as compared to
the Parkland formula.
a. True
b. False
5.
Fluid creep is the ______________ administration of fluid after
burn injuries.
a.
b.
c.
d.
overzealous
gradual
insufficient
monitored
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Introduction
Once the health team has provided initial management of burn injuries
immediately after exposure to a burn, the next phase of treatment is to
provide ongoing management of an acute burn injury. The emergency
clinician can determine how best to approach treatment methods for the
burn patient based on the information and assessment obtained during the
initial management phase.
Treatment Of Burn Injuries
Treatment of burn injuries has several facets and may include an early
phase, which involves methods of keeping the patient stable and typically
involves the first 24 to 48 hours after the burn. During this time, the acute
complications that can develop immediately after a burn injury, such as
changes in cardiovascular status, development of massive edema, and the
potential for infection or hypothermia, are all managed through initial
emergency interventions, emotional support, and continually monitoring the
patient’s status. Later, treatment of burns focuses on tissue healing,
restoration and repair of damaged skin, and, overall rehabilitation to try to
restore former activities and to regain function.
Fluid Resuscitation
Rapid and aggressive fluid administration is necessary to prevent
cardiovascular collapse. Failure to provide appropriate fluid resuscitation in a
timely manner may increase patient mortality. Following a burn injury, fluid
in the blood vessels leaks into the extracellular space because of increased
capillary permeability.1-3 Increased capillary permeability results from the
body’s response to the burn when it releases excess histamine and free
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radicals, as well as activates complement and causes coagulation of cell
proteins.
The burned patient may also respond with widespread systemic
inflammation and the release of stress hormones. These responses cause a
change in the vascular system of increased capillary permeability, and fluid
shifts from the intravascular space to the interstitial space. This fluid shift
not only results in widespread edema, but it puts the patient at risk of
severe hypovolemia and shock when not enough fluid remains in the
intravascular system. It is critically important to provide enough fluid for the
patient to prevent hypovolemia, acidosis, and subsequent shock.
Since changes in the vascular system can occur following a burn injury, the
body responds in a multitude of ways. The cardiovascular system affects
many different other body systems that respond to physiological changes
associated with a burn injury. Cardiac output is diminished when there is
less blood to pump through the heart, ultimately resulting in tachycardia and
low blood pressure. Pulses may be difficult to palpate and capillary refill
becomes slowed.
Due to the decreased volume in the bloodstream, available blood becomes
shunted to major organs, and this leads to a potential decrease in the
function of other organs, including the kidneys. A decreased glomerular
filtration rate in the kidneys due to lack of blood flow can cause a buildup of
waste products that would otherwise be filtered at a normal rate. Urine
output diminishes and urine becomes concentrated with a high specific
gravity.
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With muscle damage, such as that
involved with full-thickness burns, the
body releases myoglobin, a type of
protein that is attached to an oxygen
molecule. The myoglobin is initially
released into the bloodstream where it
is then filtered by the kidneys to be
excreted from the body. Large amounts
of myoglobin release, such as by severe
burn injuries that affect muscle tissue,
may require extensive filtration by the
kidneys and ultimate kidney damage from the myoglobin. The urine
becomes dark in color and develops a state of pigmenturia, which is dark,
tea-colored urine that appears dark red or brown in color. Although
treatment of edema through diuretics is not typically indicated during the
initial resuscitation period, diuretic therapy may be necessary with
myoglobinuria in order to clear the urine. Intravenous infusion of mannitol is
indicated for use in this situation, rather than other types of diuretics.1,10
The gastrointestinal tract is also affected in a burn injury. Within the
gastrointestinal tract, digestive processes are slowed due to decreased blood
flow. This increases the risk of paralytic ileus, malabsorption, and impaired
gastric motility.2 The American Burn Association recommends placing a
nasogastric feeding tube early in the process of burn recovery to facilitate
administration of enteral feedings. Poor nutrition following a burn wound
results in delayed recovery time, immunosuppression, and loss of lean body
mass.16,17 Early enteral feedings (within 24 hours of the burn) can improve
immunity by supporting gut flora and stimulating the gastrointestinal tract
through digestion to avoid intestinal hypomotility. Early placement of a
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nasogastric tube can also work to decompress air accumulation in the
stomach, which prevents the development of a paralytic ileus. Air
accumulation may be more likely to occur if the patient is anxious or in
considerable pain and breathing rapidly, which would involve taking in or
gulping larger amounts of air that can collect in the stomach.
The initial fluid shifts and resulting hypovolemia requires ample intravenous
fluid resuscitation to prevent shock and organ failure. Fluid shift changes
eventually stabilize within the first one to two days after the injury but, in
the meantime, the provider must calculate and administer adequate fluid
and continue to monitor for changes in the patient’s hemodynamic status.
Careful consideration of fluid needs is crucial to prevent fluid overload, which
can lead to respiratory distress and compartment syndrome in the
abdominal cavity and the extremities.1-3,27
Fluid resuscitation through rapid administration of large amounts of fluid has
been shown to improve overall outcomes after a burn injury and the
rationale is to prevent hypovolemia and burn shock. The goal of fluid
resuscitation is to provide enough fluid that the patient does not spiral into
shock but instead maintains enough circulation to remain hemodynamically
stable; alternately, fluid resuscitation requires careful and ongoing
management to prevent administration of too much fluid, which can be
equally as detrimental to the patient as not enough fluid.
Ideally, fluid resuscitation should begin within two hours of the injury to
prevent complications and to streamline interventions.10,22 The clinician must
take into account the time of the burn injury and calculate the time for fluid
administration accordingly. This depends on when the patient was brought
into the health facility for treatment as compared to when the burn occurred.
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For example, if the patient became burned and the time between
stabilization in the field and transport was one hour, the clinician at the
receiving facility should account for that hour and make up the time in fluid
administration (if the patient arrives at the facility without intravenous fluids
infusing).
The patient should initially have two, large-bore intravenous cannulas placed
for fluid administration. It is preferable to use tissue that has not been
burned for an intravenous cannula site placement, but if this is not possible
or it would otherwise delay the start of intravenous fluid administration, a
burned area can also be used for fluid to infuse.5 If possible, when starting
an intravenous site on unburned skin, an attempt should be made to use an
area that is away from burned skin enough that veins can be isolated. It is
also difficult to secure an intravenous cannula to burned skin or surrounding
burned tissue if insertion of the cannula is performed close to a burn wound.
Increased edema that develops following a burn may increase the risk of the
intravenous cannula dislodging from its original site, requiring replacement
of the line. Wrapping the extremity, or applying tape in a circumferential
pattern should never be done to secure peripheral intravenous lines, as this
technique can limit circulation to the area and lead to compartment
syndrome should edema develop distal to the site.
Peripheral sites are useful for starting intravenous fluid quickly but the
patient will most likely also need a central venous catheter. A central line
would also be necessary to monitor central venous pressure and to provide a
site for blood sampling when needed. Waiting to place a central line could
make the insertion process difficult since significant edema can affect how
well the provider is able to determine appropriate landmarks for insertion.
The central line is also at risk of becoming dislodged due to edema in the
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burn patient, particularly if a short catheter is used. Central line use, while it
has advantages, also puts the patient at increased risk of infection —
whether the patient is a burn victim or not — and sterile technique is
essential with insertion of the line as well as strict aseptic ongoing care of
the catheter site.5,7
The American Burn Association recommends that any patient with more than
15% TBSA burned should receive fluid resuscitation through calculating the
specific need of intravenous fluid amounts and administering fluid rapidly
while simultaneously monitoring the patient’s response.14 Administration of
crystalloid solution is typically preferred because of the large volume of fluid
that will be needed, the easy accessibility of this type of fluid as compared to
accessing colloid solutions, and the cost of using crystalloids when compared
to colloids.
Isotonic crystalloid solutions are administered to increase intravascular
volume and prevent burn shock. The most common type used for burn
injuries is Lactated Ringer’s (LR) solution, although other isotonic formulas
may be used as well. Lactated Ringer’s may be preferred because it contains
a solution of electrolytes, including sodium chloride, sodium lactate,
potassium chloride, and calcium chloride, which may be useful for regulating
some electrolytes in these types of patients.5
Although colloid solutions may be used to increase intravascular volume in
some patients, this practice is expensive and is typically not necessary.
Access to the large amounts of colloids needed for fluid resuscitation in this
situation would be difficult and the patient may first need laboratory testing,
such as a blood type and crossmatch, before the administration of some
types of colloids. Often clinicians caring for the burn victim do not have time
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to wait for these results and to access colloid solutions to start fluid
resuscitation. Use of colloids for burn resuscitation is controversial for
correcting volume depletion and it has been shown that they do not improve
overall survival rate when compared with crystalloids.5 However, they still
may be used to make up part of the fluid administration and if the patient
needs blood or blood products because of a burn condition.
In order to determine the amount of fluid needed to provide adequate
hydration and to prevent shock in the burn patient, the clinician may use
one of several calculations. Different formulas use various methods of
calculation for fluid requirements and each has its own benefits and
disadvantages. When calculating the patient’s fluid needs during
resuscitation, the clinician must not only account for the total body surface
area burned and the depth of the burn injuries, but also other factors related
to the patient’s history and current condition. Factors such as the patient’s
age, health status prior to injury, and the presence of comorbidities, such as
a history of diabetes, cardiovascular disease, or obesity, must all be
considered when determining the type and amount of fluid to administer
during fluid resuscitation. Methods to evaluate and calculate fluid
administration in the setting of a burn are reviewed below.1-7
Parkland Formula
One of the most common methods of determining fluid requirements in a
burn patient is by using the Parkland formula, also called the Consensus
formula, because it is universally used in burn management. To use this
formula, the provider measures the TBSA burned (excluding superficial or
first-degree burns) and calculates the amount of fluid as 4 mL/kg of body
weight for each percent of TBSA burned. This obviously requires knowing the
total body surface area burned before calculation, as well as the patient’s
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weight, which would most likely be obtained during the initial survey. After
calculation, the clinician will generally initiate an intravenous line with the
designated fluid to run through an infusion pump to better control the rate of
the fluid administration, which will be much higher as compared to standard
intravenous rates of administration for other procedures. Based on the
measurements, the first half of the total amount of fluid calculated is
administered over the course of the first 8 hours and the second half of the
amount is then administered over the next 16 hours.
The following clinical vignette will provide an example for calculating fluid
requirements for a patient using the Parkland formula:
A. S., a 35-year-old male, 6’ 2” and 206 lbs., presents to the
emergency department with partial- and full-thickness burns on his
chest, abdomen, and each arm, secondary to a fire from using paint
thinner while working in his garage. The emergency personnel have
stabilized his airway and have used cervical immobilization in case of
spinal injury. A. S. is then stabilized in the emergency room further
when staff maintains his airway, and monitors his breathing and
circulation. The emergency room staff starts two 16-gauge IVs for rapid
fluid administration and prepare for eventual central line placement.
To calculate the patient’s initial fluid needs using the Parkland formula, the
provider would first need to assess the TBSA burned in this situation. In the
case of A.S., the patient’s chest and abdomen (18%) as well as both arms
(9%) each have been burned with either partial- or full-thickness burns.
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Using the Rule of Nines for rapid estimation of TBSA, the clinician can
determine that the patient has burns on approximately 36% of the body.
This calculation excludes superficial burns that may have occurred as a
result of the accident.
In the aforementioned clinical scenario, the clinician must calculate the
patient’s weight in kilograms in order to convert the formula. The patient,
A.S., is evaluated to weigh 206 pounds. To convert to kilograms, the weight
in pounds should be divided by 2.2 kg. In this case, the patient’s weight is
93.6 kg; and, when rounded up to the nearest whole number, the result
would be 94 kg. After determining the amount of the patient’s weight in
kilograms, the clinician can insert this total into the formula. The total
amount of fluid is 4 mL/kg of body weight, which is then multiplied by the
percentage of TBSA burned:
4mL94kg 376mL 36%TBSA 13,536mL
Using the Parkland formula, the clinician can estimate that the patient needs
a total of 13,536 mL of fluid within the first 24 hours. Note that this appears

to be an exceedingly large amount of fluid at first glance, especially when
compared to the total amount that may be administered to other patients
(such as those undergoing surgery). It is important to remember that burn
patients require a much higher amount of fluid in the first 24 hours after
injury as compared to other types of patients because of the changes in the
cardiovascular system that occur as a result of their injuries. Once the total
amount has been calculated for 24 hours, the hourly rate must then be
determined. The first half of this amount is 6,768 mL, which would be
administered over the next 8 hours:
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6,768mL
 846mL / hr
8hours
After 8 hours, the provider would then turn down the infusion rate to
second amount of fluid over the following 16 hours:
administer the
6, 768mL
 423mL / hr
16hours
Although it may be understood that a burn patient would require a large

volume of formula over the course of the first 24 hours, necessitating a large
hourly infusion rate, it is still essential for health team members
administering intravenous fluid to check and recheck the infusion rate to
ensure that the total fluid given is equivalent to what is required. In most
cases, nursing clinicians at the bedside are not responsible for calculating
fluid needs based on the Parkland or other formulas. However, because
nurses administer high rates of intravenous fluid, they must vigilantly
monitor intravenous pumps, other equipment associated with fluid
administration, and the patient’s response, to determine that the process of
fluid resuscitation is helpful for the patient and not detrimental.
Modified Brooke Formula
Another formula that may be used to calculate fluid requirements is the
Modified Brooke Formula. This formula is similar to the Parkland formula
except that instead of using 4 mL/kg, the Brooke Formula uses 2 ml/kg of
body weight per TBSA. To use of the Modified Brooke Formula in this same
situation, the provider would calculate the patient’s total body surface area
burned (36%) and body weight in kilograms (94 kg). Then, 2 mL would be
substituted into the formula:
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2mL  94kg 188ml  36%  6768mL
This total would then be administered over the course of 24 hours, at a rate
of 282 mL/hour.
1 The amount administered in this situation should be of a
crystalloid solution such as Lactated Ringer’s, rather than using a colloid
solution. Most providers have found the benefits of using crystalloid solutions
during the first 24 hours of fluid resuscitation, although institutional
practices will vary. Note that the Modified Brooke Formula involves
administration of less total fluid in 24 hours when compared to the Parkland
formula. However, use of this formula and subsequent lesser amount of fluid
has been shown to reduce the risk of fluid overload in this kind of patient.
Although formulas can determine the amount of fluid to infuse per hour and
an intravenous pump can be programed to deliver the fluid at the
appropriate rate, it cannot be overstated that the process of fluid
resuscitation requires continuous and vigilant monitoring of the patient’s
response to fluid administration. Clinicians caring for a burn patient must
look for signs and symptoms that demonstrate the patient is responding to
fluid therapy; alternatively, the clinician must adjust treatment if the patient
does not seem to be responding to initial fluid therapy. Monitoring of the
patient may be more on an hour-by-hour basis, particularly during the initial
24 to 48 hours after injury. Adjustments in fluid rate should be made based
on the patient’s response, rather than on a set amount calculated at the
beginning of the fluid resuscitation process.
Following initial administration of intravenous fluids, the emergency clinician
should insert a urinary catheter to drain and monitor urinary output in the
patient. The urinary catheter provides the ability to assess a more accurate
measurement and appearance of urinary output than measuring after the
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patient voids. Additionally, in most cases, the patient may be unable to
ambulate or urinate after a burn injury and would require a urinary catheter
because of immobility.
Monitoring urinary output is an important method of ensuring that the
patient is receiving adequate fluid. With adequate fluid administration, the
patient should produce urine at a rate of 0.5-1.0 mL/kg/hr in children
weighing less than 30 kg, and 0.5 mL/kg per hour in adults. In the clinical
scenario presented above, the provider should assess urine output on the
patient through use of an indwelling urinary catheter. If the patient weighs
approximately 94 kg, the provider would expect at least 47 mL of urine per
hour to be measured in the total output.
Adequate fluid resuscitation would also be expected to occur with a pulse
rate and blood pressure within normal ranges; additionally, the clinician
should be able to adequately assess distal pulses. The clinician should
carefully monitor and assess distal pulses, capillary refill, pulse pressure,
and skin color intensively during the first 24 hours after injury while the
patient is receiving extra fluid for resuscitation. Values that remain in the
normal range when checking these signs all point to adequate fluid
resuscitation. For example, a clinician caring for the patient listed in the
clinical vignette would closely monitor vital signs, skin turgor, urine output,
and circulation every hour for the first 24 hours. If the patient has stable
vital signs, capillary refill less than 3 seconds, palpable distal pulses, and
urine output over 0.5 mL/kg per hour, the clinician can determine that fluid
administration is appropriate. Alternatively, diminished values such as low
urine output and poor capillary refill indicate inadequate fluid administration,
which may require fluid bolus or increase in the overall fluid rate.
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Fluid Creep
Fluid creep is a concept that has become more prominent recently with the
increased use of the Consensus formula and aggressive fluid administration.
Fluid creep is described as the overzealous administration of fluid after burn
injuries that is in excess of the Parkland formula and that contributes to
abdominal compartment syndrome.26 Despite having specific formulas that
allow clinicians to calculate fluid requirements, some clinicians have been
administering fluids at rates of 5 to 8 mL/kg/%TBSA, rather than the
recommended 4 mL/kg/%TBSA in the Parkland formula. These amounts are
being given to “standard” burn patients, or rather to those who do not
present with major complications associated with burn injuries, such as
inhalation injuries or high-voltage electrical burns. The reasons why
clinicians are administering such high volumes of fluids to burn patients (the
phenomenon known as fluid creep) remains unknown. “Resuscitation
morbidity” is a term that describes conditions that can develop as
complications due to fluid creep. Some conditions that may be included as
part of resuscitation morbidity is abdominal compartment syndrome,
extremity compartment syndrome, and pulmonary edema.4-7
One potential cause of fluid creep that may occur is when a clinician
overestimates the size of the patient’s burn and administers fluid based on
appearance. This may more likely happen when the clinician does not
consider the Rule of Nines or does not have access to methods of estimating
TBSA for burn patients. Furthermore, some clinicians start intravenous lines
on burn patients in the field before transporting them to an emergency
facility, and administer intravenous fluid by gravity instead of by using an
infusion pump. If the intravenous fluid is allowed to run wide open at a fast
rate, the patient may receive a significant amount of fluid before he or she
arrives at the health facility.26 In some situations, burn patients have arrived
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at the hospital having already received most of the fluid they would have
received over the next 8 hours within the first 1 to 2 hours of resuscitation.
Additionally, measuring urine output is the standard by which clinicians can
determine if fluid therapy is adequate. However, large amounts of urine
output do not indicate that the fluid is “working” and that the same rate can
continue to be provided over time simply because the formula dictates.
Instead, urine output is a controlled measure, and fluid needs should be
titrated up or down based on output, which indicates the patient’s response.
In other words, if urine output were low, the clinician would normally
respond by increasing the intravenous rate of fluid administration. If urine
output is high, the clinician should decrease the rate accordingly.
To prevent fluid creep, the clinician must maintain tight control over the rate
of fluid administration and monitor intake and output. Based on total intake
and output, this may necessitate increasing or decreasing the fluid rate. One
method of controlling fluid rate during the initial resuscitation period that
may be implemented to prevent fluid creep is by using a formula called the
Rule of 10. The Rule of 10 follows three steps for calculating fluid rate:4,10,26
1. Estimate the percentage of TBSA of the burn and round to the nearest
10.
2. Multiply the percent TBSA x 10. This will give the initial fluid rate to
administer in mL/hour. This formula is used for adults who weigh
between 40 kg and 80 kg.
3. For every 10 kg that a patient weighs above 80 kg, add 100 mL/hour
to the fluid rate.
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As an example of using the Rule of 10 with the patient described above, the
fluid rate would be factored as follows:
•
The patient’s TBSA has been calculated at 36 %. Rounded to the
nearest 10, the provider would use 40 % for calculation.
•
The provider then multiplies 40 x 10, which equals 400 mL/hr.
•
Because the patient in the scenario weighed 94 kg, which is above the
80 kg limit used in formula calculation, the clinician must add 100
mL/hr, therefore, the total administration would be 500 mL/hr.
It should be noted that this rate per hour falls between the calculated
measures for the Parkland formula and the Modified Brooke calculations for
this same patient. The Rule of 10 is devised as an initial fluid administration
guideline and fluid is not to be run at this rate indefinitely. This guideline
was developed in response to some of the high infusion rates previously
administered during resuscitation of a burn patient, and in an attempt to set
controls and prevent over-hydration of burn patients. As in other methods of
fluid calculation, monitoring the patient’s response through urine output and
vital signs is most important for understanding the effects of fluid
resuscitation and avoiding fluid creep.26
Colloid Solutions
Colloid solutions are typically not used during initial fluid resuscitation, often
because they are more expensive and most crystalloid solutions are easier to
access and use in the large volumes needed during fluid resuscitation.
Colloid solutions may be considered 24 hours after injury, particularly if the
patient does not appear to be responding well to fluid therapy with
crystalloid solutions.
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Protein may still be lost through increased capillary permeability, and protein
levels may be somewhat restored in circulation through the administration of
colloid solutions. D. Herndon, in Total Burn Care (2012) discussed some of
the differences in thought regarding colloid administration during fluid
resuscitation.1 Various institutions have protocols in place for the
administration of colloid solutions during the first 24 to 48 hours after a burn
injury. Some locations advocate against administration of colloids during the
first 24 hours, as it is thought that crystalloid solutions have the same rate
of effectiveness during this period and are easier to administer. Additionally,
some institutions believe in administering colloid solutions in combination
with crystalloid solutions from the beginning of the fluid resuscitation period.
A third position for infusion therapy, during the initial phase of burn injury
treatment, is that colloid solutions are most effective approximately 8 to 12
hours (not immediately) after a burn injury. It is thought that resolution of
plasma protein levels does not occur until 8 hours after the burn injury and
that areas of non-burned tissue seem to return to normal capillary
permeability more quickly after the injury has occurred. Furthermore, the
administration of colloids at this time may reduce hypoproteinemia that
otherwise develops in circulation after a burn injury and contributes to
edema.1
The most common types of colloid solutions administered, when used,
include albumin and fresh frozen plasma. There is not an exact amount or
rate specified for which to administer these solutions, and much of the
settings for administration would be determined by the patient’s condition
and whether crystalloid solutions are being delivered concurrently. However,
according to the American Burn Association Guidelines for Burn Shock
Resuscitation, administration of fresh frozen plasma (FFP) is not routinely
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recommended without evidence of coagulopathy or bleeding because of the
possibility of transmission of bloodborne infections. Administration of
albumin solution is definitely beneficial when correcting low levels of albumin
in the bloodstream as determined by laboratory results, since
hypoalbuminemia has been associated with increased mortality.5,14
Another alternative component that has been shown to affect the amount of
fluid required during resuscitation efforts is administration of high-dose
vitamin C as a type of adjuvant therapy. Administration of high doses of
ascorbic acid to patients with burn injuries within 24 hours of the initial
injury has been shown to reduce the need for fluid by 40% and decreased
the number of days of ventilator use. A dose of 66 mg/kg/hour administered
during the first 24 hours was the standard amount used. While ascorbic acid
as an adjunctive therapy is still not in mainstream use as a method of
managing fluid requirements, some providers, particularly those with more
experience caring for burn patients, may successfully utilize this method as
an option for fluid management during burn treatments.1
Following the first 48 to 72 hours after initial resuscitation from the burn
injury, the increased capillary permeability that had initially occurred begins
to resolve and the fluid in the bloodstream starts to return to normal. It is
essential to note at this point that continued fluid administration at the same
rate as given during the resuscitation period is no longer necessary. The rate
of fluid administration must be reduced to avoid overloading the circulatory
system and causing congestion or heart failure.5
Once the fluid resuscitation period is over and the patient’s cardiovascular
status has stabilized, the rate and concentration of intravenous fluids can be
changed. The patient may continue to require intravenous fluids, but at a
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lower rate and a different concentration, such as 0.45% sodium chloride with
dextrose and 20 mEq/L of potassium at a titrated rate that considers urine
output and blood pressure. Continued monitoring of circulatory pressure,
including through the use of central venous pressure (CVP) is necessary to
avoid administering too much fluid too quickly beyond the resuscitation
phase of fluid administration. Intravenous fluids should be titrated at this
point to ensure that the client is still making urine and that output is
appropriate.5
Wound Protection
Burn wounds should be covered after initial stabilization to protect the
wound from damage and to prevent infection. The patient may eventually
undergo skin grafting depending on the depth and extent of the burn.
Covering the burn helps to protect the area until treatment is started, and it
helps to minimize fluid loss when fluid leaks from the site. Additionally,
covering the wound also protects exposed nerve endings that may cause
extreme pain upon contact with the surrounding air.
Burn patients are at risk of infection in the burned areas when bacteria
proliferate and spread. Additionally, a burn patient may become
immunosuppressed because the skin largely acts as an initial barrier to
prevent invasion of pathogens that could cause infection. When the skin is
damaged through a burn, this method of prevention can fail, making the
patient more susceptible to infection. Burn patients have also been shown to
alter responses to internal immune processes, such as a decrease in
production of helper T cells,12 a type of lymphocyte that helps to fight off
infection in the body. Burn victims have also been shown to have altered
production of other internal immune processes, including changes in the
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amounts of neutrophils and cytokines produced, which are also important
components of fighting off infection.12
When production of these components is changed, the body has less of a
chance to fight an invasion of pathogens when it occurs. Skin that is
damaged cannot prevent the pathogens from entering in the first place.
Failure of the immune system to protect the body can lead to widespread
proliferation of bacteria, which may spread through the bloodstream, leading
to septicemia and possible organ failure. Wounds that have debris in them
must first be cleaned to remove particles that can contribute to infection and
may continue to cause pain for the patient. Removal of debris initially is
often performed by irrigation with plenty of water, although certain
substances embedded in the wound may be more difficult to remove.
Burn wounds that contain tar may be particularly difficult to clean initially
and may require application of a petroleum-based ointment over the wound
to dissolve the solution. Many centers do not use disinfectant solutions on
the skin right away because they may lead to an increased risk of infection
later and can slow the healing process. Often, soap and water is used to
clean wounds and remove particles of debris during the secondary survey
when the patient is still being stabilized after injury.
Debridement and wound treatment typically occurs later in the treatment
process and not during initial resuscitation and stabilization. Once burn
wounds are cleaned, they may be covered with a topical antibiotic to protect
against infection. Often, topical antibiotics are preferred over systemic
prophylaxis that is given intravenously. Topical antibiotic preparations cover
the wound and provide a barrier of protection that the skin would normally
provide. Some topical agents are designed to protect the skin and prevent
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infection from developing, while other agents may be used to kill pathogens
and destroy bacteria when an infection has already developed.5-7
There are a number of topical antibiotic preparations available to use as part
of infection control in the burned patient. Some examples include mafenide
acetate, Mupirocin, Neosporin, polymyxin B, and bacitracin. Each has its own
benefits and disadvantages. For example, mafenide acetate may be
particularly potent against infection with Pseudomonas bacteria, but must be
administered with an antifungal medication to protect against the possibility
of subsequent fungal infection in the burn injury.
Topical antibiotics such as those listed above are typically protective against
many different types of bacteria that can invade the body through burned
tissue, as well as proliferation of microorganisms such as Staphylococcus
that are already in the body but that could spread and colonize and cause
infection as well. Topical Nystatin may also be applied to protect against
fungal infections that could also potentially develop in the
immunocompromised burn patient. Nystatin is effective against the Candida
species, which is one of the most common fungal organisms that would
cause infection. Nystatin, in higher concentrations, can also fight off other
types of fungal organisms that can lead to this type of infection in the burn
patient.10
Topical silver is a traditional method of managing infection in burn and
wound care patients. Historically, silver has been used extensively and, while
its role as a first-line method of infection defense in wound care has taken
second place to topical antibiotics in many situations, it is still used
extensively today in burn care centers for protection against wound
infection. The return of the use of silver products in treatment of burn
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injuries has occurred in large part due to the resistance of some types of
wound bacteria to topical antibiotic preparations. Topical silver can be useful
in small concentrations in protecting wounds from infection.
One of the most common preparations is silver sulfadiazine, which is actually
a combination of silver salt and the sulfa antibiotic. It can be applied as a
topical cream to burn wounds to protect against infection. Other types of
silver products available include silver nitrate, cerium nitrate-SSD
(Flammacerium), and various types of dressings that are infused with silver
already inside the material, which can be applied directly to the wound;
examples of these products are Acticoat and Silvercel.9,10
Following wound cleansing and application of topical ointment or cream, the
wound is covered with fine gauze that will not stick to the wound. In order to
promote circulation to the burn site, it is important to apply the gauze
dressings in strips, rather than wrapping it (such as with burns to
extremities). Wrapping burn wounds with gauze or applying tight bandages
inhibits circulation and slows healing. It also promotes further edema
formation at the site distal to the bandage, which could lead to compartment
syndrome in the affected area. A gauze dressing is applied lightly to cover
the wound and then is held in place with a net bandage or light wrap to
prevent pressure on the skin.
If the burn wound cannot be covered or is otherwise left open while healing,
the antimicrobial ointment should be applied to the site to cover the wound
and reapplied as often as needed to keep it covered and to minimize drying.
If a patient has had to undergo an escharotomy to relieve underlying tissue
pressure and to prevent tissue ischemia, the incision should be cared for in a
manner similar to the burn wound. The incisions should be covered with
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antimicrobial cream to protect against infection and lightly dressed with
gauze.10
Maintaining Warm Body Temperature
Early application of cool water to burned areas is used to clean and remove
debris from the burn site, and to reduce the depth and extent of the total
burn by helping to stop the burning process. Application of cool water to
burned sites is also helpful as some amount of pain relief for burn victims.1
Although cool water is recommended for burn wounds, it is important to
avoid using too much water or otherwise cooling the patient to the point that
the body temperature drops below a safe zone.
Hypothermia may develop in some burn patients as a result of excess skin
exposure during treatment and by some of the methods used to stop the
burning process, such as applying water. While cool water is effective and
recommended for burns, ice or ice packs should never be applied to burn
sites to minimize pain or prevent further burning. Ice can cause further
damage to tissues and can contribute to a drop in the patient’s temperature,
further perpetuating hypothermia.1 If possible, the burned extremities
should also be elevated to minimize edema formation and to support return
of fluid to central circulation.
The application of wet dressings on burn wounds should be avoided, as this
can further contribute to a drop in body temperature. The patient should be
kept warm with a sheet and blankets, particularly during transport if he or
she is being moved to a burn unit or higher care facility.
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Hypothermia
Hypothermia is defined as a body temperature of less than 95 degrees.
There is a distinct difference between induced hypothermia and that which
develops as a result of an injury. Induced hypothermia may be included as
part of treatment for some patients who have suffered from injuries or
illnesses in which there was risk for decreased oxygenation to the brain; the
act of cooling the body into hypothermia is well controlled to the point that
the patient is able to maintain energy stores. Conversely, hypothermia that
develops as a result of a disease process can be harmful to the patient and
has been associated with central nervous system depression, poor oxygen
delivery, cardiac dysrhythmias, increased blood clotting, increased
intravenous fluid requirements, and poor cardiac function.1-4
Burn patients are at higher risk of hypothermia. This is due to several
factors, such as: exposure to cold water placed on burn injuries, the
administration of unwarmed intravenous fluids, which can lower core body
temperature, and because of the physiologic mechanisms of a burn injury
that reduces the burn victim’s ability to generate heat. Skin that is burned
and is missing epithelial tissue loses heat due to evaporation; and, damage
to muscle tissue can prevent shivering or the necessary mechanisms needed
to generate heat and maintain core body temperature.1-4
Research has shown that development of hypothermia is more common
among patients who receive large burns when compared to those with burns
that comprise a smaller area. Furthermore, when hypothermia does develop
in those with large burns, affected patients are at significantly higher risks of
morbidity and mortality.1,10 Hypothermia is a risk that can be prevented in
most burn patients through anticipation of factors that contribute to the
condition and by taking measures to maintain a stable body temperature.
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Keeping the patient warm requires use of some equipment that will maintain
the patient’s body temperature through internal or external means. One
example of an environmental factor that the clinician can manage to keep
the patient warm includes increasing the temperature of the patient’s room
or of the surgical suite if procedures are being performed. Operating suites,
in particular, are often cool environments; increasing the surrounding
temperature when the patient has a large area of skin exposed can help to
prevent some heat loss. Warming blankets and covers may be used to keep
the burn patient warm and to maintain body temperature.
It is important to remember that certain warming devices, including blankets
and whole-body thermal systems, should be used with caution to prevent
further burns to the patient or causing tissue damage. Internal devices that
may warm the patient from the inside include heated and humidified oxygen
when the patient requires supplemental oxygen, and using a warming
mechanism on intravenous pumps that warms the intravenous fluid before it
is infused.25,26
Patient Stabilization And Transfer Criteria
Depending on the depth and extent of the burn injury, many burn victims
can be treated in local hospitals and facilities that provide emergency room
care and inpatient treatment. However, there are a number of situations that
require transfer of the patient to a burn center that is specifically designed
for the management and treatment of burns. Burn centers have the
capabilities of providing intensive care for burn injuries, not only during the
initial stages of fluid resuscitation, but for long-term management and
rehabilitation as well.30
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In order to provide guidelines about how best to facilitate care and
treatment of burn victims, the American Burn Association has set standards
for when to refer a burn patient to a higher-level of care through a burn
treatment center. Once a referral has been made, the patient must be
carefully stabilized for the transfer process, since it typically involves moving
the patient through some method of transport, such as an ambulance or
helicopter. While it may not be necessary to complete all tasks of the
primary and secondary survey prior to transport, it is essential that the
patient has stable vital signs and an open airway to ensure that he or she
will survive the transfer.
The American Burn Association Burn Center Referral Criteria for burn injuries
that would require transfer to a burn center include those highlighted
below.14
•
Partial-thickness burns that cover 10 percent or more TBSA.
•
Full-thickness, or third degree burns that occur anywhere or are in any
age group.
•
Burns on the face, hands, feet, genitalia, perineum, or major joints of
the body.
•
Chemical burns.
•
Inhalation injuries.
•
Electrical burns, including those sustained from lightning strikes.
•
Any burn in a patient who has significant comorbidities that would
affect the process of burn healing. This includes those conditions that
impact circulation, would prolong recovery, or would already have an
impact on the patient’s lifespan before the burn occurred.
•
Any burn patient who has also suffered from a traumatic injury as a
result of the burn, such as a head injury or broken bones.
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•
A child who has been burned and the current care center does not
have the capability for caring for children.
•
Any patient who has been burned and who requires significant social,
emotional, or rehabilitative support.
The burn patient is classified as a trauma patient and should be treated as
such when managing the process of transferring to a higher care facility. If
the patient presents for care of burn injuries at a facility that does not have
the capabilities of adequate treatment, the facility should have established
transfer protocols to arrange for patient transfer to a regional burn care
center. This involves communication with the receiving facility of the need
for transfer as well as the patient’s condition and any complications that may
have developed.
Personnel transporting the patient to a higher-level burn center must be
adept at providing patient care that will keep the patient stable en route to
the next facility, which typically involves use of mechanical devices during
the transport that will adequately monitor and support the patient’s
breathing and hemodynamic status, such as a portable cardiac monitor.
Other important components required during the transfer include portable
intravenous pumps, a ventilator, oxygen tanks and methods of oxygen
delivery, and a crash cart or box that contains medications and supplies for
resuscitation.23,30
Summary
Fluid resuscitation, adequate nutrition, infection prevention, and continuous
monitoring of burn treatment are essential following the initial care at the
site of injury. Until the patient reaches the nearest health facility and/or
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transferred to a burn center, recommended burn treatments need to be
initiated and maintained according to current guidelines for resuscitation and
care of burned tissue. Existing formulas for burn care include varied factors,
such as, the patient’s age, pre-existing comorbidities, type and total body
surface area or extent of the burn, and initial interventions at the burn site
prior to the patient’s arrival to a health facility. Anticipating burn
complications and the risk of burn shock will better prepare the health team
to avoid a sudden decline in the patient’s condition and longer hospital
admissions.
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1.
Fluid resuscitation of a burn victim should begin within _____
hours of the injury:
a.
b.
c.
d.
2.
4 hours
2 hours
6 hours
None of the above
True or False: The American Burn Association recommends fluid
resuscitation of any patient with more than 15% TBSA burned
through calculating the specific need of fluid for rapid infusion.
a. True
b. False
3.
The most common isotonic crystalloid solution administered to
increase intravascular volume and prevent burn shock is:
a.
b.
c.
d.
4.
Normal Saline
5% Dextrose
Lactated Ringer’s
Answers a., and b., above
True or False: The Modified Brooke Formula involves
administration of more total fluid in 24 hours as compared to
the Parkland formula.
a. True
b. False
5.
Fluid creep is the ______________ administration of fluid after
burn injuries.
a.
b.
c.
d.
6.
overzealous
gradual
insufficient
monitored
Burn wounds should be covered after initial stabilization to:
a.
b.
c.
d.
Protect the wound until treatment is started
Provide compression to a limb with copious fluid seepage
Prevent infection
Answers a., and c., above
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7.
Silver sulfadiazine is used to treat burns and is:
a.
b.
c.
d.
8.
A combination of silver salt and the sulfa antibiotic
A topical cream used to protect burn wounds against infection
Available in various types of dressings infused with silver
All of the above
True or False: Ice or ice packs is recommended for application to
burns to minimize pain or prevent further burning.
a. True
b. False
9.
The Rule of 10 is devised _____________ administration
guideline.
a.
b.
c.
d.
for “fluid creep”
as an initial fluid
as a hydration
as a burn medication
10. Important equipment during transfer to a burn center include:
a.
b.
c.
d.
Portable intravenous pumps, ventilator, oxygen
Ice packs to cool large burned areas and to relieve pain
Emergency equipment and medications
Answers a., and c., above
11. Application of cool water to burned sites is
a.
b.
c.
d.
helpful as some pain relief for burn victims.
not recommended because it lowers body temperature.
necessary for fluid resuscitation.
best done using wet dressings.
12. Treatment of edema through diuretics
a.
b.
c.
d.
prevents the development of a paralytic ileus.
is indicated during the initial resuscitation period.
may be necessary with myoglobinuria.
prevents intestinal hypomotility.
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13. Induced hypothermia may be included as part of treatment for
some patients to help a patient
a.
b.
c.
d.
increase blood clotting.
depress the central nervous system.
maintain energy stores.
increase capillary permeability.
14. True or False: During the initial phase of burn injury treatment,
colloid solutions are most effective approximately 8 to 12 hours
(not immediately) after a burn injury.
a. True
b. False
15. The goal of fluid resuscitation is to
a.
b.
c.
d.
maintain circulation and blood flow.
induce hypothermia.
keep the patient’s body temperature in the safe zone.
encourage myoglobinuria.
16. Administration of _____________ to burn patients is typically
preferred because of the large volume of fluid that will be
needed, the easy accessibility of this type of fluid, and the cost
of using it.
a.
b.
c.
d.
mannitol
a crystalloid solution
a colloid solution
an intravenous solution
17. _______________ may also be applied to protect against fungal
infections that could also potentially develop in the
immunocompromised burn patient.
a.
b.
c.
d.
Neosporin
Mafenide acetate
Colloid solutions
Topical Nystatin
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18. True or False: Wet dressings should be applied to burn wounds
to cool the surface skin temperature.
a. True
b. False
19. According to the American Burn Association Burn Center
Referral Criteria, which of the following burn injuries requires
transfer to a burn center?
a.
b.
c.
d.
All partial-thickness burns
Inhalation injuries
Burn patients without significant comorbidities
Child burn cases
20. The return of the use of ____________ in treatment of burn
injuries has occurred in large part due to the resistance of some
types of wound bacteria to topical antibiotic preparations.
a.
b.
c.
d.
mannitol
topical Nystatin
silver products
neosporin
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Correct Answers:
1.
Fluid resuscitation of a burn victim should begin within _____
hours of the injury:
b. 2 hours
“Ideally, fluid resuscitation should begin within two hours of the
injury to prevent complications and to streamline interventions.”
2.
True or False: The American Burn Association recommends fluid
resuscitation of any patient with more than 15% TBSA burned
through calculating the specific need of fluid for rapid infusion.
a. True
“The American Burn Association recommends that any patient with
more than 15% TBSA burned should receive fluid resuscitation
through calculating the specific need of intravenous fluid amounts
and administering fluid rapidly while simultaneously monitoring the
patient’s response.”
3.
The most common isotonic crystalloid solution administered to
increase intravascular volume and prevent burn shock is:
c. Lactated Ringer’s
“The most common type used for burn injuries is Lactated Ringer’s
(LR) solution, although other isotonic formulas may be used as
well.”
4.
True or False: The Modified Brooke Formula involves
administration of more total fluid in 24 hours as compared to
the Parkland formula.
b. False
“Note that the Modified Brooke Formula involves administration of
less total fluid in 24 hours when compared to the Parkland
formula.”
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5.
Fluid creep is the ______________ administration of fluid after
burn injuries.
a. overzealous
“Fluid creep is a concept that has become more prominent recently
with the increased use of the Consensus formula and aggressive
fluid administration. Fluid creep is described as the overzealous
administration of fluid after burn injuries that is in excess of the
Parkland formula and that contributes to abdominal compartment
syndrome.”
6.
Burn wounds should be covered after initial stabilization to:
a.
b.
c.
d.
Protect the wound until treatment is started
Provide compression to a limb with copious fluid seepage
Prevent infection
Answers a., and c., above
“Burn wounds should be covered after initial stabilization to protect
the wound from damage and to prevent infection.”
7.
Silver sulfadiazine (Silvadene) is used to treat burns and is:
a.
b.
c.
d.
A combination of silver salt and the sulfa antibiotic
A topical cream used to protect burn wounds against infection
Available in various types of dressings infused with silver
All of the above
“One of the most common preparations is silver sulfadiazine
(Silvadene), which is actually a combination of silver salt and the
sulfa antibiotic. It can be applied as a topical cream to burn wounds
to protect against infection. Other types of silver products available
include silver nitrate, cerium nitrate-SSD (Flammacerium), and
various types of dressings that are infused with silver already inside
the material, which can be applied directly to the wound;…”
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8.
True or False: Ice or ice packs is recommended for application to
burns to minimize pain or prevent further burning.
b. False
“While cool water is effective and recommended for burns, ice or ice
packs should never be applied to burn sites to minimize pain or
prevent further burning.”
9.
The Rule of 10 is devised _____________ administration
guideline.
b. as an initial fluid
“The Rule of 10 is devised as an initial fluid administration guideline
and fluid is not to be run at this rate indefinitely.”
10. Important equipment during transfer to a burn center include:
a.
b.
c.
d.
Portable intravenous pumps, ventilator, oxygen
Ice packs to cool large burned areas and to relieve pain
Emergency equipment and medications
Answers a., and c., above
“Personnel transporting the patient to a higher-level burn center
must be adept at providing patient care that will keep the patient
stable en route to the next facility, which typically involves use of
mechanical devices during the transport that will adequately
monitor and support the patient’s breathing and hemodynamic
status, such as a portable cardiac monitor. Other important
components required during the transfer include portable
intravenous pumps, a ventilator, oxygen tanks and methods of
oxygen delivery, and a crash cart or box that contains medications
and supplies for resuscitation.”
11. Application of cool water to burned sites is
a. helpful as some pain relief for burn victims.
“Early application of cool water to burned areas is used to clean and
remove debris from the burn site, and to reduce the depth and
extent of the total burn by helping to stop the burning process.
Application of cool water to burned sites is also helpful as some
amount of pain relief for burn victims.”
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12. Treatment of edema through diuretics
c. may be necessary with myoglobinuria.
“Although treatment of edema through diuretics is not typically
indicated during the initial resuscitation period, diuretic therapy
may be necessary with myoglobinuria in order to clear the urine.
Intravenous infusion of mannitol is indicated for use in this
situation, rather than other types of diuretics.”
13. Induced hypothermia may be included as part of treatment for
some patients to help a patient
c. maintain energy stores.
“Induced hypothermia may be included as part of treatment for
some patients who have suffered from injuries or illnesses in which
there was risk for decreased oxygenation to the brain; the act of
cooling the body into hypothermia is well controlled to the point
that the patient is able to maintain energy stores.”
14. True or False: During the initial phase of burn injury treatment,
colloid solutions are most effective approximately 8 to 12 hours
(not immediately) after a burn injury.
a. True
“A third position for infusion therapy, during the initial phase of
burn injury treatment, is that colloid solutions are most effective
approximately 8 to 12 hours (not immediately) after a burn injury.”
15. The goal of fluid resuscitation is to
a. maintain circulation and blood flow.
“The goal of fluid resuscitation is to provide enough fluid that the
patient does not spiral into shock but instead maintains enough
circulation to remain hemodynamically stable; alternately, fluid
resuscitation requires careful and ongoing management to prevent
administration of too much fluid, which can be equally as
detrimental to the patient as not enough fluid.”
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16. Administration of _____________ to burn patients is typically
preferred because of the large volume of fluid that will be
needed, the easy accessibility of this type of fluid, and the cost
of using it.
b. a crystalloid solution
“Administration of crystalloid solution is typically preferred because
of the large volume of fluid that will be needed, the easy
accessibility of this type of fluid as compared to accessing colloid
solutions, and the cost of using crystalloids when compared to
colloids.”
17. _______________ may also be applied to protect against fungal
infections that could also potentially develop in the
immunocompromised burn patient.
d. Topical Nystatin
“Topical Nystatin may also be applied to protect against fungal
infections that could also potentially develop in the
immunocompromised burn patient.”
18. True or False: Wet dressings should be applied to burn wounds
to cool the surface skin temperature.
b. False
“The application of wet dressings on burn wounds should be
avoided, as this can further contribute to a drop in body
temperature. The patient should be kept warm with a sheet and
blankets, particularly during transport if he or she is being moved
to a burn unit or higher care facility.”
19. According to the American Burn Association Burn Center
Referral Criteria, which of the following burn injuries requires
transfer to a burn center?
b. Inhalation injuries
“The American Burn Association Burn Center Referral Criteria for
burn injuries that would require transfer to a burn center include
those highlighted below… Partial-thickness burns that cover 10
percent or more TBSA…. Inhalation injuries…. Any burn in a patient
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who has significant comorbidities that would affect the process of
burn healing … A child who has been burned and the current care
center does not have the capability for caring for children.”
20. The return of the use of ____________ in treatment of burn
injuries has occurred in large part due to the resistance of some
types of wound bacteria to topical antibiotic preparations.
c. silver products
“In a report found in the journal Recent Patents on Anti-Infective
Drug Discovery, the return of the use of silver products in
treatment of burn injuries has occurred in large part due to the
resistance of some types of wound bacteria to topical antibiotic
preparations.”
References Section
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading.
1.
2.
3.
4.
5.
Herndon, D. N. (2012). Total burn care: Expert consult. Philadelphia,
PA: Elsevier Saunders
Baldwin-Rodriguez, B. (n.d.). Burn trauma injuries. Retrieved from
http://dynamicnursingeducation.com/class_more.php?class_id=126&m
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