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BURN INJURIES: INITIAL
EVALUATION AND
EMERGENCY
INTERVENTION
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 primarily discusses the initial evaluation
and emergency interventions associated with burn injuries.
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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 3 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.
True or False: Airway edema is generally apparent in the
initial burn injury patient and the emergency team must
act immediately to stabilize a patient’s airway.
a. True
b. False
2.
During the secondary survey, the health team may uncover
injuries not initially apparent in a burn patient, such as:
a.
b.
c.
d.
3.
An escharotomy involves an incision
a.
b.
c.
d.
4.
made outside the burned skin using a scalpel.
deep enough to penetrate the subcutaneous fat.
to release pressure in the burned area.
used for debridement of eschar.
A Lund and Browder chart is used for:
a.
b.
c.
d.
5.
Fractures
Dislocations
Abdominal injuries
All of the above
estimating the burn extent in a patient.
estimating fluid loss of a burn patient.
estimating the range of motion of a burn patient.
All of the above
True or False: Range-of-motion exercises are necessary on
a regular basis to promote blood flow to the extremities
and to prevent contractures in a burn patient.
a. True
b. False
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Introduction
Burns are a leading cause of injury in the United States. Over one
million people seek medical care and treatment for burn-related
injuries each year. Burns may range from minor burns, impacting only
a small area, to major burns that require months of treatment and
rehabilitation. Major burns are a significant cause of disability,
morbidity, and mortality among burn victims.
The costs associated with caring for individuals with extensive burn
injuries are high and the treatment of burns has become highly
specialized. Consequently, regional burn centers have evolved into
treatment for high-need patients who can be transported to the closest
location where specialized care of the burn patient can occur. While
regional care services are known to improve the outcome for burn
patients, transporting patients to nearby centers that provide
comprehensive burn care requires more staff training and
understanding of burn injuries during initial patient care and
emergency transport. Clinicians who are responsible for assessing,
resuscitating, stabilizing, and transporting critical burn patients must
be well trained to understand their complex needs and to get them
safely to a regional center where their treatment will be continued.
Initial Assessment And Rapid Response
The initial assessment of a burn patient is a skill that should be
learned by clinicians responding to an emergency in the field as well as
in the receiving hospital where emergency staff will be working fast to
stabilize the patient. Firstly, a patient still in contact with the source of
the burn must be removed from that source. In the case of a thermal
or electrical burn, the patient should be removed from the area where
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the fluid or fire took place; if a chemical burn, the person first arriving
to the scene should strive to remove as much of the chemical as
possible from the patient in order to stop the burning process. This
may involve brushing away powders or particles that continue to burn
the skin, or flushing the skin or eyes to rinse away caustic chemicals
that could still cause damage.1,2
It is important for clinicians to recognize that burn patients can
deteriorate quickly, even if they initially seem stable. Clinicians in the
emergency setting must assess the patient on a continuous basis and
be familiar with the anticipated subtle changes indicating deterioration
of the patient before it is too late.
Airway Stabilization and C-Spine Immobilization
The primary survey of a burn injury involves maintaining a patent
airway to facilitate adequate air exchange for the patient. A burn
patient may have suffered injuries that could cause the airway to swell
and constrict, thereby impeding airflow. Edema formation and airway
obstruction can occur quickly with certain types of injuries, such as
inhalation injuries, or may develop slowly over time. Because airway
edema may not be apparent immediately and develop over a period of
time, the clinician must continue to assess and stabilize the airway
while providing care for the patient.
A patient with burn injuries may have been exposed to some type of
gas, smoke, or other materials that were combustible and that can be
damaging to the airway and the lungs if inhaled. The heat from the
burn source is also damaging to the respiratory tract. The body
responds to this exposure with inflammation and swelling, which
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constricts the size of the airway and can cause obstruction. The patient
should be provided with 100% humidified oxygen right away to
improve the distribution of oxygen to the tissues while the clinician
continues to monitor for changes that suggest an obstructed airway.1
If the patient shows signs of breathing difficulties or obstruction
related to airway damage from the burn, endotracheal intubation
should be performed as quickly as possible.1 Responders at the scene
of the burn or those providing initial care at the hospital should
observe for signs of inhalation injury as well as determine from
bystanders the nature of the burn potentially affecting the patient’s
ability to maintain an open airway; for example, whether the burn
injury occurred in an enclosed space. Airway intubation should be
performed to support respiratory ventilation while the emergency
clinician simultaneously addresses the extent of edema in the patient’s
throat. Waiting to intubate a patient’s airway after signs of edema and
an obstructed airway develops due to a burn injury may only lead to
difficult intubation because in such situations the edema that develops
often further constricts the throat and airway passages.1,10
There is a risk of spinal cord injury in situations where the patient was
burned as a result of an accident or fall. The clinician should be aware
that an injury to the cervical spine, although not common among burn
patients, may have occurred if the burn was associated with an
accident that would have resulted in an injury to the head or neck.
Some of the most common types of burn injuries that would definitely
require cervical spine immobilization include burns from explosions,
burns that occur as a result of a motor vehicle collision, or burns that
occur with exposure to high-voltage electricity. If there is any question
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of whether the patient has an injury that could result in damage to the
spinal cord, a cervical collar should be applied to the neck and kept in
place until the cervical spine is cleared of evidence of fracture.
A patient with cervical spine
immobilization should be monitored
until evidence determines that it is
safe to remove the collar, such as
through confirmation from
radiological studies. Also, a patient
with a cervical collar should have the
collar removed as soon as possible
after the injury, rather than
remaining with a cervical collar in
place for a long period of time.
Radiologic imaging to confirm that
no injury exists is necessary in any
patient where cervical spine injury is suspected, including those with
pain and tenderness in the neck and shoulder area and with an altered
mental status or neurological deficit. Alternatively, a patient who is
awake, and alert, has no neurological deficits or penetrating injuries,
and does not have pain in the neck and shoulder area, does not need
an X-ray to clear the cervical spine. In such cases, the cervical collar
can be removed.
Breathing Status and Interventions
An open airway does not necessarily mean a patient is breathing
adequately. If a burn patient has not been intubated and the clinician
is continuing to monitor for signs of airway obstruction, the patient’s
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breathing patterns and attempts to breathe must continue to be
evaluated. Administering humidified oxygen helps only if the patient is
breathing the oxygen. If the patient needs further assistance to
breathe because of airway damage, smoke inhalation, or carbon
monoxide poisoning, he or she must be intubated or assisted to
breathe through positive-pressure ventilation.
The clinician should look for signs of burn injury around or in the
mouth that indicate that the patient has inhaled chemicals or particles
that could cause lung damage and breathing difficulties. Signs of
inhalation include particles or fine powder around the mouth and nose,
singed hair around the mouth and nose, carbonaceous sputum with
cough, or sores or blisters on the gums or roof of the mouth.3,4
Inhalation injuries are present in up to 50% of patients who are
admitted to burn centers2 and are a leading cause of death among
affected patients because of the damage such injuries can cause to
lung tissue and subsequent oxygenation of the body. There is an
increased risk of inhalation injury associated with a greater amount of
body surface area affected by a burn. Inhalation injuries involve
injuries to the airway and lungs when the patient inhales toxic
chemicals and byproducts from the process of combustion. These
types of injuries may be classified as being either above the glottis or
below the glottis.1,2
Injuries above the glottis, or an upper airway injury, may result in
dyspnea, stridor, a dry cough, or hoarse voice. The patient may
develop edema in the upper airway that can cause blockage of the
airway and subsequent apnea. Inhalation injury below the glottis, or a
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lower airway injury, causes damage to the lung tissue. This type of
injury can quickly progress to acute respiratory distress syndrome and
respiratory failure within the first several days of the burn injury. The
patient may develop bronchial spasms that lead to airway constriction,
and sloughing of the mucous membranes occurs as a response to the
injury, causing a productive cough.1,10
Diagnosis of a lower airway injury must be done by a bronchoscopy to
verify whether damage has occurred and to understand the extent of
the injury to better predict the outcome. Those initially responding to a
burn injury should continually assess for symptoms associated with an
airway injury until an emergency clinician is able to recommend airway
treatment based on an actual diagnosis.
Initial administration of 100% oxygen by mask at 15 L should be
started right away, particularly if a patient has suffered from inhalation
injuries or carbon monoxide poisoning as a result of the burn. Initial
responders to a burn patient should remove the clothing as a potential
source of continuous burning and to assess for conditions that could
impair the patient’s ability to breathe. Circumferential burns around
the chest can limit chest expansion, leading to shallow attempts at
breathing and subsequent hypoxia. The clinician should assess breath
sounds by not only auscultating the lung fields, but also assessing for
depth and rate of respirations.
The health team should monitor a patient’s oxygen status by initially
monitoring pulse oximetry to determine if administered oxygen is
preventing hypoxia. An arterial blood gas (ABG) can provide insight
into oxygenation or carbon dioxide buildup in the bloodstream. The
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patient may also require a chest radiograph (XRAY) to assess for lung
damage and expansion. In addition to oxygen administration,
bronchodilator medications may be effective in opening airway
passages and facilitating easier breathing. This may not be an initial
part of the resuscitation process, and can be added if the patient is
showing signs of dyspnea indicative of airway constriction. It should be
raised that corticosteroids, used to minimize inflammation in the
airways, has been shown to increase the patient’s risk of infection and
is not recommended.2-4
As noted earlier, tracheal intubation should not be delayed if a patient
is showing signs of breathing difficulties and there is evidence of
inhalation injury. Because airway edema can develop rapidly, and can
quickly occlude the airway, tracheal intubation should be performed
sooner rather than later. It cannot be overemphasized that once the
airway is obstructed due to edema, it can become very difficult to pass
an endotracheal tube to ventilate the patient. A patient, who is
unconscious, has burns on the face or the neck, or with worsening
respiratory distress are all primary candidates for intubation.1 The
clinician should continue to monitor for signs of worsening respiratory
distress that indicate a need for intubation. Signs and symptoms to
observe for include:1,30

coughing, wheezing, and stridor with breathing

circumferential burns of the neck or face

hoarseness

hypoxia

hypercapnia

high levels of carbon monoxide in the body
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If a patient must be intubated to assist with breathing, it may be
difficult to secure the tube, particularly if burns to the head and neck
are present. Swelling and edema that follow a burn injury may
increase the risk of tube dislodgement, and there may be a lack of
adequate tissue to secure the tube. Tape should be avoided on
damaged skin and, if necessary, the tube should be secured with cloth
or umbilical tape by tying it around the tube and securing it behind the
patient’s ears or head. Continuous monitoring of the endotracheal tube
is necessary to ensure the patient is maintaining adequate
oxygenation with the ventilator and that the tube has not become
dislodged.
A pediatric patient may require early intubation based on consideration
of the size of the patient’s airway as well as the patient’s condition.
Pediatric patients have smaller airways, which can be difficult to
intubate even under normal conditions. The risk of airway occlusion
because of edema following a burn may prompt more rapid intubation
in the pediatric patient as compared to an adult. A clinician
experienced with endotracheal tube placement in pediatric patients,
particularly when airway damage has occurred, should be performing
the intubation procedure.4,10
Respiratory ventilator settings when initiated are based on the
individual’s needs and condition. For patients with inhalation injuries,
the American College of Chest Physicians does not offer specific
recommendations for ventilation parameters for all patients; however,
guidelines are offered that suggest minimizing plateau pressures and
the use of appropriate levels of positive-end expiratory pressure
(PEEP) in individual cases as required.1-3
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Circulation Status
Checking the heart rate and pulse typically is done during assessment
of the patient’s circulation status. Auscultating heart sounds may
reveal the rate and character of the heart rate. A heart rate of less
than 110 beats per minute (bpm) indicates that the patient has
adequate blood volume, while a heart rate greater than 120 bpm may
point to low blood volume and demonstrates the body’s attempt to
compensate. If the patient with a burn injury is hypotensive upon
arrival to an acute care center, the emergency clinician should not
assume that the low blood pressure is a direct result of the burn. It is
important to understand the patient’s history and the events
surrounding the burn before determining that blood pressure changes
are caused only by the burn injury.1,30 For example, a patient may
have been injured in a fall when trying to escape a burning building
and could have low blood pressure because of internal bleeding.
Blood pressure readings may not be the most accurate sign of
appropriate blood circulation in a burn victim. It can be difficult to take
a blood pressure if the burns are so extensive that an appropriate
location for a blood pressure cuff becomes hard to obtain. A more
accurate method of measuring blood pressure is to place an arterial
catheter for direct pressure measurement. The most common location
is the radial artery of the wrist. Because of changes in the
intravascular system, as a result of the body’s response to the burn,
fluid will shift out of the intravascular space and into the surrounding
tissues. As a result, a patient may have an increased pulse rate and
low blood pressure; capillary refill is typically delayed and it may be
difficult to detect peripheral pulses.
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A patient who has suffered an electrical burn may be at risk for cardiac
abnormalities. In a patient with an electrical burn that has an entry
and exit point cardiac arrhythmias may develop as a result of the
electricity from the burn disrupting the cardiac electrical cycle. This
can lead to heart arrhythmias or complete asystole.3 An
electrocardiogram (ECG) is done to assess for cardiac arrhythmias,
and continuous cardiac monitoring is important to measure
hemodynamic status on a regular basis and to assess for changes in
cardiac function.
While assessing circulation is an initial part of the primary survey and
stabilization, a patient who has suffered an electrical burn should
continue to receive cardiac monitoring for several hours after his or
her condition has stabilized. Ultimately, all patients who have suffered
burn injuries that require fluid resuscitation and initial stabilization
should receive cardiac monitoring on a continuous basis to measure
changes that could indicate a decline in patient status, even after the
initial stabilization period.
Burn shock can develop quickly and involves a change in
cardiovascular status. Burn shock involves a state at which the body
receives inadequate perfusion of blood and nutrients; in this case, the
condition develops as a result of severe burns.1 The patient develops
hypotension and signs of perfusion diminish, as evidenced by delayed
capillary refill.3 Pulse oximetry should be continuously checked to
assess levels of oxygen in the bloodstream, although this method of
observation is not always accurate when applied peripherally. The burn
patient may have fewer areas on the body for which to place a pulse
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oximeter; furthermore, the results of pulse oximetry may not be
accurate if circulation is impaired as a result of injury.
It is important to note that standard pulse oximetry is not an adequate
assessment when carbon monoxide poisoning has occurred and other
measures should be assessed to rule out this condition, such as lab
work to check carboxyhemoglobin levels. Some health care centers
use specialized oximetry probes that can accurately detect oxygen
concentrations in the blood when the possibility of carbon monoxide
poisoning is present. Called CO-oximetry, monitoring probes use four
wavelengths of light in comparison to standard pulse oximetry, which
uses only two wavelengths.1,10
Standard pulse oximetry cannot necessarily detect carbon monoxide
bound to hemoglobin because it can only detect hemoglobin that is
either oxygenated or deoxygenated, and not any other forms.
Alternatively, CO-oximetry has more light wavelengths that can detect
hemoglobin, oxyhemoglobin, carboxyhemoglobin, and methemoglobin.
This type of probe can specifically measure oxyhemoglobin levels that
are the same as arterial oxygen saturations. If a facility has access to
CO-oximetry, this form of monitoring can be utilized in inhalation
injuries or in the possibility that carbon monoxide toxicity exists.1,16
The Secondary Survey
The secondary survey begins as soon as a patient’s airway, breathing
abilities, and circulatory status have been assessed and stabilized. The
secondary survey consists of a head-to-toe examination to look for
other injuries and to assess the extent of the burns. During the
secondary survey, the clinician continues to keep the patient stable,
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provides intravenous fluid resuscitation, and controls other factors that
may contribute to continued injury or illness for the patient.
The secondary survey includes several important components that are
considered burn specific. Reviewing these factors about the burn will
provide a comprehensive history of the incident, which may better
prepare clinicians about how to manage the injuries involved. These
considerations include the following:
•
Mechanism of Injury:
The mechanism of injury and what happened that actually
caused the burn.
•
Time of the Injury:
This is exceedingly important information, as every minute
following a burn injury can be crucial for providing life-saving
treatment or preventing complications. Depending on the area
where the burn occurred in relation to the treating facility, there
could be considerable time that has elapsed between the injury
and the beginning of treatment.
•
Consideration of Abuse:
A patient who has used alcohol or illicit drugs prior to the burn
injury may have more complications throughout treatment as
compared with someone who has not used these substances.
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•
Height and Weight:
Obtaining the patient’s height and weight information helps
providers to calculate fluid requirements and other medications
that may be administered during the treatment period.
•
Inhalation Injury:
As stated, inhalation injuries can cause trauma to the airway
that can result in an occlusion and need for intubation.
Inhalation injuries can also cause significant lung damage and
overall toxicity when the patient breathes in toxic particles or
chemicals found in smoke.
•
Facial Burns:
Burns to the face require specialized care and can place the
patient at risk of airway occlusion, breathing difficulties, altered
oral intake, and vision loss as well as other complications. Facial
burns should be managed by an accredited burn care center and
the patient should be transferred, according to the American
Burn Association guidelines.
Evaluation of Associated Trauma
If it has not already been done, a patient’s clothing and jewelry should
be removed as soon as possible to avoid further injury and burning of
the skin. Items such as watches, rings, and belts should be removed
as part of this process as well, as these items constrict the flow of
blood and have the same effect as a tourniquet. This tourniquet effect
can lead to edema and vascular damage.1
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In most cases, patients brought to a health care facility have been
stabilized in the field to a certain extent, and removed from the source
of the burn. However, there may be times when clothing continues to
burn a patient’s skin or there are still particles of chemicals from the
initial burn present on the patient’s skin and continuing to burn the
patient. These items must be removed to stop the burning process. A
health team member removing the items, whether it is burned
clothing, chemicals, or other substances causing the burn, must be
very careful not to become injured in the process.
If chemicals have burned a patient, removing as much of the chemical
as possible is essential to stopping the burn process. Research does
not recommend attempting to neutralize chemicals by applying
countermeasures through products that stop the effects of the
burning. Not only can this process be complicated, but it could also
cause further skin damage with the application. Additionally,
neutralizing chemicals produces a certain amount of heat in the
process itself, which would only add to burn damage.1 When removing
chemicals from a burned patient, the provider should take measures to
protect themselves by wearing a mask, gloves, and goggles to avoid
getting any of the chemicals on his or her own skin and subsequently
becoming burned as well.
During the secondary survey, the health team may uncover other
injuries that have occurred that may not have been initially apparent
when the burn injuries were first being managed. There are some
types of injuries that could go unnoticed as compared to a severe burn
and the clinician must assess for signs and symptoms of other existing
problems in order to manage these as well. Some examples of injuries
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include fractures, dislocations or abdominal injuries. Additionally,
injuries to the head or face, including to the eyes and ears (such as
corneal abrasions or tympanic membrane rupture) require careful
evaluation as potential injuries associated with burns that may have
been overlooked.3,4,21,24
A neurological exam should also be performed at this point to assess
whether the patient suffered an injury that would have caused hypoxia
to the brain. If smoke inhalation has occurred, the patient may have
had a period of time of decreased oxygen to the brain. If the burn
occurred as a result of an accident, such as a fall or an explosion,
there is the potential of a head injury. A neurological exam can identify
if deficits exist based on certain findings and by understanding the
mechanism of injury and incidents surrounding the time of the burn.
A basic neurological exam can be performed on the patient to assess
for deficits and changes in level of consciousness. If the patient is
awake and able to answer basic questions, the clinician can ask the
patient: “What is your name or birthday?” If the patient can answer
these questions accurately and appears to be awake and alert, the
clinician can continue to gain information about the patient’s history,
including important information regarding past medical conditions and
the circumstances associated with the burn injury.
A patient who has suffered a traumatic injury beyond the burn wounds
and who is unable to answer basic questions, as part of a neurological
exam, may need assessment through a trauma scoring system to
determine the extent of neurological deficits that may exist. The
Glasgow Coma Scale (GCS) is a scoring system that should be used for
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any patient who presents with a burn wound as a result of an accident
or traumatic injury. The GCS is a tool used to assess neurologic
function in three different areas: best eye response (the eye opens),
verbal response, and motor response. The clinician assesses each of
these areas in the patient and then assigns a score based on the
response.1-3
The highest level of the GCS is 15 points, which is the best response
indicating very little to no neurological deficit. The lowest score is 3
points, which demonstrates that the patient has no motor or sensory
response to stimulation and does not open the eyes. The lower the
score on the GCS, the more severe the neurological deficit. The results
of the GCS can help clinicians to better manage a patient’s total
condition beyond the burn injury.
While stabilization of the burn is important during early assessment,
neurological deficits must also be addressed as severe deficits can
impact a patient’s ability to recover or even survive after a traumatic
burn. For instance, a patient with a GCS score of less than 8 would
most likely need to be intubated because he or she may have enough
neurological impairment to cause an inability to breathe without
assistance. The decision to intubate involves more than an initial
assessment of the patient’s airway as a result of a burn; because even
if the burned patient has no signs of inhalation injury or airway
obstruction, there may still be a need to intubate as a result of a low
GCS score.
During the process of checking the patient’s circulation and for the
presence of other injuries, an additional assessment involves the
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presence of circumferential burns that can affect circulation.
Circumferential burns are those that extend around a body part, such
as one that is wrapped around an extremity. It has been noted that
circumferential wounds in the chest can impact the patient’s ability to
breathe and must be checked carefully. In the extremities,
circumferential burns can impede blood flow from the damaged tissue.
This tissue, called eschar, is inelastic and will not expand to allow for
breathing or movement; consequently, it compresses the circulatory
system, causing ischemia in the distal tissues.
If a circumferential burn has been identified, rapid treatment may be
necessary to prevent continued injury. In this case, emergent
escharotomy may be needed to allow for expansion and to promote
breathing and circulation. An emergent escharotomy may be
performed in the emergency room, but it is more commonly done in a
surgical suite to allow for adequate sedation and/or anesthesia for the
patient, as well as electrocautery to manage bleeding in the event of
extensive blood loss.28 Although the operating room is the ideal
location for emergent escharotomy, in significantly dangerous
situations, escharotomy has been performed in the emergency room
and in the field before patient transport to a hospital as a life-saving
measure.
Escharotomy involves using a scalpel to cut into the burned skin; the
incision is deep enough to reach but does not penetrate the
subcutaneous fat underneath. This incision is done to release the
pressure buildup that occurs in the affected area. The eschar incision is
drawn along the length of the affected area to about 1 cm past each
end of the burn. The goal of the procedure is to reduce the pressure in
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the affected area and restore normal circulation to the site. The
clinician can check for adequacy of the procedure by assessing distal
pulses and checking capillary refill to determine if circulation has been
restored.27
Although an emergent escharotomy is not always necessary, failure to
relieve pressure that can occur from circumferential burns that impede
blood flow to parts of the body can result in disastrous consequences
for the patient. Some complications associated with failure to
recognize the need for and perform an escharotomy, or with
inadequate decompression from an escharotomy, include gangrene
development in the affected area, respiratory insufficiency, destruction
of muscle tissue, and nerve injury.27 While the process of performing
an escharotomy may be somewhat complex and may cause anxiety for
the patient, failure to perform this procedure when necessary produces
more complications than managing the patient otherwise.
Total Body Surface Area (TBSA)
Burn management is dependent on the type of burn that has occurred,
the depth of the burn, and the extent of the burn covering the body.
The source of the burn can cause different types of complications
between situations; two people may present for burn care with
different manifestations and needed management of a burn area based
on the source of a burn. For example, a patient who has suffered from
an electrical burn may require different aspects of management than a
patient who has suffered a thermal burn. The three main sources of
burns are outlined below.
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Electrical Burns
Electrical burns occur with exposure to an electrical current. They may
not always have the same appearance as a thermal burn in that the
outer skin surface may not be significantly affected. However,
electrical burns can cause significant internal damage, including
broken bones, seizures, muscle contractures, and cardiac arrhythmias.
The surface of the skin, including an entrance and/or exit wound, may
appear to be only a minor injury, or it may cause extensive skin
damage. Electrical burns may be caused by such situations as
exposure to a home power supply, a child biting an electrical cord, or
lightening.8
Chemical Burns
Chemical burns develop when a person comes in contact with a
substance that is caustic to the skin and mucous membranes. They
can affect the exterior of the body or they could cause internal burns,
such as in the case of ingestion of caustic chemicals. The extent of the
burn depends on several factors, including the amount of the chemical
that caused the burn, the concentration of the chemical, and the
duration of contact. The chemical burn will continue as long as the
chemical remains in contact with the body.2,7 Chemical burns most
often occur with exposure to substances in the workplace or in the
home, such as cleaning solutions, car battery fluid, fertilizers, or
bleach.
Thermal Burns
Thermal burns tend to be the main type of burn that people consider
when they think of someone being burned. In fact, thermal burns
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make up 90% of burns received.2 Thermal burns occur with exposure
to a heat source, such as hot liquid or fire. These types of burns can
cause extensive damage to the skin and mucous membranes. The
most common types of thermal burns occur in the home from cooking
fires and hot bath water.3 Older adults may be at higher risk of severe
burn injuries because of thinner skin that contains less collagen;
similarly, young children are also at higher risk because they often
cannot control their circumstances or prevent injuries.
Once the source of the burn has been identified, the clinician must
assess the depth of the burn. Burns are classified according to the
depth of skin tissue that is impacted. Superficial, or first-degree burns
are considered partial-thickness burns that typically affect the
epidermis and part of the dermis. First-degree burns appear as
reddened skin that may peel as part of the healing process. There may
be blisters on the surface of the skin. These types of burns heal quickly
as compared to second-degree or full-thickness burns. Most people
heal from first-degree burns within one week with minimal long-term
damage.3
Second-degree or deep partial-thickness burns are those involving the
epidermis and lower layers of the dermis but not the structures
underneath. These types of burns can be extremely painful for the
involved patient and often require frequent administration of
medications for analgesia. The skin is reddened and may have weeping
blisters; edema also may develop. A patient with a second-degree
burn may have an increased sensitivity to touch or even surrounding
air.3 These types of burns may take up to a month to heal.
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Third degree or full-thickness burns are those that involve the
epidermis and the dermis, as well as underlying subcutaneous tissue,
muscle, tendons, and bone. The skin of a full-thickness burn may not
appear similar to skin at all, but instead may be blackened, charred, or
leathery; alternatively, it may also appear white, dry, or crusty. The
patient may have less pain with a full-thickness burn as compared to a
second-degree burn, because the nerve endings may have been
destroyed with a third-degree burn, resulting in less pain.3 Treatment
of full-thickness burns is complex and healing may take weeks to
months in length, followed by rehabilitation to restore some
functioning.
The extent of the burn determines the amount of tissue involved. This
is referred to as the total body surface area (TBSA) of the burn. There
are several methods of determining TBSA, depending on the situation,
including time constraints for estimating the client’s needs and the age
and condition of the patient. Because treatment parameters will be
based on the source and depth of the burn, as well as the total body
surface area of the burn, it is important to accurately determine the
extent of injury in order to best manage injuries associated with
severe burns.
Determining TBSA
One of the most common methods of determining TBSA is the Rule of
Nines. This method is typically used among adults (and may be
modified for children) who are burned and provides a rough estimate
of TBSA. The Rule of Nines breaks down major areas of the body into
percentages divisible by nine. The clinician can determine the
approximate amount of area on the body burned by remembering the
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percentage and adding the total together. The head and neck
constitute 9%, the chest and abdomen accounts for 18% in the front
and 18% in the back, each leg is 18%, each arm is 9%, and the
perineum is 1%.3 If the patient is a child, the Rule of Nines estimation
can still be used, but the percentages are modified to account for body
surface area of the child and the size of the head in relation to the rest
of the body. According to the Rule of Nines, a child’s head and neck
are 18%, the chest and abdomen is 18% in front and 18% in back,
each leg is 14%, and each arm is 9%.6
When using the Rule of Nines to determine TBSA, if the clinician
encounters an area that does not fit with the pre-determined
percentages, the palm method of estimating burn size can be used.
This assumes that the palm of the hand is approximately 1% of body
size.6 This method can be used in situations where there are patches
of burned areas or burns that do not fit the typical size associated with
the Rule of Nines, but that still must be estimated quickly. For
example, a patient may have a burned area on the front of the upper
part of the leg on the thigh, which would not warrant classifying this
burn as 18% TBSA since it does not involve the entire leg. Instead, the
clinician can quickly use the palm method to estimate how much
surface area is burned by estimating the size of the burn according to
the size of the patient’s palm.
Although the Rule of Nines is helpful and can be instituted quickly, the
Lund and Browder method is another more comprehensive and
accurate approach to estimate burn injuries. The Lund and Browder
chart considers age-related proportions and may be used more among
children who receive burn injuries. This method also involves a scoring
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system, but the body parts assessed are grouped in smaller segments.
These smaller groups provide more accurate assessment when
compared to the Rule of Nines, particularly if a burn affects a smaller
body area.
Often, a Lund and Browder chart is kept at emergency facilities for use
to estimate burn extent in a patient. A facility that receives a burn
victim may use the chart, which shows a body outline with
percentages broken down into smaller components to compare to a
patient’s body. Because this method provides a more accurate
assessment of TBSA in a burn patient, it may be more likely to be used
when calculating fluid requirements for resuscitation.2,9
Burns are further classified as minor, moderate, or major injuries. The
following classifications categorize types of burns:2,3,9,10
•
Minor Burns:
Minor burns are considered to be burns that are superficial or
partial-thickness burns covering less than 15% of TBSA in adults
and less than 10% of TBSA in children. Minor burns do not
involve the eyes, face, ears, hands, feet, or perineum in affected
patients. A full-thickness burn may also be classified as a minor
burn if it affects less than 2% of TBSA in an adult or child.
•
Moderate Burns:
Moderate burns are partial-thickness burns that constitute 15 to
25 % of TBSA in adults or between 10 and 20% TBSA in
children. Moderate burns do not involve the face, eyes, ears,
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hands, feet, or perineum. A full-thickness burn may also be
classified as a moderate burn if it affects less than 10% TBSA.
•
Major Burns:
Major burns are partial-thickness burns, which affect more than
25% TBSA in adults and more than 20% TBSA in children. These
burns involve particular areas such as the face, eyes, ears,
hands, feet, and perineum. Full-thickness burns that cover more
than 10% of TBSA are also classified as major burns.
Edema Formation
The body’s initial response to the burn results in the release of several
chemicals that affect circulation and can cause edema. The initial, or
local response involves activation of complement, release of free
radicals, increased histamine production, and coagulation of
proteins.2,9,10 These responses all affect circulation by increasing
capillary permeability, in which fluid starts to leak out of the
intravascular space and into the interstitial space, resulting in edema.
Marked edema may be noted throughout the body, including edema of
the extremities, which places the patient at risk of limb ischemia and
compartment syndrome. Increased edema also leads to pulmonary
congestion and ultimate airway obstruction if it is not managed
properly.2,9,10,26
A significant burn injury may cause changes to the cardiovascular
system that are the same as what occurs with a severe hemorrhage,
as intravascular volume can drop significantly. In these instances, the
patient has decreased cardiac output and decreased urine output.
Alternatively, instead of blood flow leaving the body as is seen with
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hemorrhage, the fluid causes extensive edema, which must be
managed and minimized to prevent complications. The patient is at
risk of tissue ischemia and although it may seem counterproductive to
administer more fluid when excess edema is present, the patient
needs high volumes of fluid to replace what was lost from intravascular
volume.
Edema formation initially occurs in burned and damaged skin and then
moves to affect non-burned skin within the first 24 hours after injury.
Herndon (2012) Total Burn Care states that edema formation in
burned skin can occur extremely rapidly, and water content in the
tissues has been shown to double within the first hour after a burn
injury.1 The total amount of edema often peaks about 24 hours after
the initial burn injury. After about 48 hours, edema formation slows
and begins to resolve; most edema has completely resolved by 10
days after the burn injury.4 In the meantime, it is essential to provide
care to the patient that will minimize edema and control the condition
to prevent complications.1,23,24
Extremities that have been burned should be elevated in order to
promote blood flow back to the heart and to reduce the risk of such
excessive edema that compartment syndrome develops in the distal
tissues. Range-of-motion exercises are also necessary on a regular
basis to promote blood flow to the extremities and to prevent
contractures. Range-of-motion exercise is performed as the patient
tolerates, and can be very helpful in managing extremity edema.
The type and amount of fluid given during the fluid resuscitation period
may also help to control edema formation.10,27
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Administration of hypertonic saline solutions may be helpful in
reducing instances of burn shock by reducing fluid shifts from the
intravascular space to the interstitial space when the blood serum
contains more than enough sodium. Administration of hypertonic
saline solutions has been shown to reduce edema formation and to
reduce the need for emergent procedures to control excessive edema,
such as escharotomies.1 However, hypertonic saline administration is
typically not common during standard fluid resuscitation with a burn
injury. Diuretics are not recommended for use to control edema in
burn patients, except for in cases of myoglobinuria and
hyperpigmentation of the urine associated with kidney damage.
One dangerous complication of excess edema is compartment
syndrome. The muscles of the body are arranged into compartments
that are surrounded by fascia, a tough, inelastic membrane that
protects the space. With excess fluid accumulation following a burn
injury, there is risk for compartment syndrome, which is an increase in
pressure within a compartment in the body. The increased volume of
fluid from edema raises the intracompartmental pressure, leading to
pain and the potential for severe complications, including ischemia and
tissue loss.
A burn patient is at risk of compartment syndrome not only because of
the large amounts of fluid being administered during the fluid
resuscitation period, but also as a result of massive edema that may
develop following a burn injury when fluid leaks out of the
intravascular system. Compartment syndrome may develop in a
number of areas of the body, including the extremities, the abdomen,
and even the periorbital areas. As pressure increases within the
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compartment, blood flow is decreased and venous pressure rises. The
fascia overlying the area is unyielding and typically does not stretch to
accommodate the increase in fluid volume in the area. Eventually, the
blood vessels are compressed to the point of collapse and ischemia
develops in the surrounding tissue when oxygen in the bloodstream
cannot reach the area.23,27
Symptoms of compartment syndrome may include weakness,
numbness, and tingling of the area distal to the site. Additionally, the
patient may experience severe pain at the site that is proportionately
greater than the pain associated with his injuries; the pain is often
described as a deep ache or a burning pain. The area is tight and
musculature is tense at the site, and passive stretching of the muscles
causes severe pain for the patient. The skin may appear pale and cool
due to decreased circulation to the area, but this is an uncommon
finding.23,27
It may be difficult to properly identify the development of
compartment syndrome when pain is a clinical indicator. Often, burned
patients are already in pain and may not be able to identify the
difference between the pain caused from burn wounds compared to an
increase in pressure in a certain body compartment. Additionally, a
critically ill burn patient who requires mechanical ventilation and who
may be sedated will not necessarily be able to tell the provider about
increased pain in certain areas of the body. Furthermore, if the burn
patient is a child, he or she may not be able to pinpoint what is going
on and may not be able to explain exactly where the pain is or if there
are other symptoms. It is therefore up to the health team to regularly
monitor for signs and symptoms of compartment syndrome and to
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consider the effects of increased fluid administration associated with
burn treatment, as well as to take measures to minimize edema to
prevent compartment syndrome.22
Compartment syndrome has been associated with severe and
sometimes life-threatening complications for the affected patient.
Infection, contractures, paralysis, limb amputation, and kidney failure
as a result of myoglobinemia have all been seen with severe
compartment syndrome.27 If the emergency clinician suspects
compartment syndrome in a burned patient, arrangements should be
made for a surgical consult as soon as possible for further examination
of the situation and potential treatment.
Some clinicians may measure pressures within the compartment to
determine a diagnosis; however, compartment pressures are not
necessarily mandated in all situations and the clinician may choose to
treat the situation based on the patient’s presentation and the
treatment team’s report. Measurement of pressure inside a
compartment involves use of a manometer, which is a catheter-type
instrument through which a small amount of fluid can be injected into
the compartment to measure for resistance. This may not be
warranted in a patient who has been burned and, although the reading
of intracompartmental pressures is important when considering
treatment, the surgeon will decide what is most appropriate for the
patient by checking pressures or proceeding to treatment without
knowing the exact amount of pressure measurement.
Treatment of compartment syndrome involves a fasciotomy to release
the pressure within the compartment.27 Ideally, fasciotomy should be
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performed within six hours of onset of compartment syndrome to
minimize potential complications associated with the condition.
Fasciotomy involves creating a linear incision along the area where the
compartment syndrome has developed. The incision must be deep
enough to cut through the tough fascia overlying the compartment
that is contributing to increased pressure.27 Fasciotomy differs from
escharotomy in that a fasciotomy incision is deeper and cuts through
the fascia, whereas an escharotomy incision is only deep enough to
reach the subcutaneous fat and tissue and not penetrate it.
Fasciotomy may be performed after an escharotomy if the original
procedure did not relieve the pressure in the area. A fasciotomy is
typically performed in a surgical suite and should be done by a
surgeon experienced in the treatment of burn injuries. Ideally, the
procedure releases the built up pressure within a compartment and
restores blood flow to the area. Following a fasciotomy, the patient
should be monitored closely. If the procedure was performed on an
extremity, it should be elevated for 24 to 48 hours to reduce fluid
buildup distal to the site. The fasciotomy causes an open wound that
should be kept clean and monitored as any other wound, particularly
in a burn patient who may be at higher risk of infection.27
The surgeon may choose to close the fasciotomy wound later; this is
often done after several days. The swelling in the affected area needs
to go down first and there must be no evidence of a repeat occurrence
of increased pressure in the area or further development of
compartment syndrome. The patient may require a wound vacuum to
provide negative pressure for a period of time following the fasciotomy
to avoid further buildup of fluid.27
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Abdominal compartment syndrome can be extremely challenging to
control and may be associated with increased levels of fluid
administration during the fluid resuscitation period. Abdominal
compartment syndrome develops through what is known as abdominal
hypertension, when pressures in the abdominal cavity increase to
dangerous levels. Abdominal compartment syndrome is considered
when intra-abdominal pressure exceeds 20 mmHg and the patient
develops organ dysfunction that was not present at the time of the
injury. Abdominal hypertension may be more likely to develop when
crystalloid administration reaches 250 to 350 mL/kg during the
resuscitation phase. Abdominal compartment syndrome has been
shown to result in over 97% mortality among patients with burns of
over 60% TBSA.29
Abdominal compartment syndrome (ACS) may cause severe
complications, including impaired renal function, tissue ischemia in the
gastrointestinal tract, and poor perfusion to the cardiac and respiratory
systems. Monitoring urine output, while valid and applicable when
assessing the results of fluid resuscitation, will not serve as a method
of determining ACS development. The health team must instead be
acutely aware of fluid administration rates and monitor for the subtle
signs and symptoms that can indicate increased intraabdominal
pressures.29
Signs and symptoms of developing abdominal compartment syndrome
include a tense and firm abdomen, hypercapnia, decreased pulmonary
compliance, and poor urine output. If ACS is suspected, the
emergency clinician should intervene right away with further
evaluation and treatment as necessary. Nothing should be placed on
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the patient’s abdomen, and blankets or constricting clothing should be
removed.10,29
One of the fastest methods of reducing intraabdominal pressure is
through paracentesis of the abdomen to reduce excess fluid from
edema development. Paracentesis is performed to decompress the
abdomen and to restore normal pressure. It is a minimally invasive
process that is appropriate for recovering burn patients because of the
decreased risk of infection as compared to a larger incision that would
be warranted through laparotomy or an open incision to reduce
pressure. Abdominal paracentesis also has a much lower incidence of
mortality as compared to laparotomy for abdominal decompression.
The process of paracentesis involves inserting a needle into the
abdomen and drawing out excess fluid from the space. The patient
should be carefully monitored during and after the procedure for
possible complications, including bleeding and washout of lactic acid,
which can be toxic and damaging to the tissues. Some medications
may also be used to control intraabdominal pressure, the most
common includes diuretic therapy such as mannitol. However, because
burn patients are a special population, use of diuretics is not typically
recommended and abdominal compartment syndrome among this
group requires specialized management in comparison to other causes
of ACS, such as ascites.3,4,29
Continuous Monitoring
Continuous and thorough monitoring is necessary, particularly during
the acute phase after burn injury but on an ongoing basis to ensure
the patient remains in stable condition. If a large amount of TBSA is
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burned (greater than 20%) the patient will most likely need intensive
care during the initial recovery. In addition to fluid resuscitation, this
also requires hemodynamic monitoring of heart rate and blood oxygen
saturations, as well as arterial blood pressure measurements.1-4
The intensively monitored patient should also have an indwelling
urinary catheter, as urine output is one of the most important
indicators of response to fluid resuscitation. A nasogastric tube is
typically also placed to decompress the stomach, particularly among
patients with over greater than 20% total body surface area burned.
This patient population may be at greater risk of vomiting with the
further potential for aspiration of stomach contents that can lead to
infection and pneumonia in lung tissue. A nasogastric tube may be
placed at low or intermittent suction to keep excess air out of the
stomach and to prevent a gastric ileus. Additionally, the patient may
receive enteral nutrition during this time.1-3,28,30
Nutrition Status
Often, patients with extensive burns are unable to maintain adequate
oral intake; further, a patient who requires mechanical ventilation for
breathing assistance will not be able to take in any nutrition by mouth.
Enteral feedings are necessary to provide enough nutrition for wound
healing and should be started early in the burn recovery process. Part
of the monitoring process is administration of enteral nutrition to
stimulate the gastrointestinal tract and provide nutrition for the patient
as well as to determine the patient’s response.16,17
The role of early enteral nutrition in the burn patient is to prevent
gastric ileus and to promote wound healing through adequate protein
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and proper nutrient intake. However, the health team must continue to
monitor the patient’s status through nutrition intake to determine how
well he or she tolerates it and for whether there are any signs of
delayed stomach emptying or other gastrointestinal complications.
Although nothing by mouth (NPO) status is typically not warranted the
patient will need to be monitored carefully to prevent the development
of potential problems that could further complicate the healing
process.
Pain Management
Pain management is critical for the patient who has been burned.
Superficial and partial thickness burns can be extremely painful, to the
point that elevated pain levels cause changes in vital signs and may
make management of breathing and circulation difficult. While thirddegree burns may be less painful if the burn has destroyed the nerve
endings under the skin, the patient may still have significant pain
through the healing process. Pain must also be managed for necessary
surgical procedures associated with needed burn injury interventions,
including the placement of central or arterial catheters, and for any
other injuries co-occurring with the burn, such as fractures.1,10
Often a burned patient is extremely anxious about his or her injuries,
and anxiety, restlessness, and agitation may be present during the
initial stages of burn care. Alternatively, some patients have decreased
levels of consciousness and are unable to express pain; likewise,
young children cannot always express their pain or explain where it
hurts the most. In all of these situations, pain control and sedation is
important and remains a top priority in pain management of a patient
with burns. The health team should assess for signs that the patient is
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in pain regardless of whether the patient is able to express in words or
otherwise demonstrate pain. Similarly, the anxious patient may need
intravenous sedation to assist with feeling calm during the early
process of stabilization in order to complete required tasks and obtain
information about the patient’s history.
Morphine sulfate, given intravenously at 1 to 4 mg per dose, is one of
the most common methods of pain management when a burn patient
has moderate to severe pain from their wounds. This dose may be
given every 2 to 4 hours as needed for pain control. Morphine is an
opioid analgesic used for the treatment of moderate to severe pain
and, when given intravenously, can have a fairly rapid onset for pain
control. Meperidine (Demerol) is another opioid analgesic that may be
used for pain control; a typical dose would be between 10 and 40 mg
intravenously every 2 to 4 hours for severe pain.1
Since morphine and meperidine are opioids there are side effects that
both can cause, such as constipation and delayed gastric emptying,
particularly when given incrementally over a long period of time for
pain control. This should be noted in the burn patient, as gastric ileus
and decreased intestinal peristalsis are complications of which the
patient may already be predisposed. Pain medications should never be
given intramuscularly, as this method is painful for the patient and
could cause further skin and tissue damage.1
Patient History
Evaluating the patient’s history and determining if there is information
pertinent to the current situation is an important part of the patient
evaluation. The patient history may not be immediately available if the
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patient is unconscious and there are no family members present who
can provide the information. If the patient is able to answer questions,
or if there is someone with the patient who can provide appropriate
information about the patient’s history, the information can be
gathered once the patient has been stabilized. If life-threatening
circumstances are still present, it may be best to wait until the patient
is stable before attempting to gather data about the patient’s history,
unless some of the medical information directly affects the patient’s
current status.1
The best source of the patient history is directly from the patient, as
he or she can attest to what happened as the burn victim and is most
aware of their background information and health history. However,
there are times when this is inappropriate, such as if the patient is
unconscious, as mentioned, but also if the patient has consumed
alcohol or other substances that may have had a role in the injury and
impede the patient’s ability to answer questions.
Other patient circumstances may require that the clinician obtain
collateral information, such as when the patient experiences elevated
anxiety or pain levels leading to impairment of concentration or mental
cognition necessary to provide background information. If the patient
has a mental illness or other cognitive deficit, he or she may not be
able to provide accurate health information to the health team.
Children and infants who are burned are usually not reliable sources of
information about their history and events leading to the burn injury
and would require a parent or caregiver to provide information.
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Allergies
Assessment of patient allergies is an important part of the medical
history. A patient who has been burned will often need a number of
different types of fluids and medications as part of treatment and it is
essential to initially know of the existing allergies. The clinician should
learn of the patient’s allergies to avoid administering drugs or fluids
that could cause an allergic reaction, which would worsen the situation
for the patient.
Some common types of allergies encountered with patients that could
affect burn management include allergy to latex and to certain kinds of
antibiotics. While many healthcare facilities have become latex free in
their practices as a result of the increasing amounts of latex allergies
encountered, it is still important to document whether the patient has
a latex sensitivity or allergy. This is especially important if the health
team was to use any materials or equipment that could cause a latex
reaction or if the patient were to be transferred to another facility.
Since the risk of infection is high after a burn, topical antibiotics are
typically necessary. It is very important to determine if the patient has
any allergies to medications that could be given during the treatment
of burns, including antibiotics. The nurse should find out not only what
medication caused the reaction, but also the type of reaction that
occurred as well. As an example, silver sulfadiazine is a topical
ointment that is used to prevent infection in some patients with
second- or third-degree burns. Silver sulfadiazine is derived from
sulfonamides and should not be used in patients who have an allergy
to sulfa because of the possibility of a reaction.13
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Once the clinician has determined that allergies exist, the allergies
should be documented and well marked to avoid accidentally
administering medications or substances that would cause a reaction.
Since some reactions can be life threatening, it is essential to be aware
of allergies and to find out as much information about the patient’s
background as possible. It is easier to prevent an allergic reaction than
it is to manage a reaction once it has started.
Medication Reconciliation
Once the clinician finds out what type of medication the patient is
taking, he or she must decide whether or not to continue the
medication while the patient is receiving care for their burns. Through
medication reconciliation the clinician determines what medications a
patient is taking, decides whether to continue the same medications at
the same doses normally taken; and, then makes arrangements for
how the patient will take medication. The clinician will determine
whether medication will be provided by the facility pharmacy or
through the patient’s own medications.1,7
The emergency clinician should find out whether the patient is taking
any medications and the reason for taking them during the medical
history intake. This information may be gathered when learning more
about the patient’s past history. It is important to know what kinds of
medications the patient is taking, including prescription and over-thecounter preparations, as well as any herbal supplements. Since the
patient will likely receive medications as part of the burn treatment,
the clinician needs to know of any medications that the patient is
already taking in order to avoid negative drug interactions and to
prevent overdosing.
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The types of medications that the patient is taking provide helpful
information and clues about the patient’s medical history. Certain
medications have obvious purposes and knowing what medications a
patient is taking can help the clinician to better manage the patient’s
condition. For instance, if the clinician finds out that the patient
normally has a prescription for atenolol (a beta blocker medication), he
or she can know that the patient may have high blood pressure or may
have had a heart attack. Likewise, a patient who normally takes insulin
may be assumed to be diabetic even if that specific information is not
available right away.
Past Medical History
Information about the patient’s past medical history is necessary
during the treatment of burn injuries, as there could be components of
the medical history that impact the patient’s healing process. Chronic
diseases such as diabetes, kidney disease, or coronary heart disease
can impact the patient’s response to the burn and may worsen the
patient’s condition because of impaired circulation after the burn.
Learning the patient’s past medical history determines what acute or
chronic conditions exist, as well as a history of surgical procedures,
hospitalizations, and other conditions requiring medical interventions
and medications.
Understanding the patient’s history can help the medical clinician to
better deliver care and treatment of burn injuries. For example, some
conditions can further impact circulation after the initial vascular
changes have stabilized, which contributes to poor or delayed wound
healing. A patient with diabetes may have slowed wound healing while
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recovering from a burn injury; additionally, glucose levels and insulin
response must be managed throughout the recovery process.
Another aspect to consider when asking about the past medical history
is the patient’s immunization status. Although this information may not
be readily available or may not be at the forefront of the patient’s
mind after a burn injury, it is important to know if the patient has had
certain immunizations to better protect against some types of
infections.
Burn patients may be at higher risk of infection with tetanus, so it is
important to determine if the patient has had a tetanus vaccination in
the last ten years. Tetanus is a toxin created by bacteria that could
infect burn wounds, causing significant illness including muscle pain
and stiffness, seizures, and hypertension, as well as respiratory
difficulties. If a patient does not know when their last tetanus
vaccination occurred or is sure that one has not been received within
ten years, a vaccination with tetanus toxoid should be administered as
prophylaxis.1
Other factors about the patient’s medical history that would be
important to know include whether or not the patient:

is a smoker or uses alcohol or other substances.

has a history of infectious diseases, such as hepatitis or HIV.

would already be in an immunocompromised state, such as with
a cancer diagnosis or a recent organ transplant.

has a history of major illnesses or chronic diseases that may
impact the healing process, including diabetes, heart disease,
anemia, kidney problems, or lung disease.
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Many medical conditions can impact how well the patient is able to
recover from a traumatic burn injury and must be considered while the
health team is providing treatment.
Events Preceding the Injury
Knowledge of the events preceding the injury helps the health team to
understand the circumstances under which the patient became burned.
This may involve a description of an accident or event that led to the
patient becoming injured and burned; some patients may describe
events and a timeline of how they became injured as well as how they
sought help. When asking for a description of events that led to the
injury, the clinician should question whether there were other factors
present that could complicate the injury.1 For example, a burn patient
may have become injured as a result of an explosion in a grain
elevator, in which case exposure to noxious chemicals, such as
fumigant gases and nitrogen tetroxide, could have occurred.
Burns are often accompanied by inhalation of smoke or other
substances that can cause internal injuries to the respiratory tract and
mucous membranes, as well as external injuries to the skin and
subcutaneous tissues. Internal damage from carbon monoxide, smoke,
or other toxic chemicals can cause breathing difficulties and possible
airway obstruction in the burned patient.1 Exposure could also lead to
long-term lung damage when the lungs become injured as a result of
chemical exposure. For example, significant smoke exposure has been
associated with the development of acute respiratory distress
syndrome (ARDS) and eventual pulmonary fibrosis from scarring.1,20 It
is therefore a very important component of the patient’s history to
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determine if he or she was exposed to chemicals or fumes that would
have been inhaled or caused internal damage to the respiratory tract.
The emergency clinician must critically assess children who are burned
to not only care for their wounds and fluid needs but also to find out
the cause and nature of the injury.25 Children may be burned
unintentionally from such circumstances as scalds after contact with
hot food or tub water, or through injuries associated with unsafe
behavior, such as playing with matches. Alternatively, children may
arrive at a health care center after having been burned by their
caregiver as a means of punishment. A child who has been deliberately
burned may show a pattern of burns that indicates intentional injury.
The history of how the burn occurred and the pattern of the burn
injuries may not align.
A child who has been deliberately burned may be brought in for care
long after the injury occurred if the caregiver is negligent or does not
want hospital personnel involved.25 If the clinician involved in
evaluating a child suspects a deliberate burn injury was caused, he or
she should contact the proper authorities and social services for follow
up of the situation. It is also important to document information
appropriately, as it could be used at a later time during investigation.
A description of the events preceding the burn injury can also
determine whether other types of injuries occurred. The burn may not
be the only physical injury present and while management of the burn
is very important, other injuries could be present that is life
threatening or that also need to be managed concurrently with burn
care. Even a minor wound in comparison to an extensive burn, such as
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involving a broken bone, must still be managed relatively quickly, as
these conditions can cause further pain for the patient. Other
important data to obtain when learning about the events preceding the
burn include the type of burn that occurred and the substance (i.e.,
liquid, flame, electricity), object, or situation that caused the burn.
The health team may also find out the environment of where the burn
took place. It is important to know whether the patient was in an
enclosed space, such as a garage, or in an open area when the burn
occurred; and, the source of the burn injury such as fire or electricity.
It is also important to note if any bystanders or family members
stepped in to help the patient, and their actions. For example, with a
chemical burn in a place of business, a co-worker may have helped the
patient by offering assistance to flush the skin after contact with
caustic products.
Risk of Gastrointestinal Dysfunction
The risk of gastrointestinal dysfunction is increased after a severe
burn. Depending on how long it has been since the last meal, there
could be a greater potential for gastrointestinal problems if the patient
is still trying to digest food and fluids just after a burn injury. The time
of the patient’s last meal is important to know during resuscitation for
several reasons. If the patient ate a meal just prior to a burn injury,
there is an increased chance that food is still in the stomach and is
being processed in the gastrointestinal tract.1-4
Additionally, the patient with carbon monoxide poisoning as a result of
smoke inhalation is at greater risk of hypoxia and of infection in the
gastrointestinal tract. When hypoxia occurs as a result of carbon
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monoxide replacing oxygen bound to hemoglobin in the red blood
cells, the gastrointestinal tract can be adversely affected. Hypoxia
causes vasoconstriction of the intestinal tract and decreased amounts
of oxygenated blood reaching the area. As a result, food may move
more slowly through the process of digestion. There is also an
increased risk of infection when ischemic tissue does not have
adequate blood flow as a defense against bacteria proliferation.1
Finding out about the last meal a patient had prior to a burn injury is
also helpful to determine if the patient is on a special diet due to a
health condition. While some of this information may be garnered
while discussing the patient’s medical history, dietary interventions
may not be considered until the patient is asked to remember the time
and type of meal last consumed. There may also be special dietary
practices that the patient follows that are important for the health
team to know. For example, a patient may be on a gluten-free diet for
celiac disease, which provides information for the health team about
the client’s gastrointestinal health; it would also alert the clinician
about the need for a specialized diet before starting the patient on
enteral nutrition. Although it may not seem immediately important to
know the type of diet and time of the last meal consumed by a patient,
this information helps in the overall determination of medications,
treatments, and nutritional plan required to promote healing of a burn
injury.
Laboratory Work-up
Initial laboratory work-up following the burn injury can help the
medical clinician to better understand some of the internal
mechanisms occurring in the body because of the injury. Laboratory
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tests, reviewed in this section, can pinpoint many physiological
responses as a result of the injury and can help the clinician to treat
underlying issues that may be taking place but that are not outwardly
prominent.1,5,11-19
Complete Blood Count
A complete blood count (CBC) checks the status of blood cells, in
particular the red blood cells (RBC), white blood cells (WBC), and
platelets. Each of these types of cells has important functions that may
be altered by burn injuries. Red blood cells are produced in the bone
marrow and carry hemoglobin, which binds to oxygen molecules. The
red blood cells carry this oxygen throughout the body through the
bloodstream in order to provide oxygenation to the tissues and organs.
Hemoglobin levels are another component of the CBC, as well as the
hematocrit, which measures how much space the red blood cells take
up in the blood. After a burn injury, red blood cells, hematocrit, and
hemoglobin can be impacted in a number of ways. Hemoglobin may
become connected to carcinogens found in smoke associated with an
inhalation injury. These products, such as carbon monoxide, can bind
to hemoglobin and take the place of oxygen.
Red blood cell loss also occurs with a burn injury when thrombi
develop in the capillaries as the body responds to the burn by
activating the complement cascade and causing coagulation. Oxygen
free radicals are also released after the burn injury, which are
destructive to red blood cell membranes. Finally, multiple laboratory
draws and surgical procedures, as part of treatment for burn wounds,
can cause a loss of blood and, ultimately, lower levels of red blood
cells.
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Hematocrit levels are often increased in the early period after a burn.
The normal level of hematocrit is about 40% to 50% in men and 36%
to 44% in women. Following a burn injury, it is not uncommon for
hematocrit levels to rise to 55% to 60%. This suggests the need for
more fluid in the bloodstream, and is usually corrected with adequate
fluid resuscitation. However, following correction of hematocrit levels
with fluid administration, anemia may then develop in the patient. This
can occur because of the excess fluid administration, the breakdown of
red blood cells, or the inability of the body to produce more red blood
cells right away in the bone marrow. The patient most likely will need
blood transfusions, and anemia can be corrected with infusion of
packed red blood cells, which will provide less fluid than whole blood.
While it is important to monitor hematocrit levels to determine
hemoconcentration, the clinician should not set a certain hematocrit
level as a goal and attempt to transfuse to get the patient to that
point. Instead, transfusion should be based on the patient’s condition
and response, which is identified closely by monitoring the complete
blood count.
White blood cells, which are also measured in the CBC, are part of the
immune system and work to protect the body from infection. The
number of WBC in the blood is lower than the RBC count, but WBC
levels may rise quickly after an infection develops. There are several
major types of white blood cells, which would show up on a laboratory
test of a CBC that includes a differential. The major types are
neutrophils, lymphocytes, monocytes, eosinophils, and basophils. It is
essential that these cells remain in balance in order to fully protect the
body from infection. Alterations in levels of WBCs could lead to
systemic responses such as inflammation or cell destruction, which is
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ultimately detrimental to the burn patient. Platelets are essential for
blood clotting and are measured in the CBC; platelet counts often drop
after a burn injury as a result of the body’s response. The normal
amount of platelets ranges between 150,000 /L and 400,000 /L, but
low platelet counts under 100,000 /L are common for the first several
days following a burn injury.
Disorders of coagulation, including disseminated intravascular
coagulation (DIC), may be more likely to occur in burn patients due to
changes in proteins found in blood that control clotting. Systemic small
thrombi that occur in the capillaries take up extra platelets, which
result in low overall levels in the bloodstream. Small thrombi may
appear in the capillaries, which suggest an excess amount of
coagulation in the body, and these microthrombi actually inhibit blood
flow to essential organs and cause organ damage and failure. Low
platelets are also associated with infection and although initial platelet
counts may be low after the burn injury, consistently low platelet
levels several days after the injury can indicate a severe infection that
includes septicemia. A burn patient who has extensive wounds and
who develops sepsis following injury has a high rate of mortality and
sepsis, and this type of patient is associated with a low chance of
survival.
As the patient continues to recover, platelet levels may increase to the
point that the patient is at risk of blood clots and deep vein
thrombosis. The health team must provide prophylaxis in the form of
antiembolism stockings applied to nonburned areas and other methods
of maintaining adequate circulation to decrease the risk of embolism
associated with immobility. While all of CBC measures are important,
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regular checking of the patient’s platelet levels may be included in the
continuing vigilance to prevent blood-related complications following a
burn injury.
Comprehensive Metabolic Panel
The comprehensive metabolic panel (CMP) is a measure of body
electrolytes that can guide the health team as to the patient’s fluid
response, kidney and liver functions. The CMP contains several
components that are affected by burn injuries. Some of the main
components include sodium, potassium, and chloride levels, total
protein, calcium, and albumin; as well as liver function tests (LFT)
such as the aspartate aminotransferase (AST), alanine
aminotranferease (ALT), and total bilirubin.
Sodium levels change after burn injury with the shift of fluid from the
intravascular space into the interstitial space. As the fluid moves out of
circulation and into tissues, sodium particles move as well. This
decreases sodium levels in the bloodstream and causes hyponatremia.
This can be corrected in part with electrolytes found in intravenous
fluid; Lactated Ringer’s (LR) solution contains a certain amount of
sodium chloride that may be used as part of treatment and
replacement of sodium loss. Additionally, administration of Normal
Saline (NS) is a method of correcting sodium levels through
intravenous measures.
In contrast to sodium, high levels of potassium can develop in the
bloodstream as a result of muscle and tissue breakdown with burn
injuries. If kidney damage occurs because of increased myoglobin in
the bloodstream, the kidneys may be unable to excrete excess
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potassium and it can build up. This hyperkalemia can be very
dangerous and can lead to cardiac arrhythmias, some of which may be
fatal. Treatment of hyperkalemia may involve infusion of calcium
gluconate and insulin. It is very important to monitor the patient’s
potassium levels through the CMP to avoid these life-threatening
complications.
The liver can also sustain damage with a burn injury, which may be
demonstrated with altered levels of AST and ALT on the
comprehensive metabolic panel. AST and ALT are two types of
enzymes found in the liver. Measurement of the levels of these two
substances can indicate whether damage has occurred in the liver. If
the liver becomes damaged, ALT and AST may become elevated when
they leak into circulation. Edema that occurs in other parts of the body
can also develop in the liver, causing damage to the structure. These
enzymes may also be found in other structures, including the heart
and skeletal muscles; however, ALT seems to be specific to liver
injury, so when this level is elevated on the CMP blood test, it is
evidence that some level of injury to the liver has occurred. High levels
of ALT and AST may appear in blood tests as early as the first day
after the injury, and levels have been known to be as much as 200
percent higher than normal with burn injuries, indicating that liver
injury as a result of burns is rapid and can be extensive.
Albumin is a type of protein created by the liver that is necessary for
tissue repair in the body. Hypoalbuminemia may develop in burn
patients when albumin in the bloodstream leaks into the interstitial
space when capillary permeability occurs after the injury. Levels of
albumin are measured on the CMP lab test. The normal levels are
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typically between 3.4 and 5.4 g/dL. Low levels of albumin have been
shown to increase mortality among burn patients. An albumin level of
less than 2 g/dL is associated with more than 80% mortality risk in
burned patients. Because albumin is so necessary for growth and
repair of tissues, extremely low levels can significantly affect the
body’s ability to recover following a burn injury. Therefore, it is
important to continue to monitor albumin as one of the components of
the CMP blood test.
Blood Urea Nitrogen and Creatinine
Some measures of kidney function may also be determined through
the comprehensive metabolic panel lab test. The two most prominent
measures are the blood urea nitrogen (BUN) and creatinine levels. The
body creates urea as a byproduct of the breakdown of protein; urea is
normally removed from the body through the urine. If the kidneys are
not working properly, urea levels can build up in the body, causing an
elevated BUN level. Likewise, creatinine is created from the breakdown
of creatine, a substance that is made during food metabolism. Once
creatinine is formed from creatine, it is excreted from the body
through the urine. Similar to measurement of the BUN, elevated levels
of creatinine in the body can indicate that the kidneys are not filtering
this substance properly and it is building up in the bloodstream.
Creatinine may also be measured through a laboratory test known as
creatinine clearance. Checking the blood or a urine sample can be
done to perform this type of test. The creatinine clearance tests how
well the kidneys are able to excrete creatinine into the urine and the
results are typically more specific, as compared to a serum creatinine
level, to how well the kidneys are functioning. Another test, called the
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BUN-to-creatinine ratio, compares the levels of BUN and creatinine;
normally, the BUN is higher than creatinine and the ratios are between
10:1 and 20:1 in comparison. If both the BUN and the creatinine are
high, it can indicate kidney damage because the kidneys are not
properly filtering these substances from the blood. Alternatively, if the
BUN rises but the creatinine does not rise proportionately, it may
indicate that the problem is not kidney damage but, rather, the kidney
is not getting enough blood.
Blood urea nitrogen and creatinine levels are both important
measurements to consider when checking laboratory tests on a patient
who has been burned. Both levels are typically elevated after a burn
injury. If the patient does not receive enough fluids with resuscitation,
there may have low urine output, in which case the levels of BUN and
creatinine will be elevated because they are not being excreted in the
urine. Additionally, if the kidneys become damaged and are unable to
appropriately filter products into the urine, they may allow excess BUN
and creatinine to build up, causing elevated levels. By checking the
BUN/creatinine ratio, the provider can also better understand if the
kidneys are damaged or if they are not getting enough blood to
function. Along with urine output, the BUN/creatinine ratio
measurement can guide fluid resuscitation parameters and better help
providers to understand the patient’s fluid needs based on circulation
and urine production.
Glucose
Following a burn injury, the affected patient’s body begins to demand
high levels of energy for such processes as the inflammatory response
and wound healing. Burn patients typically develop hyperglycemia, a
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state in which there is too much glucose circulating in the
bloodstream. Glucose levels may be checked as part of the
comprehensive metabolic panel laboratory test, or they may be
evaluated as a separate blood test. The body responds to a burn by
increasing glucose production to meet increased energy needs.
Glucocorticoids are hormones in the body that impact the metabolism
of carbohydrates; glucocorticoids are responsible for increasing
production of glucose in the liver, which may be further elevated after
a burn injury. However, although the body may create high levels of
glucose it does not necessarily require or use all of the glucose, and
the result is sustained elevated levels of glucose circulating in the
bloodstream.
A significant burn injury is a condition that would precipitate what
researchers have termed stress-induced hyperglycemia (SIH). Stressinduced hyperglycemia occurs as a result of critical illness in which the
body causes a state of hypermetabolism in response to secretion of
various hormones and substances that occur internally when a major
injury or illness has occurred. During extreme stress, such as a burn
injury, the body secretes higher levels of epinephrine, norepinephrine,
pro-inflammatory cytokines, growth hormone, and cortisol. The body’s
response to the injury and secretion of these types of substances
results in an increase in glucose production as well.
Under normal conditions, the body would respond to increased levels
of glucose in the bloodstream by secreting insulin from the pancreas,
in order to get the cells to take up insulin to use for energy and to
reduce levels of circulating glucose in the bloodstream. However, these
effects are typically not seen in burn patients due to physiological
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factors related to the injury, such as the break down of muscle tissue
leading to a loss of lean body mass. The result is impaired glucose
tolerance and insulin resistance whereby the cells do not respond to
insulin efficiently and therefore do not use glucose in the bloodstream.
The result is hyperglycemia.
Elevated levels of blood glucose can be detrimental to burn patients.
Studies have shown that glucose should be maintained within normal
parameters in order to avoid certain risks. The burn patient with
hyperglycemia is at higher risk of wound infection, sepsis, fungal
infections, and pneumonia; and, continued hyperglycemia is
associated with poor outcome and increased morbidity. Blood glucose
levels tend to rise quickly in the acute phase following a burn injury,
but they must continue to be managed over time with regular care and
treatment of the patient.
One exact target level for blood glucose levels has not been found to
be the most beneficial and appropriate goal for burn patients. A
number of studies have shown various target glucose results to be
appropriate in response to insulin therapy. The suggested range was
from 110 mg/dL to 200 mg/dL for burn patients as appropriate
outcomes; although consistently higher levels of glucose, such as
maintaining levels at or above 200 mg/dL, has been shown to increase
mortality among burn patients.
The treatment of high blood glucose is typically intravenous
administration of insulin, which is used in conjunction with intravenous
fluids. The amount of insulin to administer is based on glucose levels,
which require frequent monitoring in the patient; the results may then
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be used to titrate the insulin dose as the body responds. Intensive
insulin therapy, which involves the administration of large amounts of
insulin in order to keep blood glucose levels below 110 mg/dL in the
burn patient, have not been shown to improve mortality in this
population.
Each institution caring for burn patients should have protocols in place
that outline the process of checking blood glucose levels, the regularity
with which this test must be performed, and the target goals of
glucose levels in this group of patients. Additionally, medical clinicians
are expected to prescribe the amount of insulin required to respond to
altered glucose levels and to set parameters according to facility policy
and research underpinning best practice guidelines at their institution
of practice. Clinicians caring for the burn patient have an important
role in the management of hyperglycemia through routine glucose
level checks and addressing the insulin requirements of the burn
patient during treatment.
Arterial Blood Gas
Blood gas analysis (ABG) is used in critically ill patients to assess for
levels of oxygenation in the bloodstream, to determine acid-base
balance of blood, and to assess for respiratory sufficiency. The normal
pH of blood is 7.35 to 7.45; the pH of the blood measures the level of
acidity. A blood pH below 7.35 is considered acidotic and a pH higher
than 7.45 is considered alkalotic. The carbon dioxide levels of the
blood gas results, if they are within normal range, should be 35 to 45
mmHg.
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Carbon dioxide (CO2) measures how much is in the bloodstream and
how well the body is able to expel it through breathing. In contrast to
the pH, a CO2 level below 35 mmHg is considered alkalotic and a CO2
level above 45 mmHg is considered acidic. The partial pressure of
oxygen (PaO2) is how much oxygen is dissolved in the bloodstream.
This level indicates how well the body is able to maintain gas exchange
at the level of the alveoli when oxygen passes from the lung tissue
into the bloodstream. The normal level of PaO2 in blood is typically 75
to 100 mmHg. A blood gas result may also show an oxygen saturation,
which indicates how much hemoglobin in the blood is saturated with
oxygen molecules. Finally, bicarbonate (HCO3) levels are measured as
part of the blood gas. Normal levels for HCO3 are between 22 and 26
mEq/L. Low levels of bicarbonate indicate acidosis, and high levels
indicate alkalosis.
The blood gas can be obtained through either an arterial sample of
blood or a venous sample. If the patient has an arterial catheter, it
may be relatively easy to obtain a sample of blood to use for blood gas
analysis. Arterial blood gases are typically more common than venous
blood gases, but venous samples may also be used particularly when
arterial blood is not available. After blood collection, the blood sample
is tested through a blood gas analyzer to measure the pH, carbon
dioxide, oxygen, and bicarbonate levels.
The outcomes of the blood gas analysis can give the health team an
idea of how well the patient is breathing and exchanging carbon
dioxide and oxygen through gas exchange in the lung tissue. If the
patient requires a mechanical ventilator, the results of the blood gas
analysis may be used to determine changes needed on the ventilator
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settings. It may not always be obvious how well the patient is
tolerating supplemental oxygen and ventilation, but a blood gas
analysis can give an indication of the patient’s internal needs, to better
identify the level of adequacy for carbon dioxide and oxygen in the
bloodstream.
Blood gas analysis is useful in determining if the patient is developing
respiratory insufficiency or is retaining carbon dioxide in the body. If a
patient has a smoke inhalation injury, the arterial PaO2 may not be
accurate. The PaO2 shows how much oxygen is dissolved in the blood
but this may be only a small portion of arterial oxygen content. If a
patient has been exposed to carbon monoxide, such as through
inhalation injury, the carbon monoxide will bind to hemoglobin instead
of oxygen, but this is not necessarily reflected in the blood gas
analysis.
A burn patient may be more likely to develop metabolic acidosis,
particularly when fluid resuscitation is inadequate. Metabolic acidosis
develops when the blood becomes too acidic and there is a reduction
in sodium bicarbonate, which is alkalotic. In other cases of metabolic
acidosis, administration of sodium bicarbonate is part of standard
treatment to regulate the blood pH and bring it back into normal
parameters. However, with the burn patient, administration of sodium
bicarbonate is not always necessary. The acidosis may be a sign that
fluid resuscitation is inadequate and that fluid must be administered at
a faster rate. Often, the acidosis is corrected when fluid administration
is corrected.
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Alkalosis, on the other hand, is more likely to develop later during the
course of treatment for burn injuries, particularly after the patient has
undergone surgical procedures and has received quantities of blood
products for transfusion. In situations where a patient is receiving
diuretics for fluid management, alkalosis may be more likely to
develop as well. The most common form of treatment of alkalosis is to
regulate the factors that are most likely causing the condition in the
first place, rather than administering medications or substances to
correct pH in the bloodstream. Regular monitoring of venous blood
gases is part of continued control of the state of pH in the blood, as
even small changes in pH on the venous gas results can be reflective
of a symptomatic state.
Carboxyhemoglobin and Lactate
Inhalation of noxious chemicals can cause changes in oxygen and
carbon dioxide levels in the bloodstream. If a patient is exposed to
large amounts of carbon monoxide because of smoke from a fire, he or
she may develop carbon monoxide poisoning. The carbon monoxide
binds to hemoglobin in the red blood cells much more readily than
oxygen; the binding of carbon monoxide with hemoglobin results in
carboxyhemoglobin and a decreased amount of oxygen reaching the
brain and other organs. A carboxyhemoglobin level should be drawn as
part of laboratory work, particularly in patients where increased levels
of carbon monoxide may be present, including any patient who has
suffered a moderate or major burn. A carboxyhemoglobin level is a
blood test that can be performed to measure the amount of carbon
monoxide and hemoglobin in the blood. Because carbon monoxide has
an affinity for hemoglobin that is 240 times that of oxygen, carbon
monoxide poisoning will demonstrate increased binding of carbon
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monoxide to hemoglobin in the blood, resulting in decreased oxygen
binding and resultant hypoxia.
Normal values for carboxyhemoglobin are less than 2.0% of total
hemoglobin. This number may be slightly elevated if the patient is a
smoker, and reference ranges are between 4.0% and 8.0% of total
hemoglobin, depending on how much the patient smokes. Values of up
to 20% may cause no symptoms in the patient, but as levels increase,
there is potential for symptoms of confusion, nausea, vomiting,
hypotension, and ultimately coma and death. Initial treatment of
carbon monoxide poisoning is administration of 100% oxygen, which
may be necessary for several hours until symptoms of toxicity resolve
and carboxyhemoglobin levels return to normal.
Smoke inhalation that occurs as part of a thermal burn injury may also
lead to acute cyanide poisoning, particularly when the patient is
exposed to fire in an enclosed area. The breakdown of certain
components produces cyanide gas, which can then be inhaled with
smoke exposure by the injured patient. Cyanide is considered a poison
that, upon entering the bloodstream, impacts important enzymatic
processes in the body, resulting in impaired functioning of the central
nervous and cardiovascular systems. The tissues and organs may still
receive oxygen in the bloodstream but they are unable to extract it
and use it effectively. Consequently, the patient may develop
symptoms such as confusion, decreased level of consciousness, and
seizures, which could ultimately lead to coma and death. In the
cardiovascular and respiratory systems, the effects of cyanide
exposure lead to hypotension, tachycardia, and possible ventricular
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fibrillation. The patient’s respiratory rate becomes dampened and may
lead to hypoventilation and ultimate apnea.
Serum lactate levels may be checked as part of laboratory testing
when a patient presents with smoke inhalation after a burn injury.
Increased levels of lactate may be associated with exposure to
cyanide. Normal levels of lactate are 0.5 - 2.2 mmol/L, but levels
above 8 mmol/L have been correlated with cyanide poisoning.
Increased lactic acid levels may develop in the bloodstream during
times of hypoxia. Lactic acid is a by-product of the breakdown of
skeletal muscle cells and red blood cells. Elevated levels of serum
lactate may occur as a result of hypoxia associated with cyanide
exposure.
It may be difficult to determine if the patient is suffering from
symptoms related to the burn injury or another injury associated with
the burn, such as a head injury from an accident that resulted in a
burn. Certain injuries can lead to similar symptoms that may also be
associated with carbon monoxide or cyanide poisoning, such as altered
level of consciousness, tachycardia, and hypotension. If carbon
monoxide or cyanide poisoning is a possibility in any patient,
carboxyhemoglobin and serum lactate levels should be drawn as part
of lab work to determine if toxicity is present.
Blood Type and Crossmatch
Blood type and crossmatch is most likely necessary in order to provide
appropriate blood products for the patient when needed. Blood typing
refers to determining whether the patient is type A, B, AB, or O and to
determine if the patient is Rh negative or positive. The crossmatch
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involves mixing a small amount of the patient’s blood with a small
amount of donor blood to determine if the samples are compatible or if
there would be a transfusion reaction.
The blood type and crossmatch is performed in case the patient needs
blood products, even if the need is not necessary right away. It will be
necessary to monitor the patient’s lab work, including the hemoglobin
and hematocrit levels, to determine if the patient needs blood
products. Consideration should be made between whole blood and
packed red blood cells, as whole blood contributes more to fluid levels
in the bloodstream as compared to packed red cells. A patient already
receiving large amounts of crystalloids may not tolerate further fluid
through whole blood if their condition can otherwise be corrected with
packed red blood cells. Although it is common that burn patients
typically need transfusion of blood products at some point during
hospitalization, the decision at what point to transfuse depends upon
the patient’s condition and status, as well as the provider’s
understanding of the situation and the facility guidelines.
Summary
Appropriate burn care requires an initial period of rapid response to
stabilize the patient and prevent complications that could be life
threatening. Following the initial response and the acute period after
the burn, ongoing care and vigilance is essential to ensure that the
patient receives proper treatment and does not develop further
problems associated with the traumatic injury. While it is essential to
provide initial care through management of the patient’s airway,
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breathing, and circulation, other measures are also necessary after
these initial components of stabilization are complete.
Fluid resuscitation, enteral nutrition, infection prevention, and
monitoring of laboratory values, as well as maintaining patient
comfort, are just some of the measures implemented in providing total
burn care during the initial period after injury. Continued monitoring
and response to changes can ensure that a burn patient moves toward
recovery in as safe a manner as possible.
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1.
True or False: Airway edema is generally apparent in the
initial phases of a burn injury requiring immediate airway
stabilization.
a. True
b. *False
2.
During the secondary survey, the health team may uncover
injuries not initially apparent in a burn patient, such as:
a.
b.
c.
d.
3.
An escharotomy involves an incision
a.
b.
c.
d.
4.
made outside the burned skin using a scalpel.
deep enough to penetrate the subcutaneous fat.
*to release pressure in the burned area.
used for debridement of eschar.
A Lund and Browder chart is used for
a.
b.
c.
d.
5.
Fractures
Dislocations
Abdominal injuries
*All of the above
*estimating the burn extent in a patient.
estimating fluid loss of a burn patient.
estimating the range of motion of a burn patient.
All of the above
True or False: Range-of-motion exercises are necessary to
promote blood flow to the extremities and prevent
contractures in a burn patient.
a. *True
b. False
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6.
While providing care for a burn patient, which of the
following best expresses a provider’s care for a patient
with potential edema formation and airway obstruction?
a. Provider must assess and stabilize the airway for inhalation
injuries only
b. Provider must assess airway obstruction only if patient has
difficulty breathing
c. *Provider must continually assess and stabilize the airway
d. Provider must stabilize airway immediately after injury
7.
Morphine sulfate may be administered to a burn patient as
follows:
a.
b.
c.
d.
8.
The comprehensive metabolic panel (CMP) is used to help
guide treatment of the burn patient but does not include:
a.
b.
c.
d.
9.
*Intravenously, 1 to 4 mg per dose every 2 to 4 hours
Intramuscularly, 10 mg per dose every 6 hours
Mild narcotic analgesia needed for pain control
Intravenously, 0.5 to 1 mg per dose every hour
potassium level
sodium level
liver function tests
*neutrophil count
True or False: A nurse who suspects deliberate burns to a
child by a caregiver should contact the proper authorities
and social services for follow up of the situation.
a. *True
b. False
10. Blood gas analysis (ABG), used to assess for levels of
oxygenation in the bloodstream, have normal values of:
a.
b.
c.
d.
pH of 7.35 to 7.45
CO2 of 35 to 45 mmHg
PaO2 of 75 to 100 mmHg
*All of the above
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11. Airway intubation should be performed to support
respiratory ventilation
a. for inhalation injuries only.
b. after signs of edema or an obstructed airway are present.
c. *while the provider assesses the extent of edema formation
in the patient’s throat.
d. if the throat and airway passages are constricted.
12. A patient who is awake and alert, and who has no
neurological deficits or penetrating injuries, and does not
have pain in the neck and shoulder area, ______________
to clear the cervical spine and for removal of a cervical
collar.
a.
b.
c.
d.
must have a GCS score of 15 points
must have an x-ray
*does not need an x-ray
must have airway intubation
13. True or False: Serum lactate is checked for all electrical
burns.
a. True
b. *False
14. In a patient with an ______________ that has an entry
and exit point, cardiac arrhythmias may develop.
a.
b.
c.
d.
burn shock
pulse oximetry
impaired circulation
*electrical burn
15. A patient with burns that extend around a body part or
wrap around an extremity is said to have
a.
b.
c.
d.
*circumferential burns.
burn shock.
superficial burns.
impaired circulation.
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16. Burn management is dependent on the following factor(s):
a.
b.
c.
d.
superficial versus deep burns.
*type, depth and extent of burns.
formation, obstruction and neurology.
resuscitation, nutrition, and infection prevention.
17. Which of the following burn types involves the epidermis
and lower layers of the dermis but not the structures
underneath?
a.
b.
c.
d.
First-degree burns
Circumferential burns
Third-degree burns
*Second-degree burns
18. With a burn patient, administration of sodium bicarbonate
is part of standard treatment
a.
b.
c.
d.
*to regulate the blood pH.
in all cases.
for alkalosis.
for electrical burns.
19. As the fluid moves out of circulation and into tissues,
sodium particles move as well. This decreases sodium
levels in the bloodstream and causes
a.
b.
c.
d.
hypercapnia.
hypoxia.
*hyponatremia.
hypoalbuminemia.
20. True or False: With burn patients, a provider should set a
certain hematocrit level as a goal and attempt to transfuse
to get the patient to that point.
a. True
b. *False
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Correct Answers:
1.
True or False: Airway edema is generally apparent in the
initial phases of a burn injury requiring immediate airway
stabilization.
b. False
“Because airway edema may not be apparent immediately
and develop over a period of time, the clinician must continue
to assess and stabilize the airway while providing care for the
patient.”
2.
During the secondary survey, the health team may uncover
injuries not initially apparent in a burn patient, such as:
a.
b.
c.
d.
Fractures
Dislocations
Abdominal injuries
*All of the above
“During the secondary survey, the health team may uncover
other injuries that have occurred that may not have been
initially apparent when the burn injuries were first being
managed…. Some examples of injuries include fractures,
dislocations or abdominal injuries.”
3.
An escharotomy involves an incision
c. to release pressure in the burned area.
“Escharotomy involves using a scalpel to cut into the burned
skin; the incision is deep enough to reach but does not
penetrate the subcutaneous fat underneath. This incision is
done to release the pressure buildup that occurs in the
affected area. The eschar incision is drawn along the length of
the affected area to about 1 cm past each end of the burn.
The goal of the procedure is to reduce the pressure in the
affected area and restore normal circulation to the site.
“Fasciotomy differs from escharotomy in that a fasciotomy
incision is deeper and cuts through the fascia, whereas an
escharotomy incision is only deep enough to reach the
subcutaneous fat and tissue and not penetrate it.”
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4.
A Lund and Browder chart is used for
a. estimating the burn extent in a patient.
“Although the Rule of Nines is helpful and can be instituted
quickly, the Lund and Browder method is another more
comprehensive and accurate approach to estimate burn
injuries… This method also involves a scoring system, but the
body parts assessed are grouped in smaller segments. These
smaller groups provide more accurate assessment when
compared to the Rule of Nines, particularly if a burn affects a
smaller body area.”
5.
True or False: Range-of-motion exercises are necessary to
promote blood flow to the extremities and prevent
contractures in a burn patient.
a. True
“Range-of-motion exercises are also necessary on a regular
basis to promote blood flow to the extremities and to prevent
contractures.”
6.
While providing care for a burn patient, which of the
following best expresses a provider’s care for a patient
with potential edema formation and airway obstruction?
c. Provider must continually assess and stabilize the airway
“A burn patient may have suffered injuries that could cause
the airway to swell and constrict, thereby impeding airflow.
Edema formation and airway obstruction can occur quickly
with certain types of injuries, such as inhalation injuries, or
may develop slowly over time. Because airway edema may
not be apparent immediately and develop over a period of
time, the clinician must continue to assess and stabilize the
airway while providing care for the patient.”
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7.
Morphine sulfate may be administered to a burn patient as
follows:
a. Intravenously, 1 to 4 mg per dose every 2 to 4 hours
“Morphine sulfate, given intravenously at 1 to 4 mg per dose,
is one of the most common methods of pain management
when a burn patient has moderate to severe pain from their
wounds. This dose may be given every 2 to 4 hours as
needed for pain control.”
8.
The comprehensive metabolic panel (CMP) is used to help
guide treatment of the burn patient and does not include:
d. neutrophil count
“The comprehensive metabolic panel (CMP) is a measure of
body electrolytes that can guide the health team as to the
patient’s fluid response, kidney and liver functions. The CMP
contains several components that are affected by burn
injuries. Some of the main components include sodium,
potassium, and chloride levels, total protein, calcium, and
albumin; as well as liver function tests (LFT) such as the
aspartate aminotransferase (AST), alanine aminotranferease
(ALT), and total bilirubin.”
9.
True or False: A nurse who suspects deliberate burns to a
child by a caregiver should contact the proper authorities
and social services for follow up of the situation.
a. True
“If the medical provider or nurse involved in evaluating a
child suspects a deliberate burn injury was caused, he or she
should contact the proper authorities and social services for
follow up of the situation.”
10. Blood gas analysis (ABG), used to assess for levels of
oxygenation in the bloodstream, have normal values of:
a.
b.
c.
d.
pH of 7.35 to 7.45
CO2 of 35 to 45 mmHg
PaO2 of 75 to 100 mmHg
*All of the above
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“Blood gas analysis (ABG) is used in critically ill patients to
assess for levels of oxygenation in the bloodstream, to
determine acid-base balance of blood, and to assess for
respiratory sufficiency. The normal pH of blood is 7.35 to
7.45; …. The carbon dioxide levels of the blood gas results, if
they are within normal range, should be 35 to 45 mmHg …
The normal level of PaO2 in blood is typically 75 to 100
mmHg.”
11. Airway intubation should be performed to support
respiratory ventilation
c. while the provider assesses the extent of edema formation
in the patient’s throat.
“Airway intubation should be performed to support respiratory
ventilation while the emergency provider simultaneously
addresses the extent of edema formation in the patient’s
throat.”
12. A patient who is awake and alert, and who has no
neurological deficits or penetrating injuries, and does not
have pain in the neck and shoulder area, ______________
to clear the cervical spine and for removal of a cervical
collar.
c. does not need an x-ray
“Alternatively, a patient who is awake, and alert, has no
neurological deficits or penetrating injuries, and does not
have pain in the neck and shoulder area, does not need an xray to clear the cervical spine. In such cases, the cervical
collar can be removed.”
13. True or False: Serum lactate is checked for all electrical
burns.
b. False
“Serum lactate levels may be checked as part of laboratory
testing when a patient presents with smoke inhalation after a
burn injury…. If carbon monoxide or cyanide poisoning is a
possibility in any patient, carboxyhemoglobin and serum
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lactate levels should be drawn as part of lab work to determine
if toxicity is present.”
14. In a patient with an ______________ that has an entry
and exit point, cardiac arrhythmias may develop.
d. electrical burn
“A patient who has suffered an electrical burn may be at risk
for cardiac abnormalities. In a patient with an electrical burn
that has an entry and exit point cardiac arrhythmias may
develop as a result of the electricity from the burn disrupting
the cardiac electrical cycle.”
15. A patient with burns that extend around a body part or
wrap around an extremity is said to have
a. circumferential burns.
“Circumferential burns are those that extend around a body
part, such as one that is wrapped around an extremity.”
16. Burn management is dependent on the following factor(s):
b. type, depth and extent of burns.
“Burn management is dependent on the type of burn that has
occurred, the depth of the burn, and the extent of the burn
covering the body.”
17. Which of the following burn types involves the epidermis
and lower layers of the dermis but not the structures
underneath?
d. Second-degree burns
“Second-degree or deep partial-thickness burns are those
involving the epidermis and lower layers of the dermis but not
the structures underneath.”
18. With a burn patient, administration of sodium bicarbonate
is part of standard treatment
a. to regulate the blood pH
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“In other cases of metabolic acidosis, administration of
sodium bicarbonate is part of standard treatment to regulate
the blood pH and bring it back into normal parameters.
However, with the burn patient, administration of sodium
bicarbonate is not always necessary.”
19. As the fluid moves out of circulation and into tissues,
sodium particles move as well. This decreases sodium
levels in the bloodstream and causes
c. hyponatremia.
“As the fluid moves out of circulation and into tissues, sodium
particles move as well. This decreases sodium levels in the
bloodstream and causes hyponatremia.”
20. True or False: With burn patients, a provider should set a
certain hematocrit level as a goal and attempt to transfuse
to get the patient to that point.
b. False
“While it is important to monitor hematocrit levels to
determine hemoconcentration, the provider should not set a
certain hematocrit level as a goal and attempt to transfuse to
get the patient to that point.”
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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.
Herndon, D. N. (2012). Total burn care: Expert consult.
Philadelphia, PA: Elsevier Saunders
2. Baldwin-Rodriguez, B. (n.d.). Burn trauma injuries. Retrieved
from
http://dynamicnursingeducation.com/class_more.php?class_id=1
26&more=91
3. Rice, P. L., Orgill, D. P. (2014, Apr). Emergency care of moderate
and severe thermal burns in adults. Retrieved from
http://www.uptodate.com/contents/emergency-care-ofmoderate-and-severe-thermal-burns-in-adults
4. Bacomo, F. K., Chung, K. K. (2011). A primer on burn
resuscitation. Journal of Emergencies, Trauma and Shock 4(1):
109-113. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097558/#!po=36
.6667
5. University of Michigan Trauma Burn Center. (2014). Fluid
resuscitation. Retrieved from
http://www.traumaburn.org/referring/fluid.shtml
6. University of Wisconsin (2016). Assessing Burns and Planning
Resuscitation: Rule of Nines. Emergency Medicine. Retrieved
online at http://www.uwhealth.org/emergency-room/assessingburns-and-planning-resuscitation-the-rule-of-nines/12698.
7. Nurse Labs. (2012, Mar.). Burn injury. Retrieved from
http://nurseslabs.com/burn-injury-nursing-management/
8. Kirchheimer, S. (2013, Dec.). Electrical burns. Retrieved from
http://www.med.nyu.edu/content?ChunkIID=163347
9. Rice, P., et al. (2016). Classification of burns. Up To Date.
Retrieved online at
http://www.uptodate.com/contents/classification-of-burns.
10. Gauglitz, G. and Williams, F. (2016). Overview of the
management of the severely burned patient. Up To Date.
Retrieved from https://www.uptodate.com/contents/overview-ofthe-management-of-the-severely-burnedpatient?source=search_result&search=burn%20injuries&selected
Title=3~150.
11. Hamel, J. (2011, Feb.). A review of acute cyanide poisoning with
a treatment update. Critical Care Nurse 31(1): 72-81.
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12. Fazal, N. (2012). T-cell suppression in burn and septic injuries.
Retrieved from http://cdn.intechopen.com/pdfs-wm/29072.pdf
13. Wiktor, A. and Richards, D. (2016). Treatment of Minor Thermal
Burns. Up To Date. Retrieved online at
https://www.uptodate.com/contents/treatment-of-minor-thermalburns?source=search_result&search=silvadene&selectedTitle=6~
34.
14. American Burn Association. (n.d.). Burn center referral criteria.
Retrieved from
http://www.ameriburn.org/BurnCenterReferralCriteria.pdf
15. Hall, K. L., Shahrohki, S., Jeschke, M. G. (2012, Nov.). Enteral
nutrition support in burn care: A review of current
recommendations as instituted in the Ross Tilley Burn Centre.
Nutrients 4(1): 1554-1565. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509506/
16. Parrillo, J. E., Dellinger, R. P. (2014). Critical care medicine:
Principles of diagnosis and management in the adult (4th ed.).
Philadelphia, PA: Elsevier Saunders
17. Aguayo-Becerra, O. A., Torres-Garibay, C., González-Ojeda, A.
(2013, Jul.). Serum albumin level as a risk factor for mortality in
burn patients. Clinics (Sao Paulo) 68(7): 940-945. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714858/
18. Davita.com. (2014). What is creatinine? Retrieved from
http://www.davita.com/kidney-disease/overview/symptoms-anddiagnosis/what-is-creatinine?/e/4726
19. Mecott, G. A., Al-Mousawi, A. M., Gauglitz, G. G., Herndon, D. N.,
Jeschke, M. G. (2010, Jan.). The role of hyperglycemia in burned
patients: Evidence-based studies. Shock 33(1): 5-13. Retrieved
from
http://journals.lww.com/shockjournal/Fulltext/2010/01000/The_R
ole_of_Hyperglycemia_in_Burned_Patients_.3.aspx
20. Micak, R. (2016). Inhalation injury from heat, smoke or chemical
irritants. Up To Date. Retrieved online at
https://www.uptodate.com/contents/inhalation-injury-from-heatsmoke-or-chemicalirritants?source=search_result&search=smoke%20inhalation&sele
ctedTitle=1~90.
21. U.S. Army Medical Department. (2013). Emergency war surgery
(4th ed.). Fort Sam Houston, TX: Borden Institute
22. Sharar, S. and Olivar, H. (2016). Anesthesia for burn patients. Up
To Date. Retrieved online at
https://www.uptodate.com/contents/anesthesia-for-burnpatients?source=search_result&search=burn%20and%20fluid%2
0administration&selectedTitle=2~150.
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23. Henry, M. C., Stapleton, E. R. (2012). EMT prehospital care (4th
ed.). Burlington, MA: Jones & Bartlett Learning
24. Alharbi, Z., Piatkowski, A., Dembinski, R., Reckort, S., Grieb, G.,
Kauczok, J., Pallua, N. (2012). Treatment of burns in the first 24
hours: Simple and practical guide by answering 10 questions in a
step-by-step form. World Journal of Emergency Surgery 7(13).
25. Joffe, M. (2016). Emergency care of moderate and severe thermal
burns in children. Up To Date. Retrieved online at
https://www.uptodate.com/contents/emergency-care-ofmoderate-and-severe-thermal-burns-inchildren?source=search_result&search=pediatric%20burn%20car
e&selectedTitle=3~150.
26. Aityeh, B. S., Zgheib, E. R. (2012, Jun.). Acute burn resuscitation
and fluid creep: It is time for colloid rehabilitation. Annals of Burn
and Fire Disasters 25(2): 59-65. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506208/
27. Stracciolini, A., Hammerberg, E. M. (2014, Jul.). Acute
compartment syndrome of the extremities. Retrieved from
http://www.uptodate.com/contents/acute-compartmentsyndrome-of-the-extremities
28. Boffard, K. D. (Ed.). (2011). Manual of definitive surgical trauma
care (3rd ed.). Boca Raton, FL: CRC Press
29. Gestrig, M. (2016). Abdominal Compartment Syndrome. Up To
Date. Retrieved online at
https://www.uptodate.com/contents/abdominal-compartmentsyndrome-inadults?source=search_result&search=abdominal%20compartmen
t%20syndrome&selectedTitle=1~60.
30. Pollack, A. N. (Ed.). (2011). Critical care transport. Sudbury, MA:
Jones and Bartlett Publishers.
31. Armstrong, D. and Meyr, A. (2016). Clinical assessment of
wounds. Up To Date. Retrieved online at
https://www.uptodate.com/contents/clinical-assessment-ofwounds?source=search_result&search=eschar&selectedTitle=2~9
5.
32. Wolf, S. (2016). Overview and management strategies for the
combined burned trauma patient. Up To Date. Retrieved online at
https://www.uptodate.com/contents/overview-and-managementstrategies-for-the-combined-burn-traumapatient?source=search_result&search=eschar&selectedTitle=3~9
5.
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