A major burn is a horrifying injury, requiring painful treatment and a long period of rehabilitation. It’s commonly fatal or permanently disfiguring and incapacitating (both emotionally and physically).
Thermal burns, the most common type, are commonly the result of residential fires, automobile accidents, children playing with matches, improperly stored gasoline, space heater or electrical malfunctions, or arson. Other causes include improper handling of firecrackers, scalding accidents, and kitchen accidents (such as a child climbing on top of a stove or grabbing a hot iron). Some burns in children are traced to parental abuse.
Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkalis, or vesicants. Electrical burns usually occur after contact with faulty electrical wiring or high-voltage power lines; many children sustain them by chewing on electric cords. Friction, or abrasion, burns happen when the skin is rubbed harshly against a coarse surface. Sunburn, of course, follows excessive exposure to sunlight.
In the United States, about 2.4 million people suffer burns annually. Fire ranks fifth among accidental injuries, after motor vehicle accidents, poisoning, falls, and drowning.
One goal of assessment is to determine the depth of skin and tissue damage. A partial-thickness burn damages the epidermis and part of the dermis, whereas a full-thickness burn affects the full dermis and, possibly, subcutaneous tissue. A more traditional method gauges burn depth by degrees. However, most burns are a combination of different degrees and thicknesses. (See Gauging burn depth.)
Burn degrees are classified as follows:
❑ First degree — Damage is limited to the epidermis, causing erythema and pain.
❑ Second degree — The epidermis and part of the dermis are damaged, producing blisters and mild to moderate edema and pain.
❑ Third degree — The epidermis and the dermis are damaged. No blisters appear, but white, brown, or black leathery tissue and thrombosed vessels are visible.
❑ Fourth degree — Damage extends through deeply charred subcutaneous tissue to muscle and bone.
Another assessment goal is to estimate the size of a burn, which is usually expressed as the percentage of body surface area (BSA) covered by the burn. The Rule of Nines chart usually provides this estimate, but the Lund and Browder chart is more accurate because it allows for BSA changes with age.
A correlation of the burn’s depth and size permits an estimate of its severity as follows:
❑ major — third-degree burns on more than 10% of BSA; second-degree burns on more than 25% of adult BSA (more than 20% in children); burns of hands, face, feet, or genitalia; burns complicated by fractures or respiratory damage; electrical burns; all burns in poor-risk patients
❑ moderate — third-degree burns on 2% to 10% of BSA; second-degree burns on 15% to 25% of adult BSA (10% to 20% in children)
❑ minor — third-degree burns on less than 2% of BSA; second-degree burns on less than 15% of adult BSA (10% in children).
Here are other important factors in assessing burns:
❑ Location — Burns on the face, hands, feet, and genitalia are the most serious because of possible function loss.
❑ Configuration — Circumferential burns can cause total occlusion of circulation in an extremity as a result of edema. Burns on the neck can produce airway obstruction, whereas burns on the chest can lead to restricted respiratory expansion.
❑ History of complicating medical problems — Note any disorders that impair peripheral circulation, especially diabetes, peripheral vascular disease, and chronic alcohol abuse.
❑ Patient age — Victims younger than age 4 or older than age 60 have a higher incidence of complications and, consequently, a higher mortality.
❑ Smoke inhalation — This can result in pulmonary injury. Inhalation injury should be suspected if the victim was in an enclosed space.
❑ Other injuries sustained at the time of the burn — Explosion and blast injuries can be caused by the person being thrown or falling from a height, resulting in other traumatic injuries.
Immediate, aggressive burn treatment increases the patient’s chances of survival. Later, supportive measures and strict sterile technique can minimize infection. Because burns require such comprehensive care, good nursing can make the difference between life and death. (See Managing burns with skin grafts.)
❑ Immediately assess the patient’s airway, breathing, and circulation (ABCs). Be especially alert for signs of smoke inhalation and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Assist with endotracheal intubation and administer 100% oxygen as ordered.
❑ When you have ensured the patient’s ABCs, take a brief history of the burn. Draw blood samples for complete blood count, type and crossmatch, and electrolyte, glucose, blood urea nitrogen, creatinine, and arterial blood gas levels, including a carboxyhemoglobin level.
❑ Control bleeding and remove smoldering clothing (soak it first in normal saline solution if it’s stuck to the patient’s skin), rings, and other constricting items. Be sure to cover burns with a clean, dry, sterile bed sheet. (Never cover large burns with saline-soaked dressings because they can drastically lower body temperature.)
❑ Begin I.V. therapy immediately to prevent hypovolemic shock and maintain cardiac output. Use lactated Ringer’s solution or a fluid replacement formula as ordered. (See Fluid replacement after a burn.) Closely monitor intake and output and frequently check vital signs. Although doing so may make you nervous, don’t be afraid to take the patient’s blood pressure because of burned limbs.
For minor burns, immerse the burned area in cool normal saline solution (557 F [12.87 C]) or apply cool compresses. Administer pain medication as ordered. Debride the devitalized tissue, taking care not to break any blisters. Cover the wound with an antimicrobial agent and a nonstick bulky dressing, and administer tetanus prophylaxis as ordered.
❑ Tissue damage from electrical burns is difficult to assess because internal destruction along the conduction pathway is usually greater than the surface burn would indicate. Electrical burns that ignite the patient’s clothes may cause thermal burns as well. If the electric shock caused ventricular fibrillation with cardiac and respiratory arrest, begin cardiopulmonary resuscitation at once. Get a voltage estimate. (For more details, see “Electric shock,” page 312.)
❑ Irrigate a chemical burn with copious amounts of water or normal saline solution. Using a weak base such as sodium bicarbonate to neutralize hydrofluoric acid, hydrochloric acid, or sulfuric acid on skin or mucous membrane is contraindicated because the neutralizing agent can actually produce more heat and tissue damage.
If the chemical entered the patient’s eyes, flush them with large amounts of water or normal saline solution for at least 30 minutes; in an alkali burn, irrigate until the pH of the cul-de-sacs returns to 7. Have the patient close his eyes, and cover them with a dry, sterile dressing. Note the type of chemical that caused the burn and the presence of any noxious fumes. The patient will need an emergency ophthalmologic examination.
❑ Don’t treat the burn wound itself in the emergency department if the patient is to be transferred to a specialized burn care unit within 4 hours after the burn. Instead, prepare the patient for transport by wrapping him in a sterile sheet and a blanket for warmth and elevating the burned extremity to decrease edema. Then transport him immediately.
While the patient is hospitalized:
❑ A central venous pressure line and additional I.V. lines (using venous cutdown if necessary) and an indwelling urinary catheter may be inserted. To combat fluid evaporation through the burn and the release of fluid into interstitial spaces (possibly resulting in hypovolemic shock), continue fluid therapy as ordered.
❑ Check vital signs every 15 minutes (the physician may insert an arterial line if blood pressure is unobtainable with a cuff). Send a urine specimen to the laboratory to check for myoglobinuria and hemoglobinuria.
❑ Consult nutritional therapy to provide tube feeding, total parenteral nutrition, or a high-calorie diet, as appropriate.
❑ Insert a nasogastric tube to decompress the stomach and avoid aspiration of stomach contents.
Before the patient is released from the hospital:
❑ Ensure that the patient’s immunizations are current, particularly tetanus.
❑ Arrange physical and occupational therapy consultations for the severely burned patient, as indicated.
❑ Provide referral to a reconstructive surgeon for the patient disfigured by burns. Psychological counseling may also be beneficial.
❑ Provide thorough teaching and complete aftercare instructions for the patient. Stress the importance of keeping the dressing dry and clean, elevating the burned extremity for the first 24 hours, taking analgesics as ordered, and returning for a wound check in 1 to 2 days.
Review other book chapters online related to Electrical burns:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
» Next page: Burns (Handbook of Diseases)
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