1. Burns Today, Burns Tomorrow
Cindy Schmitz RN, MS, ANP
Melissa Beltran, MSN, RN, CCRN
Carl Hershey

2. Objectives
Describe initial evaluation and management of a burn patient
Review Burn Center locations and referral criteria
Discuss life after burn injury from a patient’s perspective

3. Types of Burns 2005-2014 data from ameriburn.org
Admission Cause: 43% Fire/Flame, 34% Scald, 9% Contact, 4% Electrical, 3% Chemical, 7% Other

4. Where Burns Occur 2005-2014 data from ameriburn.org
Place of Occurrence: 73% Home, 8% Occupational, 5% Street/Highway, 5% Recreational/Sport, 9% Other

5. Admissions by Age

6. % of Admissions vs. Burn Size

7. Skin Anatomy

9. The inflammatory phase
The inflammatory phase. Bacteria and debris are removed from the wound, and factors are released that cause the migration and division of cells involved in the proliferative phase.
The proliferative phase is characterized by collagen deposition, granulation tissue formation, epithelialization, and wound contraction. New blood vessels are formed and epithelial cells proliferate and ‘crawl’ atop the wound bed, providing cover for the new tissue.[7]
The contraction phase. The wound is made smaller by the action of myofibroblasts, which establish a grip on the wound edges and contract themselves.
Maturation and remodelling phase, collagen is remodelled and realigned along tension lines and cells that are no longer needed are removed by apoptosis (natural predetermined cell death).

10. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

11. Smoke Inhalation Assessment
Flame burns
Enclosed space
Burns to face, mucosal membranes
Singed eyelashes, nasal hairs
Carbonaceous sputum
Hoarseness
Difficulty swallowing
Wheezing, stridor
Restlessness, confusion

12. Smoke Inhalation Carbon Monoxide Poisoning Time to CO clearance
Add CO graph from slide 14
CO levels associated symptoms

13. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

14. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

15. Estimate % TBSA Burned Rule of Nines
Patient’s palmar surface = 1% TBSA

16. Estimate % TBSA Burned
Lund and Browder Chart

17. Estimate Burn Depth Factors Temperature Duration of contact
Dermal thickness
Blood supply
Special Consideration: Very young and very old have thinner skin

18. Burn Depth

19. Superficial : 1st Degree
Epidermis only
Pain & redness
Heals in few days;
outer injured epithelial cells peel
Seldom clinically significant

20. Partial Thickness: 2nd Degree
Entire epidermis & portion of dermis
Pain, blisters, moist, capillary refill
Uninjured dermis & epidermal appendages at risk
Heals spontaneously in 2-3 weeks
Deeper partial thickness -Skin graft may improve functional & cosmetic outcome

21. Full Thickness: 3rd degree
All skin layers are affected
white, hemorrhagic, brown, black, or charred
Inelastic and leathery
painless or numb
Requires skin grafting for definitive closure

22. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

23. IV Access Large burn -2 large bore IV’s
Smaller burn (< 15% TBSA) – one IV is OK
oral resuscitation possible
IV through non-burn area if possible
Suture IV’s started through burns

24. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

25. Pre-hospital Fluids For Burns over 20% TBSA burned
American Burn Association Recommendations
For Burns over 20% TBSA burned
EMT/Paramedics Start IV Fluid:
Adults: 500 mL/hour
Children (<40 kg): 250 mL/hour
Children (<10 kg): 125 mL/hour

26. Calculated Resuscitation in First 24 Hours
Parkland formula - LR
2 mL x weight in kg x % TBSA burned
Give ½ the volume in first 8 hours
Give other ½ over next 16 hours
Example
2 ml x 100 kg x 45% TBSA burned
2 x 100 x 45 = 9,000 ml over the first 24 hours
½ of that is 4,500 over first 8 hours
Start LR at 560 ml/hour

27. Calculated Resuscitation in First 24 Hours
Pediatric patients <20 kg
Parkland Formula - LR
2 ml x 13 kg x 45% tbsa burned
1170 ml
Start LR at 75 ml/hr
Also run maintenance fluid
D5 LR at maintenance rate
Calculated Using the "4-2-1" Rule:
For 0-10kg: 4 mL/kg/hr
For 10-20kg: + 2 mL/kg/hr
For >20kg: + 1 mL/kg/hr
46 ml/hr
Continuous infusion- don’t titrate

28. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm

29. Monitor Urine Output Place Foley if > 20% TBSA Adequate output is:
1mL/kg/hr in children
0.5 mL/kg/hr in adults (30 – 50 mL/hr)
Titrate LR to maintain urine output
Do not use diuretics to increase urine output
Urine output goal 100mL/hr if concern for myoglobinuria

30. Initial Evaluation & Management
Assess airway/breathing
Ensure source of heat removed
Estimate extent of burn
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
KEEP PATIENT WARM!!!!!

31. Next Priorities
Insert NG tube
Escharotomies
Medications
Wound care

32. Next Priorities
Insert NG tube
Escharotomies
Medications
Wound care

33. Escharotomies Only for leathery, circumferential, full-thickness burns
Rarely needed if transport < 12 hours
Almost always done at the Burn Center
Emergent indications:
Unable to ventilate
Pulseless, painful extremity

34. Next Priorities
Insert NG tube
Escharotomies
Medications
Wound care

35. Medications Pain control More pain control Tetanus immunization
NO need for systemic antibiotics

36. Non-Medication Methods
Cover burns with plastic wrap
Keeps air off wound less pain
Wet dressings will stick and cause more pain
Other burn dressings are expensive and not necessary
Quik Clot is expensive and will not provide any patient benefit
Distraction

37. Ice Pack---DO NOT USE EVER!
DOES NOT
Reverse temperature
Inhibit destruction
Prevent edema
DOES
Delay edema
Reduce pain
can worsen tissue distruction

38. Pain Medications IV Narcotics Oral Narcotics Dilaudid Fentanyl
Morphine
Oral Narcotics
Oxycodone

39. Next Priorities
Insert NG tube
Escharotomies
Medications
Wound care

40. Wound Care Debridement and dressings done after transfer
Transport patient in DRY sheet or plastic wrap and blanket
If transport delayed > 12 hours
Debride loose tissue and clean with soap and water
Apply Silver Sulfadiazine and wrap loosely with gauze

41. Burn Center Referral All burned children Any burn > 10% TBSA
Any full-thickness burn
Burns to hands, face, feet or perineum
Any Electrical or Chemical burns
Inhalation injury
Burns and concomitant trauma when the burn injury poses the greatest risk
Burn and preexisting medical problems
Excerpted from Guidelines for the Operation of Burn Centers (pp ), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons

42. Regional Burn Centers Dwan Burn Center in Duluth, MN
The Burn Center – Regions Hospital in Minneapolis, MN
Hennepin County Medical Center Burn Center in Minneapolis, MN
Columbia St. Mary’s Hospital Regional Burn Center in Milwaukee, WI
UW Health Burn Center in Madison, WI
Children’s Hospital of Wisconsin in Milwaukee, WI
Ameriburn.org
Loyola University Medical Center near Chicago, IL
Sumner L. Koch Burn Center in Chicago, IL
University of Chicago Burn Center in Chicago, IL

43. Key Take Aways
Transport patient in plastic wrap and DRY sheets or blankets
Give fluids as recommended by the American Burn Association for burns greater than 20% TBSA
Burns hurt! Provide narcotics and non-pharmacological methods to control pain.

44. Questions??

45. Meet Carl

46. References
American College of Surgeons (2014). Guidelines for Trauma Centers Caring for Burn Patients. Resources for Optimal Care of the Injured Patient (2014). Chicago, IL: Committee on Trauma, American College of Surgeons
Burn Center Regional Map (n.d.). Retrieved from
Burn Incidence and Treatment in the United States: 2016 (n.d.). Retrieved from
National Burn Repository (n.d.). Retrieved from