CHAPTER 33 Burn Trauma

Cheryl Wraa, RN, MSN

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Burn Injuries

Thermal and Inhalation Burns

Chemical Burns

Electrical/Lightning Burns

Each year in the United States, approximately 2 million people seek medical attention for burn injuries. Of these patients, 51,000 require acute hospital admission. Approximately 20,000 have major burns involving at least 25% of total body surface. Annually, 4500 people die of burns and related inhalation injuries, and up to 10,000 people die of burn-related infections. Advances in areas such as fluid resuscitation, inhalation injury treatment, wound care practice with early débridement and excision, and a better understanding of the importance of increased nutritional support have contributed to a decrease in burn-related deaths. Very young and very old patients have a high risk of death because of their immature and stressed immunologic systems and preexisting medical conditions, respectively. Burns in combination with an inhalation injury always worsen a patient’s prognosis.

A burn injury is defined as tissue injury that results from exposure to flames, hot liquids, hot objects, caustic chemicals or radiation, or electric current. Burn injury can cause serious pathophysiologic responses in all systems of the body. The injury initiates an inflammatory response, which includes heat, redness, pain, and localized and systemic edema formation. The amount of edema is related to the extent and depth of the burn injury and the amount of fluid administered during fluid resuscitation. The combination of fluid shift, edema formation, and evaporative water loss from the burn wound can lead to hypovolemia (“burn shock”). Loss of plasma is greatest during the first 4 to 6 hours after the burn injury. The decreased circulating blood volume becomes thickened and sluggish, thereby diminishing tissue oxygenation and causing injury to end organs such as the kidneys. Hypovolemia reduces cardiac output and thus causes the sympathetic nervous system to respond by releasing catecholamines, a process that leads to increased peripheral vascular resistance, increased afterload, and increased heart rate. Fluid resuscitation can stabilize cardiac output during the resuscitative phase of burn injury. Because of the tissue damage that occurs with major burn injuries, hemolysis may occur. Hemolysis results in hemoconcentration, thrombocytopenia, decreased platelets, and potential clotting abnormalities. Rhabdomyolysis can occur with significant injury to muscle tissue, and it can cause hyperkalemia and renal failure. Burn injuries are classified according to the depth and extent of the injury. Populations at risk for burn injury include children, elderly persons, persons with alcoholism, smokers, and people with suicidal ideation.

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)

2. Focused assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

b) Pain (see Chapter 9)

c) Length of time exposed to burn source

d) Time of occurrence

e) Body area involved and type of burn

(1) Environment in which patient was found: enclosed space, industrial setting, presence of combustible substances (e.g., wood, petroleum products, plastics)

(2) Electrical/lightning injury: amount of voltage, alternating current (AC) or direct current (DC), resistance, path of current

(3) Chemical injury: type of chemical, concentration, chemical’s mechanism of action, extent of tissue penetration, duration of contact, treatment prior to arrival

f) Level of consciousness

g) Related injuries: cervical spine, spine, leg or arm fractures, evidence of maltreatment

h) Cardiopulmonary resuscitation (CPR) at the scene

i) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current preexisting diseases/illness

(1) Cardiovascular disease

(2) Pulmonary disease

(3) Diabetes

b) Previous surgical procedures

c) Smoking history

d) Substance and/or alcohol use/abuse

e) Last normal menstrual period: female patients of childbearing age

f) History of suicidal behavior

g) Current medications

(1) Prescription

(2) Over-the-counter/herbal

h) Allergies

i) Immunization status

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Airway: patent, maintainable, not maintainable

(1) Carbonaceous sputum

(2) Singed hair, nasal hairs/eyebrows

(3) Face and/or neck burns

(4) Carbon deposits and inflammation/blistering in the oropharynx

b) Burned tissues

(1) Erythema of area

(2) Red or mottled appearance

(3) Blister formation

(4) Dark or leathery appearance

(5) Waxy white appearance

c) Cardiac rhythm on monitor

d) Sternal retractions

3) Auscultation

a) Breath sounds: wheezing, rhonchi

b) Heart sounds

c) Bowel sounds

4) Palpation

a) Peripheral and central pulses

b) Deformities

c) Sensory perception surrounding burned tissue

3. Psychological/social/environmental factors

a. Occupational risk factors

1) Firefighters, emergency medical service, and rescue personnel

2) Occupation involving exposure to excessive heat, electricity, or chemicals

3) Military

b. Alterations in ability to perceive environmental threats

1) Age of the patient

a) Pediatric: decision-making and recognition of threat limited to developmental level

b) Elderly: reduced mobility, changes in vision, and decreased sensation in the feet and hands

c. Social risk factors

1) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

2) Homelessness

3) Depression: suicide ideation

d. Environmental risk factors

1) Contact with flame, hot object, water, or chemicals

2) Enclosed area

3) Contact with electricity or lightning

4. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Carboxyhemoglobin (HbCO) level

4) Type and crossmatch

5) Coagulation profile

6) Urinalysis; pregnancy test in female patients of childbearing age

7) Arterial blood gas (ABG) determinations

8) Serum and urine toxicology screens

b. Imaging studies

1) Chest radiograph

2) Cervical spine, extremity radiographs as indicated for associated injuries

3) Computed tomography (CT) scan for associated injury

4) Focused Assessment Sonography for Trauma (FAST) as indicated for associated abdominal trauma (see Chapter 32)

c. Other

1) Possible peritoneal lavage for associated trauma (see Chapter 32)

2) 12- to 15-lead electrocardiogram (ECG) if electrical or lightning injury

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Risk for ineffective airway clearance

2. Risk for impaired gas exchange

3. Risk for ineffective breathing pattern

4. Risk for deficient fluid volume

5. Risk for hypothermia

6. Acute pain

7. Risk for ineffective tissue perfusion

8. Risk for infection

9. Impaired skin integrity

10. Anxiety related to fear

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/blood byproducts/medications

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plans as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or developmental related

1) Death from burns is among the leading causes of death in children

2) Infants and children have small airways that are more easily obstructed by edema from inhalation injury

3) Children’s high ratio of total body surface area (TBSA) to body mass increases heat exchange with the environment and directly affects their ability to regulate core temperature

4) Lack of substantial subcutaneous tissue and thin skin contribute to increased evaporative heat loss and caloric expenditure

5) Children are dependent on caregivers to educate and protect them about environmental hazards

6) The potential for maltreatment should be considered

7) Children’s healing responses are more rapid than those of adults

b. “Pearls”

1) Children are curious about their environment and may not be afraid to touch flame or a hot object

2) Burns occur in 6% to 20% of maltreated children. Findings associated with inflicted burns include burns to both hands or both legs, brands/contact burns (imprint of a hot object), cigarette burns (circular and of uniform depth), and immersion burns, usually seen on the buttocks or legs or in a stocking or glove distribution on the extremities (sparing of the palms, soles, and skin folds where knees and hips are flexed is common)

3) Hypothermia may render an injured child refractory to treatment, prolong coagulation times, and adversely affect central nervous system (CNS) function. During resuscitation, if exposed, overhead heat lamps or heaters may be necessary to maintain body temperature. IV fluids, blood products, and inhaled gases should be warmed

2. Geriatric

a. Aging related

1) Loss of subcutaneous tissue and thinning of the dermis the elderly predispose to a deep injury from thermal burn

2) Decreased touch receptors with corresponding slowing of reflexes and pain sensation

3) Decreased proliferative potential of skin delays wound healing and vitamin D production

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