BURNS: CLASSIFICATION AND SEVERITY
Burns result from thermal, electrical, chemical, mechanical, or radioactive injury to tissues. The extent of burn depth varies from superficial, involving the epidermis, to deeper structures, including muscle, bone, and organs, particularly the lungs (Stavrou et al., 2014). The cardiovascular and nervous systems are significantly impacted by electrical and lightning insults, potentially resulting in immediate cardiac or respiratory arrest (Moore, 2015b). Each year, more than 265,000 deaths occur worldwide related to burns, producing life-altering changes for victims and their families (Zuo, Medina, & Tredget, 2017). Serious burns result in a cascade of physiological responses that can influence morbidity and mortality for affected patients (Jewo & Fadeyibi, 2015).
Annually, more than 500,000 people in the United States are evaluated in emergency departments for burns annually. Burns and fires are the fifth most common cause of accidental death in children and adults, and account for an estimated 3,500 adult and child deaths per year. Burn-risk is highest in children. Younger children are more likely to sustain scald burns, whereas children older than 6 years of age are more likely to experience burns from flames. Toddlers and children are more often burned by a scalding or flames and nearly 75% of all scalding burns in children are preventable. Most children ages 4 and younger who are hospitalized for burn-related injuries suffer from scald burns (65%) or contact burns (20%). Children with scald burns that have clear lines of demarcation and in a stocking or glove formation should be evaluated for child abuse (Hazinski, Mondozzi, & Baker 2014).
Hot tap water burns cause more deaths and hospitalizations than burns from any other hot liquids. The most common etiologies of burns are thermal (flame, steam, scalds), electrical (alternating current [AC] and direct current [DC], lightning) and chemical (alkaline and acid). The length of time that tissues are exposed to a burn source, the intensity of the source, and skin thickness determine the degree of burn (Rau, Spears, & Petruska, 2014). Burns impart injury by damaging skin surfaces, by impairing airways and lungs via inhalation burns, and by ingesting chemicals or objects capable of causing mucosal burns. Multiple organs, tissues, and body systems are susceptible to burns as primary or secondary injuries. Complications of burn shock, infection, respiratory compromise, and multisystem organ failure may result in death (Stavrou et al., 2014). Prevention or rapid correction of these complications is essential to achieving desirable outcomes for burn victims.
31Thermal burns may directly affect only the epidermis and dermis, or may involve deeper structures of fat, muscle, and bone. The extent of injury caused by electrical burns is determined by the type of electrical current; either low voltage (less than a 1,000 volts) or high voltage (more than 1,000 volts). Severity is also determined by the length of time the victim is in contact with an electrical current. Lower voltage and less time exposed to the electrical source usually impart less severe injury (Moore, 2015b). Chemical burns require early identification and rapid decontamination and treatment. The concentration and acidity or alkalinity of a chemical, combined with the length of time the skin or mucosa is exposed to the agent, determine the significance of a chemical burn (Moore, 2015a).
Burn depth is categorized as first (superficial), second (partial thickness), and third degree (full thickness), with a deepest fourth-degree category being possible (Zuo et al., 2017). First-degree burns commonly are superficial and involve the epidermis only, requiring little or no treatment. Second-degree burns include both superficial and deep partial-thickness burns. Superficial partial-thickness burns include injuries to the epidermis and the outermost dermis. Redness, swelling, and discomfort or pain accompany these burns. Deep partial-thickness burns damage both the epidermal and dermal layers, causing necrosis and intercellular edema, resulting in blister formation. Second-degree burns are typically more painful than first-degree burns, with loss of skin integrity and subsequent fluid depletion. Full-thickness burns damage the epidermis, dermis, and subcutaneous tissue. Tissue necrosis evolves, producing eschar (leathery, sloughing, dead tissue) and leaving no protective barrier for remaining structures. Eschar increases the risk for bacterial infection in burns. Edema, inflammation, and vasodilation accompany this type of burn, and little or no sensation remains (Rau et al., 2014). Complications, including shock, infection, respiratory compromise, and multisystem organ failure are common in burn injuries and evolve during the acute phase of injury (Stavrou et al., 2014).
Determining the percentage of total body surface area (TBSA) and depth of burns is an early step in burn resuscitation (Stavrou et al., 2014). Selection of appropriate resuscitation fluid and the correct amount to infuse over the first 24 hours following burn injury directly affect burn wound healing and chances for survival (Cancio, 2014). There are multiple tools available to calculate the approximate area of burns in the prehospital and acute phase settings. The rule of nines, modified Lund and Browder chart, and Parkland formula are among the most common measurement systems used for this purpose. More advanced methods for determining burn extent, such as laser Doppler imaging, may be initiated 2 to 5 days following preliminary burn resuscitation in order to avoid over-resuscitation with fluids, which poses an additional danger to patient outcomes (Martin, Lundy, & Rickard, 2014). The starting point for fluid resuscitation is typically between 2 and 4 mL/kg/TBSA/24 hr (Lundy et al., 2016).
Evaluation and definitive management of airway, breathing, circulation, and fluid resuscitation are the most crucial elements of care for burn patients with life-threatening injuries. Early intubation is imperative for patients sustaining airway burns. A detailed history of injury, including time, mechanism, voltage if electrical source of injury, details of decontamination for chemical sources, a chemical safety data sheet if available, associated trauma, syncope, smoke exposure, abuse potential, and prehospital treatment should be obtained. Wet linens should be rapidly replaced with sterile dry linens. All jewelry and clothing should be removed, and careful evaluation of nonburn injuries should be done. Placement of urinary catheter and nasogastric tube should be accomplished during the reassessment phase of care (Cancio, 2014).
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
Multiple factors must be considered following the acute phase of burn resuscitation. Hypothermia is an early complication of burns. The greater the surface area burned, the more vulnerable the patient is to development of hypothermia. It is important that the patient be kept warm and dry in order to conserve energy expended from the postburn hypermetabolic state. Persistent hypermetabolism and muscle wasting in extensive burns requires early nutritional reinforcement, but balancing calories and the composition of nutrients must be individualized to avoid overconsumption and increased risk for hyperglycemia (Rowan et al., 2015). Pruritus (itching) is an unfortunate and very common result of burns. It occurs in almost every pediatric burn patient, and in as much as 87% of affected adults. Itching may not respond favorably to anti-inflammatory drugs and other analgesics (Stavrou et al., 2014). Optimal management of pruritus should be addressed after patient stabilization during hospitalization, and in discharge planning.
Contractures manifest related to loss of skin elasticity, and pose great risk of loss of physical function. Mobilization of joints should begin as soon as possible during hospitalization. Essentially every body system and organ can be affected following a significant burn injury. Duodenal ulcers, anemia, hypermetabolic syndrome, insulin resistance, and liver dysfunction may develop in response to injury. In addition, other common sequelae, including central nervous system inflammation, cardiac dysfunction, and respiratory compromise, may develop. Compartment syndrome from circumferential burns may develop acutely, necessitating escharotomy or fasciotomy in any area of the body. Kidneys may be damaged by lactic acidosis and urine myoglobin production (Rau et al., 2014). Elevation in urine myoglobin levels is commonly associated with rhabdomyolysis, an associated complication of significant burn injuries (Moore, 2015b). Monitoring urine output is important in guiding titration of fluid resuscitation. It is important that IV fluids for burn resuscitation be initiated early, and that fluid intake and output be accurately measured, recorded, and reported. The urine output goal for adults is 30 to 50 mL/hr, and for children, weighing 30 kg or less, 1 mL/kg/hr (Lundy et al., 2016).
33Deep vein thrombosis (DVT) prevention strategies should begin immediately in burn patients, since these injuries result in a hypercoagulable state (Zuo et al., 2017). Nurses should anticipate initiation of anticoagulant prophylaxis therapy. Burn severity impacts the degree of pain that patients experience. Long-term pain and sensory dysfunction accompany more extensive burns. Acutely burned patients may experience pain in the form of many abnormal sensations, including burning, dullness, itching, and dysesthesia (Rau et al., 2014). Frequent pain assessment and response to specific medications are important to determine the most effective pain treatment options for individual patients.
Prevention of infection in burn patients is crucial to survival. Burn sepsis typically presents within the first week postinjury. The most common causes of burn sepsis include pneumonia, central vascular access devices, and burn-injured skin. It is essential that health care workers maintain sterile technique and adhere to strict infection control practices while caring for burn patients. Antibiotic selection is carefully determined by specimen cultures to avoid pathogen resistance (Zuo et al., 2017). Significant burn wounds often require wound debridement and advanced wound care. Skin grafting is necessary for almost all full-thickness burns. Aesthetic changes related to deeper burns can have lasting effects on mental, emotional, and social well-being. Anxiety and depression are common especially within the first year after injury. Symptoms of posttraumatic stress disorder may emerge during the recovery process (Stavrou et al., 2014). Psychosocial support is essential in provision of holistic patient care, and to improve long-term outcomes.
Rapid communication with a regional burn center is advised by American Burn Association guidelines for patients with burn extent greater than 10% TBSA. Patients with inhalation injuries; burns associated with trauma; burns of the hands, feet, perineum, genitalia, or over major joints regardless of surface area burned; any third-degree burn; electrical, chemical, or lightning injuries; pediatric patients; and special needs patients, including those with social, emotional, or rehabilitation needs, require consultation with a burn center (Cancio, 2014).
Burn injuries pose significant challenges to children of all ages related to acute and long-term care. Children are much more vulnerable to changes in the temperature of the environment because they produce and lose heat faster than adults. Knowing what to do in case a burn or thermal injury occurs can help prevent a medical emergency. Nurses should remain current and knowledgeable regarding burn pathophysiology, assessment, and treatment significant to the pediatric population. Awareness of the most current evidence-based care available to burn patients assists nurses to provide them relative and efficient care.