CHAPTER 30 Nursing the patient with burn injury

Introduction

Imagine for a moment having lost everything: your loved ones; your home and possessions, including mementoes from the past; your health and ability to function normally; your appearance – in other words, yourself. This not infrequently occurs when people are victims of a house fire.

Most people experience minor burns more than once in their lifetime but few have any conception of the horror associated with severe burns injury. Extensive burns injury is catastrophic, both physically and psychologically, for the patient and their family. It is also one of the most challenging and arduous types of injury to treat. In order to help the patient and their family to achieve optimal function, the responsibility of care must be distributed throughout the multidisciplinary team. However, the nurse, being the only professional in 24-h attendance, will play an especially important role. Nurses also attend to many patients whose burns are not extensive, providing care in the community, in emergency departments (ED) and in general surgical wards. This chapter provides information which will help nurses care for patients with burn injuries in all settings.

Prevention of burn injuries

Burns are frequently described as being among the most serious of injuries because of the long-term problems which are often associated with them. Advances in treatment and improved facilities have led to a reduction in mortality rates (Pereira et al 2004), but the resultant morbidity is such that prevention is the responsibility of all health care personnel.

Studies emphasise that, in order to be effective, burn prevention programmes should involve assessment of the incidence of burn injuries, followed by planning, implementation and evaluation of appropriate interventions (Liao & Rossignol 2000).

Assessment

This includes identifying the extent of the problem, its causative agents and any predisposing factors.

The extent of the problem

It is estimated that, in the UK, 112 000 people attend emergency departments annually suffering from the effects of burn injuries, with a further 250 000 presenting at GP services; approximately 7765 people require hospital admission and 211 people die each year as a result of burn injury (Benson et al 2006). Although statistical data on burn mortality are generally available, the incidence of burn morbidity is difficult to estimate.

Causative agents

Scalds or flame burns are the most common type of burn injury. Contact burns (touching hot objects) also have a high incidence. Chemical and electrical burns occur less frequently.

The Office of the Deputy Prime Minister (2003), previously responsible for collating fire statistics, identified the most common cause of death in domestic fires as careless handling of fire and hot substances, mainly smokers’ materials. Non-fatal burn casualties result from the misuse of equipment or appliances, most commonly cooking appliances. Hot water in plumbing systems is also a considerable cause for concern in countries where there is no legislation governing the upper limit of plumbed water temperature. Although many authorities advocate a temperature of 50°C (which would take 2–3 min to cause a burn), because of altered sensation and reduced mobility in older people, this figure has been reduced to 43°C in residential accommodation for older people (Stone et al 2000).

Predisposing factors

Epidemiological studies identify toddlers as being at greatest risk of burn injuries, with scalds accounting for most of these (Tse et al 2006). Adult high-risk groups include those with epilepsy (Unglaub et al 2005) and those who smoke tobacco, drink alcohol in excess and take prescribed psychotropic medications (Anwar et al 2005). Older people have also been identified as being more susceptible to burn injury and as having a higher mortality rate following injury (DeSanti 2005). Studies agree that males of all ages are at higher risk than females.

The common denominator of predisposition to burn injury appears to be a combination of reduced awareness of danger and decreased mobility.

Planning and implementation

Planning for a burns prevention programme must be realistic. While it is impossible to modify certain risk factors, e.g. gender and age, having identified the groups most at risk, it should be possible to alter some of the related predisposing factors.

There are already numerous health education/promotion campaigns aimed at persuading the public not to smoke and to only drink alcohol in moderation. It seems unlikely that those who do not comply would be influenced by the knowledge that smoking and drinking alcohol increase their risk of burn injuries. Tones and Tilford (2001) state that, unlike the promotion of commercial products, which is based on enhancing pleasure and promising immediate gratification, health promotion usually urges people to stop doing something which they find pleasurable in the hope of long-term benefit. They also state that people have a right not to be unreasonably frightened. Blatant shock tactics are therefore considered unacceptable and are likely to make people ‘switch off’. More subtle, but potentially potent, messages may be conveyed, e.g. by incidental reference in popular television series.

Identification of the burn agent or energy source results from epidemiology studies. The agent may be a result of poor design of equipment, e.g. the hot water jug with a higher centre of gravity than a kettle, or a radiator which produces a high surface temperature. Once the problem has been recognised, design modification may be sufficient to eradicate the danger.

Product modification may be carried out voluntarily by manufacturers; however, legislation is often required. Since 1990, it has been against the law to sell new or re-upholstered soft furnishings which are padded with foam that is not combustion modified or which are covered with fabric that does not resist ignition tests for both smouldering cigarettes and match-like flames.

Previous legislation and regulations include the prohibition of the sale of highly flammable children’s nightwear and the requirement that all new gas or electric fires and radiant oil-burning stoves are fitted with a fireguard which passes British Standards specifications.

With regard to the environment, probably the greatest single factor in reducing death and injury by fires in the home has been the introduction of smoke detectors/alarms. In North America, their installation into both new and established domestic properties is legally required. In the UK, legislation is more arbitrary and installation into established properties is voluntary. It must be recognised that the groups at highest risk of burns, i.e. older or disabled people, may be less able than others to buy safer soft furnishings and heating appliances. Smoke detectors may be bought for as little as £5, but their fitting, although simple for the able-bodied, may be impossible for older or disabled individuals.

Health care workers, therefore, not only have a responsibility to disseminate information on the prevention of burn injuries, but also must work closely with other interested groups such as the Fire Service, The Royal Society for the Prevention of Accidents (Useful websites) and both local and national government in order to lobby for more effective legislation and regulations (Box 30.1). Nurses working in the community have the opportunity to observe the environment and to give specific advice relating to burns prevention.

Box 30.1 Reflection

Reducing burn injuries

Will and some friends returned home after a night out and, feeling hungry, decided to have some chips. Will put the chip pan on the stove, leaving the fat to heat whilst he checked his e-mail and put on some music. Sometime later, smelling smoke, Will rushed back to the kitchen to find the saucepan in flames. In his panic he tried to douse the flames by smothering them with a towel, which promptly caught fire. He then remembered to put the lid on the saucepan and turn off the stove. The noise alerted his friends, who phoned 999 for an ambulance and the fire service. Will was rushed to the nearest emergency department, where, on examination, he was found to have a total of 8%, mainly superficial, burns to his hands, forearms, chest and face.

Activity

• Reflect on the potential reasons why this burn injury occurred and why the chip pan was well alight before Will and his friends were aware of the fire.

• Visit the Fire Service website (www.fireservice.co.uk/safety/chippans.php) and discuss with your mentor how you could use the Fire Service information to reduce burn injury caused by chip pan fires.

First aid treatment of burns

Burn injuries result from the transfer of energy from a heat source to vulnerable tissues. The higher the temperature of the heat source and the longer it is in contact with the tissues, the greater will be the destruction.

The first priority of first aid treatment is to remove the individual from the source of heat. If the causative agent is electricity, it is important to switch off the supply, if possible, or to use non-conducting material to rescue the person.

Frequently, there is a continuing source of heat if the individual’s clothing is on fire or saturated by a hot liquid. The most effective way to remove this continuing heat source is to throw cool liquid, which is neither flammable nor corrosive, over the affected material, thus dousing the flames or reducing the temperature of the scalding liquid. If no such cool liquid is immediately to hand, rapid removal of hot saturated clothing will arrest the heat transfer. Where clothing is on fire, it is important to stop the person running around as this will fan the flames. The person assisting should lie the victim on the ground and use heavy material such as a coat or blanket to smother the flames. If chemicals are the causative agent, prompt sluicing with copious amounts of water will dilute the strength of the agent and limit the penetration of the chemical into the skin, where it will continue to cause damage for many hours. Hojer et al (2002) demonstrate the advantage of taking this universal first aid measure rather than taking time searching for specific neutralising agents. In the clinical situation, a useful means of identifying whether a chemical is acid or alkaline is to apply a urine testing strip, as this will give a pH reading.

After removal of the heat source from the skin, the next measure is to cool the superheated tissues. The easiest means of doing this is to place the affected part in cold water. For the face, however, cold soaks should be applied. The application of ice or chilled water below 8°C is contraindicated, as Venter et al (2007) found that this was associated with increased likelihood of tissue damage. There is no doubt that continued cooling reduces pain from the burn wound, but if a large area of the body surface is involved there is a risk of hypothermia.

Since patients with extensive burns have problems retaining body heat, the use of space blankets or other heat-retaining coverings is advised during transfer to hospital.

Many burns units in the UK are now advising that the temporary wound dressing of choice is polyvinyl chloride film, e.g. cling film (Hudspith & Rayatt 2004). The reasons for this are:

• The film is sterile on the inner rolled surface.

• It does not adhere to the wound surface and cause pain on removal.

• It conforms closely to the body contours and excludes air, thus reducing pain.

• The wound can be viewed without removal of the transparent film.

This kind of material is often available in the home but, if not, a clean cloth should be used as a temporary cover. The use of ointments, lotions and powders should be avoided as they may change the appearance of the wound and thus impair the assessment of the burn.

To summarise, first aid treatment of burn injuries consists of:

• separating the individual from the source of injury

• immersion of the affected part in cold water for 10 min or application of cold soaks to the face

• application of cling film or a clean cloth to the wound; cold soaks may be used for wounds which are not extensive.

Assessing the severity of burn injuries

The majority of patients with burn injuries do not require hospitalisation. The UK National Burn Injury Referral Guidelines (2001) recommend that when deciding whether to refer patients to a burn unit, consideration should be given to the complexity of the burn injury rather than simply to the size of the burn wound. The categories of patients for whom admission or referral to a regional burns unit is advisable include those:

• under 5 years or over 60 years of age

• whose burns exceed 5% of the body surface area

• with burns on functionally important areas such as face, hands, feet, perineum, joints or flexor surfaces

• with electrical or chemical burns

• with infected wounds or evidence of infection

• with small, full-thickness burns which would benefit from early excision and grafting

• whose injury limits their capacity to care for themselves at home

• with associated injuries, e.g. smoke inhalation, crush injuries, fractures

• with other medical conditions, e.g. epilepsy, diabetes mellitus

• where there is doubt, either suspected non-accidental injury or uncertainty about the depth of the burn.

For patients who do not fall into any of these categories, relief of pain and local treatment of the burn wound are generally all that is required. Both interventions will be described later (p. 782).

The UK guidelines also suggest that in the post-acute phase of burn injury, practice nurses and district nurses should refer patients whose burn has not healed within 14 days, as any resulting scarring may have significant impact on the subsequent physical and psychological rehabilitation of the patient.

Assessment of the severity of the burn injury involves estimation of the:

• extent of body surface area involved

• depth of tissue damage

• probability of associated respiratory tract injury.

Knowledge of the circumstances of the accident, e.g. whether electricity was involved, and information about the individual’s general health and domestic situation will help in deciding whether the patient may, or may not, be managed by the primary health care team.

Extent of burn

Whenever tissues are traumatised, the inflammatory response occurs, resulting in increased circulation to the area (hyperaemia) and increased movement of fluids from intravascular to interstitial compartments. If this occurs in a small area, i.e. over less than 5% of the body surface, the effects are localised. However, when a larger percentage of the body surface is injured, there is a massive shift of fluids into the tissues with a corresponding reduction in circulating volume. It is generally accepted that children with burns involving more than 10%, and adults with burns of more than 15%, of body surface area will suffer from hypovolaemic shock unless there is prompt intravenous replacement of fluid (see Ch. 18).

In order to estimate the percentage of body surface affected, the simplest and most easily remembered method is the long established ‘rule of nines’ introduced by Wallace in 1951 (Figure 30.1). In this method, the head and upper limbs each equal 9%, while the anterior trunk, the posterior trunk and the lower limbs each equal 18%. The remaining 1% is usually applied to the perineum. Another rapid approximation of the percentage can be made by using the palmar aspect of the patient’s hand (with fingers together) as 1% of the body surface area.

Figure 30.1 Wallace’s rule of nines.

The rule of nines should never be used for estimating burn percentage in young children as it does not allow for the different proportions of head and lower limbs in infants and toddlers. Under the age of 1 year the child’s head equals 19% of the body surface area and the lower limbs are correspondingly smaller. A more accurate chart which allows for the changing proportions of different age groups and which shows percentages applicable to smaller, more specific areas of the body surface is the Lund and Browder (1944) burn chart (Figure 30.2). This is generally in use in specialist units and is available in EDs throughout the UK.

Figure 30.2 The Lund and Browder burn chart.

Burn depth

The depth of a burn influences the rate at which the wound will heal spontaneously. The longer the wound takes to heal, the greater the probability of infection and the worse the scarring and loss of function. There are a number of methods of classifying burn depth. In the UK, the most popular is to differentiate between partial-thickness and full-thickness skin destruction. Partial-thickness burns involve the epidermis and part of the dermis. Full-thickness burns destroy the epidermis and all of the dermis.

See website Figures 30.1 and 30.2

Full-thickness burns may also involve deeper structures such as fat, muscle and bone. Partial-thickness burns are classified as ‘superficial’ or ‘deep’, depending on the amount of dermis involved. As a general rule, deep partial-thickness and full-thickness burns require skin grafting.

As may be seen from Figure 30.3, the more superficial the injury, the greater the number of surviving epithelial sources from which cells migrate across the wound surface; thus a more superficial burn heals more rapidly and causes less wound contraction. The effects of superficial partial-thickness burns and full-thickness burns are described below and in Table 30.1.

Figure 30.3 Classification of burn depth.

Table 30.1 Indications of burn depth

Depth	Signs and Symptoms	Related Anatomy/Physiology
Superficial partial-thickness burns	Very painful	Sensory nerve endings in the dermis are stimulated by the injury and/or exposed to air
	Oedema, blister formation, serous exudate where blisters have burst	As a result of the inflammatory response, the capillary walls are more permeable and fluid leaks into the interstitial spaces of the dermis, collecting below the non-germinating layers of the epidermis or exuding from the wound surface
	Wound surface warmer than unburned skin	Also due to the inflammatory response; arteriolar dilatation causes increased blood flow
	Wound appears bright pink and blanches with pressure	Due to increased blood flow Pressure greater than capillary blood pressure occludes the flow of blood
Full-thickness burns	Painless, no sensation	Sensory nerve endings in the dermis are destroyed
	Wound surface dry. No blistering	Cessation of blood flow through dermal capillaries
	No overt oedema	Necrosis of dermis renders it inelastic
	Wound surface cooler than unburned skin	Cessation of blood flow through dermal capillaries
	Wound colour may be white, brown, translucent showing thrombosed vessels, or bright red (does not blanch on pressure)	Cessation of blood flow through dermal capillaries. Brown or red appearance is caused by release of haem pigments from the destroyed erythrocytes (red blood cells)

Problems in assessment

The assessment of burn depth is an inexact science, although much work has been carried out to make it more exact in recent years. The use of a hypodermic needle to test for pinprick sensation was first described by Bull and Lennard-Jones (1949). More recently, McGill et al (2007) found that both laser Doppler imaging and video microscopy may be used successfully in aiding assessment of burn depth; however, these options are not readily available outwith specialist burn units. Frequently, assessment of burn depth is dependent on the visual characteristics of the wound, the information regarding the circumstances of the accident, the agent involved and the first aid measures carried out.