Management of Burn Injuries
by the WoundSource Editors
As the fourth of July rolls around, hospitals and clinics all over the country will begin to see an increase in burn incidents. According to the Consumer Product Safety Committee, 68% of the estimated total fireworks-related injuries in 2016 happened between June 18 and July 18.1 From simple blisters obtained by holding a sparkler too close, to third-degree, full-thickness burns obtained from a stray firework, it is important that health care providers know how to effectively manage burn injuries.
Burn management is typically based on the severity of the wound, and the goals are to prevent shock, relieve pain and discomfort, and reduce the risk of infection.2 Pathogens are present everywhere, and any breach in the skin, especially burns, can lead to infection. When burns cover up to 35% in adults and 30% in children, they are considered major burns, and anything above those levels is considered critical or life-threatening.3 A thorough assessment of the patient and burn site is necessary to determine the most appropriate treatment interventions given the type and severity of the burn injury.
Fluid replacement is imperative and a medical emergency for those with extensive burns. It is adjusted based on intake, output, and other vital parameters of the patient. The damage to blood vessels from the burn can result in fluid loss. Low blood volume can cause the patient to become hemodynamically unstable in response to hypovolemia and decreased cardiac output. Without adequate blood flow, ischemia and cell death occur from a lack of oxygen and nutrient supply.4 Depending on the size of the burn this can also result in the body’s inability to maintain core body temperature. For this reason, replacement fluids may need to be warmed.
In second-degree burns, blisters are common and develop secondary to a collection of plasma between the dermal layer of skin and dead epidermis. This plasma is rich in proteins and a perfect culture medium for microoganisms and should not be drained or removed. This is vital in the effort to prevent infection. Blood-filled blisters may indicate deeper tissue damage, hematoma, or fracture. Jewelry and clothing should be removed, and cool water run over the area of the burn. If blisters are broken or clothing is stuck to the burn do not run water over the area or try to remove the clothing as this may damage tissue further and promote shock.2
Full-thickness burn injuries should be covered with a clean cloth, sheet, or sterile non-adhesive bandages if possible, taking care not to disrupt blisters. For burned toes or fingers, separate with non-adhesive dressing material. To reduce inflammation, elevate the affected body part above the level of the heart. Any clamminess of hands or feet, weakness, increased pulse, rapid breathing, low blood pressure, or paleness of skin may indicate shock. Lay the person down, elevate the person’s feet to increase blood flow to vital organs, and cover the person to maintain core body temperature until emergency medical assistance is available. When dealing with any type of burn, certain standard precautions should be taken into account, such as:
- Ice should not be applied to the affected area because of the risk of further tissue damage and hypothermia.
- No ointments, butter, or oil-based products should be applied to the burned area as these can trap heat in affected areas and allow further tissue damage.
- The damaged skin should not be picked at or peeled, as this can increase scarring and the risk of infection.
- Coughing or breathing directly on the affected area should be avoided to decrease the risk of infection.2, 3
Eschar, or burned dead tissue, is present in many full-thickness burns and is tan, brown, or black, leathery, and non-elastic in texture. If it forms a band circumferentially around an extremity or digit it can compromise blood flow by compression of proximal blood vessels. If the eschar is circumferential around the trunk it can cause respiratory difficulty. Either constriction may necessitate the need for escharotomy, removal or scoring of the eschar, or fasciotomy, opening of deep fascia and all compartments to release pressure and regain blood flow or lung expansion.3
As we know, healing takes extensive physical resources including adequate nutrition. Therefore, planning and implementing intake of adequate nutrition, with special attention to proteins and calories, are essential to the healing process.
As scars form, they may result in an overgrowth of scar tissue or the development of keloid scars. These scars can be restrictive and cause difficulty in regaining mobility and function, especially over joint areas. The destruction of tendons and ligaments and the development of scar tissue can result in contractures that tighten and shorten skin, muscles, or tendons, thus permanently preventing joints from regaining proper alignment and position. Scar management and surgical revision may be necessary to regain functionality, as well as for aesthetic reasons.4, 5
Dressing choice for a burn injury should be based on prime objectives that support wound healing. First, the dressing should protect and maintain an optimal environment reducing the risk of colonization and infection. Second, dressings should maintain an optimal moisture level. If the wound is too wet there is an increased chance of bioburden formation and bacterial growth combined with potential maceration of the wound bed and surrounding tissue, thus increasing susceptibility to breakdown. If the wound is too dry, then the wound becomes desiccated and retards the healing process. A balance of moisture is needed to maintain cell division and migration. Third, understand the periwound skin and consider edema, wound edges, pain level, impact of adhesives, and a need for skin barrier on the periwound skin. The fourth objective is to provide compression to reduce scar formation and edema, which reduces tension on wound edges that impedes the healing process. Pain management is the fifth objective. Using non-adherent dressings protects delicate granulation tissue and reduces pain. This aids in patients’ compliance with treatment regimens. Special areas of consideration are the face, head, neck, ears, hands, perineum, and genitals, especially because dressings for these areas can be complex and challenging.4, 6
Rehabilitation and Burn Injuries
The final phase of burn care is the long road to rehabilitation and reconstruction, and it begins as soon as the burn occurs and proceeds with establishing and adhering to a plan of care focused on a positive outcome. It includes acute care treatment, range of motion exercise and minimization of edema, regaining mobility, function, and independence, and improvement of quality of life. It can depend on the extent of the burn, resources available, and dedication toward positive goals and outcomes. It can last months. It can last years, but in the end, it is designed to meet the needs of each patient.
1. Tu Y. Fireworks-related death and emergency department-treated injuries during 2016. 2016 Fireworks Annual Report. https://www.cpsc.gov/s3fs-public/Fireworks_Report_2016.pdf?t.YHKjE9bFiab.... Published June 2017. Accessed July 2, 2018.
2. WoundSource. Burns, deep partial-thickness (deep second-degree). WoundSource. http://www.woundsource.com/patientcondition/burns-deep-partial-thickness.... Accessed January 3, 2018.
3. Tiwari VK. Burn wound: how it differs from other wounds? Indian J Plast Surg. 2012 May-Aug;45(2):364-73. doi: 10.4103/0970-0358.101319.
4. Ansell Healthcare Products. A Self-Study Guide: Burns – Assessment and Management: Registered Nurses. Ansell Health Care Media. http://ansellhealthcare.com/pdf/edPro/RN_CEU_BurnsMgmt_Final.pdf. Published 2017. Accessed January 3, 2018.
5. Stotts NA, Wipke-Tevis DD, Hopf HW. Chapter 7. Cofactors in impaired wound healing. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014:79-87.
6. Vowden K, Vowden P. Wound dressings: principles and practice. Surgery. 2014;32(9):462-7. doi:10.1016/j.mpsur.2014.07.001.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.