Nurses: Are you prepared to manage burn injuries? Here’s what you need to know
Evaluate for traumatic injuries, decide on patient’s disposition, and relieve pain
Don’t forget to assess for life-threatening traumatic injuries before you assess a patient’s burn injury, stresses Cheryl Wraa, RN, BSN, immediate past president of the National Flight Nurses Association, based in Park Ridge, IL. "The burn itself is dramatic in appearance and can be distracting during the initial resuscitation of the patient," she notes.
Assess for other injuries or potential complications. "Don’t be so shocked by the appearance of the burn injury that you forget to treat the patient like a trauma patient," cautions Teresa Merk, RN, BSN, transport coordinator at Shriners Burns Hospital for Children in Cincinnati, OH. "A full assessment of the patient for additional trauma is necessary."
An initial survey including airway, breathing, circulation, deficits, and complete exposure should be done, says Wraa. "The evaluation of the burn is done after life threatening issues are addressed," she adds. "It is also very important to elicit a history of the event, so you can anticipate any other injuries or impending airway problems and any medical history which might affect the patient’s response to the injury. The key to the initial resuscitation is: Treat the patient, not the burn."
Management of major burns includes airway support, treatment for associated trauma and preexisting medical conditions, fluid resuscitation, protection against hypothermia, and initial wound treatment, Wraa notes.
Most burn patients are awake, alert, and in a great deal of pain. "Both the patient and [his or her] family may be anxious and overwhelmed by the suddenness and magnitude of the injuries," says Wraa.
The initial concern will be the patient’s survival, Wraa notes. "Questions should be answered as gently, tactfully, and honestly as possible," she advises. "Their first contact in the ED will establish a strong base for a trusting relationship for the many months the patient may be in the hospital and in rehabilitation."
Burn victims face fear of loss of earning ability, dependence, and possibly anger at their own responsibility for the accident, says Tom Trimble, RN, an ED nurse and webmaster of Emergency Nursing World, a practice-based Internet resource for emergency nurses. "We must convince the victim that the accident causing the injury is over, pain will be eased and controlled, [he or she] can do things to help his [or her] body heal, and [he or she] will resume control over his [or her] life and future," he explains.
Manage patient’s pain
Pain control is always a challenge with burn injuries, says Merk. "Burns that are third degree are called insensate,’ which means they are not painful, but a burn that is first or second degree will be very painful," she notes.
Finding the right amount of pain medication to keep the patient comfortable can be difficult. "Administer small incremental doses intravenously, because drug absorption from subcutaneous and intramuscular sites is erratic during the immediate postburn period," says Merk. "Give enough to keep the patient comfortable, but not enough to make them so sleepy they can’t do the things they need to be doing, like coughing and deep breathing, eating, and exercising. You may need to frequently medicate during the initial hours following the burn injury." Immersing burns in cool water can relieve pain, but generally should not continue for longer than 20-30 minutes, says Judy Selfridge-Thomas, RN, MSN, CEN, FNP, nurse practitioner for the department of emergency medicine at St. Mary Medical Center in Long Beach, CA. "After that, pain control needs to be achieved some other way, either with dressing the injured area, or with pain relief medications."
Most burns have already been sufficiently cooled prior to arrival, but patients may desire cooling for pain relief, says Trimble. "The water acts as an air barrier to the irritated sensory nerve ends of the burn," says Trimble. "Permitting the immersion until adequate’ analgesia has time to take effect is humane. A continuing explanation of how the dressing will keep the patient comfortable while the body repairs itself, helps the patient to give up the bowl of water for the treatment that you propose."
When the wound is approximately the same temperature (or slightly greater allowing for hyperemia) as surrounding areas, cooling can be stopped. "An adequate layer of silver sulfadiazine cream and/or non-stick dressings and bandaging exclude air and render the burn comfortable," says Trimble. "With typical minor burns treated as an outpatient, at this point the patient should need little further analgesia."
Including a non-steroidal anti-inflammatory drug as part of the initial analgesia minimizes the need for subsequent narcotic dosing, says Trimble. "However, it should still be made available to the patient, as no one can perfectly predict how much or how little pain there will be," he notes.
Prompt and sufficient analgesia is also key, says Trimble. "A combination of a potent NSAID and a narcotic provide a good one-two punch’ for initial and persistent relief," he recommends.
Decide on disposition
Making the decision to treat or transfer a patient is key, says Selfridge-Thomas. "Treatment may vary depending on whether the patient will continue treatment as an outpatient or will be an inpatient at a burn center," she explains.
With severe burns, disposition is the principle issue in the ED [emergency department], says Trimble. "You need to determine if the patient is safe and suitable for outpatient management. If the patient will be treated as an inpatient, is it to be here’ or at a specialized facility or other referral center? And if the patient is going to be transferred, when and with what preparations will the patient be stable for transport?" he asks.
Often, the best place for burn patients is a specialized burn unit, says Merk. "It takes a lot of teamwork to successfully manage a burn patient, including doctors, nurses, respiratory therapists, occupational/physical therapy, play therapy, school teachers, and even those individuals charged with watching our handwashing technique," she notes.
If the patient needs to be refered to a specialized burn center, do so rapidly, stresses Merk. "Rapid transfer to a burn unit to facilitate early excision/grafting, sometimes done within the first few days, is important," she says. "Find a burn unit that is also aggressive with physical therapy. Having the patient learn care and be a working member of the team from early on during the recovery is important."
Social factors should be considered, in addition to burn severity. "Factors such as age, limitation of activities of daily living, solitary living or inadequate family resources, and loss of bread-winning capacity, may argue for at least brief hospitalization while resources, home care, or social work can be arranged," says Trimble.
If the patient is discharged from the ED, patients should be educated adequately. "It is helpful if a positive outlook and attitude can be modeled for the patient, including things that can be done to help the burn heal quickly, and plans to control and ease any discomfort," says Trimble. "Also review symptoms of infection with the patient, so they understand to come back to the ED right away so that it can be taken care of before it becomes worse."
Here are some tips to consider when treating patients with burn injuries:
Assess burn adequately to determine treatment. "Things to assess are burn location, depth of burned tissue, whether or not blistering has occurred, are the burns circumferential, amount of body surface area burned, is sensation and feeling intact or absent in burned tissue and surrounding tissue, any other injury present, and any airway compromise," says Selfridge-Thomas.
Find out about how the injury occurred. "Certainly, obtaining information related to the circumstances surrounding the burn incident becomes important. Was it an isolated flame burn, was the patient in an enclosed space, was there an explosion, etc.," says Selfridge-Thomas. "Also, find out if the patient has any previous history that may impede healing, such as diabetes, or vascular problems."
When taking a medical history, ask about preexisting disease or associated illness, medications, allergies, and tetanus immunization, says Merk. "Patients with a history of asthma will have to be carefully monitored, as the trauma of a burn injury may aggravate the condition," she notes.
Address unique needs of pediatric patients. "Children have a smaller airway and a larger head in proportion to body surface area. Also, depending upon the injury and circumstances, is it possible that abuse is present?" Merk asks. "Also, find out who really has legal custody of the child. This is often difficult in a crisis situation, but necessary."
Reduce risk of infection. Infection risks are reduced with soap and water cleansing, sharp debridement where indicated, dressings with silver sulfadiazine, xeroform or other anti-infective, and updating tetanus prophylaxis, Trimble says. "The first wound re-check should be done in 24 hours, with follow-up 5-7 days thereafter. Give the patient strict cautions regarding the signs of infection and the necessity of immediate return," he explains.
After initial resuscitation, the burned areas should be cleansed with a surgical disinfectant and gently debrided, says Wraa. "Body hair at the wound and around the periphery is shaved," she explains.
The burned area is covered with a topical antimicrobial agent and covered with dry dressings. "The most common antimicrobial agents used contain silver sulfadiazine. The cream is soothing to the wound, has a good antimicrobial spectrum, and has almost no systemic absorption or toxicity," says Wraa. "Do not use these creams on patients who are allergic to sulfa drugs."
Dead tissue should be debrided, and large blisters may need to be broken and debrided, says Selfridge-Thomas. "Care should be administered under as sterile conditions as possible to prevent infection," she advises. "If treatment will continue on an outpatient basis, then dressings need to be changed daily until adequate healing has occurred."
Generally, infectious complications are associated with length of hospital course, rapidity of ultimate burn wound treatment (including skin grafting if necessary), and the number and duration of invasive procedures required by the burn victim, says David Dries, MSE, MD, professor of surgery for the division of trauma, burns, and emergency surgery at the University of Michigan Health System.
Stop the burning process. "This means removing anything which may continue to burn the patient," says Wraa. Remove clothing, rings, watches, and jewelry, flush chemical burns, and remove from electrical source, she stresses.
Be prepared for patients with chemical burns. "All chemicals used in the work environment must have the MSDS [Material Safety Data] sheet available," says Merk. "If a patient presents in the ED from a work related chemical injury, the MSDS sheet should be requested. This will help in the treatment of the patient."
Be aggressive with airway managment. The two most significant contributors to infection in the burn injured patient are the wound (which should be rapidly treated with topical antimicrobials and grafted) and the airway," says Dries. "Patients with respiratory distress require endotracheal intubation."
However, the presence of carbonaceous sputum and evidence of facial injury does not necessitate the use of intratracheal tube, says Dries. "Excessive use of intubation in burn-injured patients is associated with a significant risk of an iatrogenic pneumonia due to aspiration and other airway injury," he notes. "Patients should be intubated on the basis of clinical examination, rather than history of closed space environment during burning and evidence of cutaneous facial injury."
Give 100% oxygen and be prepared to suction and support ventilation, and maintain c-spine, says Merk. "There have been many advances in the management of airways for burned children. This is the most important aspect of care for all patients," she stresses.
Address fluid resuscitation. "This is important in burns because if adequate amounts of fluid are not administered, cardiovascular collapse and/or kidney damage will result, necessitating dialysis," says Merk. "It could also result in irreversible hypovolemic shock."
The amounts of fluid required are often very large, maybe several liters of fluid per hour, Merk notes. "The nurse should know how much fluid to give the patient each hour to prevent complications," she says.
Resuscitation fluids should not be given in the form of a bolus, but rather, as a steady infusion intended to maintain the urine output of 30-50 mL per hour, says Dries. "Bolus administration of intravenous fluids will not address the changes in capillary permeability, which extend for 12-24 hours after thermal injury occurs," he explains. "Excessive fluid administration will contribute only to excessive tissue edema, with diminished delivery of oxygen to the point of tissue injury."
Be sensitive to emotional needs of family members. "Many parents feel tremendously guilty about their child’s injury," Merk notes. "Maybe they turned their back for a second or left the child with a sitter. This takes time to work through, and I’m not sure it ever goes away completely."
Nurses should not make promises to the family about scarring and survival, says Merk. "This will give them false hope," she stresses. "Calm reassurance that their child is being evaluated and simple explanation of current treatment will help families feel focused and calm. Encourage the family to comfort their child by holding their hand, stroking their head, and verbal reassurance."
Informing the patient and his or her family what to expect is important and initially may have to be repeated, says Wraa. "Their anxiety may inhibit their ability to receive and remember a lot of information at one time," she explains.
Emotional support can best be provided to patients after pain medication has been given, says Merk. "[Give] verbal reassurance in a calming manner; touch reassurance (in areas that are not burned of course) is also good," she says. "We also let parents in as much as possible, depending on what they can tolerate. The only time we really don’t want parents to see the child’s treatment is during an escharotomy or during the grafting procedure."
Keep education up to date. Attend an Advanced Burn Life Support Class (ABLS) course, Merk recommends. "It is important for nurses to educate themselves regardless of reimbursement by their facility," she says. "The ABLS course is wonderful, and intended for those involved in the emergency management and treatment of burns. I highly recommend it."
Rule out associated injuries. Do a head-to-toe secondary survey. "Remember, the patient is a trauma patient, not just a burn patient," stresses Merk. "Patients may have secondary injuries from electrical contact, auto accidents, being thrown from burning buildings, explosions, etc."
Many families are concerned with vision when their child has facial burns, says Merk. "Typically, the eyes are protected even if the lid is burned, however it is best to have a consult evaluate," she notes.
Prevent scars and contractures. "Beginning with initial resuscitation through the time it takes the scars to fully mature (at least 12 months), positioning the body and helping the patient perform range-of-motion exercises is essential," says Wraa. Range of motion exercises are usually done during dressing changes initially, she adds.
For the best functional outcome results, attention must focus on early mobility, says Wraa. "Splints are used to maintain arm, legs, and hands in extended yet functional positions," she explains. "After sufficient healing, custom-fitted pressure garments are worn to prevent hypertrophic scarring."
Use protocols. Protocols should include criteria grading severity of burn, management plan, and disposition options with their criteria. (See protocol on page 7.) "Associated injury such as carbon monoxide, smoke inhalation, or pulmonary burns, should be addressed," says Trimble. "Protocols should also include where to get additional resources, both human and institutional, if there is more than one casualty."
Be aware of new management approaches. "The most exciting recent development in the management of burn injury is the development of biologic and synthetic dressings which may be applied to partial thickness injuries," says Dries. "These dressings simplify nursing care of patients, shorten hospitalization, and improve pain relief."
Dressings can be secured with skin tape and will peel off as the wound heals beneath, says Dries. "A risk associated with the use of these dressings is underlying infection, therefore, careful management of the burned area is necessary. Nonetheless, we are rapidly approaching a time when the use of these dressings may be appropriate for acute management of patients with superficial burn injuries in the ED."
For more information about the management of patients with burns, contact the following:
• David Dries, MD, University of Michigan, Division of Trauma, Burn and Emergency Surgery, 1C421 University Hospital, Box 0033, 1500 E. Medical Center Drive, Ann Arbor MI 48109-0033. Telephone: (734) 936-9690. Fax: (734) 936-9657. E-mail: email@example.com
• Teresa Merk, RN, BSN, Shriners Hospital for Children, 3229 Burnet Avenue, Cincinnati, OH 45229. Telephone: (513) 872-6000 x. 6262. Fax: (513) 872-6999. E-mail: firstname.lastname@example.org
• Judy Selfridge-Thomas, RN, MSN, CEN, FNP, 3450 Pacific Coast Highway, Ventura, CA 93001. Telephone: (805) 641-3483. Fax: (805) 641-3870. E-mail: email@example.com
• Tom Trimble, RN. Fax: (415) 472-4914. E-mail: firstname.lastname@example.org World Wide Web: http://www.enw.org
• Cheryl Wraa, RN, BSN. Fax: (916) 734-3503 E-mail: email@example.com
• For more information on ABLS courses, contact the American Burn Association, 625 North Michigan Ave., Suite 1530, Chicago, IL 60611. Telephone: (800) 548-2876.