BURN MANAGEMENT AND

PLASTIC SURGERIES
 The burns patient has the same
priorities as all other trauma patients.

Assess:
- Airway
- Breathing: beware of inhalation and
rapid airway compromise
- Circulation: fluid replacement
- Disability: compartment syndrome
- Exposure: percentage area of burn.
 Essential management points
- Stop the burning
- ABCDE
-Good IV access and early fluid replacement.
-Determine the percentage area of burn
(Rule of 9’s)
The severity of the burn is determined by:
- Burned surface area
- Depth of burn
- Other considerations.
 Burn Management in Adults
• The “Rule of 9’s” is commonly used to estimate the burned
surface area in adults.
 
• The body is divided into anatomical regions that represent
9% (or multiples of 9%) of the total body surface. The
outstretched palm and fingers approximates to 1% of the
body surface area.
 
• If the burned area is small, assess how many times patient’s
hand covers the area.
 
• Morbidity and mortality rises with increasing burned surface
area. It also rises with increasing age so that even small
burns may be fatal in elderly people.
Rule of Nines for Establishing Extent of
Body Surface Burned
Anatomic % of total
Surface body surface
Head and neck 9%
Anterior trunk 18%
Posterior trunk 18%
Arms, including
9% each
hands

Legs, including
18% each
feet
Genitalia 1%
Burn Management in Children
 Depth of burn
Depth of burn Characteristics Cause
First degree burn • Erythema • Sunburn
• Pain
• Absence of blisters

Second degree • Red or mottled  

(Partial thickness) • Flash burns • Contact with hot
liquids

Third degree • Dark and leathery • Fire

(Full Thickness) • Dry • Electricity or
lightning
• Prolonged exposure to
hot liquids/
objects
 Serious burn requiring hospitalization
- Greater than 15% burns in an adult
- Greater than 10% burns in a child
- Any burn in the very young and the elderly or the
infirm
- Any full thickness burn
- Burns of special regions: face, hands, feet, perineum
- Circumferential burns
- Inhalation injury
- Associated trauma or significant pre-burn illness:
e.g. diabetes
 TREATMENT
• General information
– All burn patients should initially be treated with the
principles of Advanced Burn and/or Trauma Life
Support
• The ABC's (airway, breathing, circulation)
• Search for other signs of trauma
• Verified Burn Centers provide advanced support
for complex cases
– Certified by the American College of Surgeons (ACS)
Committee on Trauma and the American Burn
Association (ABA)
– Resources will give advice or assist with care
• Burn Unit Referral Criteria
 AIRWAY

Massive burns :-All patients with deep burns >35-

40% TBSA should be endotracheally intubated

Burns to the head and Burns inside the mouth :-

Intubate early if massive burn or signs of obstruction
Intubate if patients require prolonged transport and
any concern with potential for obstruction
If any concerns about the airway, it is safer to intubate
earlier than when the patient is decompensating
 Signs of airway obstruction
• Hoarseness or change in voice
• Use of accessory respiratory muscles
• High anxiety

– Tracheostomies not needed during

resuscitation period
– Remember: Intubation can lead to
complications, so do not intubate if not
needed
 BREATHING
Hypoxia:- Fire consumes oxygen so people may suffer
from hypoxia as a result of flame injuries
Carbon monoxide (CO)
Byproduct of incomplete combustion
Binds hemoglobin with 200 times the affinity of oxygen
Leads to inadequate oxygenation
 Diagnosis of CO poisoning

Nondiagnostic Diagnostic

PaO2 Carboxyhemo-
Oximeter globin levels
<10% is normal
Patient >40% is severe
intoxication
color

Treatment:-Remove source , 100% oxygen until

CO levels are <10% .
 Smoke inhalation injury
Smoke particles settle in distal bronchioles

Mucosal cells die

Sloughing and distal atelectasis

Increase risk for pneumonia

 Diagnosis

Bronchoscopy History

Nondiagnostic
Non-diagnostic
clinical findings
clinical tests • Soot in sputum or
• Early chest x-ray saliva
• Early blood gases • Singed facial hair

Treatment :-Supportive pulmonary management

and Aggressive respiratory therapy
 CIRCULATION

Obtain IV access anywhere possible

Unburned areas preferred
Burned areas acceptable
Central access more reliable if proficient
Cut-downs are last resort
 Resuscitation in burn shock
(first 24 hours)
• Massive capillary leak occurs after major burns
• Fluids shift from intravascular space to
interstitial space
• Fluid requirements depends on severity of burn
• IV fluid rate dependent on physiologic response
– Place Foley catheter to monitor urine output
– Goal for adults: urine output of 0.5 ml/kg/hour
– Goal for children: urine output of 1 ml/kg/hour
– If urine output below these levels, increase fluid rate
• Preferred fluid: Lactated Ringer's Solution
 RESUSCITATION FORMULAS
PARKLAND FORMULA

Fluid calculation
– 4 x weight in kg x %TBSA burn
• Give 1/2 of that volume in the first 8 hours
• Give other 1/2 in next 16 hours
– Adjust fluid rate to maintain urine output of 50 ml/hr
– Albumin may be added towards end of 24 hours if not
adequate response
 RESUSCITATION ENDPOINT
Maintenance rate
• When maintenance rate is reached (approximately 24 hours),
change fluids to D50, 5NS with 20 mEq KCl at maintenance
level
• Maintenance fluid rate = basal requirements + evaporative
losses
– Basal fluid rate
• Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
• Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)
– May use
» 100 ml/kg for 1st 10 kg
» 60 ml/kg for 2nd 10 kg
» 20 ml/kg for remaining kg for 24 hrs
– Evaporative fluid loss
• Adult: (25 + % TBSA burn) x (BSA) = ml/hr
• Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr
COMPLICATIONS OF OVER-RESUSCITATION
LIMB COMPARTMENT SYNDROMES
• Symptoms of severe pain (worse with movement), numbness,
cool extremity, tight feeling compartments
• Distal pulses may remain palpable despite ongoing
compartment syndrome (pulse is lost when pressure > systolic
pressure)
• Compartment pressure >30 mmHg may compromise
muscle/nerves
• Measure compartment pressures with arterial line monitor
(place needle into compartment)
• Escharotomies may save limbs
• Fasciotomies may be needed if pressure does not drop to <30
 Chest Compartment Syndrome

• Increased peak inspiratory pressure (PIP) due to

circumferential trunk burns
• Escharotomies through mid-axillary line,
horizontally across chest/abdominal junction
Abdominal Compartment Syndrome
• Pressure in peritoneal cavity > 30 mmHg
• Signs: increased PIP, decreased urine
output despite massive fluids,
hemodynamic instability, tight abdomen
• Treatment
• Abdominal escharotomy
• NG tube
• Possible placement of peritoneal catheter to
drain fluid
• Laparotomy as last resort
Acute Respiratory Distress Syndrome (ARDS)

– Increased risk and severity if over-resuscitation

– Treatment supportive
• Medications
– All pain medicines should be given IV
– Tetanus prophylaxis should be given as appropriate
– Prophylactic antibiotics are contraindicated
– Systemic antibiotics are only given to treat infections
 SPECIAL BURNS
• Often require specialized care
• Calling a Verified Burn Center is advised
• Electrical injuries
– Extent of injury may not be apparent
• Damage occurs deep within tissues
• Damage frequently progresses
• Electricity contracts muscles, so watch for associated
injuries
– Cardiac arrhythmias may occur
• If arrhythmia present, patient needs monitoring
• CPR may be lifesaving
• Myoglobinuria may be present `

– Color best indicator of severity

– If urine is dark (black, red), myoglobinuria needs to be treated
• Increase fluids to induce urine output of 75-100 ml/hr in adults
• In children, target urine output of 2 ml/kg/hour
• Alkalinize urine (give NaHCO3)
• Check for compartment syndromes
• Mannitol as last resort
– Long-term neuro-psychiatric problems may result
• CHEMICAL BURNS
– Brush off powder
– Prolonged irrigation required
– Do not seek antidote(Delays treatment ,May result in heat
production )
– Special chemical burns require contacting a Verified Burn
Center, for example: Hydrofluoric acid burn
 WOUND CARE
FIRST AID
• If the patient arrives at the health facility without first aid having been given, drench
the burn thoroughly with cool water to prevent further damage and remove all
burned clothing.
 
• If the burn area is limited, immerse the site in cold water for 30 minutes to reduce
pain and oedema and to minimize tissue damage.
 
• If the area of the burn is large, after it has been doused with cool water, apply clean
wraps about the burned area (or the whole patient) to prevent systemic heat loss and
hypothermia.
 
• Hypothermia is a particular risk in young children.
 
• First 6 hours following injury are critical; transport the patient with severe burns to a
hospital as soon as possible.
 
 Initial treatment
• Initially, burns are sterile. Focus the treatment on speedy healing and prevention of
infection.
 
• In all cases, administer tetanus prophylaxis.
 
• Except in very small burns, debride all bullae. Excise adherent necrotic (dead) tissue
initially and debride all necrotic tissue over the first several days.
 
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine
solution, 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic.
• Do not use alcohol-based solutions.
 
• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of antibiotic
cream (silver sulfadiazine).
 
• Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to
the outer layers.
 Daily treatment
• Change the dressing daily (twice daily if possible) or as often as necessary to
prevent seepage through the dressing. On each dressing change, remove any
loose tissue.
 
• Inspect the wounds for discoloration or hemorrhage, which indicate developing
infection.
 
• Fever is not a useful sign as it may persist until the burn wound is closed.
 
• Cellulitis in the surrounding tissue is a better indicator of infection.
 
• Give systemic antibiotics in cases of haemolytic streptococcal wound infection
or septicaemia.
 
• Pseudomonas aeruginosa infection often results in septicaemia and death. Treat
with systemic aminoglycosides.
Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5%
aqueous) is the cheapest, is applied with occlusive dressings but does not
penetrate eschar. It depletes electrolytes and stains the local environment.
 
• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing.
It has limited eschar penetration and may cause neutropenia.
 
• Mafenide acetate (11% in a miscible ointment) is used without dressings. It
penetrates eschar but causes acidosis. Alternating these agents is an
appropriate strategy.
 
• Treat burned hands with special care to preserve function.
− Cover the hands with silver sulfadiazine and place them in loose polythene
gloves or bags secured at the wrist with a crepe bandage;
− Elevate the hands for the first 48 hours, and then start hand exercises;
− At least once a day, remove the gloves, bathe the hands, inspect the burn
and then reapply silver sulfadiazine and the gloves;
− If skin grafting is necessary, consider treatment by a specialist after healthy
 Healing phase
• The depth of the burn and the surface involved influence the
duration of the healing phase. Without infection, superficial
burns heal rapidly.
 
• Apply split thickness skin grafts to full-thickness burns after
wound excision or the appearance of healthy granulation tissue.
 
• Plan to provide long term care to the patient.
 
• Burn scars undergo maturation, at first being red, raised and
uncomfortable. They frequently become hypertrophic and form
keloids. They flatten, soften and fade with time, but the process
is unpredictable and can take up to two years.
 In children
- The scars cannot expand to keep
pace with the growth of the child and
may lead to contractures.
- Arrange for early surgical release of contractures before they
interfere with growth.
 
• Burn scars on the face lead to cosmetic deformity, ectropion
and contractures about the lips. Ectropion can lead to
exposure keratitis and blindness and lip deformity restricts
eating and mouth care.
 
• Consider specialized care for these patients as skin grafting
is often not sufficient to correct facial deformity.
 OTHER WOUND CARE METHODS
Exposure Method: 
Leaving a burn open is a poor option but where
dressings are not possible it may be the only
option. 
The patients is washed daily and kept of clean dry
sheets with another sheet or mosquito net draped
over a frame to reduce the pain from air currents
and to reduce contamination from the
environment. 
Ambient temperature control is important to maintain
normothermia.
 Tubbing
Most modern burn units avoid the regular immersion
of patients in water both because they practice
early excision and grafting and because of the
high risks developing resistant strains of bacteria
in the tub environment and of patient cross-
infection.  That said, tubbing can be helpful to
clean the wounds and gently remove eschar as it
separates. 
When early wound infections develop avoid the
routine immersion of infected patients in bathtubs.
 Bland Dressings
These provide a clean, moist wound healing
environment, absorb exudates protect from
contamination and provide comfort. Paraffin gauze is
used and can be manufactured locally i.e. Honey and
ghee etc. Gauze sheets can be applied directly to
wound in a single layer and covered with plain dry
gauze to absorb exudates,then wrapped.  
Dressings should be changed
at least ever second day, or
when soiled.
 Antimicrobial dressing
These are effective in delaying
the onset of invasive wound
infections. There are newer
silver-ionized agents that
can be used; however they
are often very costly and
inaccessible in low-income
countries.
SURGICAL TREATMENT OF
BURNS
PLASTIC SURGERY FOR
BURNS OR WOUNDS
 Time of performing procedure
Urgent procedures
• Exposure of vital structures (such as eyelid releases)
• Entrapment or compression of neurovascular bundles
• Fourth degree contractures
• Severe microstomia
Essential procedures
• Reconstruction of function (such as limited range of
motion)
• Progressive deformities not correctable by ordinary
methods
Desirable procedures
• Reconstruction of passive areas
• Aesthetics
 Techniques for burn reconstruction
Without deficiency of tissue
• Excision and primary closure
• Z-plasty
With deficiency of tissue
• Simple reconstruction
• Skin graft
• Dermal templates and skin grafts
Transposition flaps (Z-plasty and modifications)
• Reconstruction of skin and underlying tissues
Axial and random flaps
Myocutaneous flaps
Tissue expansion
• Free flaps
Essentials of burn reconstruction
• Strong patient-surgeon relationship
• Psychological support
• Clarify expectations
• Explain priorities
• Note all available donor sites
• Start with a “winner” (easy and quick operation)
• As many surgeries as possible in preschool years
• Offer multiple, simultaneous procedures
• Reassure and support patient
 Escharotomy
• Definition.—An escharotomy is defined as a
surgical incision through burn eschar (necrotic
skin). This procedure is usually performed
within the first 24 hours of burn injury. Burn
eschar has an unyielding, leathery consistency
and is characterized by denatured proteins
and coagulated vessels in the skin, which are
the result of thermal, chemical or electrical
injury.
Escharotomy
 Debridement of Burn Wounds
• Definition—Debridement is the removal of loose,
devitalized, necrotic, and/or contaminated tissue,
foreign bodies, and other debris on the wound
using mechanical or sharp techniques (such as
curetting, scraping, rongeuring, or cutting). The
level of debridement is defined by the level of the
tissue removed, not the level exposed by the
debridement process.
• Purpose—Debridement cleans the wound and
allows it to heal more rapidly with reduced risk of
infection.
 Excision of Burn Wounds
Definition—Excision is a surgical procedure requiring incision
through the deep of open wounds, burn scars. This entails surgical
removal of all necrotic tissue.
Purpose—Excision is typically performed on deep burns that would
not heal on their own. The goal is to remove all necrotic and non-
viable tissue and to prepare the wound for immediate or delayed
wound closure. Excisional techniques create a wound surface that is
fully vascularized and ready for application of temporary or
permanent skin replacement or substitute.
Technique—
Tangential excision involves surgical removal of successive layers of
the burn wound down to viable dermis.
Full thickness excision—often using electrocautery involves removal
of the burn wound down to viable subcutaneous tissue or to fascia.
Tangential excision Full thickness excision
 Skin Grafts
Skin is removed from one area of the body and
transplanted to another. There are two types of skin
graft:

• split-thickness grafts in which just a few layers of

outer skin are transplanted
• full-thickness grafts, which involve all of the dermis.
There is usually permanent scarring that is
noticeable.
 Single- and Multiple-Stage Excision and
Grafting

Single-Stage Excision and Grafting :- Surgical closure of burn

wounds achieves two goals.
The first is to facilitate optimal and rapid healing of the
wound, minimizing deleterious consequences such as scar
contracture while maximizing the best functional and
cosmetic outcomes.
The second is to improve the adverse influence of the burn
wounds on the body’s systemic responses, especially the
immune and metabolic systems. Meticulous wound
preparation and application of skin grafts leads to excellent
functional and cosmetic results.
The single-stage approach to excision and grafting of burn
wounds includes seven intraoperative components:
1. Initial decision-making
a. Area(s) to be excised
b. Depth of the excision
c. Location of donor sites
2. Excision of the burn wound,
3. Achieving hemostasis with electrocautery
and topical application of solutions
containing vasoconstrictive agents (such
as epinephrine or phenylephrine) and/or
pro-coagulants (such as thrombin)
4. Harvesting the donor skin
5. Modification/expansion of the skin
graft by meshing.
6. Applying and securing the skin graft
to the excised wound
7. Placement of dressings and splints to
avoid mechanical shear of the grafts
and to maintain proper positioning.
 Multiple-Stage Excision and Grafting
• It is performed in steps in a planned sequence where part of the
burn wound is excised initially and the remainder is removed in
one or more subsequent operations.
• This is often done with cosmetically important areas such as the
face, as well as with more extensive burns or burns in
physiologically less stable patients.
• The excision is done on the initial operative day and the freshly
excised wound bed is protected with a temporary covering to
prevent desiccation and infection.
• This is followed in one to two days by harvesting and placement
of the skin autografts.
• Staged skin grafting of face burns allows inspection for
hematomas or inadequately excised areas that would lead to graft
loss and can result in nearly 100% graft take.
Single-Stage Excision and Grafting Multiple-Stage Excision and Grafting
 BURN WOUND COVERAGE

• Covering the burn wound helps to prevent

infection, decrease fluid losses, and reduce the
risk of scar contractures.

• Simple, small burn wounds are excised and

covered by either a full thickness skin graft or
by a split-thickness skin graft. The thicker the
graft, the less it will contract and the more
difficult it is for the donor site to heal.
Skin Substitutes and Skin Replacements

Skin substitute [commercial product]: A biomaterial,

engineered tissue or combination of materials and
cells or tissues that can be substituted for skin
autograft or allograft in a clinical procedure

Skin replacement: A tissue or graft that permanently

replaces lost skin with healthy skin.
 
 Temporary Wound Coverage
Temporary skin substitutes are used when the wound is too
extensive to be closed in one stage because:-
• there is not enough donor skin available
• the patient is too ill to undergo the creation of another
wound that results when skin is harvested from a donor
site
• there is a question regarding the viability of the recipient
bed
• concern regarding potential infectious complications.
• The gold standard temporary skin substitute is cadaver
allograft
 Allograft
• Allograft is obtained from skin banks
to ensure quality and safety.
Allograft may be used as fresh,
refrigerated tissue or as frozen
tissue, which is thawed immediately
prior to use.
• Other temporary skin substitutes are
used to provide transient wound
coverage and to create a
physiologically homeostatic
environment. Skin Xenografts—also
termed heterografts .
 Xenograft
Pigskin is used at many
institutions in the same
manner as allograft.
The application of
xenograft on a
debrided mid-dermal
burn might prevent/
obviate the need for
excision and auto-
grafting.
 Permanent Wound
Coverage
A full-thickness skin graft contains
epidermis, dermis, hair follicles and
nerve endings. The most important
advantage of full-thickness grafts is
decreased scar formation
the donor site of a full-thickness skin
graft must be closed either with primary
direct closure or with a split-thickness
skin
 Split-thickness Skin Graft
The split-thickness skin graft
is the most common method
used to achieve permanent
wound coverage. It includes
the entire epidermis but the
dermal layer is split by the
dermatome blade.
 There are a number of commercially
available products
to facilitate permanent wound coverage. 
• Acellular human dermal allograft
(Alloderm®)
• Dermal regenerative template (Integra®)
• Cultured epidermal autograft (CEA;
Epicel®)
 OTHERS
Microsurgery Microsurgery
may allow organs to be re-
attached. Simply stated, it is a
procedure in which the
surgeon uses a microscope
for surgical assistance in
reconstructive procedures. By
using a microscope, the
surgeon can actually sew tiny
blood vessels or nerves,
allowing him or her to repair
damaged nerves and arteries.
 Free flap procedure
A free flap procedure is often
performed during breast
reconstruction or following
surgery to remove head or neck
cancer. During the procedure,
muscle, skin, or bone is
transferred along with the original
blood supply from one area of the
body (donor site) to the surgical
site in order to reconstruct the
area. Total recovery may take six
to eight weeks or longer.
Tissue expansions
Tissue expansion is a medical
procedure that enables patient’s body
to "grow" extra skin for use in
reconstructive procedures. This is
accomplished by inserting san
instrument known as a "balloon
expander" under the skin near the area
in need of repair. Over time, this
balloon will be gradually filled with
saline solution (salt water), slowly
causing the skin to stretch and grow,
much the same way a woman's skin
stretches during pregnancy.
Dealing with deficiency of tissue
If there is no deficiency and local tissues
can be easily mobilised, excision and
direct closure or Z-plasties can be
performed.​
(1) The burn scar, showing the skin
tension lines.
(2) Z-plasty is performed by rotating two
transposition flaps with an angle of
60° with the middle limb of the Z on
the scar.
 Skin Changes After Cosmetic
Surgery
As patient continue to heal, patient will notice
changes in the color, appearance, and feeling of
patient’s skin at the surgical site. Patient also may
notice numbness, a tingling sensation, or minimal
feeling around patient’s incisions. This is normal.
These sensations will continue to improve over the
next few months.
Perfusion and Circulation After Cosmetic
Surgery
After patient’s cosmetic surgery, it is important to
monitor perfusion and circulation of the wound
site.
Avoid wearing clothing that constricts or applies
pressure around patient’s wound.
Also, patient’s doctor may give patient a
additional instructions to help with circulation
to the wound.
 Signs of Infection At the
Surgical Site
Notify patient’s doctor right away if patient
experience any of the following symptoms:

• White pimples or blisters around incision lines.

• An increase in redness, tenderness, or swelling
of the surgical site.
• Drainage from the incision line.
• A marked or sudden increase in pain not
relieved by the pain medication.
• A persistent elevation of body temperature greater than
100.5 degrees Fahrenheit
• Sweats or chills
• Skin rash
• Sore or scratchy throat or pain when swallowing
• Sinus drainage, nasal congestion, headaches, or tenderness
along the upper cheekbones
• Persistent, dry or moist cough that lasts more than two
days
• White patches in patient’s mouth or on patient’s tongue
• Nausea, vomiting, or diarrhea.
• Trouble urinating: pain or burning, constant urge or
frequent urination
• Bloody, cloudy, or foul-smelling urine.
 POST-OPERATIVE DAILY EVALUATION AND
MANAGEMENT

• Operated Burn Wounds

• Care of Burn Wounds Unrelated To
Previously Operated Wounds
• Unrelated Conditions
 POST-DISCHARGE BURN WOUND
MANAGEMENT

• Discharge and Follow Up

• Follow-up
• Scar prevention
• Contracture prevention
• Psychological sequelae
 NUTRITIONAL MANAGEMENT
Assessment
• All inpatients with a deep burn injury are assessed by a
dietitian, in order to establish whether a need exists for
nutritional intervention.
Goals of nutritional management
• To promote optimal wound healing and rapid recovery
from burn injuries
• To minimise risk of complications, including infections
during the treatment period
• To attain and maintain normal nutritional status
• To minimise metabolic disturbances during the treatment
process
Objectives of nutritional management

• Provide nutrition via enteral route within 6 -

18 hours post burn injury
• Maintain weight within 5 % - 10 % of pre-burn
weight
• Prevent signs and symptoms of micronutrient
deficiency
• Minimise hyperglycaemia
• Minimise hypertriglyceridaemia    
 Nutritional Management
• Enteral Feeding Should Be Commenced Early
• Aggressive Nutritional Support is Often
Required
• Energy Requirements are Elevated by the Burn
Injury
• Protein Requirements are Substantially
Increased
• An Increased Requirement Exists for Nutrients
Associated with Healing and Immune Function
COMPLICATIONS OF SURGERIES
FOR BURN MANAGEMENT

Complications to surgery in patients with

burns include bleeding, infection, or graft
loss. If infection is suspected, dressings
can be changed to include broad
spectrum aqueous Sulfamylon solution.
 Outcome and Prognosis
With the exception of infants, the prognosis for
survival in children and adolescents is quite
good.
In the past decade, the size of a survivable injury
has increased from 70% BSA burned to more
than 95% BSA burned in children younger than
15 years.
 NURSING MANAGEMENT
Assessment:-
• Obtain Thorough History including- Causative
agent, duration of exposure, circumstances of
injury, age, initial treatment taken, pre-existing
medical problems, allergies, tetanus
immunization, height, weight.
• Perform ongoing assessment of hemodynamic
and respiratory status, condition of wounds and
signs of infection.
Ineffective gas exchange related to inhalation
injury.

Goal:- Achieve adequate oxygenation and respiratory

functions.
Interventions:-
• Provide humidified 100% oxygen until CO level is
known.
• Assess for signs of hypoxemia.
• Note character and amount of respiratory secretions.
• Provide mechanical ventilation when required.
 Decreased Cardiac output related to fluid
shift and hypovolemic shock.

Goal:- support cardiac output.

Intervention:-
• Position the patient to increase venous return.
• Give fluids as prescribed.
• Monitor vital signs.
• Check level of conscious.
 Ineffective peripheral tissue perfusion
related to edema.

Goal:-promote peripheral circulation.

Intervention:-
• Remove all jewelry and clothing.
• Elevate extremities.
• Monitor peripheral pulses hourly.
• Monitor tissue pressure.
 Risk for infection related to reconstructive
surgeries.
Goal:- Prevent risk for infections.
Interventions:-
• Check vital signs.
• Assess signs of wound infection-redness and
discharge.
• Change dressing as prescribed.
• Apply antibiotic topically and also administer
through IV route.
• Risk for excess fluid volume related to fluid resuscitation.
• Impaired skin integrity related to burn injury and surgical
intervention.
• Impaired urinary elimination related to indwelling catheter.
• Ineffective thermoregulation related to loss of skin surface.
• Impaired physical mobility related to edema, pain, skin and
joint contractures.
• Impaired nutrition: less than body requirement related to
hypermetabolic response to burn injury.
• Risk for injury related to decreased gastric mobility and stress
response.
• Acute pain related to injured nerves in burn wound and skin
tightness.
• Ineffective coping related to fear and anxiety.
• Disturbed body image related to cosmetic and functional
sequelae of burn wound.
 BIBLIOGRAPHY
BOOK REFERENCES:-
• Basavanthappa BT. A Textbook of Medical Surgical Nursing.NewDelhi. Jaypee Brothers.ed.2 nd
• Black M. A Textbook of Medical Surgical Nursing.Noida.Elsevier.ed.8 th
• Brunner S. A Textbook of Medical Surgical Nursing.Philadelphia. Lippincott
Company.ed.5th.1982
WEBSITE REFERENCE:-
• Greenwood JE. Burn injury and explosions: an Australian perspective. Eplasty. 2009 Sep
16;9:e40. [PubMed Citation]
• Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb 26;360(9):893-
901. [PubMed Citation]
• Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6 Suppl 2):S180-
7. [PubMed Citation] 47
• American Medical Association. CPT Assistant. Skin Replacement Surgery and Skin Substitutes.
Volume 16, October 2006. Herndon DN, ed. Total burn care. 2nd ed. London: WB Saunders,
2002.
• Engrav LH, Donelan MB. Operative techniques in plastic and reconstructive surgery. Face
burns: acute care and reconstruction. London: WB Saunders, 1997.
• Achauer BM. Burn reconstruction. New York: Thiene, 1991.
• Barret JP, Herndon DN. Color atlas of burn care. London: WB Saunders, 2001.
• Brou JA, Robson MC, McCauley RL. Inventory of potential reconstructive needs in the patient
with burns. J Burn Care Rehabil 1989;10: 555-60.
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