Chapter 25 Burns

Burn Center Referral Criteria

1. Partial-thickness burns >10% of total body surface area (TBSA). 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 3. Third-degree burns in any age-group. 4. Electrical burns, including lightning injury. 5. Chemical burns. 6. Inhalation injury. 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality risk (e.g., heart or kidney disease). 8. Any patients with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn center. The health care provider will need to use his or her judgment, in consultation with the regional medical control plan and triage protocols. 9. Burn injury in children in hospitals without qualified personnel or equipment needed to care for them. 10. Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention.

Lower airway injury more info

An inhalation injury to the trachea, bronchioles, and alveoli is usually caused by breathing in toxic chemicals or smoke. Tissue damage is related to the duration of exposure to toxic fumes or smoke. Clinical manifestations of lower airway lung injury are presented in Table 25-3. Pulmonary edema may not appear until 12 to 24 hours after the burn, and then it may manifest as acute respiratory distress syndrome (ARDS)

Patient Risk Factors

Any patient with preexisting cardiovascular, respiratory, or renal disease has a poorer prognosis for recovery because of the tremendous demands placed on the body by a burn injury. The patient with diabetes mellitus or peripheral vascular disease is at high risk for poor healing, especially with foot and leg burns. 8 General physical debilitation from any chronic disease, including alcoholism, drug abuse, or malnutrition, makes it challenging for the patient to fully recover from a burn injury. In addition, the burn patient who has also sustained fractures, head injuries, or other trauma has a more difficult time recovering.

Fluid Therapy

At least two large-bore IV access sites must be in place for patients with burns that are 15% TBSA or more. It is critical to establish IV access that can handle large volumes of fluid. For patients with burns greater than 30% TBSA, consider a central line for fluid and drug administration and blood sampling (central lines are discussed in Chapter 17). An arterial line is often placed if frequent ABGs or invasive BP monitoring is needed. Fluid replacement is achieved with crystalloid solutions (usually lactated Ringer's), colloids (albumin), or a combination of the two. 12 Paramedics generally give IV saline until the patient's arrival at the hospital.

Upper airway manifestations lung injury of burns

Blisters, edema • Hoarseness • Difficulty swallowing • Copious secretions • Stridor • Substernal and intercostal retractions • Total airway obstruction

Two types of pain that burn patients experience

(1) continuous, background pain that might be present throughout the day and night; and (2) treatment-induced pain associated with dressing changes, ambulation, and rehabilitation activities.

Classification of Burns is based on..

(1) depth of burn, (2) extent of burn calculated in percent of total body surface area (TBSA), (3) location of burn, and (4) patient risk factors (e.g., age, past medical history).

Early in the postburn period IV pain meds should be given because

(1) onset of action is fastest with this route; (2) oral medications have a slower onset of action and are not as effective when GI function is slowed or impaired because of shock or paralytic ileus; and (3) intramuscular (IM) injections will not be absorbed adequately in burned or edematous areas, causing pooling of medications in the tissues. Consequently, when fluid mobilization begins, the patient could be inadvertently overdosed from the interstitial accumulation of previous IM medications.

Goals of wound care for burns

(1) prevent infection by cleansing and debriding the area of necrotic tissue that would promote bacterial growth and (2) promote wound re-epithelialization and/or successful skin grafting.

approachs to burn wound management

(1) the open method and (2) the use of multiple dressing changes (closed method). In the open method the patient's burn is covered with a topical antimicrobial and has no dressing over the wound. In the multiple dressing change, or closed method, sterile gauze dressings are impregnated with or laid over a topical antimicrobial (Fig. 25-11). These dressings are changed anywhere from every 12 to 24 hours to once every 14 days (depending on the product). Most burn centers support the concept of moist wound healing and use dressings to cover the burned areas, with the exception of facial burns. prevent shivering by keeping the room warm (approximately 85° F [29.4° C]). Before leaving one patient, remove your PPE. Don new equipment before you treat another patient. Perform thorough hand washing both before and after patient contact to prevent cross-contamination.

Contractures

(an abnormal condition of a joint characterized by flexion and fixation) develops as a result of the shortening of scar tissue in the flexor tissues of a joint. Areas that are most susceptible to contracture formation include the anterior and lateral neck areas, axillae, antecubital fossae, fingers, groin areas, popliteal fossae, knees, and ankles. Some areas encompass major joints. Not only does the skin over these areas develop contractures, but the underlying tissues, such as the ligaments and tendons, also have a tendency to shorten during the healing process. Encourage proper positioning, splinting, and exercise to minimize this complication. Tell the patient to continue with these strategies until the skin matures at around 1 year posthealing. Rehabilitative therapy is aimed at the extension of body parts because the flexors are stronger than the extensors. Burned legs may first be wrapped with elastic (e.g., tensor, Ace) bandages to assist with circulation to leg-graft and donor sites before ambulation. Burned arms can be wrapped with a layer of tubular elastic gauze (e.g., Tubigrip). This interim pressure prevents blister formation, promotes venous return, and decreases pain and itchiness. Once the skin is completely healed and less fragile, custom-fitted pressure garments replace the elastic bandages and tubular gauze.

Collodial Solutins

(e.g., 5% albumin) may also be given. However, administration is recommended after the first 12 to 24 hours postburn when capillary permeability returns to normal or near normal. After this time, the plasma remains in the vascular space and expands the circulating volume. The replacement volume is calculated based on the patient's body weight and TBSA burned (e.g., 0.3 to 0.5 mL/kg/%TBSA burned).

Physical and Occupational Therapy

Continuous physical therapy, throughout burn recovery, is imperative if the patient is to regain and maintain muscle strength and optimal joint function. A good time for exercise is during and after wound cleansing, when the skin is softer and bulky dressings are removed. Passive and active ROM should be performed on all joints. Ensure that the patient with neck burns continues to sleep without pillows or with the head hanging slightly over the top of the mattress to encourage hyperextension. Maintain the occupational therapy schedule for wearing custom-fitted splints, which are designed to keep joints in functional position. Examine the splints frequently to ensure an optimal fit, with no undue pressure that might lead to skin breakdown or nerve damage.

Third and Fourth Degree Burns

Dry, waxy white, leathery, or hard skin; visible thrombosed vessels. Insensitivity to pain because of nerve destruction. Possible involvement of muscles, tendons, and bones. Flame Scald Chemical Tar Electric current All skin elements and local nerve endings destroyed. Coagulation necrosis present. Surgical intervention required for healing.

Superficial first degree burn

Erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters (although after 24 hr skin may blister and peel). Superficial sunburn Quick heat flash Superficial epidermal damage with hyperemia. Tactile and pain sensation intact.

Extent of Burn

Extent of Burn Two commonly used guides for determining the TBSA affected or the extent of a burn wound are the Lund-Browder chart (Fig. 25-4, A) and the Rule of Nines (Fig. 25-4, B). (First-degree burns, equivalent to a sunburn, are not included when calculating TBSA.) The Lund-Browder chart is considered more accurate because it considers the patient's age in proportion to relative body-area size. The Rule of Nines is often used for initial assessment of a burn patient because it is easy to remember. For irregular- or odd-shaped burns, the patient's hand (including the fingers) is approximately 1% TBSA. The Sage Burn Diagram is a free, Internet-based tool for estimating TBSA burned

Deep second degree burn

Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured). Severe pain caused by nerve injury. Mild to moderate edema. Flame Flash Scald Contact burns Chemical Tar Electric current Epidermis and dermis involved to varying depths. Skin elements, from which epithelial regeneration occurs, remain viable.

Nutritional Therapy

In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours. If a large nasogastric tube is inserted, gastric residuals should be checked to rule out delayed gastric emptying. Assess bowel sounds every 8 hours.

Inhalation Injury

Initial • Assess airway, breathing, and circulation. • Stabilize cervical spine. • Assess for thermal burn. • Provide 100% humidified O2. • Anticipate endotracheal intubation and mechanical ventilation with significant inhalation injury. • Monitor vital signs, level of consciousness, O2 saturation, and heart rhythm. • Remove nonadherent clothing, jewelry, glasses, or contact lenses (if face was exposed). • Establish IV access with two large-bore catheters if burn >15% TBSA. • Begin fluid replacement. • Insert indwelling urinary catheter if burn >15% TBSA. • Elevate burned limb(s) above heart to decrease edema. • Obtain arterial blood gas, carboxyhemoglobin levels, and chest x-ray. • Administer IV analgesia and assess effectiveness frequently. • Identify and treat other associated injuries (e.g., fractures, pneumothorax, head injury). • Cover burned areas with dry dressings or clean sheet. • Anticipate need for fiberoptic bronchoscopy or intubation. Ongoing Monitoring • Monitor airway. • Monitor vital signs, level of consciousness, respiratory status, O2 saturation, and heart rhythm. • Monitor urine output.

Electrical Burns: • Leathery, white, or charred skin • Burn odor • Loss of consciousness • Impaired touch sensation • Minimal or absent pain • Dysrhythmias • Cardiac arrest • Location of contact points • Diminished peripheral circulation in injured extremity • Thermal burns if clothing ignites • Fractures or dislocations from force of current • Head or neck injury if fall occurred • Depth and extent of wound difficult to visualize. Assume injury greater than what is seen

Initial • Remove patient from electrical source while protecting rescuer. • Assess airway, breathing, and circulation. • Stabilize cervical spine. • Provide supplemental O2 as needed. • Monitor vital signs, heart rhythm, level of consciousness, respiratory status, and O2 saturation. • Check pulses distal to burns. • Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed). • Cover burned areas with dry dressings or clean sheet. • Establish IV access with two large-bore catheters if burn >15% TBSA. • Begin fluid replacement. • Obtain arterial blood gas to assess acid-base balance. • Insert indwelling urinary catheter if burn >15% TBSA. • Elevate burned limb(s) above heart to decrease edema. • Administer IV analgesia and assess effectiveness frequently. • Identify and treat other associated injuries (e.g., fractures, head injury, thermal burns). Ongoing Monitoring • Monitor airway. • Monitor vital signs, heart rhythm, level of consciousness, respiratory status, O2 saturation, and neurovascular status of injured limbs. • Monitor urine output. • Monitor urine for development of myoglobinuria secondary to muscle breakdown and hemoglobinuria secondary to RBC breakdown. • Anticipate possible administration of NaHCO3 to alkalinize the urine and maintain serum pH >6.0.

upper airway assessment

Mechanical obstruction can occur quickly, presenting a true medical emergency. Carefully assess the patient for facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and clothing burns around the chest and neck.

Fluid Rescutation

Parkland (Baxter) Formula* 4 mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface area (% TBSA) burned = Total fluid requirements for first 24 hr after burn Application ½ of total in first 8 hr ¼ of total in second 8 hr ¼ of total in third 8 hr

Clinical Manifestations of Acute Phase

Partial-thickness wounds form eschar, which begins separating fairly soon after injury. Once the eschar is removed, reepithelialization begins at the wound margins and appears as red or pink scar tissue. Epithelial buds, from the hair follicles and glands in the dermal bed, eventually close the wound. Healing is spontaneous and usually occurs within 10 to 21 days. Margins of full-thickness eschar take longer to separate. As a result, full-thickness burn wounds require surgical debridement and skin grafting to heal.

Pneomnia and burns

Pneumonia, a common complication of major burns, is the leading cause of death in patients with an inhalation injury.

Safety alert for burns

SAFETY ALERT • Check the patient for any allergies to sulfa, since many burn antimicrobial creams contain sulfa.

Small thermal burns (10% or less of TBSA)

Small thermal burns (10% or less of TBSA) should be covered with a clean, cool, tap water-dampened towel for the patient's comfort and protection until medical care is available. 9 Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury. If the burn is large (greater than 10% TBSA) or an electrical or inhalation burn is suspected, first focus your attention on the ABCs

GI system and acute phase

System. The GI system may also experience complications during this phase. Paralytic ileus can be caused by sepsis. Diarrhea may result from the use of enteral feedings or antibiotics. Constipation can occur as a side effect of opioid analgesics, decreased mobility, and a low-fiber diet. Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). It is caused by a generalized stress response to decreased blood flow to the GI tract. The patient has increased gastric acid secretion. Aim to prevent Curling's ulcer by feeding the patient as soon as possible after the burn injury. Antacids, H2 -histamine blockers (e.g., ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach acids and inhibit histamine and the secretion of hydrochloric acid (see Table 25-13). Patients with major burns may also have occult blood in their stools during the acute phase and require close monitoring for bleeding.

Tetanus Immunization

Tetanus toxoid is given routinely to all burn patients because of the likelihood of anaerobic burn wound contamination. If the patient has not received an active immunization within 10 years before the burn injury, tetanus immunoglobulin should be considered.

Fluid shift and burns

The greatest initial threat to a patient with a major burn is hypovolemic shock (Fig. 25-5). It is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability and can begin as early as 20 minutes postburn. As the capillary walls become more permeable, water, sodium, and plasma proteins (especially albumin) move into the interstitial spaces and other surrounding tissue. The colloidal osmotic pressure decreases with progressive loss of protein from the vascular space. This results in more fluid shifting out of the vascular space into the interstitial spaces (Fig. 25-6). Fluid accumulation in the interstitium is termed second spacing. Fluid also moves to areas that normally have minimal to no fluid, a phenomenon termed third spacing. Examples of third spacing in burn injury are exudate and blister formation, as well as edema in nonburned areas. Other sources of fluid loss are insensible losses by evaporation from large, denuded body surfaces and the respiratory system. The normal insensible loss of 30 to 50 mL/hr is increased in the severely burned patient. The net result of the fluid shifts and losses is termed intravascular volume depletion. Clinical signs of hypovolemic shock are decreased blood pressure (BP) and increased heart rate. If hypovolemic shock is not corrected, irreversible shock and death may result. (Shock is discussed in Chapter 67.) The circulatory system is also affected by the hemolysis of RBCs from circulating factors (e.g., oxygen free radicals) released at the time of the burn, as well as by the direct insult of the burn injury. Thrombosis in the capillaries of burned tissue causes an additional loss of circulating RBCs. An elevated hematocrit is commonly caused by hemoconcentration resulting from fluid loss. After fluid balance has been restored, dilution causes the hematocrit levels to drop.

Metabolic asphyixation

The majority of deaths at a fire scene are the result of inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide. Oxygen delivery to or consumption by tissues is impaired. The result is hypoxia and, ultimately, death when carboxyhemoglobin (i.e., hemoglobin combined with CO) blood levels are greater than 20%. CO and hydrogen cyanide poisoning may occur in the absence of burn injury to the skin.

Urinary System and the emergent phase of burns

The most common complication of the urinary system in the emergent phase is acute tubular necrosis (ATN). If your patient becomes hypovolemic, blood flow to the kidneys is decreased, causing renal ischemia. If this continues, acute kidney injury may develop. With full-thickness and major electrical burns, myoglobin (from muscle cell breakdown) and hemoglobin (from RBC breakdown) are released into the bloodstream and occlude renal tubules. Carefully monitor the adequacy of fluid replacement because this can counteract obstruction of the tubules.

Ger considerations Burns

The older patient presents many challenges for the burn team. The normal aging process puts the patient at risk for injury because of unsteady gait, limited eyesight, and diminished hearing. As people age, skin becomes drier and more wrinkled. Older adults have thinning of the dermal layer, a loss of elastic fibers, a reduction in subcutaneous adipose tissue, and a decrease in vascularity. As a result, the thinner dermis, with reduced blood flow, sustains deeper burns with poorer rates of healing. 35 Once injured, the older adult has more complications in the emergent and acute phases of burn resuscitation because of preexisting medical conditions. For example, older patients with diabetes, heart failure, or chronic obstructive pulmonary disease have morbidity and mortality rates exceeding those of healthy, younger patients. In older patients, pneumonia is a frequent complication, burn wounds and donor sites take longer to heal, and surgical procedures are less well tolerated. Weaning from a ventilator can be a challenge. Although usually selflimiting, delirium, if it develops, may be distressing. It usually takes longer for these patients to rehabilitate to the point where they can safely return home. 36 For some, a return home to independent living may not be possible. As the population ages, developing strategies to prevent burn injuries in older adults is a priority.

Prevention of Hypothermia with Burn patients

To prevent hypothermia, cool large burns for no more than 10 minutes. Do not immerse the burned body part in cool water because it may cause extensive heat loss. Never cover a burn with ice, since this can cause hypothermia and vasoconstriction of blood vessels, thus further reducing blood flow to the injury. Gently remove as much burned clothing as possible to prevent further tissue damage. Leave adherent clothing in place until the patient is transferred to a hospital. Wrap the patient in a dry, clean sheet or blanket to prevent further contamination of the wound and to provide warmth.

Chemical Burns

are the result of contact with acids, alkalis, and organic compounds. In addition to tissue damage, eyes can be injured if they are splashed with the chemical. Acids are found in the home and at work and include hydrochloric, oxalic, and hydrofluoric acid. Alkali burns can be more difficult to manage than acid burns, since alkalis adhere to tissue, causing protein hydrolysis and liquefaction. Alkalis are found in oven and drain cleaners, fertilizers, and heavy industrial cleansers. Organic compounds, including phenols (chemical disinfectants) and petroleum products (creosote and gasoline), produce contact burns and systemic toxicity.

Rehabilation Phase

begins when the patient's wounds have healed and he or she is engaging in some level of self-care. This may happen as early as 2 weeks or as long as 7 to 8 months after the burn injury. Goals for the patient now are to (1) work toward resuming a functional role in society and (2) rehabilitate from any functional and cosmetic postburn reconstructive surgery that may be necessary.

Hyponatremia and burns

can develop from excessive GI suction, diarrhea, and water intake. Manifestations of hyponatremia include weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion. The patient may also develop a dilutional hyponatremia called water intoxication. To avoid this condition, encourage the patient to drink fluids other than water, such as juice or nutritional supplements.

Thermal Burn

caused by flame, flash, scald, or contact with hot objects, are the most common type of burn injury

Burn Management phases

emergent (resuscitative), acute (wound healing), and rehabilitative (restorative).

Nutritional info and acute phase

focuses on having enough calories The patient may benefit from an antioxidant protocol, which includes selenium, acetylcysteine, ascorbic acid, vitamin E, zinc, and a multivitamin. Meeting daily caloric requirements is crucial and should begin within the first 1 to 2 days postburn. The daily estimated caloric needs must be regularly calculated by a dietitian and readjusted as the patient's condition changes (e.g., wound healing improves, sepsis develops). Monitor laboratory values (e.g., albumin, prealbumin, total protein, transferrin) on a regular basis.

Smoke and inhalation injuries

from breathing hot air or noxious chemicals can cause damage to the respiratory tract. Three types of smoke and inhalation injuries can occur: metabolic asphyxiation, upper airway injury, and lower airway injury. Because smoke inhalation injuries are a major predictor of mortality in burn patients, rapid assessment is critical.

CO posining

is suspected, treat the patient with 100% humidified O2 . Patients who have both body burns and an inhalation injury must be transferred to the nearest burn center.

Sedatives/Hypnotics

lorazepam (Ativan) Reduce anxiety midazolam (Versed) Provide short-acting amnesic effects zolpidem (Ambien) Promote sleep

Hypernatremias and burns

may be seen after successful fluid resuscitation if copious amounts of hypertonic solutions were required. Hypernatremia may also be related to tube feeding therapy or inappropriate fluid administration. Manifestations of hypernatremia include thirst; dried, furry tongue; lethargy; confusion; and possibly seizures. Sodium restrictions may be applied to IV fluids and enteral or oral feedings until levels return to safe limits.

Hyperkalemia and burns

may occur if the patient has renal failure, adrenocortical insufficiency, or massive deep muscle injury (e.g., electrical burn) with large amounts of potassium released from damaged cells. Cardiac dysrhythmias and arrest can occur with elevated potassium levels. Muscle weakness, cramping, and paralysis are found clinically

Analgesics

morphine (Avinza) sustained-release morphine (MS Contin) hydromorphone (Dilaudid) sustained-release hydromorphone (Dilaudid CR) fentanyl (Sublimaze) oxycodone and acetaminophen (Percocet) methadone (Dolophine) Nonsteroidal antiinflammatory (e.g., ketorolac [Toradol]) Adjuvant analgesics (e.g., gabapentin [Neurontin])

Hypokalemia and burns

occurs with vomiting, diarrhea, prolonged GI suction, and IV therapy without potassium supplementation. Potassium is also lost through the patient's burn wounds. Signs and symptoms of hypokalemia include fatigue, muscle weakness, leg cramps, cardiac dysrhythmias (e.g., premature ventricular contractions), paresthesias, and decreased reflexes

Acute Phase

of burn care begins with the mobilization of extracellular fluid and subsequent diuresis. It concludes when partial-thickness wounds are healed or full-thickness burns are covered by skin grafts. This may take weeks or months.

Electrical Burn assessment

perform a rapid assessment of the patient with electrical injury. Transfer to a burn center is indicated. The severity of an electrical injury can be difficult to determine, since most of the damage is below the skin (known as the iceberg effect). Determination of electric current contact points and history of the injury may help determine the probable path of the current and potential areas of injury. Contact with electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. Another reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury. For this reason, all patients with electrical burns should be considered at risk for a potential cervical spine injury. Cervical spine immobilization must be used during transport and subsequent diagnostic testing completed to rule out any injury. Electrical injury puts the patient at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria. The electric shock event can cause immediate cardiac standstill or ventricular fibrillation. Delayed cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours after injury. Myoglobin from injured muscle tissue and hemoglobin from damaged red blood cells (RBCs) are released into the circulation whenever massive muscle and blood vessel damage occurs. The released myoglobin pigments travel to the kidneys and can block the renal tubules, which can result in acute tubular necrosis (ATN) and acute kidney injury

Emergent phase

phase is the time required to resolve the immediate, life-threatening problems resulting from the burn injury. This phase usually lasts up to 72 hours from the time the burn occurred. The primary concerns are the onset of hypovolemic shock and edema formation. The emergent phase ends when fluid mobilization and diuresis begin.

Nursing management during emergent phase

predominantly consists of airway management, fluid therapy, and wound care

Electrical Burns

result from intense heat generated from an electric current. Direct damage to nerves and vessels, causing tissue anoxia and death, can also occur. The severity of the electrical injury depends on the amount of voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time that the current flow was sustained.

Antidepressants

sertraline (Zoloft) citalopram (Celexa) Reduce depression, improve mood

Partial-Thickness (superficial; first-degree) Burn • Redness • Pain • Moderate to severe tenderness • Minimal edema • Blanching with pressure Partial-Thickness (deep; second-degree) Burn • Moist blebs, blisters • Mottled white, pink to cherry-red • Hypersensitive to touch or air • Moderate to severe pain • Blanching with pressure Full-Thickness (third- and fourth-degree) Burns • Dry, leathery eschar • Waxy white, dark brown, or charred appearance • Strong burn odor • Impaired sensation when touched • Absence of pain with severe pain in surrounding tissues • Lack of blanching with pressure

• Assess airway, breathing, and circulation. • Stabilize cervical spine. • Assess for inhalation injury. • Provide supplemental O2 as needed. • Anticipate endotracheal intubation and mechanical ventilation with circumferential full-thickness burns to the neck and chest or large TBSA burn. • Monitor vital signs, level of consciousness, respiratory status, O2 saturation, and heart rhythm. • Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed). • Cover burned areas with dry dressings or clean sheet. • Establish IV access with two large-bore catheters if burn >15% TBSA. • Begin fluid replacement. • Insert indwelling urinary catheter if burn >15% TBSA. • Elevate burned limbs above heart to decrease edema. • Administer IV analgesia and assess effectiveness frequently. • Identify and treat other associated injuries (e.g., fractures, head injury). Ongoing Monitoring: • Monitor airway. • Monitor vital signs, heart rhythm, level of consciousness, respiratory status, and O2 saturation. • Monitor urine output.

Lower airway manifestations of lung injury with burns

• High degree of suspicion if patient was trapped in a fire in an enclosed space or clothing caught fire • Presence of facial burns or singed nasal or facial hair • Dyspnea • Carbonaceous sputum • Wheezing • Hoarseness • Altered mental status

Urine and Cardiac Parameters

•Urine output: 0.5 to 1 mL/kg/hr; 75 to 100 mL/hr for electrical burn patient with evidence of hemoglobinuria or myoglobinuria. •Cardiac parameters: Mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/minute. MAP and BP are best measured by an arterial line. Manual BP measurement is often invalid because of edema and vasoconstriction.