CCRN · Multisystem · 8 min read
Burns: Assessment, Resuscitation and Inhalation Injury
- Differentiate burn injury depth, accurately calculate total body surface area (TBSA) using the Rule of Nines, and initiate weight-based crystalloid resuscitation while monitoring for burn shock and fluid creep.
- Recognize the clinical manifestations of upper and lower airway inhalation injuries, carbon monoxide exposure, and cyanide toxicity, and execute provider-directed airway, ventilator, and antidote interventions.
- Manage specialized multisystem burn emergencies, including high-voltage electrical injuries, chemical exposures, circumferential burns requiring escharotomy, and essential supportive critical care protocols.
Burn Depth Classification and Initial Shock Pathophysiology
Accurate assessment of burn depth forms the foundation of initial critical care triage and resuscitation planning. Superficial burns, commonly referred to as first-degree burns, involve solely the epidermal layer. Because the protective dermal barrier remains intact and significant fluid shifts do not occur from this layer, superficial burns are completely excluded from total body surface area (TBSA) resuscitation calculations. In contrast, partial-thickness and full-thickness injuries disrupt the dermis and deeper structures, initiating profound local and systemic responses that demand meticulous critical care nursing interventions.
Superficial partial-thickness burns extend into the upper dermal layers, typically forming fluid-filled blisters. These wounds appear moist, weep fluid continuously, blanch briskly with capillary pressure, and are exquisitely painful due to exposed, intact nerve endings. Deep partial-thickness burns penetrate deeper into the dermis, presenting with a pale or waxy-white appearance, sluggish capillary refill, and decreased sensation to touch. Full-thickness burns destroy the entire epidermal and dermal architecture; they often appear dry, leathery, or charred, and do not blanch under pressure. Because cutaneous nerve endings are destroyed in full-thickness injuries, the burned center characteristically lacks light-touch and pinprick sensation, although surrounding partial-thickness zones may remain intensely painful.
Major burns trigger extensive systemic consequences. Severe capillary hyperpermeability allows plasma to leak unabated into the interstitium, causing rapid intravascular volume depletion and burn shock. In the immediate post-burn hours, laboratory analysis often reveals an elevated hematocrit. This rise does not reflect increased red blood cell mass, but rather hemoconcentration driven by acute plasma volume loss. As fluid resuscitation progresses, this hematocrit value falls; the critical care nurse must interpret these trends alongside the patient's overall fluid balance and tissue perfusion markers. Concurrently, rapid cellular lysis releases intracellular potassium, resulting in early hyperkalemia, while massive fluid shifting drives early hyponatremia.
| Burn Classification | Tissue Depth | Wound Appearance | Capillary Refill and Sensation |
|---|---|---|---|
| Superficial | Epidermis only | Dry, red; excluded from TBSA calculations | Intact sensation; not included in fluid shock formulas |
| Superficial Partial-Thickness | Epidermis into upper dermis | Blisters present, weeping fluid | Brisk blanching; exquisitely painful |
| Deep Partial-Thickness | Epidermis into deep dermis | Pale or waxy-white appearance | Sluggish capillary refill; decreased sensation |
| Full-Thickness | Entire epidermis and dermis | Dry, leathery, or charred; non-blanching | Center lacks light-touch and pinprick sensation; margins remain painful |
Common mistakes
- Including superficial (first-degree) burns in the total body surface area (TBSA) calculation, which results in inaccurate Parkland fluid resuscitation volumes.
- Relying on standard pulse oximetry (SpO2) readings to evaluate oxygenation in patients with suspected carbon monoxide poisoning, missing severe carboxyhemoglobinemia.
- Administering analgesics via intramuscular or subcutaneous routes during initial burn shock resuscitation, leading to poor absorption and unpredictable delayed release.
- Applying ice or ice water directly to extensive burn wounds, which worsens tissue ischemia through local vasoconstriction and exacerbates systemic hypothermia.
Key points
- Superficial burns involve only the epidermis and are excluded from TBSA calculations; partial- and full-thickness burns require careful mapping using the Rule of Nines to direct resuscitation.
- The traditional Parkland formula calculates 4 mL/kg/%TBSA over 24 hours, with the first half timed from injury; current adult guidance may start at 2 mL/kg/%TBSA for burns involving at least 20% TBSA, with subsequent titration under protocol or provider orders to urine output and other perfusion endpoints.
- Upper airway edema peaks between 24 and 48 hours; inspiratory stridor requires immediate escalation for airway control, while ARDS requires lung-protective ventilation (4 to 8 mL/kg PBW, plateau pressure 30 cm H2O or less).
- Carbon monoxide poisoning shifts the oxyhemoglobin dissociation curve left and warrants co-oximetry testing and 100% oxygen; cyanide poisoning inhibits cytochrome oxidase and may cause severe lactic acidosis, sometimes with elevated ScvO2, prompting provider-directed hydroxocobalamin treatment when suspected.
- High-voltage electrical injuries cause hidden deep tissue necrosis and myoglobinuria, requiring continuous ECG monitoring and higher fluid titration goals of 1 to 1.5 mL/kg/hr of urine output.
- Provider-performed escharotomy through constricting eschar can restore chest wall excursion or extremity perfusion; supportive care includes warming, intravenous analgesia during initial resuscitation when absorption by other routes is unreliable, early enteral nutrition when feasible, and avoidance of routine prophylactic systemic antibiotics.
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