1. Majority of burns that occurs are mostly treated in emergency departments and later followed on an
outpatient basis. Burns are usually accompanied with other minor injuries which are also treated
inemergency departments. If the patient does not have any complications or he /she has burns of
limited severity he can be seen on outpatient setting. Most of the burns that are experienced and
seen inemergency departments are minor burns but it has been noted that; most of the individuals
caring for these patients don’t have maximum skills required to approach the burnt patient. In today’s
healthcare it is important for burn care management team to develop educational and clinical
relationships with their referral emergency departments to deliver quality treatment and follow ups to
their patients.
There are three major types of burns that are mostly experienced: first degree, second degree and
third degree burns. Each of these is treated differently and healing process takes different time
period for recovery. Some of the significant burns are treated in burn care centers as they usually
need thorough follow up and special care treatment.
Burns are caused by anything that tend to inflame the outer skin (epidermis) or that causes injury to
inner skin (dermis). Burns that occur to children are usually contact burns but they heal without any
complications. Parents need to be educated on how to protect their children as most of these cases
of burns are preventable (Swaminatha V Mahadevan, 1994)
Setting an emergency room.
Emergency rooms that receive burn victims are usually occupied with physicians and mostly there
are no burn specialists. As soon as the victim arrives in an emergency room it is necessary to follow
the following procedure:
Check whether the burning process has stopped.
It has been noted that patients who sometimes arrives at emergency departments comes smoldering
in fire because the first aiders may not have fully stopped the burning on the victims body. At this
point it is always necessary to determine the cause of burn on the victim’s body as different
procedures are followed on different causes of burns. It is important not to try supplementing oxygen
on someone who is still on fire as this can cause further explosion. If the victim is still on fire, you can
try to put out the fire by using a blanket and by removing his /her clothes that are on fire. For injuries
that have been caused by scalds cool water should be poured to the affected area within first thirty
minutes. After thirty minutes it is of no help to the patient, therefore it is necessary to act expediently
and fast as soon as the patient arrives in emergency room. (Pollack &Jonathan, 2008)
For chemical burns, pour a lot of water to the victim as little water can cause further reaction of the
chemical. Plentiful amount of water will help to dilute the effects of the chemical. After the victim has
been administered, it is necessary to examine the type of chemical injury that has been caused and

2. apply appropriate neutralizer. It is worth to note that chemical injuries can make someone lose
his/her sight and it is therefore important to flush the victims eyes with a lot of water immediately the
accident happens even before taking him to emergency department or it may be too late.
Tar, melted plastics and asphalts are treated differently as removing them is always very painful.
These materials can retain heat for a very long time and it is necessary to first cool off the patient.
They are later removed by use of chemicals but it is necessary to first give the victim an adequate
airway.
Electrical burns that are caused by low voltage current are most serious as the current enter the
body through a very small opening and then exits through a small opening. This normally causes
shock, unconsciousness, convulsion or loss of memory. A counter shock or a few minutes of CPR
can help to restart the heart as most of this people are resusitatable.
Inhalation injuries also cause death through carbon monoxide poisoning. The primary concern
should therefore be to supplement the victim with plenty of oxygen and remove the patient from
congested environment. After an emergency treatment has been given it is necessary now to
treat the patient in case of any other complication apart from burn.
Assess Airway, Breathing and Circulation
Airway-Intubation is necessary as edema occurs within the first few hours with all burn victims. This
is usually a breathtaking challenge that takes place within a very short period of time but it is
necessary especially when the victim is suffering from burn on the face, tongue and hard palate.
Definite intubation is required where the victim suffers from epiglottis, vocal cords, respiratory
depression, hoarseness and posterior pharynx burns. It should be presumed that any victim whoa
has been burned in a closed area suffers from inhalation injury until proved otherwise.
There are three major types of airway injuries which are:
Inhalation injury above the glottis.
Carbon monoxide poisoning
Inhalation below the glottis.
Carbon monoxide poisoning is the most common type of airway injury as it is caused by incomplete
burning of fuels. Carbon monoxide which has high affinity than oxygen takes hemoglobin and forms
carboxy haemoglobin, this can make the patient to develop myocardial and cerebral hypoxia. It
inhibits hemoglobin found in red blood cells from taking oxygen and takes carbon monoxide instead
since it has high affinity. Common signs are central nervous systems complications: loss of memory,
headache and confusion. The victim should be treated by immediate application of high flow oxygen.

3. Inhalation injuries above the glottis are caused by nasopharynxes which dissipate heat to the nose,
mouth and throat. This may cause edema which can be experienced for a few hours and it can result
to airway obstruction. The victims should immediately be intubated to protect the airway.
Inhalation below the glottis normally affects the lungs and it is asymptomatic for the first 48 hours
and the patient may have normal arterial lood gas levels. The victim should be intubated and at the
same time be treated for respiratory distress.
Breathing –whether the patient is suffering from external or internal injury it is necessary to allow
enough airflow. For external injury, IV sedation may be required to help in incisions which start from
axillaly lines. This process is normally not painful.
For internal injury initial ventilation and intubation is normally required. Lavage can always be
performed later if the physician find it necessary to the patient; Bronchodilating aerosols may be
beneficial in this case.
Circulation- fluid replacement is always necessary as it enables the victim to have frequent outflow
of urine. Circulation sometimes may be restricted due to circumferential burns and Escharotomies
should be performed if blood flow cannot be exhibited. Before performing peripheral escharotomies it
is necessary to have good urine output that reflects adequate core volume.(Michael Brennan)
Evaluate the extent and depth of the burn
Burns are treated according to extreme at which they have affected the skin
First degree burns are simple to heal as they only involves the upper layer of the skin and the very
obvious example of this kind of a burn is the sunburn. The victim experiences tenderness and
redness of the skin and they don’t make you very sick. Many people resuscitate themselves with oral
fluids and they don’t need to be hospitalized. The wounds normally heal on their own and it takes
about four to five days for recovery. The most important thing in first degree burns is to treat the
symptoms and special care be given to avoid dehydration and loss of fluids.
A second burn degree involves the epidermis and part of the dermis layer of the skin. You can detect
whether a person suffers from second degree burn by observing the burn site. It usually appears
red, blistered and it may be swollen and the victim may be experiencing some pain. Second degree
burn may be as a result of scald injuries, flames or direct contact with hot object. Symptoms of a
second degree burn are blisters, deep redness, painful touch, wetness and shininess of the skin and
sometimes the victim may have a burn that is white and discolored in an irregular pattern.

4. Healing process of a second burn degree may take about three weeks to heal as long as the wound
is treated and cleaned regularly. Sometimes if the victim has deep burn, it may take long than three
weeks but this does not mean that the patient will not fully recover.
A burn that does not extend to 10 percent of the skin surface can be treated on outpatient basis.
Treatments may include administration of antibiotic ointments, dressing changes, cleaning of the
wound depending on the severity of the burn and systemic antibiotics. A pain reliever like may be
needed when dressing the wound since it is normally painful.
Third degree burns are referred to as full thickness burn as it destroys the outer layer of the skin and
the entire layer beneath. Third degree burns can be caused by a scalding liquid, flames from fire,
electrical source or a chemical source. Most common symptoms of third degree burn are: swelling,
dry leathery skin, black, white or yellow skin and the victim may be suffering from nerve failure.
Healing process takes long as epidermis and hair follicles are destroyed and therefore no new skin
will grow.
Thorough medical attention should be followed but specific treatment is determined by extent of the
burn, location of the burn, cause of the burn and severity of the burn. Treatment of the third burn
includes: removal of the dead skin and tissue from the burned area, administration of intravenous
(IV) containing electrolytes, antibiotics by mouth or intravenous, antibiotic ointment or creams, pain
medications, warm humid environment for the burn and sometimes graft can be required to achieve
closure of the wounded area. In case of very serious scars that are left after healing, functional and
cosmetic reconstruction is necessary if the victim is okay with it. During the process of healing the
patient should be supplemented with all type of nutrients and administration of high supply of
proteins.
Assess the criteria for referral to a burn center
After administration of proper procedures the wound it is necessary to refer the patient to a burn
centre where the follow up is necessary. Here the patient can be released to go home and be seen
by the physician as an out patient. It all depends with the seriousness of the burn and the treatment
required by the victim. Patients who experience serious burn injuries should be referred to a burn
centre for special treatment.
Observe and treat burn and associated injuries
In case the patient is admitted in burn care centre related burn injuries. It is necessary to mote that
patients may have a very large burn but they can survive and at the same time die because of other
injuries that requires major attention. At burn centre the victim can be treated by experienced
physicians who are experienced and have the know how to treat different types of burns. After the

5. cause and depth of burn has been noted, the burn should be covered with silver sulfadiazine and dry
sterile dressings.
Fluid replacement is the first initial burn treatment that is given to the patient. Once the person gets
burnt, their capillaries began to leak and endothelial cells separate and become very porous and
blood inside the vessel cannot be contained. Fluids in large amounts fluids therefore flow out into the
tissue. Large burns are always accompanied by fluid that accumulates everywhere in the body and
these patients can develop a significant amount of edema at the expense of vascular volume. As the
consequence the blood volume goes down and the patient can develop what we call hypovolemic
shock. ( Monafo WW,2001)
Patients who have received burn greater than 10% require resuscitation but this depends on age
and health of the victim. When resuscitating a patient who is twenty years old and is healthy, they
can do the same for themselves by use of oral fluids but they should be given close observation.
Victims who mostly suffer from electrical injury and inhalation injury always get s fluid resuscitation.
This should be done within the first 24 hours.
The main goal of resuscitating a patient is to make sure that he /she maintains his volume during the
period of hypovolemia. Most of the burn centers have a formula that they use when performing
resuscitation, it normally has two advantages i.e. calls for large amount of fluid and it is easy to
remember. Urine volume is appropriate indicator of whether fluid resuscitation is adequate for the
patient. Lactated lingers are also necessary if given to patients because they are most like
extracellular fluid. Saline is not well recommended as it contains huge amount of chloride which may
cause metabolic acidosis.
Kidneys on the other hand are supposed to be perfumed adequately to help the patient make
enough urine, lack of enough fluid can be indicated by patient making very little amount of urine but
all the same diuretics should not be given to the patient.
Electrical injuries patients or those with very deep tissue damage may have myoglobin in their urine.
In a case like this these patients may require double the flash of urine to remove myoglobin from the
kidney. It is very difficult to access the amount of fluid required in the patient’s body as this cannot be
determined by the extent of burn on their bodies. It has been noted that edema get worse as
resuscitation continues, this is most likely where there is a major burn of extremity that swells very
quick.
The burns in third degree are very hard and rigid and elasticity is always compromised. As fluid is
continuously administered to these patients, the burn becomes tighter and tighter and circulation
also become compromised. The patient may be seen to lose peripheral pulses, nerve function or
motor function and these may lead to cyanotic. At this point the patient may start complaining about
deep throbbing pain but this is always very difficult to evaluate in the field (.Königová R, 2004).

6. Escharotomy is a treatment that is given to patients to restore pulses; it involves cutting of the
burned tissue with a scalpel medially and laterally. This makes the skin to spread apart as a result of
tension and tightness caused by the swelling and this may cause complications related with edema.
Edema also affects the chest and this can complicate breathing but through incision the chest can
be put back in normal. Edema can also cause the swelling f the airway and it is therefore necessary
to intubate the patient immediately as swellings can even occur inside affecting pharyngeal tissues
and this can lead to death. Intubation is necessary even if the patient does not need it but it is of
great help because it does not have any side effect to the same patient. ( Papini RP,1999)
Treatment of minor burns (first burn degree)
Minor burns are frequently experienced but they are not very difficult to treat as they get better on
their own. Dressings and use of antibiotics are not a must but the most important thing is to keep the
wound clean and make the patient feel comfortable. All blisters and devitalized tissues should be
removed because if not removed, they can cause infection because of the fluid that collects within a
blister. Nonadhearant gauze should be applied as it is more comfortable for the patient. It is
necessary at the same time to apply ointment as it makes the patient more comfortable and it
facilitates washing and to remove the old ointment. Washing of a minor burn has been
recommended to fasten the healing of a minor burn. (Barbara Ravage, 2005)
Burns of lower extremities may require a patient to be ace wrapped to make him/her feel more
comfortable. The following procedure should be followed for special treatment of a wound:
Clean the wound with plenty of water and soap.
Remove the devitalized tissue.
Make sure you have removed all the blisters
All the hairs that are adjacent to the wound should be shaved.
Regularly apply bland ointment.
You can leave the wound open or wrap it lightly with gauze.
Repeat ointment and cleanse the wound regularly through out the day.
Never do the following to treat a minor burn:
Soak the wound in ice water-this can make the burn to be more extensive and frostbite injury
over a burn is great.
Wrap in occlusive dressing.
Treatment of second burn degree
The main goal for treating second degree burns is normally to reduce pain and prevent infection.
The following should be followed to treat a victim who has second degree burns:

7. Remove the victim’s clothes or any other sort of thing that is in direct contact with the body.
Holds the burnt area with a moist cloth for around 10 minutes to stop the burning.NB don’t
use cold ice water since this will just worsen the situation.
Blisters should not be broken openly as these can cause a greater risk of infection. If blisters
are open it is worth to note that running water should be avoided as this can increase the risk
of shock.
Place dry sterile gauze over the burn but any bandages with adhesive should be avoided.
Drape a clean sheet over the wound but it should be loose to allow air in the wound.
Butter oils and burn ointments should be avoided as this make the burn to take long to heal.
Replace fluids through intravenous (IV) line through a tube that is placed into a vein.
Give the patient antibiotics to protect the burned area from infection
Sometimes a tetanus booster is needed if the patient’s immune system is down
In case of scarring a skin graft can be done where a healthy skin is taken from an unburned
area and be transplanted to the burned area. This is referred to as autograft.
Treatment of third burn degrees.
Minor third degree burns sometimes can be treated in a doctor’s office but other serious injuries can
only be treated under special care as medical emergency. The following should be followed in
treatment of a third degree burn victim:
Get the person to an emergency room as soon as possible as the patient requires urgent
treatment.
Remove the victim’s clothes or any other sort of thing that is in direct contact with the body.
Holds the burnt area with a moist cloth for around 10 minutes to stop the burning.NB don’t
use cold ice water since this will just worsen the situation.
Hospitalize the patient for further treatment.
Administer in a constant mode a lot of fluids as the patient becomes dehydrated very first.
Give the patient antibiotics to protect the wound from further infection.
If the patient has severe burn he/she is put in a special room that is normally filled with pure
oxygen under high pressure, this room is referred to as hyperbaric chamber and the patient
is attended within the first 24 hours.
Clean the wound and cover it with antibiotic cream and sterile bandages.
Closely monitor the burned area to avoid any infection. It is necessary to change the
bandage frequently.
In some cases the patient may need a cover in his burned area through grafting.
In a case where a human skin cannot be used, plastic surgeon can use animal skin and this
is called xenograft or use a skin of another human and this is referred to as allograft. Both
xenograft and allograft are temporary and they facilitate the healing of the skin.

8. Skin graft is usually performed after the removal of dead skin and tissue and after a graft procedure
has been done the donor site normally looks like a skinned knee. Third degree burns may take
weeks or months to heal and the patient require continuous physical therapy which helps restoration
of burned areas and minimization of scars that occurs after healing. ( Carsin H,2000)
Expected clinical outcome after treatment of burns
After the patient has been treated from burns, he /she can fully recover or require some other
medications to improve the status of the skin damaged. Pediatric burn injuries are one of the
hazardous injuries that are experienced during childhood. Most of these injuries are very severe
and they require multiple surgeries in order to heal the damaged skin. Cultured skin substitutes are
required for healing massive burn wounds, and grafting is also necessary. Cultured skin grafts which
are made from patient’s skin cells are combined with the fabric which stimulates the development of
epidermal barrier or the outermost protective layer of the skin.
After cultured skin grafts have been made they are taken to the operation room where they are
applied to the patients wound. Cultured skin grafts are mostly applied to patients who have received
second or third degree burns over more than 50% total body surface area. The healed skin of a
patient who has undergone cultured skin process can be determined by softness, color, and shape
and blood flow of the healed skin. Cultured skin results in faster recovery and improved outcome in
the treatment of bums of more than 90 percent of the part of the body burned. (Carsin H& Aiinaud
P,2004).
Patients with burns can improve the likelihood of survival with implementation of treatments,
supportive therapy, nutrition and advances in the control of sepsis. The superficial appearance of
scars can be improved through a procedure known as dermabrasion. All larger areas around the
neck and hands shows great improvement after the patient have been treated.( Glenn D.&Warden
,M.D,2001).
Hyperpigmented Scars differs with different patients where some patients may have black powder
like tattoos and some can have smaller dark spots or freckle-like lesions.
Erbiurn YAG laser is a valuable tool that is used for reconstructive burn surgery. The YAG laser can
effectively improve the fine irregularities and some hyperpigmentations and dotted tattoos which
might have been caused from burn trauma. Normal skins after dermabrasion will reeepithelialize
quickly from dermal glands and hair follicles
Aboriginal and non- aboriginal burn victims responds differently from epithelial auto graft, ventilation
and early skin repair. Aboriginal people are faced with inequities in access to health services which
affects them greatly. (Wood FM, 1994)

9. As burned skin heals a thick scabbed surface called eschar develops and these can prevent blood
from flowing to the injured area. Escharotomy procedure is applied in this case and the eschar is cut
to enable the health tissue underneath to receive the blood flow required. ( Königová R,2004).
Tips to remember when attending any burn victim
For chemical burns water as the antidote should be used and one is supposed to first
remember the causative agents before administering any antidote.
Suspect carbon monoxide poisoning in all thermal and inhalation injuries. Hyperbaric oxygen
is not required in these cases.
Never transport an unstable patient as these will make it difficult for him to produce adequate
urine.
Don't forget about Td and allergy status
For electrical burns which poses the victim to high risk of renal failure that is caused by
methemoglobinuria due to underlying muscle necrosis, urine output of about 1 cc/kg/hr is
necessary.
Antibiotics should not be given prophylactically and steroids should not be indicated in burn
management
Dosages of IV Morphine as a standard pain relief should be titrated to patients with great
care to avoid respiratory depression.
An NG tube is indicated for burns >15% due to anticipated ileus.( Bras, Marijana; Loncar,
Zoran,2005)