 Hi, welcome to the nursing school explained in this video on burns. Before we talk about burns, we have to review the different layers of the skin because the layer affected will determine the degree of burn. First of all, let's keep in mind that burns can occur from three different sources. So they can be electrical, they can be chemical, or they can be thermal. So electrical burns are anything from like an electrical outlet, for example, or maybe even from lightning when that strikes. Chemical burns can be anything like household chemicals, acids, alkalines, anything like that. And then thermal burns can be from the sun, like a sunburn, or maybe hot water, subversion, or any kind of burn like that. And if we look at the different layers of skin here, so first we have the epidermis, second layer is the dermis, then we have the subcutaneous tissue, muscle tissue, and bone. And depending again on what layer is affected, will depend on the degree of burn. So if it's the epidermis, we usually have first degree burns when the epidermis and dermis are involved at second degree. And those are sometimes referred to as partial thickness burns. Now when the subcutaneous tissue and muscle and or bone are involved, we talk about third and fourth degree burns or full thickness burns, you might have heard this terminology as well. Signs and symptoms depend on the degree of the burn. So in first degree burns, the patient probably has localized pain, erythema, edema, but there are no blisters. It's basically to shred warm to the touch. But depending on the extent of the burn, the patient might have symptoms such as nausea, vomiting, and chills. Imagine somebody who has a sunburn over the entire anterior surface of their body. That's a lot of area that is burned, therefore the patient can have more significant symptoms, even with a first degree burn. Second degree burns are usually characterized by blisters and might be mild to moderate erythema and pain because now we have nerves involved in the second layer of the dermis here. But if these blisters rupture, then underneath we might see this kind of a white and waxy appearance. In third and fourth degree burns, now we see either this white waxy appearance or it might even be brown or black and leathery. Imagine if you're at a campfire and you're burning a piece of wood, eventually it'll turn kind of brown and then as it gets burns more and more, it'll turn kind of black and that's exactly what happens to our skin. There might be visibly thrombose veins because the skin elasticity is now being completely destroyed by the burn. And in third and fourth degree again, we have no blisters because it's we're way beyond the layer of the dermis here. Now with any of these first through fourth degree burns, the patient might have smoke inhalation and that usually is because of a fire. And evidence that there's smoke inhalation can be cinched nose hair, mucosal burns such as to the nose nasal oropharynx, changing voice of coughs or horse voice because of this airway edema that's happening, also because airway edema of the patient might have some wheezing or dark sputum or soot in their nose or mouth. So initially there might be fire, there might be no evidence or maybe just mild evidence of a first degree burn, but whenever there is smoke inhalation involved, we have to think about our ABCs. This is a critically ill patient or he or she can turn critically ill very quickly because this again is involvement of the airway and as things get swollen, the airway might close and then we have a big problem. Now for burns, in order to assess the degree or the extent of the burn and treat the patient properly, we have to figure out by the rule of nines, their total body surface area affected. And keep in mind here, this here is a chart that's called the rule of nines and that applies for adults. In children, the formula is a little bit different because children have different proportions of their body size depending on their age and that's usually the long broader chart that we use here. But for adults, so the rule of nines, so these are multiples or fractions of nines, so the patient's front and the back here, so the head is 4.5%, each upper extremity is worth 4.5%, each lower extremity is 9% and the torso 18. Same thing on the back, head 4.5, upper extremity is 4.5 each, lower extremity is 9 each and the torso 18. Now keep in mind, the patient might not just be burned on one leg, right? There might be blotches in different areas. So depending on your best estimation, you are going to determine the total body surface area that this patient is burned and we'll get to why this is important in a little bit here. When there are major burns, and these are usually characterized by 30 degree burns of greater than 10% body surface area, second degree burns of greater than 25% body surface area, or any burns to the face, hands, feet and dentals, any sort of respiratory compromise such as with smoke inhalation or high risk patients, those with severe comorbidities, transplant recipients, severe underlying health conditions. If any of this occurs, major burns, they need to go to a burn center because only their patients can receive the specialized care that they need in order to get them well, get them better, and have the appropriate wound care, hyperbaric chambers, whatever that might be available to treat their burns. Now nursing assessment, we always want to focus on our ABCs. And a burn patient you can almost consider as a trauma patient. And whenever we're talking about emergency assessment of a patient, we go way beyond the ABCs, we go in the alphabet all the way down to I. So it's A-B-C-D-E-F-G-E-G-H-I. And so I've learned that, I'll learn that here. So we know our airway breathing and circulation are always first, and we need to intervene at any level when we find something abnormal here. D is for disability. So that would be an assessment of the neurostatus, also level of consciousness, how are they doing over logically. E is for exposure. Because we need to assess the patients full extent of the burns, we need to completely expose them and assess their skin from head to toe so that we can determine that how total body surface area burned. F stands for full vital signs. G gives comfort measures. Imagine you have a third degree burn upgrade and 10% of your body surface area, how painful that is. So analgesia is very, very important here. H goes into history and head to toe assessment. So history of the patient to determine if they're high risk or any other underlying comorbidities. I is for inspection of the posterior surface. Again, we need to assess the patient in detail front and back to assess what's going on with them. In addition to the A through I, we also need to establish two large more IVs and clearly we want to stay away from any sites that have been affected by the burn. The patient will most likely need a catheter if a large area of their body is affected. And we need to attend to their wound care. And the way that we usually do that, if there are minor burns, we can just cover them or maybe put an ice pack on cold compress to help with treatment of the erythema, the edema and the localized pain. Certainly analgesia will be important here too. And if there is a partial thickness burn or a major burn, then we want to keep the area clean and dry and maybe cover them with some sterile dressing or a sterile sheet. Or maybe if there's a large area that's burned, we need to cover them with saline soaked dressings. But we need to be careful because the skin integrity has now been impaired and if we cover the patient with a cool dressing that might alter their ability to regulate their temperature. So everything has to be very carefully monitored here. And then what happens pathophysiologically when we have major burns here is that massive fluid shifts occur from the intrabascular space due to the increased capillary permeability. So now the cells are being destroyed and the capillaries want to seep out some fluid and they take it away from the intrabascular space and we know that when fluid gets removed from the intrabascular space, the patient's blood pressure will drop. Then there's a shift of water, sodium and albumin to the interstitial space and that can be to blisters or exudates. So now the volume is not sitting in the intrabascular space but it's seeping into that interstitial space which then when we lose our abdomen we also lose our oncotic pressure resulting in low blood pressure. And then there is third spacing again to blisters, exudate and so forth which again takes the fluid out of the intrabascular space and causes a drop in blood pressure. Therefore very clearly here we can see these three things can lead to a complication of hyperbolic shock. So burn patients are at high risk for hyperbolic shock and they need fluids very rapidly otherwise their chance of survival are very low. In addition to this hyperbolinia, red blood cells haemolyze because they're being destroyed from the burn and then potassium that is usually an intracellular electrolyte. When the cells are being destroyed, they're being haemolyzed, the potassium moves into the intrabascular space and can cause hyperokalemia. So these patients are very very critically ill. What do we do for treatment? We already talked about our ABCs all the way down through eye and then because we have this risk here for hyperbolic shock with all this cascade that's happening we need to be very diligent about fluid replacement and that will usually be in the first 24 hours a crystalline solution such as normal saline or lactated ringers and then after 24 hours the patient will usually also get our buimine to help with that oncotic pressure and actually keep holding the fluid in that intrabascular space. And the formula that we use here is called the Parkland formula and that is the formula that will determine how much fluid the patient will need and it is four milliliters per kilogram per total percent of body surface area burned that will give you the fluid volume that the person that the patient will need in the first 24 hours. So half of that will be infused in the first eight hours a quarter in the second eight hours and then another quarter in the third eight hours. So we space it out initially we give them half and then the other two quarters we space out over the next 16 hours and that is really intended to produce a urine output of at least 0.5 to 1 milligram milliliters of urine per kilo per hour or titrated to a mean arterial pressure of 65 or systolic blood pressure greater than 90 because remember we're dealing with blood pressure problems here and the sign that the patient is being profused is they have urine output or their map and their systolic blood pressure will meet these parameters. Now if we look at this here's an example of a patient who weighs 75 kilos which is 160 pounds but on average sorry 165 pounds but an average size person if they have 30 percent of the body surface area burned according to the parkland formula they will get 9 000 milliliters of fluid in the first 24 hours 9 000 milliliters 9 bags of crystalline solution that is a lot of fluid that usually scares the Jeepers out of us because we know we have to be very careful with fluid administration but knowing what's happening physiologically it makes perfect sense because we don't want the patient to go to hyperbolemic shock and die from that right we have a lot to deal with this patient already hyperbolemic shock is what we don't want so 9 000 milliliters so they would get 4500 milliliters over the first eight hours and then 2250 over each of the next eight hours so that's a large large amount of fluid to help prevent this hyperbolemic shock which will usually result in death if the patient gets there and then certainly we'll have to take care of the patient's wounds we have to do wound treatment again that's why severely or patients with major burns go to burn centers we have to be very meticulous about infection control because now that first protective mechanism the layer of the skin has been disrupted and there's a high risk for infection however we don't usually treat the patient with prophylactic antibiotics because the burned areas there's no vascularity right these blood vessels have probably been burned in these layers of the skin so there's no vascularity there so we have to be very careful with with the wound care and keeping everything as sterile as possible now if the patient has severe burns they might require skin grafting and then absolutely important as well as emotional support because burns can be disfiguring they can be very disturbing to the patient's body image and we have to provide emotional support to these critically ill patients more so later on as the healing continues and they're out of this critical phase so thank you for watching this video on burns also take a look at my videos on the oncotic pressure and the basic IV fluid administration to review that if you haven't already if you don't already have a good grasp on that please like my video if you enjoyed it subscribe to my channel and I'll see you soon right here on nursing school explained