Burns are injuries that occur when the skin or other tissues are damaged by heat, electricity, radiation or chemicals (Jeschke et al., 2018).

The incidence and mortality of these injuries are most concentrated in middle and low-income areas. Globally, there were 9 million new fire, heat and hot substance injuries in 2017, and they caused 120 000 deaths in 2019 (James et al., 2019). In Canada, burns are the fifth leading cause of serious work injury and are more common in males than females. Risk factors differ according to ethnicity, age, and sex (Papp & Haythornthwaite, 2014). They are also related to social determinants of health like unsafe and living working conditions, lack of prevention programs, poor access to quality treatment centres, motor vehicle accidents and alcohol intake (Jeschke et al., 2018).

Children and seniors are the most vulnerable population to burn injuries. In children, burns are mainly caused by contact with hot water, steam, food, oil, grease, liquid glue or liquid wax. In adults, sun, fire, flame and smoke burns are more frequent in females, while electricity is in males. In old adults, the risk increases if they have a cognitive or mental impairment or a musculoskeletal disorder.

The initial assessment and stabilization of thermally injured patients require a systematic approach that first seeks to identify the greatest threats to life, following the ABCD steps: airway management, breathing and ventilation, circulation and cardiac status, disability, neurologic deficit and gross deformity (ISBI Practice Guidelines Committee et al., 2016). Then, the evaluation of the burn should estimate the total body surface, the severity and the depth of the injury using standardized methods like the Wallace rule of Nines for adults, the Lund and Browder Chart, or the Pediatric Assessment Ruler (Jeschke et al., 2018).

According to depth, signs and symptoms of burns are classified into four categories or degrees. First-degree or superficial produces a painful blanchable erythema in the epidermis. The second degree creates blisters in the dermis. Third-degree burns show full-thickness skin loss and are insensitive to pain and pressure. In four-degree underlying structures are exposed, and eschar may be present. It is important to remember that burn depth may increase over time, so a 24-72 hours reassessment is necessary.

 The therapy focuses on appropriate resuscitation, prevention of burn shock, organ failure and sepsis, adequate pain management and wound care. Drug therapy includes IV solutions, systemic antibiotics, opioids and tetanus immunization (ISBI Practice Guidelines Committee et al., 2016). Superficial burns require topical emollients, sun protection, and massage after healing. Multiple specific dressings and topic products recover skin integrity (Potter et al., n.d.). Surgical interventions like debriding, escharotomy and fasciotomy should be performed if extremities or vital organs are compromised (ISBI Practice Guidelines Committee et al., 2016). Nutritional support is another cornerstone of the acute phase of recovery.

Regarding standards of care associated with curative, health promotion, and illness prevention, the most critical step is identifying the appropriate healthcare professionals and services to ensure organizational and system support (Jeschke et al., 2018). Common expected outcomes (by depth) establish that superficial burns heal within 3-5 days without scarring. Second-degree burns heal within 14 to 21 days without not scarring if they don’t require skin grafting. Third-degree burns require prolonged healing. They will need skin grafting, and there will be considerable scarring and contractures. In fourth-degree, amputation may be possible. At discharge, people at risk of burn injuries and their caregivers need information regarding re-injury causes and risk factors. Both formal and informal educational methods are beneficial.

Specific teaching relevant to a newly closed burn should focus on promoting skincare, itchiness at the burn site, and hypertrophic scarring.  
– Skincare: products that are pH-balanced, non-scented and non-sensitizing are preferred. The fragile tissue should also be protected from the sun during this period, as it is more prone to sunburn, and sun exposure may cause further pigmentation changes.
– Burn itch: itchiness at the site of the burn injury is expected after the wound closure and can be worsened by heat, stress and physical activity.
– Hypertrophic scarring: the amount of scar tissue produced generally relates to the depth of the injury. If not managed appropriately, scars can become hypertrophic, and if they happen to cross one joint or more, it can cause contracture and decreased area function.

When the care goals have not been met on time, it is imperative to go back to step 1 of the wound prevention and management cycle: assess and reassess the patient, the wound, and the environment. They will most often reveal modifiable factors that need to be addressed.

Checklist

When adequate healing, the wound will decrease in size. If not, ask:
1. Patient’s perception of skin integrity and intervention.
2. Previous patient response to planned nursing therapies: what worked and what did not.
3. Support surfaces and wound management treatment.
4. Whether standards of practice are being followed.
5. Possible surgical & nonsurgical management.
6. Infection prevention and control: development, implementation and monitoring of the local antibiotic stewardship program.
7. Nutrition: energy requirements should be estimated by formulas that use variables such as burn size, age, and weight.
8. Rehabilitation: positioning and splinting of the burn patient.
9. Ethical issues: respect autonomy regarding personal treatment decisions regardless of ethnicity, gender, beliefs, or socioeconomic class.

General Strategies to Support Burn Prevention

Scald Prevention – Ensure water heater temperatures are not too high. – Keep hot drinks away from the table/counter edges. – Avoid drinking hot liquids through a straw. – Turn the handles of saucepans inward. – Put cold water into baths first, followed by hot water, and test the temperature before using.
Contact Burn Prevention – Test the temperature of car seats before placing children in them. – Unplug hot irons and keep them out of reach of children. – Keep children away from grills. – Use approved glass or metal protective screens in front of fireplaces. – Wear oven mitts to remove items from the stove.
 Fire/Flash/Flame Prevention – Install smoke alarms and consider installing sprinklers. – Make a fire escape plan and have regular fire drills. – Use child resistant-lighters and safely store lighters and matches. – Use space heaters carefully, and keep them away from anything that can burn. – Never leave candles unattended.
Electricity Burn Prevention – Put covers on electrical outlets within a child’s reach. – Throw out electrical cords that are frayed or damaged. – Avoid overloading extension cords or outlets. – If flooding occurs, turn off electrical circuits before stepping into the water. – Avoid using hairdryers or other electrical appliances near water.
 Radiation Burn Prevention – Avoid direct sun exposure between 10 a.m. and 4 p.m. – Wear clothing with UPF 50+ protection. – Wear sunglasses with UV protection. – Avoid tanning and UV tanning beds. – Apply sunscreen to your entire body 30 minutes before going outside and reapply every two hours and immediately after swimming.
Chemical Burn Prevention – Store chemicals in their original containers. – Maintain labels on containers holding chemicals. – Store chemicals out of the reach of children. – When possible, purchase chemicals with the least toxicity. – Purchase chemicals with child-resistant closures. – Wear protective clothing/equipment when handling chemicals (follow manufacturer labels).

References

ISBI Practice Guidelines Committee, Ahuja, R. B., Gibran, N., Greenhalgh, D., Jeng, J., Mackie, D., Moghazy, A., Moiemen, N., Palmieri, T., Peck, M., Serghiou, M., Watson, S., Wilson, Y., Altamirano, A. M., Atieh, B., Bolgiani, A., Carrougher, G., Edgar, D., Guerrero, L., … van Zuijlen, P. (2016). ISBI Practice Guidelines for Burn Care. Burns, 42(5), 953–1021. https://doi.org/10.1016/j.burns.2016.05.013

James, S. L., Lucchesi, L. R., Bisignano, C., Castle, C. D., Dingels, Z. V., Fox, J. T., Hamilton, E. B., Henry, N. J., McCracken, D., Roberts, N. L. S., Sylte, D. O., Ahmadi, A., Ahmed, M. B., Alahdab, F., Alipour, V., Andualem, Z., Antonio, C. A. T., Arabloo, J., Badiye, A. D., … Mokdad, A. H. (2019). Epidemiology of injuries from fire, heat and hot substances: Global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study. Injury Prevention: Journal Of The International Society For Child And Adolescent Injury Prevention. https://doi.org/10.1136/injuryprev-2019-043299

Jeschke, M., McCallum, C., Baron, D., Iiwcc, Bs., Godleski, M., Knighton, J., & Shahrokhi, S. (2018). Prevention and Management of Burns. BEST PRACTICE, 68.

Papp, A., & Haythornthwaite, J. (2014). Ethnicity and Etiology in Burn Trauma. Journal of Burn Care & Research, 35(2), e99–e105. https://doi.org/10.1097/BCR.0b013e3182a223ec

Potter, P. A., Perry, A. G., Stockert, P., Hall, A., Astle, B. J., & Duggleby, W. (n.d.). Canadian Fundamentals of Nursing. 4753.