EMERGENT

PHASE OF
BURN
 INTRODUCTION
The emergent phase is the period of time required to resolve
the immediate, life-threatening problems resulting from the
burn injury. This phase may last from the time of the burn to 3
or more days,but it usually last 24 to 48 hours. The primary
concern is the onset of hypovolemic shock and edema
formation. The phase ends when fluid mobilization and diuresis
begin.
This phase begins immediately at the time of injury and ends
with the restoration of capillary permeability. The main goal of
this phase is to prevent hypovolemic shock and preserve vital
organ functioning. Methods used during this time are
prehospital care and emergency room care.
 DEFINITION

The emergent phase is the period of time required to resolve

the immediate,life-threatening problems resulting from the
burn injury.
 ETIOLOGY
 CHEMICAL BURNS:It is caused by the exposure to acid,
alkali or organic compound.

 INHALATION INJURY:It is caused by exposure of respiratory

tract to intense heat or flames.

 ELECTRICAL BURNS:It result from coagulation necrosis

caused by intense heat generated from an electrical
current.it may result from direct damage to nerves and
vessels causing tissue anoxia and death.

 THERMAL BURNS:It is caused by flames, flash,scald, or

contact with hot objects.It is the most comon type of burn.
 CLINICAL MANIFESTATION
 Pain
 Hypovolemia
 Blisters
 Severe dehydration (absent or decreased bowel sound)
 Hypoxia
 Redness
 Edema
 Impaired touch sensation
 Cardiac arrest
 COMPLICATIONS
The three major organ system most susceptible to
complications during the emergent phase of burn injury are
the cardiovascular , respiratory , and urinary systems.

CARDIOVASCULAR SYSTEM:Cardiovascular system

complication include dysrhythmias and hypovolemic
shock,which may progress to irreversible shock. Circulaion to
the extremities can be severely impaired by circumferential
burns and subsequent edema formation. These process
occlude the blood supply, causing ischemia, paraesthesias ,
necrosis and eventually gangrene. An escharotomy (a scalpel
incision through the full thickness eschar) is frequently
performed following transfer to a burn unit to restore
circulation to compromised extremites.
Initially , there is an increase in blood viscosity with burn
injuries because of the fluid loss that occurs in the emergent
period.

RESPIRATOY SYSTEM:the respiratory system is especially

vulnerable to two types of injury(1)upper airway burns that
cause edema formation and obstrution of the airway and (2)
inhalation injury . upper airways distress may occur with or
without smoke inhalation and airways injury at either level
may occur in the abscense of burn injury to the skin.

UPPER RESPIRATORY TRACT INJURY:upper respiratory tract

injury results from direct heat injury or edema formation and
can lead to mechanical airway obstruction and
asphyxia.mechanical obstruction of the airway is not limited
to the patient with flames burns to the upper airway.swelling
that accompanies scald burns to the face and neck can be
lethal , as can pressure from the accumulated edema
compressing the airway externally.

INHALATION INJURY:inhalation injury refers to a direct insult

at the alveolar level secondary to the inhalation of chemical
fumes or smoke the result is interstitial edema that prevent
the diffusion of oxygen from the alveoli into the circulatory
system. The patient with smoke inhalation may not exhibit
physical manifestation of injury during the first 24 hours after
sustaining a major burn.

OTHER RESPIRATORY PROBLEM:The patient with preexisting

respiratory problem (eg COPD)is more likely to develop a
respiratory infection . pneumonia is a common cause of major
burns(especioally in older adults) because of debilitation ,
abundant microbial flora and relative immobility of patient. If
fluid replacement is vigorous , the older adult patient can
develop pulmonary edema.

URINARY SYSTEM:The most common complication of the

urinary system in the emergent phase is ATN. If the patient is
allowed to become hypovolemic, blood flow to the kidney
may be decreased ,causing renal ischemia. If continues acute
renal failure may develop.
NURSING MANAGEMENT
AIRWAY MANAGEMENT:Airway management frequently
involves early endotracheal intubation. Early intubation
eliminates the necessity for emergency tracheostomy after
respiratory problem have become apperent. In general the
patient with major injuries involving burns to the face and
neck requires intubation within 1 to 2 hours after burn injury.

FLUID THERAPY:
 Asses fluid needs
 begin IV fluid replacement
 Insert urinary cathether
 Monitor urine output

WOUND CARE:
 Start hydrotherapy or wound clensing
 Debride as necessary
 Assess extent and depth of burns
 Initiate appropiate wound care
 Administer tetanus toxoid or teteanus antitoxin

DRUG THERAPY:
Analgesia
 Morphine
 Hydromorphine
 Fentanyl
 Oxycodane
 Methadone
 Non-steroidal anti-inflammaory (ketoprofen)
 Adjuvant analgesics (eg:gabapentin)

Sedation

 Haloperidol
 Lorazepam
 Midazolam

Gastrointestinal support
 Ranitidine
 Nystatin
 Antaacid

Nutrition support
 Vitamins A,C,E and mulivitamin
 Minerals:zinc , iron
 oxandrolone
PATHOPYSIOLOGY
Burn

Increased vascular permeability

Edema Decreased intravascular volume

Decreased blood Increased hematocrit

Volume

Increased viscosity

Increased peripheral resistance

BURN SHOCK
 RESEARCH EVIDENCE
INTRODUCTION:
The quantity and quality of research evidence in peer-reviewed
burn care journals have never been evaluated. The aim of this
study was to empirically assess the evidence available in this
literature.

METHODS:
All studies published in Burns and Journal of Burn Care and
Research between 1st January 1982 and 31st December 2008
were reviewed. Articles were tabulated according to their study
design into the following groups: meta-analyses; randomised
controlled trials; controlled trials; comparative studies and case
series/reports.

RESULTS:
A total of 2215 original articles were evaluated, of which 67.0%
were from Burns and 33.0% were from Journal of Burn Care and
Research. There were 3 meta-analyses (0.1%), 179 (8.1%)
randomised controlled trials, 56 (2.5%) controlled clinical trials, 715
(32.3%) comparative studies and 1262 (57.1%) case
series/reports. Journal of Burn Care and Research published a
higher proportion of randomised controlled trials than Burns (11.9%
vs. 6.2%; p<0.001). There was no significant difference in the
proportion of published controlled trials between the two journals
(3.0% vs. 2.3%; p=0.333). Journal of Burn Care and Research
published a higher proportion of comparative studies than Burns
(27.9% vs. 41.4%; p<0.001). Case series/reports made up the
highest proportion of articles in both Burns (63.6%) and Journal of
Burn Care and Research (43.7%), with Burns publishing a higher
proportion of these than Journal of Burn Care and Research
(p<0.001). From 1982 to 2008, when articles from both journals
were considered together there were significant increases in the
proportion of randomised controlled trials (0 (0%) to 10 (9%);
p<0.001) and controlled clinical trials (0 (0%) to 1 (1%); p<0.001).
There were no significant changes in the proportion of comparative
studies (11 (44%) to 28 (16%); p=0.846) or case series/reports (14
(56%) to 71 (65%); p=0.448).
DISCUSSION:
The burn care literature suffers from a relative shortage of high-
quality evidence. More randomised controlled trials are warranted.
 SUMMARY
Burns are a type of injury caused by heat. The heat can be
thermal, electrical, chemical, or electromagnetic energy. Most
burn accidents happen at home. About 75% of all burn injuries
in children are preventable.
Smoking and open flame are the leading causes of burn injury
for older adults. Scalding is the leading cause of burn injury for
children. Both infants and the elderly are at the greatest risk for
burn injury.

A burn injury usually results from an energy transfer to the

body. There are many types of burns caused by thermal,
radiation, chemical, or electrical contact:

Thermal burns. Burns due to external heat sources that raise

the temperature of the skin and tissues and cause tissue cell
death or charring. Hot metals, scalding liquids, steam, and
flames, when coming in contact with the skin, can cause
thermal burns.
Radiation burns. Burns caused by prolonged exposure to
ultraviolet rays of the sun, or to other sources of radiation such
as X-ray.
Chemical burns. Burns caused by strong acids, alkalies,
detergents, or solvents coming into contact with the skin
and/or eyes.
Electrical burns. Burns from electrical current, either alternating
current (AC) or direct current (DC).
 CONCLUSION
Burn wound mortality and morbidity have steadily decreased
over the last 30 years. Recognition of the potential
complications, early excision and wound closPatients with
severe burns have metabolic rates 100 to 150% higher than
normalure has led to these changes.
Burn wounds can be classified as first; second or third degree
based on surface appearance.
First-degree wounds are superficial and reddened. They do not
require surgical intervention and are generally treated with
topical moisturizers and avoidance of recurrent injury. Typically
from prolonged sun exposure without blisters.
Second-degree burns are deeper, causing a superficial edema
deposition between deeper viable tissue and injured, more
superficial tissues. The surface appearance is moist with blisters
in various degrees of rupture. Treatment involves debridement
of intact blisters at risk for rupture to remove the fluid, which
contain high concentrations of thromboxanes and coverage
with topical antimicrobial agents or synthetic wound dressings.
The deeper elements of the skin remain intact and can
regenerate the epithelial layer.
Third degree wounds are deepest and appear whitened, black,
or dry, leather like skin. They require surgical debridement and
skin grafting if larger than two centimeters.