Nursing Guidelines for Burn Treatment

• Treatment is conducted on an outpatient basis.
• Topical treatment: Sulfadiazine dressings (for children aged 2 months and older and adults) or sterile fatty tulle (except for superficial first-degree burns).
• Pain management: Paracetamol ± Tramadol is usually effective.

 Second: Severe Burns

1. First Aid:
   Upon hospital admission:
• Ensure the airway is unobstructed and provide high-flow oxygen, even if blood oxygen saturation is normal.
• Establish an intravenous line through unburned skin if possible (use intraosseous access if intravenous access is unavailable).
• Administer Lactated Ringer's solution: 20 mL/kg in the first hour, even if the patient is stable.
• Administer subcutaneous morphine: 0.2 mg/kg (level 1 and 2 analgesics are ineffective).
• For chemical burns: Wash thoroughly with copious amounts of water for 15–30 minutes, avoiding contamination of intact skin. Do not attempt to neutralize the chemical agent.

Once the patient is stabilized:

• Remove clothing if it is not adhered to the burns.
• Take a burn history: mechanism, causative agent, time of occurrence, etc.
• Assess the burn: extent, depth, charred areas; check for burns to the eyes, functionally significant areas, circumferential burns of the limbs, chest, or neck. Wear a sterile face mask and gloves during the examination.
• Evaluate associated injuries (fractures, etc.).
• Protect the patient and keep them warm using a clean/sterile sheet or a thermal blanket.
• Insert a urinary catheter if burn surface area exceeds 15% of total body surface area (TBSA), in cases of electrical burns, or burns to the perineum/genital area.
• Insert a nasogastric tube if burn surface area exceeds 20% TBSA (done in the operating room during dressing procedures).
• Calculate fluid requirements for the first 24 hours and initiate administration.
• Closely monitor the following: level of consciousness, heart rate, blood pressure, oxygen saturation, respiratory rate (hourly); temperature and urine output (every 4 hours).
• Perform laboratory tests: hemoglobin, blood typing, and urinalysis.
• Prepare the patient for the first dressing procedure in the operating room.

Notes:

• Burns do not bleed initially. Investigate any bleeding if hemoglobin levels are normal or low.
• Burns do not alter consciousness on their own. Changes in consciousness suggest head injury, poisoning, or a preexisting condition like epilepsy.
• Clinical signs of electrical burns vary widely with the type of electrical current. Look for complications (e.g., arrhythmias, neurological disorders).

2. General Measures During the First 48 Hours Resuscitation Measures:
   Administer intravenous fluids to correct hypovolemia:

• (A) Maintenance fluid: Alternate between Lactated Ringer's and 5% Dextrose solutions:
• 4 mL/kg/hour for the first 10 kg of body weight.
• +2 mL/kg/hour for the next 10 kg of body weight.
• +1 mL/kg/hour for each additional kg (above 20 kg, up to 30 kg).

Note: Increase fluid volume by 50% (3 mL/kg × % TBSA for the first 8 hours) in cases of inhalation injury or electrical burns. For burns > 50% TBSA, limit calculations to 50% TBSA. Adjust fluid administration based on systolic blood pressure and urine output to avoid fluid overload.

  Vascular Resuscitation Targets:

For patients with oliguria despite adequate fluids:

• IV dopamine: 5–15 mcg/kg/min via an infusion pump.
• Or IV epinephrine: 0.1–0.5 mcg/kg/min via an infusion pump.

Discontinue IV fluids after 48 hours if oral fluid intake can meet hydration needs.

 Types of Fluids Used in the Burn Unit:

• Crystalloids:
• Lactated Ringer's Solution: The first choice for fluid resuscitation.
• Normal Saline: Used in specific cases, but monitor for metabolic acidosis.
• Colloids:
• Albumin or plasma expanders: Used later to replenish proteins and osmotic pressure.