General management of burns patients after 24 hours
Burn patients require different care and treatment as their wounds change and heal. After the first 24-48 hours after the burn injury – called the ‘ebb phase’ – the patient enters what is known as the ‘flow phase’. Here you can find information about patient care, including pain management, fluid balance, respiration, nutrition and psychological support.
Patient care 24 hours after burn injury
After the first 24 hours following a burn injury, it is important to prevent infection and to provide care, comfort and rehabilitation.
Complications after 24 hours
A burn patient can encounter various complications after 24 hours following their injury, including delirium, renal failure and sepsis. Read more at:
During patient care, your main aims are to maintain body homeostasis and to mitigate the pathophysiological responses to burn injury.
A patient’s pathophysiological response to a burn injury happens in two phases:
First 48 hours
The ‘ebb phase’ – characterized by hypovolemia and a low cardiac output.
After 48 hours
The ‘flow phase’ – characterized by a hyperdynamic response and catabolism.
Close the wound surgically
As the burn wound heals, the pathophysiological changes diminish. It is therefore imperative to close the wound early with surgical treatment.
Nursing a burn patient: 3 principles
The right patient care is vital to ensure the burn wound heals. To provide the best care possible, here are three general nursing principles.
1 Nurse the patient in a semi-upright position
This reduces edema of the head and neck, reduces the effort required for breathing and, for patients on ventilators, may help to reduce the incidence of ventilator-associated pneumonia.
2 Get the patient moving early
There is increasing evidence that mobilization helps reduce muscle wasting and catabolism. We therefore encourage physiotherapy, exercise and getting the patient out of bed at the earliest opportunity.
3 Keep the patient warm
Patients lose heat when wound exudate evaporates. It is important to minimize the amount of energy required to keep the body warm. This means nursing the patient in an ambient temperature of more than 30˚C, particularly in temperate regions. Take extra care to keep the patient warm when changing dressings and in the operating theater, as they lose extra heat due to exposure and blood loss. We recommend using blood and fluid warming devices.
Pain management and sedation of burn patients
It is vital to treat a burn patient’s pain adequately. Good pain management and sedation can:
- Improve mental wellbeing
- Reduce catabolism
- Facilitate rehabilitation
Pain therapy for burn patients
There are two main approaches to pain therapy for burn patients: non-pharmacological and medication.
Effective wound coverage is the most effective form of pain therapy. Other effective non-pharmacological techniques include:
- Virtual reality therapy
- Watching movies
- Breathing exercises
- Stress inoculation
- Cognitive behavioral therapy
Every burn patient should receive paracetamol (acetaminophen). You can add non-steroidal anti-inflammatory drugs (NSAIDs) as a second step, provided there are no contra-indications, such as decreased renal function or other relevant co-morbidities. Ideally, prescribe NSAIDs with a proton inhibitor. Slow-release opiate medication is effective but beware of tachyphylaxis.
For procedures such as dressing changes, Entonox (50% nitrous oxide in oxygen), low-dose Ketamine and short-acting opiates are useful, but these require careful titration and monitoring. Patients on ventilators require more sophisticated analgesia, such as continuous intravenous opiates and adjunct medication, to reduce endotracheal irritation and to suppress excessive coughing.
Sedating burn patients
Burn patients may require sedative medication. A burn is a traumatic event. Admission to hospital, and intensive care in particular, adds to a patient’s feelings of disorientation and anxiety. A significant number of burn patients will have some degree of post-traumatic stress disorder. Many patients may also have pre-existing psychological problems. Sedation can help these patients cope.
Sedatives should be carefully titrated. Excessive sedation can have serious side effects, including:
- Respiratory depression
Ideally, prescribe burn patients with sedation in the form of hypnotics. This will encourage them to sleep at night and allow them to be alert during the day.
A wide variety of drugs are available, including benzodiazepines, such as oxazepam and temazepam. Augment these medications as appropriate with melatonin or haloperidol.
For patients on ventilators, continuous intravenous medication may be more appropriate, for example midazolam or propofol.
Drugs require continuous monitoring to prevent overdosing. To facilitate accurate dosage, you can include daily “wake up” periods, or titration to the Ramsay sedation scale.
The Ramsay sedation scale divides the level of sedation into six categories, ranging from severe agitation to deep coma.
Ramsay sedation scale
|Ramsay score||Sedation level|
|1||Patient is anxious and agitated or restless, or both|
|2||Patient is co-operative, oriented, and tranquil|
|3||Patient responds to commands only|
|4||Patient exhibits brisk response to light glabellar tap or loud auditory stimulus|
|5||Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus|
|6||Patient exhibits no response|
Burn patients undergo significant pharmacological changes: the way their bodies react to drugs changes due to the burn. Although these changes have not been studied in detail, it is important to consider them when prescribing medication.
Changes in cardiac output, the presence of edema fluid and altered plasma protein levels change drug distribution. During the first 48 hours, hypovolemia lowers the rate and volume of drug distribution. Later, the hypermetabolic state increases the volume of distribution.
The presence of edema forms an ill-defined ‘third space’ for water-soluble drugs. Elimination is affected by changes in liver function and, significantly, by an increased glomerular filtration rate in otherwise healthy patients. Drugs are also lost via wound exudate.
Serum albumin is often low in burn patients; drugs that bind to this include diazepam, midazolam and morphine. Renal excretion of most antibiotics is increased.
Studies have shown that antibiotic levels are generally low in burn patients and should be prescribed at relatively high dosages.
The muscle relaxant succinyl choline is contra-indicated because of the risk of cardiac arrest following increased potassium release from myocytes.
Non-depolarizing drugs are less effective. Curare-like drugs bind to alpha-1-glycoprotein, which is often increased in burn patients, and many are excreted in urine.
Hemodynamics in burn patients
Following resuscitation, the patient’s pathophysiological response to their burn injury changes, and they experience:
- Increased cardiac output
- Reduced peripheral vascular resistance
- Possible hypotension, especially if the circulating volume is low
It is important to give sufficient fluids. Other considerations for hemodynamics include administering propranolol, treating anemia and avoiding venous thrombosis.
Propranolol (beta blocker)
- Can be titrated to attenuate tachycardia (e.g. less than 100 beats per minute)
- Reduces heart rate and cardiac effort
- May have beneficial effects on muscle catabolism
- Mildly anxiolytic
Children with severe burns in low and middle income countries are often anemic. Depending on the severity, treat anemia following local protocols by giving iron rich nutritional supplements, iron tablets and folic acid or blood transfusions.
Burn patients move less, which means they are at increased risk of venous thrombosis. They also display hypercoagulability. To reduce the risk of thrombosis, administer thromboprophylaxis in the form of low molecular weight heparin.
Respiration in burn patients
As with other vital systems, the respiratory system is under increased strain in burn patients for a number of reasons.
The hypermetabolic response leads to increased oxygen demand and increased CO2 production. Burns of the thorax or abdomen may reduce chest wall compliance; if burns in these areas are extensive, an escharotomy should be performed. Inhalation injury may severely compromise respiratory function.
Supporting respiration in burn patients
Positioning the burn patient in a semi-upright position reduces the effort needed for them to breathe. Chest physiotherapy and frequent position changes are also beneficial.
Atelectasis and pneumonia are common in burn patients, especially following smoke inhalation. Many patients become hypoxic; oxygen therapy is ideally titrated to oxygen saturation levels.
Bronchodilators, such as salbutamol, can be freely administered if indicated. Acetyl cysteine is useful for loosening secretions.
Daily physical examination should include chest auscultation. If possible, confirm any changes with X-ray.
Oral hygiene is important: the patient should brush their teeth daily and rinse with an antiseptic mouthwash. They may need dental work for carious teeth or infected gums.
Mechanical ventilation (MV)
Mechanical ventilation (MV) should be avoided if possible. MV impedes cardiac output, increases fluid retention and increases the risk of pneumonia. MV in burns is an independent predictor of mortality. Patients on ventilators should be weaned as soon as is practicable.
Less invasive forms of respiratory support, such as continuous positive airway pressure (CPAP) by mask might be appropriate but are problematic in combination with facial burns.
However, MV is required in certain cases, including to prevent occlusion of the upper airway and in the development of respiratory failure.
When a patient has sustained a burn injury to the upper airway caused by the inhalation of hot gases (or, rarely, steam), endotracheal intubation may be a life-saving procedure in the first few hours following injury. Intubation is then required urgently to prevent occlusion of the upper airway by edema.
Read more about inhalation injury management during the first 24 hours.
In other circumstances, MV is only indicated by the development of respiratory failure. This may develop even later than 24 hours following smoke inhalation or following complications such as pneumonia or sepsis.
Psychological support for burn patients after 24 hours
Patients with burn injuries need psychological support alongside treatment of their physical wounds. This is important at every phase, including admission and critical care, in-hospital recuperation, reintegration and rehabilitation.
Consult psychologists and social workers to provide psychological support to the patient and to family members and caregivers.
|Phase of care and recovery||Common psychological problems|
|Admission and critical care||Overstimulation, under stimulation, delirium, impaired communication, sleep disturbance and pain.|
|In-hospital recuperation||Pain, anxiety, depression, sleep disturbance, grief and premorbid psychopathology. Patients become aware of the physical and psychological impact of the injury. Around one-third develop symptoms of post-traumatic stress disorder.|
|Reintegration and rehabilitation||Physical – e.g. itching, limited endurance and decreased function. Psychosocial – e.g. re-integration to work, body image, sexual dysfunction and acceptance.|