ER nurse wondering whats the best way to treat burns

Pediatric Critical Care Columnist · Jul 18, 2009

I'd be listening to the burn unit nurse. The heat loss is just a fact of life with burns and we tend to keep the room toasty to minimize it as much as possible. There's also huge fluid losses that the wet-to-dry tend to mitigate somewhat. The key is to cover the open areas to protect from infection until they can be transferred to the burn unit and be seen by plastics.

theatredork · Jul 27, 2009

I would ask the ER attending to order Silvadene. It's pretty much the standard treatment initially for burns, at least for the first dressing. Silvadene, covered with a non-adherent dressing (adaptec non-adherent gauze) and then wrapped with kerlix (not tightly).

I hated it when I would see patients in wet dressings upon transfer, especially on children. Xeroform is the next best thing if you can't get an order for silvadene. It'll keep the wound covered without adhering to the wound itself. And wrap that with kerlix.

The nurses at the burn center are going to change the dressing upon arrival anyway to assess the burns, so it doesn't have to look pretty, it just needs to be functional. :)

UMichSCN07 · Jul 27, 2009

ABLS (Advanced Burn Life Support, sponsored by the American Burn Association, required training for all in my unit) states that any burns over 20% TBSA are to go into DRY DRESSINGS. Heat loss is not "just a fact of life" with burn patients, hypothermia can kill a burn patient just as surely as sepsis. If you just want to temporarily cover the burns for transport to the unit, sterile towels moistened (NOT WET) with NS are OK. Xeroform would be OK, silvadene would probably be better, except for the fact that, like Sondheim said, the dressings are coming off when the pt gets to the burn unit anyway.

I guess my main question would be, is your burn unit in-house or do the patients have to be air/ground transported to the burn center? If it's in house, the moistened sterile towels (covered in warm blankets) will work. If it's an external transfer, silvadene covered with kerlex, then burn net.

Next time, I would also recommend starting LR instead of NS, per the Parkland Burn Resuscitation Formula (2-4 cc fluid x weight in kg x % TBSA, give 1st half in 8 hours, give 2nd half over 16 hours).

I sincerely appreciate your asking the question here as a way to improve your practice. I have seen more than a few mishandled major burns in my almost 2 years in a major burn center.

Mike in Michigan

patrice meursault · Jul 29, 2009

Nice reply Mike! I think the few things to remember is the percentage of body surface the burn covers, the area (airway involvement always keep in mind inhalation injuries.INTUBATE INTUBATE,INTUBATE--when in doubt-INTUBATE!!!!!!) You can always extubate. It is also the best way to manage pain too-when properly sedated and paralyzed while on the vent. Airways go bad VERY FAST!!!

ALWAYS CALL the BURN CENTER and take orders from them--they are the Gurus!!

-Keep in mind the distance of transport- a reputable transport team will (should) also know what to do.

-Lastly remember allergies- Silvadene contains Sulfa.

Nurse_FF_EMT · Nov 23, 2010

Good info,

I work in an ER where we had a patient with 20% degree 2nd & 3rd degree burns come in. We tried to do a basic dressing to last long enough for the patient to be transferred to the burn center. Turns out that we do not stock any sort of big dressing supplies.

We could have used insane amounts of 2x2 or ABD pads with Kerlix, in the end I used a sterile cloth surgical gown (was decent thickness) as it was the only large sterile anything that I had. I did ask our docs about wetting it down, but they wanted it as a dry dressing. I know it was not a pretty dressing, but at this point I was mainly concerned about trying to cut down on infections (sterile gowns) and keeping heat loss down.

The patient suffered from a flash burn, had a few 1st degree burns to his face but no soot or burning noted to lips or nose and was able to maintain a very good airway. I did keep an intubation tray at bedside and RSI drugs in my pocket just in case.

We did start fluid therapy with LR and bilateral 18's.

I feel we did everything else as good as we could, but I was very disappointed at not having better dressings, so after talking with our manager I am now on a mission on putting together a burn protocol and make a "burn pack" for our ER. We have a burn center in the same large city as us (about 20-30 minute transport by ground) so we just have to keep these burns treated for a short time.

One of the other places I have worked (Lvl 4 ER) used a very simple pack: Big silver bowl, 3-4 flat sheets, wrapped in a surgical pack and autoclaved. Cheap and easy to prepare by central supply and if we had a burn we would simply open the pack and used the sterile flat sheets moistened with sterile saline, then wrap with kerlix. Not sure what the burn nurses here think about that, but I was thinking about maybe doing something similar.

We get maybe 1-2 burns a year most years as walk-ins, EMS will transport all burns to the burn center ER, so using a home-made pack would be more cost-effective for us I think. I will talk to the burn center as well to get their input, but I am just doing some data finding right now. We are big on evidence based care, so I am looking for articles supporting this as well. Looks like the ENA Core Curriculum doesn't really address how to dress it other than "20% or more surface area should have dry dressings".

Thanks for any input.

LiveZen · Jan 8, 2011

I work peds burn unit, when we do our admission dressing for a deep 2nd/third degree, we wash with hibaclens/sterile water then slather on about 1/4 inch thick layer of Silvadene right on the wound (no Xenoform/Adaptic at this stage) and then cover with clean burn dressing (basically a thin sheet of gauze, I think it's like 12x12 or something) and wrap with Kerlix or other dry rolled dressing.

For a superficial 2nd degree , we we wash with hibaclens/sterile water then cover with adaptic gauze (Xenoform) that has been coated with Bacitracin, then the layer of burn dressing, then Kerlix. The families do this same dressing at home, but they will be using regular antibacterial soap.

The Parkland formula is essential! We see so many over fluid resuscitated kids that come from outlying facilities and that causes all sorts of issues for these patients. We use Normosol as the initial fluid for these kids. We also promote early feeding and try to get tube feeds started on the big burns immediately.

soapaddictOH · Jan 10, 2011

I did burn nursing first, then ER. I did a little inservice for my er peeps on burn care a few years ago, and I have to say my fellow ER nurses don't listen!

Triage will 99.9% of the time put ice on a burn. I will immediately take it away and throw it down the sink. Then families get upset and I have to explain to them to never put ice on a burn. It's even in our discharge instructions to put ice on a burn!

Other nurses will cover a pt head to toe in saline dressings if they are flying out. Or slather Silvadene all over. Nooo! Dry sterile dressings! That's all the pt needs, because once they get to the burn unit they are going to the spray table.