Today in the chart

In the past year, burn injuries have seen increased media attention partly due to climate-related burn injuries (Maui wildfire, California wildfires, extreme heat in Arizona and Nevada) and the well-covered burn injury of comedian Jay Leno. In light of recent attention to burn injuries, here are five clinical pearls from a burn nurse should you encounter a burn patient in your clinical practice. 

1. Airway

Early in my career, I learned that the ABCs of ACLS were different for burns. When talking about airway in the burn center, we say: “A is for airway, B is for better have an airway, and C is for you can’t do anything because you didn’t get an airway and your patient died.” I think about this every time a new burn patient rolls into our ED. Airways are difficult to secure in burn patients—especially those with burns to their face that cause the face to be constantly wet. Most commercial oral endotracheal tube holders will not secure the airway of a burn patient because the skin is too damaged for the adhesive to affix. Don’t be afraid to secure the airway using twill or tape. Swelling in burn patients gets worse before it gets better. Always err on the side of caution, and remember the burn airway ABCs.

2. Fluid

Each hospital has its own resuscitation algorithm for burn patients, usually resuscitating patients with extensive burn injuries greater than 20% of their body surface area. Without fluid, burn patients become hypovolemic quickly, leading to hypovolemic shock and end-organ damage. Getting fluids started as early as possible is key to survival. Nowhere to put an IV because all the skin is burned? Not a problem—go right through the burned skin or obtain intraosseous access. Just like the airway, IVs can be challenging to secure. You may have to get creative with securing your IV; items like stretch net or even ACE wraps can work extremely well to help secure IVs through burned skin. Many burn centers prefer peripheral lines over central lines, so obtaining central access does not need to be prioritized. 

3. Temperature

People are often surprised when I tell them how hot the burn unit is. As burn patients lose their ability to thermoregulate due to skin loss, they become hypothermic extremely quickly, leading to coagulopathies and wound bed conversion. Keeping burn patients warm is highly important in the initial phase of resuscitation. Warm IV fluids and blankets can help, as can keeping the room as warm as possible. In addition, limiting patients’ exposure by only uncovering necessary body parts can be helpful.

4. Cool Water

Despite what our mothers told us, putting cold water or ice on a burn is rarely a good idea. Cooling the burn wound too much can increase the size and depth of the burn injury. Instead, cool water and a clean, dry towel are all that is needed.

5. Psychosocial Support

As we have seen with the recent devastating wildfires in Hawaii, burn injuries often occur concomitantly with traumatic events. The burn nurse plays a vital role in establishing early therapeutic communication with the burn survivor and their family. You never get the chance to do the first dressing change again. Make sure you take your time so the patient knows this is a time for connection with their healthcare team, not anxiety. Early involvement with grief counselors, social workers, and burn psychologists, if available, is so important for the patient and their support network. 

Burn Nursing Professional Development Opportunities

Burn nurses are some of the most skilled nurses in practice. In addition to Advanced Cardiovascular Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS), burn nurses must also obtain Advanced Burn Life Support (ABLS) to provide burn care. In the coming months, and for the first time, RNs and APRNs can get board certified in burn care by earning the Certified Burn Registered Nurse (CBRN) certification. Offered widely by the Board of Certification for Emergency Nursing (BCEN) later this year, CBRN certification will validate advanced burn nursing knowledge across the burn care continuum, including prehospital and acute care, patient and family support, recovery and rehabilitation, and prevention and education. 

Visit the CBRN website for updates on the new burn nursing specialty credential and information about free CE webinars and burn expert-led online CE courses on important burn care topics.