A burn causes lesions that break down skin exposing the body to infection. There are three causes of burns: heat (thermal), electricity (electrical), and chemicals. All cause the same kind of skin lesion.

Burns are classified by degree, which is based on the tissue depth of the burn. There are three burn classifications: first-degree, second-degree, and third degree. Burns are assessed by the percentage of body area that has been burned. This is commonly referred to as the Rule of Nines (see Table 20-3). For example, if a patient's left leg is burned, then 18% of the patient's body is burned.

First-degree (superficial) burns

First-degree burns affect only the epidermis (outer layer) of skin. The burn site is red, painful, dry, and with no blisters such as seen in a mild sunburn. Rarely

Table 20-3. Rule of nines.

Body Area

Percentage Assessed



Front Torso


Back Torso


Right Arm


Left Arm


Right Leg


Left Leg




is there any long-term tissue damage and it usually results in an increase or decrease in the skin color.

Treatment involves placing a cold, wet compress on the burned area in order to constrict blood vessels and reduce swelling and pain. Less tissue damage occurs if the burned area is cooled quickly. Remove clothing immediately and flush the burned area with water if a chemical agent caused the burn.

Don't apply greasy ointments, butter, or a dressing to the burned area. This inhibits heat loss and increases tissue damage. Bacitracin with polymyxin B (Polysporin) and similar over-the-counter antibiotics should be used.

Second-degree (partial thickness) burns

Second-degree burns expose the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

These burns can be quite painful and can become infected easily. They should be cleaned with a non-abrasive solution, treated with antibiotic ointment such as silver sulfadiazine (Silvadine), protected with a non-stick dressing, and the patient should be given an analgesic based on the amount of area burned and the pain experienced.

Third-degree (full thickness) burns

Third-degree burns destroy the epidermis and dermis and may also damage underlying nerve, bones, muscles, and tendons. The burn site appears white or charred and the patient has no sensation in the area since the nerve endings are destroyed.

Third-degree burns can be very painful because they are generally mixed (that is, second- and third-degree). Analgesics are used to manage the pain (see Chapter 16). Burn patients are susceptible to infection. With the skin gone, the patient is exposed to infection.

Third-degree burns are treated by first removing the charred skin (eschar) which is called debridement. This is a painful procedure. The patient is then given multiple antibiotics to prevent infections. The patient is also at risk for fluid and electrolyte imbalances (see Chapter 10) and at high risk for stress ulcers (see Chapter 18). Burn patients must be assessed for possible smoke inhalation. If it exists, the patient is treated with respiratory medications (see Chapter 14).

Burned areas must be cleansed with sterile saline solutions and an antiseptic such as povidone-iodine (Betadine). Broad-spectrum topical antibiotics are then applied to burn areas. These include antibacterials such as mafenide acetate

(Sulfamylon), silver sulfadiazine (Silvadene), silver nitrate 0.5% solution, and nitrofurazone (Furacin).

Third-degree burns are best managed in a designated burn center by a burn specialist or surgeon.

A list of drugs utilized in the treatment of burns is provided in the Appendix. Detailed tables show doses, recommendations, expectations, side effects, contraindications, and more; available on the book's Web site (see URL in Appendix).

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