Winter 2020 From the President’s Desk

BURN INJURIES:  Pitfalls to Recognize

In researching a recent burn injury case, I came across some information that might interest some of you and be useful in your own cases.

Burn injuries can be devastating and are one of the leading causes of accidental death and injury in this country. The American Burn Association (ABA) reports severe burn injuries affect almost a half million Americans annually, with 3,275 deaths yearly. Hospitalizations related to burn injury number approximately 40,000 each year in the United States, with 30,000 of those admissions to verified Burn Centers. Survival of a burn injury depends on many factors: Severity of the injury, total body surface area (TBSA) damaged, co-morbidities, availability of treatment and early interventions. Due to improved treatment, burn victim survival rates have improved from historical average mortality of 50% to an estimated 96.8% today.

Early intervention in treatment of burn patients is key to improved survival and must include aggressive fluid resuscitation of burns greater than 15% TBSA. The point is to ensure perfusion of the organs (liver, kidneys, etc.) to prevent multiple organ dysfunction syndrome (MODS) which enhances mortality. The Parkland/Baxter Formula and the Rule of Tens, are two guides used for fluid resuscitation. Adequacy of fluid resuscitation is monitored by blood pressure readings, particularly mean arterial blood pressure (MAP), an indicator of organ perfusion and urine output greater than 0.5 ml/kg/ hr. The second key to survival is monitoring for development of sepsis; a potentially life-threatening response to infection by the body. Per the National Institute of Health, damage to the protective layer of skin causes an inflammatory response, which can be overwhelming in patients with burns over 20% of their body and induce MODS. Topical antibiotics are used proactively to burned areas to mitigate risk, with frequent dressing changes and monitoring of wound condition. Guidelines for referral to a Burn Center per ABA include:

• Partial thickness burns greater than 10% of TBSA.
• Burns involving face, hands, feet, or genitalia.
• Third degree burns.
• Electrical burns including lightening injury.
• Chemical burns.
• Inhalation injury.
• Pre-existing comorbidities (i.e., chronic lung disease) complicating management, prolonging recovery and affecting mortality.
• Burns with concomitant trauma (fractures), increasing morbidity.
• Children in facilities unqualified to treat pediatric patients.
• Patients with special social, emotional or rehabilitation needs.

Should there be an adverse outcome associated with a burn injury, documentation of treatment cohesive with guidelines for care of burn patients is critical. The American Journal of Medical Ethics reported in 2018, that referral criteria, though established with the best of intentions, has led to decreased ability/willingness to treat burns outside of Burn Centers. The report noted insufficient education in U.S. medical schools regarding treatment of burn patients, resulting in lack of preparation for first line providers in the medical community. Idaho, Montana, Wyoming, South Dakota, North Dakota and Alaska do not have burn centers, making it especially challenging to meet burn care guidelines.

Evaluation of burn cases requires assessment of the cause of injury – was it associated with negligence? Was the medical treatment timely and appropriate? Common errors include: Delayed or inadequate fluid resuscitation; incorrect documentation of percent burned leading to inadequate treatment; failure to monitor; failure to appropriately intervene; and failure to recognize complications of burn injury. Burn injuries must be assessed with knowledge of treatment criteria, thus allowing for recognition of treatment pitfalls critical to making a case, or refuting one.

Patricia Mitchell, RN, BSN, CLNC
President, Greater Orlando Chapter of AALNC

Meet the Greater Orlando Chapter AALNC Officers and Board of Directors

• Patty Mitchell, RN, BSN, CLNC – President
• Kathryn Natale, RN, MSHS – President Elect
• Judy A. Young, MSN, MHL, RN, LNCC – Immediate Past President, Membership & Education Chair, Webmaster
• Mary Smallwood, RN – Secretary
• Kasia Cuenca, BA, RN, LHRM – Treasurer
• Pam Cohn, RN, BSN – Director At Large
• Phil Hargreaves, MSN, RN – Director At Large
• Tory Palivoda, BS, RN, CLNC – Director At Large
• Jillian Talento, BSN, RN, CEN – Director At Large