Chapter 8: Burns and Shock

Introduction

This chapter introduces the emergency assessment and management of patients with burn injuries and shock. Burn injuries and shock are commonly seen in emergency care settings in the United Kingdom (UK), both as primary problems and in combination with other illnesses / injuries, and both are a major cause of severe disability and death. It is essential that nurses working in emergency care settings are able to efficiently assess and manage these conditions. This chapter will describe the pathophysiology and classification of burn injuries, their rapid assessment and their management in the emergency care setting. It will go on to explain the pathophysiology and classification of shock, and how to assess and manage a patient with shock in the emergency care setting.

Introduction to burn injury

Burns - both minor and significant, and as a primary injury or in combination with other injuries - are a common reason people present to emergency care settings in the UK. A burn occurs when the tissues of the body are injured by one or more of the following:

• Heat - thermal burns a caused by flame, flash, scale or direct contact with a hot object. These are the most common types of burns seen in emergency care settings.
• Smoke inhalation - the inhalation of hot air and noxious chemicals produced by a fire can cause significant damage to the delicate tissues of the respiratory tract. There are three primary types of smoke and inhalational injury: (1) carbon monoxide (CO) poisoning, which displaces oxygen (O₂) from haemoglobin molecules in the blood and results in asphyxiation; (2) inhalation injury above the epiglottis, including burns of the mucosa of the oropharynx and larynx; and (3) inhalation injury below the glottis, including in the deep tissues of the lungs, the signs of which may take some time to manifest. It is important to note that smoke inhalation injuries are very serious, and are a significant predictor of mortality in patients presenting with burns.
• Chemical burns - chemical burns are caused by contact with either an acid (e.g. hydrochloric acid, oxalic acid, etc.), an alkali (e.g. drain cleaners, some fertilisers, etc.) or an organic compound (e.g. phenols, petroleum products). The management of burns caused by alkaline substances is particularly complex, because alkalis are not neutralised by the body's tissue fluids and continue burning for up to 72 hours following initial exposure. It is important to remember that many patients who present with chemical burns are unaware of the nature of the substance that caused the burn, so nurses must ensure they protect themselves from harm.
• Electrical burns - these are caused by the intense heat generated by an electrical current passing through the body's tissues. The severity of an electrical burn depends on the amount of voltage to which the body's tissues were exposed, the resistance of these tissues to the voltage (e.g. depending on their density), the pathway the current took through the body, the size of the body surface area in contact with the current, and the length of time the current flow was sustained. It is essential to remember that electrical burns are predominately internal; therefore, a patient is at risk of complications such as dysrhythmia, cardiac arrest, severe metabolic acidosis and / or myoglobinuria leading to acute renal failure, etc.
• Exposure to extreme cold - this results in cold burns, including frostbite. Frostbite occurs when the tissues, particularly in the peripheries, freeze when in prolonged contact with cold ambient temperatures and / or snow and ice. Deep frostbite - which involves acute peripheral vasoconstriction, the formation of ice crystals in the intracellular spaces of the deep tissues and the destruction of cell membranes - may result in tissue death, and amputation may be required.

It is important for nurses to remember that the severity of a burn depends on: (1) the temperature of the burning agent, (2) the duration of its contact time with the body tissues, and (3) the type of tissue that is injured. 

Assessment and classification of burn injury

There are a variety of different ways in which burns injuries may be classified and described, and it is important that nurses working in emergency care settings familiarise themselves with their organisation's policies and procedures. During the assessment of a patient with a burn injury, their injury is generally classified according to:

• The depth of the burn - read the information in the following table:

• The extent of the burn - there are two ways the extent of a burn may be measured: (1) using the Lund-Browder chart, or (2) using the 'rule of nines'. Both measures use simple formulas to determine the total body surface area affected by a burn. Although the Lund-Browder chart is considered to be more accurate, the rule of nines is easy to remember and is therefore often used in emergency care settings. You can obtain a copy of the Lund-Browder chart and diagrams illustrating the rule of nines online, and you are encouraged to familiarise yourself with these.
• The location of the burn - this also determines its classification and severity. In the short-term, burns affecting the face and neck, and circumferential burns to the chest and back, are considered the most severe as they are likely to interfere with respiratory function. Face and neck burns also indicate the possibility of inhalational injuries, and circumferential burns often interfere with circulatory function.

Consider the following example of the assessment and classification of a burn injury:

When assessing a patient with a burn injury, it is important to bear in mind that most patients who have sustained a burn - even a severe burn - are usually conscious and alert. They are able to participate in the assessment by providing information about the cause of the burn and the symptoms they are experiencing. Unless a burn is very severe and death is imminent, unconsciousness or altered mental status is usually not a result of the burn. Other causes - such as smoke inhalation and head trauma - should be investigated.

In addition to the actual burn injury, nurses working in emergency care settings must remember that patients may present with a variety of other injuries. These include:

Emergency management of burn injury

In the management of a burn injury, as with all injuries and illnesses, the priority must be to stabilise the patient's airway, breathing and circulation. Nurses must remove the person from the source of the burn to stop the burning process, if this has not already been done (e.g. by the paramedics attending the patient at the scene of the injury). Often in the emergency care setting, this involves flushing the burn with bags of normal saline (which are usually used for intravenous infusion). It is important that the saline used is warmed, as patients with large burns in particular are prone to rapid heat loss and hypothermia. Patients who have experienced burns generally have all their clothing removed; this is done not only in an attempt to stop the burning process (particularly in chemical burns), but also to help preserve the cleanliness of the burn - an important consideration for infection prevention.

The most significant threat to the wellbeing of a patient with a major burn in the emergency care setting involves the massive shift of fluid and electrolytes out of the blood vessels. This occurs because the walls of the blood vessels - in particular, the capillaries - become more permeable, allowing water, sodium and other key electrolytes, and plasma proteins (e.g. albumin) to move into the interstitial space and the surrounding tissues. In major burns, massive exudate, extensive blister formation and oedema may contribute to the fluid and electrolyte shifts. The net result of fluid and electrolyte shifts is volume depletion - which may be manifested as decreased blood pressure, increased heart rate and other symptoms of hypovolaemic shock (which you will study in a later section of this chapter). However, there are a number of other immediate complications associated with burn injuries, including those affecting:

• The cardiovascular system - usually underpinned by the circulatory disturbances described above. In circumferential burns which result in eschar (i.e. rigid surface tissues), severe oedema may also obstruct blood supply to the tissues; in the emergency care setting, this is often managed using an escharotomy, a scalpel incision through the eschar to relieve pressure in the underlying tissues.
• The respiratory system - usually due to the inhalational burns described in an earlier section of this chapter. Remember: inhalational burns may involve injury above the epiglottis, including burns of the mucosa of the oropharynx and larynx, and / or inhalation injury below the glottis, including in the deep tissues of the lungs. Circumferential burns to the neck and chest which result in eschar may physically restrict the patient's capacity to breathe. Oedema of the airways may also result in their mechanical obstruction.
• The renal system - usually secondary to hypovolaemia, where reduced blood flow to the kidneys results in renal ischaemia and acute tubular necrosis. With severe burns, myoglobin (from muscle cell breakdown) and haemoglobin (from red blood cell breakdown) may contribute to acute tubular necrosis.

In the emergency care setting, a variety of strategies are used to manage burns and their complications. The goal of these interventions is to stabilise the patient whilst planning for further interventions - such as surgery for debridement or grafting, or admission to a specialist burns unit, etc. - is undertaken. Common interventions are described following:

• For severe burns, early intubation is often indicated as a strategy to manage the airways. For more minor burns involving inhalational injury, the administration of humidified oxygen (including via positive end-expiratory devices), and bronchodilators may also be used.
• All patients with moderate to severe burns are given intravenous fluid therapy. For patients with burns to >15% body surface area, fluid therapy is aggressive - as described in a previous chapter of this module. The aim of this fluid therapy is direct fluid replacement to maintain circulatory function and minimise renal damage. Crystalloids, colloids or a combination of these are typically used.
• Care of the burn wound begins in the emergency care setting. It initially involves flushing the wound, as described earlier in this chapter. Burns, and particularly when they are large, may also be temporarily dressed, often using moist sterile gauze or gauze impregnated with topical antimicrobial medications. 
• For severe burns in particular, analgesics - often intravenous narcotics - are administered to promote the comfort of the patient. Prophylactic intravenous antibiotics may also be administered, as systemic sepsis is a leading cause of death in patients with major burns. Even if they are not intubated, patients with burns may also be prescribed sedatives, as the experience of major burns can be very psychologically traumatic. 

Although it is a fundamental aspect of nursing care in all settings, the psychosocial care of a patient with burns is a particularly important consideration. Burns can significantly and irreversibly alter a person's physical image, and some people may find this extremely distressing. Furthermore, the situation which caused the burn (for example, a building fire or motor vehicle crash), and the experience of a sudden and painful systemic injury, can be very upsetting. It is also important to highlight that burns often require long-term management beyond that provided in the emergency care setting; it is important to be familiar with referral and admissions processes for patients who have experienced burns.

Introduction to shock

Shock is a disorder characterised by a combination of decreased tissue perfusion and impairments in cellular metabolism. Shock may be caused by: (1) reduced blood flow, and / or (2) the maldistribution of blood flow. Review the information in the following table:

Although the cause, emergency presentation and management of the various types of shock differs, the pathophysiological mechanisms are fundamentally similar. Essentially, shock involves low blood flow. This creates an imbalance between: (1) the demand for oxygen and nutrients by the body's tissues, which exceeds (2) the supply of oxygen and nutrients to the cells of the tissues. Shock progresses through three distinct, but often overlapping, phases:

• The compensatory stage, where the body attempts to respond to low blood flow and maintain homeostasis. Often during this stage, patients present with increased blood pressure and heart rate; this is a result of peripheral vasoconstriction as the body attempts to maintain blood flow to the vital organs. The patient may also present with signs of decreased blood flow to the lungs (e.g. hyperventilation, changes in blood oxygenation, etc.), signs of decreased blood flow to the gastrointestinal system (e.g. hypoactive bowel sounds, etc.), and skin which is pale and cool. 
• The progressive stage, where the body rapidly looses its ability to compensate for low blood flow and maintain homeostasis. Patients will often present signs of mild to moderate cerebral ischaemia (e.g. listlessness, agitation, decreased responsiveness to stimuli, etc.), decreasing blood pressure, signs of decreased coronary perfusion (e.g. dysrhythmias, myocardial infarction, etc.), signs of decreased peripheral perfusion (e.g. diminished pulses, slow capillary refill, etc.), acute respiratory distress syndrome, signs of decreased renal perfusion (e.g. dysuria, changes in chemical values of blood / urine, etc.), signs of decreased hepatic perfusion (e.g. jaundice), disseminated intravascular coagulation (DIC), and skin which is cold and clammy.
• The refractory stage, where decreased cardiac output, peripheral vasoconstriction and progressive pooling of the blood result in acute tissue hypoperfusion, anaerobic metabolism and an accumulation of lactic acid. Patients present as unresponsive, with a loss of reflexes and unreactive, dilated pupils. Patients will have profound hypotension (e.g. with bradycardia, dysrhythmia, etc.), severe hypoxaemia and respiratory failure, major metabolic failure, and skin which is mottled and cyanotic. It is important to note that recovery from the refractory stage of shock is unlikely.

Assessment and emergency management of shock

The assessment of a patient with shock can be complex; indeed, there is no single diagnostic test which can be used to determine whether a patient is in shock. Nurses working in emergency care settings should be guided by their local policies and procedures. Typically, shock is diagnosed following: (1) a detailed patient history to identify possible causes of shock (e.g. cardiac problems, fluid loss [e.g. haemorrhage], spinal cord injury, anaphylaxis, major infection, etc.), in combination with (2) a critical evaluation of the results of a primary and secondary survey. Consider the following example:

When assessing a patient who is suspected to be in shock, a nurse in an emergency care setting must assess (and continually monitor):

• The patient's neurologic status, (e.g. using the Glasgow Coma Scale [GCS]). In particular, the patient's orientation and level of consciousness should be assessed; changes in these are the first indications of decreased cerebral perfusion.
• The patient's cardiovascular status, including their heart rate and blood pressure.
• The patient's respiratory status (including the rate, depth and rhythm of respiration) and blood oxygen saturation (including by arterial blood gas analysis, if indicated).
• The patient's renal function, including hourly measurements of urine output.
• The patient's body temperature and changes in their skin; changes in both can indicate severe peripheral vasoconstriction requiring emergency intervention.
• The patient's gastrointestinal status; shock can lead to rapid gastrointestinal ileus, and nasogastric drainage may be required to minimise gastrointestinal distention.

As described in the previous section of this chapter, there are a number of different types of shock. In assessing a patient in the emergency care setting, a nurse may identify one or more of these types of shock. The different types of shock, and their management in the emergency care setting, are described following:

• Cardiogenic shock - occurs when there is dysfunction in the pumping action of the heart, resulting in reduced cardiac output. The dysfunction in the heart may be: (1) systolic, where the heart is unable to pump blood forward to the lungs and / or the wider body, or (2) diastolic, where the left and / or right ventricles are unable to fill with blood during diastole (i.e. the relaxation phase of the cardiac cycle). The management of cardiogenic shock often focuses on strategies to improve cardiac function - such as thrombolytic therapy, angioplasty and stenting, emergency revascularisation, valve replacement, etc. Medications may also be administered - for example, nitrates to dilate the coronary arteries, diuretics to reduce preload, vasodilators to reduce afterload, and β-adrenergic blockers to reduce heart rate, etc.
• Hypovolaemic shock - occurs when there is a loss of intravascular fluid volume. This may be: (1) absolute, when fluid is lost from the body directly (e.g. through haemorrhage, diuresis, etc.), or (2) relative, when fluid is lost into the extravascular space (e.g. in sepsis, with some types of burns, etc.). The body may compensate for hypovolaemia to some degree, however when 30% of the body's fluids are lost (or less, if the patient is already compromised), the patient will rapidly deteriorate and aggressive resuscitation (e.g. fluid therapy, blood transfusion) is required. The management of hypovolaemic shock focuses on the aggressive administration of either fluid and / or blood products; resuscitative interventions were described in a previous section of this unit, and you should revise this section now, if required.
• Neurogenic shock - occurs (occasionally) following a spinal cord injury at or above the T5 vertebrae. You studied neurogenic shock and its emergency management in an earlier chapter of this module; you should revise this chapter now, if required.
• Anaphylactic shock - occurs (occasionally) during anaphylaxis, a severe and life-threatening allergic reaction to a substance (e.g. medication, food, a chemical, a vaccine, insect venom, etc.). Anaphylactic shock is underpinned by massive vasodilation and the loss of fluid into the extravascular space. Anaphylaxis itself is treated using intramuscular adrenaline; however, the management of anaphylactic shock itself focuses on aggressive fluid therapy.
• Septic shock - occurs (occasionally) as an acute inflammatory response in patients with sepsis (i.e. systemic infection). The pathophysiology of septic shock is very complex, however like many of the other types of shock it involves vasodilation and loss of fluid into the extravascular space. Again, the management of septic shock, like many other types of shock, focuses on aggressive fluid therapy. Treatment must also include aggressive antibiotic therapy to treat the cause of the septic infection; broad spectrum intravenous antibiotics are given initially, and once the results of blood cultures have been obtained, more targeted antibiotics can be prescribed. Other medications, including vasopressors (to reduce systemic vasodilation) and ionotropic agents (e.g. dobutamine, to decrease stroke volume), may also be used. Septic shock is a common cause of morbidity and mortality in emergency care settings in the UK; therefore, you will study its management in greater detail in the 'hands-on scenario' which accompanies this chapter.

The above section of this chapter described the management of various different types of shock. However, there are a number of general management strategies used for patients who present to emergency care settings in shock; the aim of these interventions is to improve tissue perfusion, and to protect the organs from dysfunction and failure. Key interventions for the management of all types of shock in the emergency care setting include:

• Supplemental oxygen and, in severe shock, mechanical ventilation; the goal is to maintain a blood oxygen saturation of >90% and so avoid hypoxaemia.
• Resuscitation, via the aggressive administration of either fluid and / or blood products; again, resuscitative interventions were described in a previous section of this unit, and you should revise this section now, if required. It is important to note that patients in shock who are administered fluid and / or blood products are at risk of coagulopathy (i.e. a lack of clotting factors in the blood); depending on a patient's clinical situation, they may also be administered with clotting factors.
• Intravenous drug therapy, the primary goal of which is to correct decreased tissue perfusion. Drugs administered may include: (1) sympathomimetic drugs, which act on the sympathetic nervous system (e.g. vasopressors, a last line therapy, are used to increase mean arterial pressure - however, they do so by causing vasoconstriction, which may further compromise tissue perfusion); or (2) vasodilator drugs, which act to correct extreme peripheral vasoconstriction.

It is important for nurses working in emergency care settings to note that patients with shock can develop two other complex, interrelated problems; (1) systemic inflammatory response syndrome (SIRS), which involves general inflammation of the organs, and / or (2) multiple organ dysfunction syndrome (MODS), which involves the failure of two or more organ systems. Patients with shock and SIRS and / or MODS may present with the signs of shock (as described earlier in this section of the chapter), as well signs of organ impairment - for example, acute respiratory distress syndrome, changes in chemical values of blood / urine, and an acute change in neurological status (e.g. confusion, disorientation, aggression, seizures, etc.). The management of SIRS and MODS focuses on supporting the failing organ systems - for example, patients with acute respiratory syndrome require aggressive oxygen therapy, and patients with acute renal failure may require emergency haemodialysis, etc. It is important to note that SIRS and MODS can be longer-term conditions which persist beyond the resolution of shock in the emergency care setting, and patients often require admission to an acute care unit for ongoing management.

Conclusion

Burn injuries and shock are commonly seen in emergency care settings in the UK, both as primary problems and in combination with other illnesses / injuries, and both are a major cause of disability and death. It is essential that nurses working in emergency care settings are able to efficiently assess and manage these conditions. This chapter has described the pathophysiology and classification of burn injuries, their rapid assessment and their management in the emergency care setting. It has also explained the pathophysiology and classification of shock, and how to assess and manage a patient with shock in the emergency care setting.

'Hands on' scenario

Emergency nursing care for a patient admitted to in an A&E Department with severe septic shock

Kate is a graduate nurse working in a Type 1 A&E Department in Manchester. During her shift, a 77-year-old patient named Rose is admitted via the helicopter emergency medical service (HEMS). Rose is a resident of a nursing home, and her care providers report she collapsed suddenly while showering. Rose has recently had major gastrointestinal surgery. On assessing Rose, the medical team find she has a heart rate of 120 beats per minute (high), a blood pressure of 142/92 (high), a respiratory rate of 22 breaths per minute (high), a blood oxygen saturation of 88% (low), a temperature of 38.5° Celsius (high) and significant peripheral vasoconstriction. Kate suspects Rose is in shock. Blood studies show a major bacterial infection (i.e. sepsis), likely originating from Rose's recent major gastrointestinal surgery. Rose is therefore diagnosed with septic shock.

According to the National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline, Rose is at moderate to high risk of disability and / or death from sepsis. The signs with which Rose has presented suggest she is in the progressive phase of shock; her body is rapidly losing its ability to compensate for low blood flow and maintain homeostasis. Her collapse indicates that acute deterioration and progression into the refractory phase of shock may be imminent; therefore, it is vital that Kate and the other members of the health care team implement emergency management interventions.

The first of the emergency management interventions implemented for Rose is aggressive fluid therapy. As per the National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline, Rose is given a bolus of intravenous fluid as prescribed by the emergency consultant. Consistent with the guideline (NICE, 2016), the fluid given is a crystalloid containing sodium in the range of 130-154mmHg, and it is given at the rate of 500mL over a maximum of 15 minutes. Kate administers this fluid therapy rapidly, knowing that the NICE guidelines (2016) highlight that the commencement of fluid therapy within the first hour of presentation increases the likelihood of positive outcomes for patients, such as Rose, who have been diagnosed with severe sepsis.

Whilst fluid therapy is underway, Kate takes a blood sample from Rose and sends it to the hospital's laboratory for culturing. The National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline recommends that, in addition to blood cultures, blood samples should be assessed for levels of blood gasses, lactate, glucose, C-reactive protein (an inflammatory marker), urea, electrolytes, creatinine and clotting factors, and a full blood count (including blood type, for cross-matching) be undertaken. However, the most important of these results is the blood culture, as it will inform decisions about the antibiotic which is most appropriate to treat Rose's sepsis.

It is important to note that, in many cases, patients presenting to hospital via an air or road ambulance will have already commenced broad spectrum antibiotic therapy; although this may impair the results of later blood culturing, antibiotic administration for patients with sepsis is considered too important to delay. Rose arrives in A&E with an intravenous antibiotic running; Kate ensures this antibiotic is being delivered as prescribed, and that there are no obvious complications. As soon as Rose's blood culture results return, a more targeted intravenous antibiotic is prescribed as per the local hospital guidelines; Kate ceases the first antibiotic, flushes the intravenous line, and commences the second. Again, this is done rapidly to maximise the likelihood of positive outcomes for Rose.

Because Rose has presented with a very low blood oxygen saturation, a typical sign of septic shock, oxygen therapy is also important. As per the National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline, Kate gives Rose high-flow oxygen via a non-rebreather mask, aiming to achieve a blood oxygen saturation of 94-98%. Once Rose's blood oxygen saturation has normalised, oxygen administration continues via nasal prongs (unless deterioration becomes evident, in which case the use of a mask is re-established).

It is essential that patients such as Rose who present with severe sepsis are closely monitored. The National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline recommends that high-risk patients are monitored at least once every 30 minutes, and that physiological 'track-and-trigger' systems are utilised. These systems use graphs with coloured bands to alert clinicians to progressive patient deterioration, as indicated by measurements of their vital signs.

It is important to recognise that patients with severe shock may fail to respond to the interventions described so far in this scenario, and enter the refractory stage despite aggressive fluid therapy and treatments. This may be indicated by signs such as: (1) a systolic blood pressure which is persistently <90mmHg; (2) a persistent reduced level of consciousness; (3) a respiratory rate >25 breaths per minute, and / or the need for mechanical ventilation; and / or (4) a lactate value which is not declining, indicating acidosis (NICE, 2016). In this situation, other supportive therapies may be required - for example, human albumin solution, vasopressors (to reduce systemic vasodilation) and ionotropic agents (e.g. dobutamine, to decrease stroke volume). However, this is not the case with Rose, who responds rapidly to the antibiotic, fluid and oxygen therapy; over the next few hours, her vital signs gradually return to within their normal limits. Rose tells Kate she feels "much better now".

As soon as Rose is stabilised, investigations into the cause of her sepsis can be undertaken. This is consistent with the National Institute for Health and Clinical Excellence's (2016: p. 37) Sepsis: Recognition, Diagnosis and Early Management guideline, which states that emergency care staff should "carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage". Imaging of the abdomen suggests that Rose's gastrointestinal surgery site may be infected. As per the guideline, the hospital's abdominal surgical team is alerted and Rose is prepared for surgery.

Although it is a fundamental aspect of nursing care in all settings, the psychosocial care of a patient with sepsis and their family or carer is a particularly important consideration for nurses working in emergency care settings. As per the National Institute for Health and Clinical Excellence's (2016) Sepsis: Recognition, Diagnosis and Early Management guideline, Kate provides Rose and her family, when they arrive in A&E, with an explanation of sepsis and its causes, a description of the investigations undertaken and the management plan, and regular updates on Rose's treatment, care and progress. Kate provides this information to Rose and her family using language they can understand (e.g. avoiding medical jargon). Kate also allows Rose and her family time to have their questions answered.

Because of the medical team's timely intervention with antibiotic, fluid and oxygen therapy, Rose is stabilised before she reaches the refractory stage of shock. This allows the cause of her sepsis, her infected gastrointestinal surgical wound, to be effectively managed, and her sepsis and shock resolved. This is a positive outcome to a complex scenario.

Reference list

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National Institute for Health and Clinical Excellence. (2016). Sepsis: Recognition, Diagnosis and Early Management. Retrieved from: https://www.nice.org.uk/guidance/ng51/resources/sepsis-recognition-diagnosis-and-early-management-1837508256709

NHS England. (2013). Specialist Burn Care. Retrieved from: https://www.england.nhs.uk/wp-content/uploads/2014/04/d06-spec-burn-care-0414.pdf

Surviving Sepsis Campaign. (2012). International Guideline for the Management of Severe Septic Shock. Retrieved from: http://www.sccm.org/Documents/SSC-Guidelines.pdf

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Wounds International. (2014). Best Practice Guidelines: Effective Skin and Wound Management in Non-Complex Burns. Retrieved from: http://www.woundsinternational.com/best-practices/view/best-practice-guidelines-effective-skin-and-wound-management-in-non-complex-burns