Taggart on burns uncovered then covered 2

Sue TaggartCNC Burns SupportCRGH

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Assessment of burns % Total Body Surface Area burntBurn depth

Initial management of the burn woundImportance of burn wound closureDescribe acute burn wound products

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TOTAL BODY SURFACE AREA (TBSA) RULE OF 9’S

Palmar MethodPalm & fingers of the patient = 1% TBSA

LUND AND BROWDER

5

Epidermis

Dermis- capillaries- nerves

Fat

Epidermal

Superficial Dermal

MidDermal

DeepDermal

Full Thickness

Assessment of Burn Depth

SUMMARY OF BURN DEPTH ASSESSMENT

©EMSB

Depth Colour Blisters Cap Refill

Sensation

Healing

Epidermal

Red No Present Present Yes

Superficial Dermal

Pale Pink

Small Present Pain + Yes7-10d

Mid-dermal

Dark Pink

Present Sluggish Pain + Usually21d

Deep Dermal

Blotchy Red

+/- Absent < Pain >3 wks

Full thickness

White No Absent <Pain No

Assess tissue perfusion- Blanching & capillary refill

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Zone of injury – (stasis)Zone of stasis

Jacksons Burn Model

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Assess co morbidities

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Day 5

Day 1 - 86yr F 18% bath scald

Day 10

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LOOK

DO

AIRWAY

BREATHING

CIRCULATION

DISABILITY

EXPOSURE

FLUIDSANALGESIATESTSTUBES

Assess TBSARule of 9’sIV FluidsParkland formulaIDC/NGIV OpioidsEUC/FBC/ABG/COAGXrays

A.M.P.L.E. History

Head to Toe Examination

EscaharotomyTetanus

Documentation and Transfer

Support

C spine O2Haemorrhage

control I.V.AVPU & Pupils

Environmental Control

Primary Survey First Aid Secondary Survey

Emergency Management of Severe Burns (ANZBA 2014)

First Aid will provide pain relief as it decreases the inflammatory response, oedema, decreases cell damage◦Cold tap water 20 minutes, within 3hrs injury◦Aware of hypothermia (Cuttle and Kimble 2010)

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Cold tap water Burn Aid™

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Escharotomy

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines_2013-14_-_web.pdf

Analgesia / sedation

BetadineIncise medially

/laterally avoiding nerves/veins

Calcium alginateAntimicrobial

dressing

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Prontosan -.1 % Betaine (surfactant) and Polihexamethylene Biguanide PHMB (antimicrobial ) $12. 50 bottle

Efective against Staphylococcus aureus, methicillin-resistant S. aureus, S. epidermidis, Pseudomonas aeruginosa, Escherichia Coli, and Klebsiella pneumonia,Anti fungal

Cleansing

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Epidermal burn/1°/ErythemaPain, red, intact, heal within <7 daysMoisturise, protective dressing

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Cleanse, silicone dressing eg Mepilex Lite™, retain with hypafix, elevate

Superficial dermal/2°/Superficial Partial

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Mid Dermal / 2 ° / Partial Thickness/ heals 7 - 10 days

Incise blister, leave epidermis intact . 5% chlorhexidine with paraffin gauze Bactigras. - $12 roll

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Deep Dermal burn /2°/Deep partial thickness burnPink/white, pain , capillary refill >3 seconds. 2 - 3 weeks to heal, may require a graft

Hydrocolloids dressings• gelatin, pectin, carboxymethylcellulose• Facilitates autolytic debridement

Examples, Duoderm, comfeel wafer (10 x 10 cm2 $3.40 )

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Full thickness burns / 3° white, leathery, charred, cherry red, no capillary refill, requires grafting

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• Day 4 post flame burn• 93 yr old • 20% burn

Full Thickness Burn / 3 °

Silver - Acticoat™

Nano crystaline silver Acticoat™ 40cm x 40cm $164Reduces bacterial count by blocking

the respiratory enzyme system and impairs DNA replication

two layers of high-density polyethylene silver net with an inner layer of rayon

Broad spectrum antimicrobial including gram pos/neg, MRSA, anti fungal

slowly releases silver over 2 – 3 days if kept moist with water

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Cling wrapMepilex Lite™ Solosite gel™

Hypafix™ border /sprayMoist kerlix™H2O

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BiobraneTemporary skin substitute

Day 1 – Contact burn 7% Dermal burnInk cartridge exploded when thrown into fire

Cost $41.17 per 100cm2 13cm x 38cm = $223 medium glove = $800

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10 days post burn

Biobrane: The use of biosynthetic dressings is associated with a improved healing and a reduction in pain during burn dressings changes (Level I evidence Wasiak , 2009 Cochrane review)

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Early Excision and Split Skin Grafting

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SSG applied after debridement and surfasoft appliedSurfasoft - polyamide transparent dressing$3.48 100cm2

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3 days post graft, surfasoft intact, reduces shearing allows exudate to move from wound to outer dressings

Burns uncovered - covered

BURNS UNCOVERED - COVEREDAutologous SSG Allograft – donor screenedArrive frozen – 135c cryopreserved and streptomycin & penicillin. Thawed, rinsed, applied40% TBSA $19,925

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Kaltostat - $2.73 10 x 10 cm 2Calcium/Sodium Alginateabsorbent haemostatic fibre

Aquacel Ag $20.07 10cm2Broad spectrum CMC fibre

Mepilex Transfer $ 7.42 10 x 10 cm

Duoderm $2.34 10 x 10 cm

Donor Sites

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93 yr femaleDay 10 post flame burnDay 1 post op, SSG, BiobraneDay 15 deceased

Surgery – early excision ?

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Day 5 post full thickness burn – delay in surgeryFlammacerium applied. Flammazine provides Antimicrobial cover and the cerium nitrate hardens the eschar – reduces inflammatory Response

Flammacerium

Flammazine plus Cerium Nitrate$295 tub

Negative Wound Pressure TherapyVACFoam $60, Cannister $65, Rent $65 day

Burns uncovered - covered

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Discharge7 days post surgery 10 days post surgery

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Full thickness burn Neo Dermis applied - Pelnac™

7 days post Pelnac 6 months post surgery

53 days post Pelnac25 days post SSG

Conclusion Assess % Total Body Surface Area

Rule of 9’s in the initial primary assessment Lund and Browder Chart

Assess depth History Clinical examination - colour Capillary refill

Burn wounds are dynamicTopical wound management can aid wound healing,

control microbial activity, reduce pain Early excision of full thickness burn ideal

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a nurse participant in Rudge’s (1998) study explained “... i t ’s such a horrif ic area to work in, visually... deal with the wound, wrap it up and they’re a person again”

Mother of 21-year-old (32% flame burn) explained (Gull ick et al 2014),

“ It took my breath away. It took everything I had not to cry... I had to think ‘This is your child, he’s no different’...

A patient who had sustained a 36% flame burn (Skylas, Taggart, Gull ick 2014)

‘ I ts hard and traumatic experience. I just wanted to get knocked out and just forget about it ’ .

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1. Herndon 2014 . Tota l Burn care Herndon, D. Tota l Burn Care, 2012. Forth Edi t ion. Harcourt L td

2. Latenser B 2009. Cr it ica l Care of the burns pat ient : the first 48hrs: Cri t ica l Care Medic ine Vol 37 no. 10

3. Cutt le L and Kimble R. (2010) First a id t reatment of burn in jur ies . Wound Pract ice and Research, Vol. 18, No.1.

4. Orgi l l , D. P. and Piccolo N. , Escharotomy and decompression therapies in burns. J Burn Care and Research, 2009. 30(5) :p .759-68

5. Wasiak J , C le land H, Campbel l F. (2009) Dress ings for superficia l and part ia l th ickness burns (Review). The Cochrane Col laborat ion. I ssue 1.

6. Macintrye PE, Scott DA, Schug SA, Visser E J , Walker SM. (2010) Acute pa in management: Sc ient ific evidence. Austra l ian and New Zealand Col lege of Anaesthet is ts .

7. Greenwood JE, C lausen J , Kavanagh S. (2010) Exper ience with Biobrane; uses and caveats for success. Wound Pract ice and Research, Vol .18, No. 1 , pp 50-56.

8. http: / /www.aci .hea lth .nsw.gov.au/__data/assets/pdf_file /0004/162634/Burns_Transfer_Guide l ines_2013-14_-_web.pdf

9. Gu l l ick J , Taggart S , Johnson R, Ko N 2014, The Trauma Bubble: Pat ient and fami ly exper ience of ser ious burn in jury, Internat iona l Journal of Burn Care and Research.

10. Rudge T. Sk in as cover: the d iscurs ive effects of 'cover ing ' metaphors on wound care pract ices . Nurs Inq 1998;5:228-237.

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Biobrane and Full thickness burns

Burns uncovered - covered

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Day 5

Day 1 - 86yr F 18% bath scald

Day 10

DOMESTIC BATHROOM SCALDS IN THE ELDERLY

• When elderly patients were ‘not fit for surgery’ the use of Versajet ™ successfully removed adherent burn tissue

• Treatment continued with the application of hydrocolloids which supported autolytic debridement and epithelialisation

Patient D 12 weeks post burn 4 weeks post Versajet ™

BURNS UNCOVERED - COVERED7/9/12 Day 5 post burn day 2 post debridement Biobrane

BLISTER MANAGEMENT

Option 2- Incise blister

Day 1 Deep dermal burn - hot water scald

BLISTER MANAGEMENTOption 2 – Incise blister, Acticoat application

DEEP PARTIAL THICKNESS BURN

Comfeel wafer™

Acticoat Metallic nano crystaline silver Broad spectrum antimicrobial

including gram pos/neg, MRSA, Fungi

minimizing the bacterial colonization of wounds

800 mcg/day Agryia Reacts much more slowly with

chloride and thus is deactivated less rapidly in wounds – change every 2 -3 days

Silvazine/Flammazine Ion ic s i lver Active against Gram neg and

positive bacteria minimizing the bacterial

colonization of wounds Forms a pseudo-eschar over

burn 3025 mcg/day rapidly deactivated by wound

exudate (especially chloride ions), thus requiring daily application

Contains sulphur - al lergies Slows wound healing ( Wasiak

2009 The Cochrane Col laborat ion)

BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN

BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN

Hypoperfusion: Full thickness burn - can not expand (protein denaturation and oedema). Perfusion is reduced therefore necessary to release burn surgically - escharotomy

CASE STUDY: KUNUNURRA

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Neuropathic Pain- Hyperalgesia, Allodynia

◦ Anti convulsants e.g. Gabopentin ◦ Anti depressants e.g.

Amitriptaline◦ Paracetamol◦ Tramadol8 days post contact burn

7 weeks post burn18 days post burn

Burn Wound dressings, Skin Substitutes and Bioengineered Skin

Donor sitesDuoderm $2.34 10cm2Mepilex Transfer $7.42 10cm2

BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN

BIOBRANE• Outer silicone membrane with a nylon fabric • Porcine collagen incorporated into both layers which aids adherence to the wound•. Temporary protective semi permeable skin substitute•

Partial Thickness burns/Dermal Burns

BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN

Cultured Epithelial Autografts - CEA

Skin biopsy for Cultured Epithelial AutograftsCEA

Burn Wound dressings, Skin Substitutes and Bioengineered Skin

Triad of critical careHypothermia 33 ⁰cvasoconstriction/hypoperfusionCoagulopathy (ineffective platelet function)

Myocardial performance Impairment of wound healing

(Fredrikson 2011)

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57

WOUND PROGRESSION

Day 1 post burn

Day 3

Day 7 post burn, day 4 post Biobrane

74 yr old female, hot water scald

“My head looked like The Elephant Man... On the end of my shoulders was this thing like a Star Wars movie. It was disgusting… I was so embarrassed… my head blew up, so as the night went on I became uglier and uglier. It was like nothing I’d ever seen”

Wound healing trajectory

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