Mod 15 Burns - Wong Ch 30 p1091-1103

Nursing 4 Module 15 – Burns

THERMAL INJURY – BURNS

Burn injuries are usually attributed to extreme heat sources but may also result from exposure to cold, chemicals, electricity, or radiation. Most burns are relatively minor and do not require definitive medical treatment. However, burns involving a large body surface area, critical body parts, or the geriatric or pediatric population often benefit from treatment in specialized burn centers. The American Burn Association has established criteria to guide decisions regarding the severity of injury and the need for transfer for specialized care.

When burns are characterized by patients' age and type of injury, the following patterns become apparent: (1) hot-water scalds are most frequent in toddlers, (2) flame-related burns are more common in older children, (3) 10% to 20% of documented cases of child abuse include burn injuries, and (4) children playing with matches or lighters account for 1 in 10 house fires.

The extent of tissue destruction is determined by the intensity of the heat source, the duration of contact or exposure, the conductivity of the tissue involved, and the rate at which the heat energy is dissipated by the skin. A brief exposure to high-intensity heat from a flame can produce burn injuries similar to those induced by long exposure to less intense heat in hot water.

Characteristics of Burn Injury

The physiologic responses, therapy, prognosis, and disposition of the injured child are all directly related to the amount of tissue destroyed. Therefore the severity of the burn injury is assessed on the basis of the percentage of total body surface area (TBSA) burned and depth of the burn. Among children in the school age—group or younger age-groups, a burn that is 10% TBSA can be life threatening if not treated correctly. Other important factors in determining the seriousness of the injury are the location of the wounds, the child's age and general health, the causative agent, the presence of respiratory involvement, and any associated injury or condition.

Type of Injury.

The majority of burns result from contact with thermal agents such as a flame, hot surfaces, or hot liquids. Electrical injuries caused by household current have the greatest incidence in young children, who insert conductive objects into electrical outlets and bite or suck on connected electrical cords. These burns occur most commonly during the spring and summer months and are also associated with risk-taking behaviors in boys. Direct contact with high- or low-voltage current, as well as lightning strikes, is the most frequent mechanism of injury. The resistance of the tissue and the path of the electric current are responsible for the damage incurred. Electric current travels through the body following the path of least resistance, which involves the tissues, fluid, blood vessels, and nerves. A more localized burn is produced if skin resistance is high at the area of contact, and a more systemic pattern of injury is produced if skin resistance is low. Often compared with a crush injury, serious electrical trauma results from current passing through vital organs, muscle compartments, and nerve or vascular pathways. Loss of limbs, cardiac fibrillation, respiratory collapse, and burns are common occurrences after exposure to electrical energy. Criteria for admission, as derived from evidence-based practice for electrical burn injuries, includes a history of loss of consciousness, electrocardiographic (ECG) changes, 10% TBSA affected, or the need for monitoring an affected extremity. Cardiac monitoring is therefore included in standard burn care when ECG changes are identified on admission.

Chemical burns are seen in the pediatric population and can cause extensive injury. The severity of injury is related to the chemical agent (acid, alkali, or organic compound) and the duration of contact. The mechanism of injury differs from that in other burns in that there is a chemical disruption and alteration of the physical properties of the exposed body area. Noxious agents exist in many cleaning products commonly found in the home. In addition to concern for localized damage, the potential for systemic toxicity must be addressed. Of particular concern is the exposure of the eyes to chemical agents, the ingestion of caustic substances, and inhalation of toxic gases produced from chemicals.

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Extent of Injury.

The extent of a burn is expressed as a percentage of the TBSA. This is most accurately estimated by using specially designed age-related charts (Fig. 30-15). It is more efficient to use a chart designed to assign body proportions to children of different ages.

Depth of Injury.

A thermal injury is a three-dimensional wound that is also assessed in relation to depth of injury. Traditionally the terms first-, second-, and third-degree have been used to describe the depth of tissue injury. However, with the current emphasis on wound healing, these have been replaced by more descriptive terms based on the extent of destruction to the epithelializing elements of the skin (Fig. 30-16).

Superficial (first-degree) burns are usually of minor significance. With these burns, there is often a latent period followed by erythema. Tissue damage is minimal, the protective functions of the skin remain intact, and systemic effects are rare. Pain is the predominant symptom, and the burn heals in

5 to 10 days without scarring. Mild sunburn is an example of a superficial burn.

Partial-thickness (second-degree) injuries involve the epidermis and varying degrees of the dermis. These wounds are painful, moist, red, and blistered. Superficial partial-thickness burns involve the epidermis and part of the dermis. Dermal elements are intact, and the wound should heal in approximately 14 days with variable amounts of scarring (Fig. 30-17). The wound is extremely sensitive to temperature changes, exposure to air, and light touch. Although classified as second-degree or partial-thickness burns, deep dermal burns resemble full-thickness injuries in many respects. Sweat glands and hair follicles remain intact. The burn may appear mottled, with pink, red, or waxy white areas exhibiting blisters and edema formation. Systemic effects are similar to those encountered with full-thickness burns. Although many of these wounds heal spontaneously, healing time may be extended beyond 14 days. These burn wounds often heal with extensive scarring.

Full-thickness (third-degree) burns are serious injuries that involve the entire epidermis and dermis and extend into subcutaneous tissue (see Fig. 30-16). Nerve endings, sweat glands, and hair follicles are destroyed. The burn varies in color from red to tan, waxy white, brown, or black and is distinguished by a dry, leathery appearance (Fig. 30-18). Normally, full-thickness burns lack sensation in the area of injury because of the destruction of nerve endings. However, most full-thickness burns have superficial and partial-thickness burned areas at the periphery of the burn, where nerve endings are intact and exposed. Excised eschar and donor sites also cause exposed nerve fibers. As the peripheral fibers regenerate, painful sensations return. Consequently, children often experience severe pain related to the size and depth of the burn. Full-thickness wounds are not capable of reepithelialization and require surgical excision and grafting to close the wound.

Fourth-degree burns are full-thickness injuries that involve underlying structures such as muscle, fascia, and bone. The wound appears dull and dry, and ligaments, tendons, and bone may be exposed (Fig. 30-19).

Severity of Injury.

Burns are classified as minor, moderate, or major, which is useful in determining the disposition of the patient for treatment. Burn patients are categorized as (1) those with a major burn injury, who Wong Ch. 30 p. 1091-1103 2

TABLE 30-10: Severity Grading System Adopted by the American Burn Association

MINOR* MODERATE MAJORPartial-thickness <10% TBSA >10%-20% TBSA >20% TBSA

Full-thickness All

Treatment Usually outpatient; may require 1- to 2-day admission

Admission to hospital, preferably one with expertise in burn care

Admission to a burn center

* Minor burns exclude any burn involving the face, hands, feet, perineum, or crossing joints; electrical burns; any injury complicated by the presence of inhalation injury or concomitant trauma; children with psychosocial factors affecting the injury.


require the services and facilities of a specialized burn center; (2) those with a moderate burn, who may be treated in a hospital with expertise in burn care; and (3) those with minor injuries, who may be treated on an outpatient basis. The extent and depth of the burn (Table 30-10), the causative agent, the body area involved, the patient's age, and concomitant injuries and illnesses determine the severity of the injury.

Because the skin of infants is so thin, it is likely to sustain deeper injuries compared with older children. Children younger than 2 years of age, especially 6 months or younger, have a significantly higher mortality rate than older children with burns of similar magnitude. Acute or chronic illnesses or superimposed injuries also complicate burn care and response to treatment.

Inhalation Injury.

Trauma to the tracheobronchial tree often follows inhalation of the heated gases and toxic chemicals produced during combustion. Although direct thermal injury to the upper airway may occur, heat damage below the vocal cords is rare. Inspired heated air is cooled in the upper airway before reaching the trachea. Reflex closure of the cords and laryngospasm also prevent full inhalation. However, evidence of direct thermal injury to the upper airway includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestations may be delayed as long as 24 to 48 hours. Wheezing, increasing secretions, hoarseness, wet rales, and carbonaceous secretions are signs of respiratory tract involvement. Upper airway obstruction is often associated with burn shock and fluid resuspara. In such situations, endotracheal intubation may also be necessary to preserve a patent airway.

Inhalation of carbon monoxide is suspected when the injury has occurred in an enclosed space. Mucosal erythema and edema followed by sloughing of the mucosa are manifestations of respiratory tract injury. A mucopurulent membrane replaces the mucosal lining and seriously compromises respiration and ventilation.

Early in the postburn period most pulmonary infections result from nosocomial exposure, immobility, and abdominal distention. The hematogenous variety occurs later and is related to the septic burn wound or other foci, such as phlebitis at the site of an invasive IV line. A significant increase in mortality has been observed when inhalation injury and pneumonia are both present.

Deep burns, especially those circling the thorax, may cause restriction of chest excursion as a result of edema and inelastic eschar formation. Young children are particularly at risk because of the pliability of the skeletal structure. Restriction of the chest is relieved by an escharotomy incision, which allows expansion of the chest wall to facilitate ventilation.

Pathophysiology

Thermal injuries produce both local and systemic effects that are related to the extent of tissue destruction. In superficial burns the tissue damage is minimal. In partial-thickness burns there is considerable edema and more severe capillary damage. With a major burn greater than 30% TBSA, there is a systemic response involving an increase in capillary permeability, allowing plasma proteins, fluids, and electrolytes to be lost. Maximum edema formation in a small wound occurs about 8 to 12 hours after injury. After a larger injury, hypovolemia, associated with this phenomenon, will slow the rate of edema formation, with maximum effect at 18 to 24 hours.

Another systemic response is anemia, caused by direct heat destruction of red blood cells, hemolysis of injured red blood cells, and trapping of red blood cells in the microvascular thrombi of damaged cells. A long-term decrease in the number of red blood cells may occur as a result of increased red blood cell fragility. Initially there is an increased blood flow to the heart, brain, and kidneys, with decreased blood flow to the gastrointestinal tract. There is an increase in metabolism to maintain body heat, providing for the increased energy needs of the body.

Complications.

Thermally injured children are subject to a number of serious complications, both from the wound and from systemic alterations resulting from the injury. The immediate threat to life is related to airway compromise and profound shock. During healing, infection—both local and systemic sepsis—is the primary complication. Mortality associated with thermal trauma in children increases with the severity of injury and decreases as age advances. In children older than 3 years, the mortality rate is similar to that of adults. Below this age, the survival rate with burns and their associated complications lessens considerably.

A less apparent respiratory tract injury is inhalation of carbon monoxide. Carbon monoxide has a greater affinity for hemoglobin than does oxygen, thereby depriving peripheral tissues and oxygen-dependent organs (such as the heart and brain) of the oxygen needed for survival. Treatment for either of these two problems is 100% oxygen, which reverses the situation rapidly.

Pulmonary problems are a major cause of fatality in children with either thermal burns or complications in the respiratory tract. Respiratory problems include inhalation injuries, aspiration in unconscious patients, bacterial pneumonia, pulmonary edema, pulmonary embolus, posttraumatic pulmonary insufficiency, and atelectasis. The most common cause of respiratory failure in the pediatric age-group is bacterial pneumonia, which requires prolonged intubation and sometimes a tracheostomy. Tracheostomies increase the incidence of serious complications and are performed only in extreme cases.

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A less common complication is pulmonary edema resulting from fluid overload or acute respiratory distress syndrome (ARDS) in association with gram-negative sepsis. ARDS results from pulmonary capillary damage and leakage of fluid into the interstitial spaces of the lung. A loss of compliance and interference with oxygenation are the consequences of pulmonary insufficiency in conjunction with systemic sepsis.

Wound Sepsis.

Sepsis is a critical problem in the treatment of burns and an ever-present threat following the shock phase. Initially, burn wounds are relatively pathogen free unless they are contaminated with potentially infectious material, such as dirt or polluted water. However, dead tissue and exudate provide a fertile field for bacterial growth. On approximately the third postburn day, early colonization of the wound surface by a preponderance of gram-positive organisms (primarily staphylococci) changes to predominantly gram-negative opportunistic organisms, particularly Pseudomonas aeruginosa. By the fifth postburn day, bacterial invasion is well under way beneath the surface of the burn wound. Early surgical excision of eschar together with placement of autograft reduces the incidence of sepsis.

Therapeutic Management

Emergency Care.

The initial management of the burn patient begins at the scene of injury. The first priority is to stop the burning process (see Emergency Treatment box). The child should then be transported immediately to the nearest medical facility for treatment and evaluation. The child and the family are usually extremely frightened and anxious; sensitivity to their emotional state and reassurance should be provided during the transport process.

Stop the Burning Process.

The chief aim of rescue in flame burns is to smother the fire, not fan it. Children tend to panic and run, which spreads the flames and makes assistance more difficult. The injured child should be placed in a horizontal position and rolled in a blanket, rug, or similar article, with care taken not to cover the head and face because of the danger of inhalation of toxic fumes. If nothing is available, the victim should lie down and roll over slowly to extinguish the flames. Remaining in the vertical position may cause the hair to ignite or the inhalation of flames, heat, or smoke.

Major burns with large amounts of denuded skin should not be cooled. Heat is rapidly lost from burned areas, and additional cooling leads to a drop in core body temperature and potential circulatory collapse. Wet dressings also promote vasoconstriction because of cooling, resulting in impaired circulation to the burned area and increased tissue damage. Chemical burns require continuous flushing with large amounts of water before transport to a medical facility. The use of neutralizing agents on the skin is contraindicated, since a chemical reaction is initiated and further injury may result. If the chemical is in powder form, the addition of water may spread the caustic agent. The powder should be brushed off if possible.

Burned clothing is removed to prevent further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. This also provides access to the wound and prevents painful removal later.

Assess the Victim's Condition.

As soon as the flames are extinguished, the child is assessed. Airway, breathing, and circulation are the primary concerns. Cardiopulmonary complications may result from exposure to electric current, inhalation of toxic fumes and smoke, hypovolemia, and shock. Emergency measures are instituted as appropriate.

Cover the Burn.

The burn wound should be covered with a clean cloth to prevent contamination, decrease pain by eliminating air contact, and prevent hypothermia. No attempt should be made to treat the burn. Application of topical ointments, oils, or other home remedies is contraindicated.

Transport the Child to Medical Aid.

The child with an extensive burn is not given anything by mouth to avoid aspiration in the presence of paralytic ileus and upper airway edema and to prevent water intoxication. The child is transported to the nearest medical facility. If this cannot be accomplished within a relatively short period, IV access should be established, if possible,

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Emergencytreatment – BurnsMINOR BURNSStop the burning process:▪ Apply cool water to the burn or hold the burned area

under cool running water.▪ Do not use ice.Do not disturb any blisters that form, unless the injury is from a chemical substance.Do not apply anything to the wound.Cover with a clean cloth if risk of damage or contamination.Remove burned clothing and jewelry.

MAJOR BURNSStop the burning process:▪ Flame burns—smother the fire.▪ Place victim in the horizontal position.▪ Roll victim in a blanket or similar object; avoid covering

the head.Assess for an adequate airway and breathing.If child is not breathing, begin mouth-to-mouth resuspara.Remove burned clothing and jewelry.Cover wound with a clean cloth.Keep victim warm.Transport to medical aid.Begin intravenous and oxygen therapy as prescribed.


with a large-bore catheter. Oxygen is administered, if available, at 100%. A report of the initial assessment and any interventions implemented is given to the medical facility assuming care of the child.

Provide Reassurance.

Providing reassurance and psychologic support to both the family and the child helps immeasurably during the period of postinjury crisis. Reducing anxiety conserves energy the family and child will need to cope with the physiologic and emotional stress of injury.

Minor Burns.

Treatment of burns classified as minor can usually be managed adequately on an outpatient basis when it is determined that the parent can be relied on to carry out instructions for care and observation. Patients with less than optimum circumstances may require close follow-up to ensure adherence with treatment.

The wound is cleansed with a mild soap and tepid water. Débridement of the wound includes removal of any embedded debris, chemicals, and devitalized tissue. Removal of intact blisters remains controversial. Some authorities argue that blisters provide a barrier against infection; others maintain that blister fluid is an effective medium for the growth of microorganisms. However, blisters should be broken if the injury is due to a chemical agent to control absorption. Most practitioners favor covering the wound with an antimicrobial ointment to reduce the risk of infection and to provide some form of pain relief. The dressing consists of nonadherent fine-mesh gauze placed over the ointment and a light wrap of gauze dressing that avoids interference with movement. This helps keep the wound clean and protect it from trauma. The caregiver is instructed to wash the wound, reapply the dressing, and return the child to the office or clinic as directed for wound observation. The frequency of dressing changes may vary from every other day to once a day.

Some practitioners prefer an occlusive dressing, such as a hydrocolloid, which is placed over the wound after cleansing. Hydrogel dressings, which are soothing and nonadherent, may also be used. The dressing is changed when leakage occurs—at regular intervals or at least weekly. This method eliminates the discomfort associated with frequent dressing changes but impairs visualization of the wound surface.

If there is a high probability of infection or other complications or if there is doubt about the ability to carry out instructions, the caregiver may be directed to bring the patient in daily for dressing changes and inspection. Another option is have a nurse make a home visit to inspect the wound and perform the dressing change. Frequent removal of the dressing is an effective mode of débridement. Soaking the dressing in tepid water or normal saline before removal helps loosen the dressing and debris and reduce discomfort. Burns of the face are usually treated by an open method. The wound is washed and débrided in the same manner, and a thin film of antimicrobial ointment is applied.

A tetanus history is obtained on admission. If there is no history of immunization, or if more than 5 years have passed since the last immunization, tetanus prophylaxis is administered. There is no evidence that systemic antibiotic prophylaxis decreases the incidence of infection in small burn wounds. Therefore antibiotics should be used only when there is evidence of infection. A mild analgesic such as acetaminophen is usually sufficient to relieve discomfort; the antipyretic effect of the drug also alleviates the sensation of heat.

Most minor burns heal without difficulty, but if the wound margin becomes erythematous, gross purulence is noted, or the child develops evidence of systemic reaction, such as fever or tachycardia, hospitalization is indicated. The child should also be evaluated for functional impairment, and the caregiver should be instructed in the exercise and ambulation program. After wound healing, an evaluation of scar maturation and range of motion will indicate any need for further therapy.

Major Burns.

The first priority is airway maintenance. The inhalation of noxious agents or respiratory burns is suggested when there is a history of injury in an enclosed space; edema of the oral and nasal membranes; thermal injury to the face, nares, and upper torso; hyperemia; and blisters or evidence of trauma to the upper respiratory passages. When respiratory involvement is suspected or evident, 100% oxygen is administered and blood gas values, including carbon monoxide levels, are determined.

If the child exhibits changes in sensorium, air hunger, or other signs of respiratory distress, an endotracheal tube is inserted to maintain the airway. When severe edema of the face and neck is anticipated, intubation is performed before swelling makes intubation difficult or impossible. Controlled intubation is preferred to an emergency procedure. Intubation allows for the delivery of humidified oxygen, the removal of secretions from respiratory passages, and the provision of ventilatory support.

When full-thickness burns encircle the chest, constricting eschar may limit chest wall excursion, and ventilation of the child becomes more difficult. Escharotomy of the chest relieves this constriction and improves ventilation.

Fluid Replacement Therapy.

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The objectives of fluid therapy are to (1) compensate for water and sodium lost to traumatized areas and interstitial spaces, (2) reestablish sodium balance, (3) restore circulating volume, (4) provide adequate perfusion, (5) correct acidosis, and (6) improve renal function.

Fluid replacement is required during the first 24 hours because of fluid shifts that occur after the injury. Various formulas are used to calculate fluid needs, and the one adopted depends on practitioner preference. Crystalloid solutions are used during this initial phase of therapy. Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuspara.

After the initial 24-hour period, theoretically there is a capillary seal, and capillary permeability is restored. Colloid solutions such as albumin, Plasma-Lyte, or fresh frozen plasma are useful in maintaining plasma volume. However, children with burn injuries usually require fluids in excess of their calculated maintenance and replacement volume. Reasons for this may include underestimation of burn size (particularly in pediatric patients), pulmonary injury that sequesters resuspara fluid in the lung, electrical injury with greater tissue destruction than that which is visible, and a delay in the initiation of fluid resuspara. Irreversible burn shock that persists despite aggressive fluid resuspara remains a significant cause of death in the immediate postburn period. Fluid balance may continue to be a problem throughout the course of treatment, especially during periods in which there may be considerable evaporative loss from the wound.

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Nutrition.

The enhanced metabolic requirements and catabolism in severe burns make nutritional needs of paramount importance and often difficult to satisfy. The diet must provide sufficient calories to meet the increased metabolic needs and enough protein to avoid protein breakdown. Hypoglycemia can result from the stress of the burn injury because the liver glycogen stores are rapidly depleted.

A high-protein, high-calorie diet is encouraged. Many children have poor appetites and are unable to meet energy requirements solely by oral feeding. Most children with burns in excess of 25% TBSA require supplementation with tube feeding. Early and continued nutritional support is an important part of therapy for seriously burned patients. Enteral feeding provides direct nourishment to the gastrointestinal tract and helps reverse the defective gut barrier that accompanies burn shock.

If nutritional requirements cannot be met entirely by the enteral route, parenteral hyperalimentation is used to supplement intake. However, enteral feeding increases blood flow in the intestinal tract, preserves gastrointestinal function, and minimizes bacterial translocation by decreasing mucosal atrophy of the intestines. These factors make enteral feeding the preferred route of nutritional support.

To facilitate growth and proliferation of epithelial cells, administration of vitamins A and C is begun early in the postburn period. Zinc is also supplemented because of its important role in wound healing and epithelialization.

Medication.

Antibiotics are usually not administered prophylactically. The administration of systemic antibiotics to control wound colonization is not indicated, since decreased circulation to the injured area prevents delivery of the medication to areas of deepest injury. Surveillance cultures and monitoring of the clinical course provide the most reliable indicators of developing infection. Appropriate antibiotics are instituted to treat the specific identified organism. Otitis media should not be overlooked as a source of fever in the pediatric population.

Some form of sedation and analgesia is required in the care of burned children. Morphine sulfate is the drug of choice for severe burn injuries. Morphine has extensive distribution but is metabolized rapidly; continuous infusion or frequent administration is needed for pain management in burns. Morphine is administered intravenously and titrated to individual need. The unstable circulatory status and edema formation preclude intramuscular or subcutaneous administration. When combined, midazolam (Versed) and fentanyl (Sublimaze) also provide excellent IV sedation and analgesia to control procedural pain in children with burns. The oral form of fentanyl, Oralet, provides effective analgesia in a convenient form that the child can suck. Dosage monitoring is important because tolerance to opioids may develop. IV analgesics are most effective when they are administered just before the onset of procedural pain.

The use of short-acting anesthetic agents, such as propofol (Diprivan) and nitrous oxide, has proved beneficial in eliminating procedural pain. Pharyngeal reflexes remain intact, thus ensuring a patent airway. Propofol is an IV sedative hypnotic agent that produces sedation in less than 1 minute and lasts only a few minutes. Nitrous oxide is a useful short-term analgesic when given in a mixture of gases on a fixed ratio of 50% nitrous oxide and 50% oxygen. Initiation of action is approximately 1 minute, with peak effect reached in 3 to 5 minutes. Nitrous oxide is useful to alleviate anxiety and raise the threshold of pain during procedures. The child may self-administer the nitrous oxide mixture with assistance. For any conscious or unconscious sedation, the child must be monitored continuously during the procedure.

Management of the Burn Wound.

After the initial period of shock and the restoration of fluid balance, the primary concern is the burn wound. The objectives of wound management include prevention of infection, removal of devitalized tissue, and closure of the wound. The application of dressings and topical antimicrobial therapy reduce pain by minimizing the exposure to air.

Primary Excision.

In children with large, full-thickness burn wounds, excision is performed as soon as the patient is hemodynamically stable after initial resuspara. Because the burn wound precipitates an exaggerated physiologic response, many complications do not resolve until the eschar is excised and the wound is closed. Early excision of deep partial- and full-thickness burns reduces the incidence of infection and the threat of sepsis.

Débridement.

Partial-thickness wounds require débridement of devitalized tissue to promote healing. Débridement is painful and requires analgesia and a sedative before the procedure. Medications given for pain need to be readily available during this procedure and may need to be titrated up during the procedure. Hydroxyzine and diphenhydramine are often needed for itching that occurs after whirlpool and débridement. The itching becomes particularly bothersome as the burns heal.

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Hydrotherapy is employed to cleanse the wound and involves soaking in a tub or showering at least once a day for no more than 20 minutes. The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Hydrotherapy helps to cleanse not only the wound but the entire body and aids in maintenance of range of motion. Mesh gauze serves to entrap the exudative slough and is readily removed during hydrotherapy. Any loose tissue is carefully trimmed away before the wound is redressed.

Topical Antimicrobial Agents.

Methods used for managing the burn wound include:

Exposure—Wounds are left open to air; crust forms on partial-thickness wounds, and eschar forms on full-thickness burns.

Open—Topical antimicrobial agent is applied directly to the wound surface and the wound is left uncovered.

Modified—Antimicrobial agent is applied directly or impregnated into thin gauze and applied to the wound; gauze or net secures the area.

Occlusive—Antimicrobial agent is impregnated in gauze or applied directly to the wound; multiple layers of bulky gauze are placed over the primary layer and secured with gauze or net.

All these methods provide wound coverage and employ some type of topical agent. Topical agents do not eliminate organisms from the wound but can effectively inhibit bacterial growth. To be effective, a topical application must be nontoxic, capable of diffusing through eschar, harmless to viable tissue, inexpensive, and easy to apply. A topical ointment should not encourage the development of resistant strains of bacteria and should produce minimal electrolyte derangement. A comparison of commonly used agents is summarized in Table 30-11.TABLE 30-11: Comparison of Common Topical Preparations

AGENT DRESSINGS ADVANTAGES DISADVANTAGESSilver nitrate 0.5% (AgNO3)

Open, modified or occlusive; impedes joint movement; dressings changed twice daily; keep dressing moist, rewet at least every 2 hours

Greatly reduces evaporative losses; does not interfere with wound healing; bacteriostatic action against major burn flora, including Pseudomonas and Staphylococcus organisms; inexpensive

Does not penetrate eschar; ineffective on established burn wound infections; little effect on Klebsiella and Aerobacter groups; stains skin, clothing, linens; makes assessment of the wound difficult because of staining; hypotonicity pulls electrolytes from the wound, depleting sodium, potassium, chloride, and magnesium; stings on application

Silver sulfadiazine 1% (AgSD)

Occlusive; motion of joints maintained; applied twice daily; do not use with a history of allergy to sulfa

Little pain on application; bactericidal by altering DNA and cell metabolism; effective against gram-positive and gram-negative bacteria; easy to apply; nontoxic

Transient neutropenia; does not penetrate eschar; forms proteinaceous gel on wound surface that is painful to remove; occasional rashes and pruritus; decreases granulocyte formation

Mafenide acetate 10% (Sulfamylon)

Cream—Usually open; do not apply to face; apply twice dailySolution—Occlusive; keep dressing moist (rewet at least every 2 hours); protect solution from light

Penetrates eschar and diffuses rapidly into burn wound and underlying tissues; effective in deep flame, electrical, and infected wounds; biostatic against many gram-positive and gram-negative organisms, including Pseudomonas and Clostridium

Difficult and painful to remove cream; pain on application; metabolic acidosis, hypercapnia, and carbonic anhydrase inhibition; inhibits wound healing; hypersensitivity in some patients

Bacitracin Open, modified; motion of joints maintained; change dressing twice daily

Bactericidal and bacteriostatic against gram-positive organisms; low toxicity; painless application; easy to apply

Limited activity against gram-negative organisms; allergic reaction in sensitive individuals

Biologic Skin Coverings.

Permanent coverage of extensive burns is a prolonged process that requires repeated operative procedures using general anesthesia for atraumatic care in débridement and grafting. Early closure shortens the period of metabolic stress and decreases the likelihood of burn wound sepsis. In the acute phase, biologic dressings cover and protect the wound from contamination, reduce fluid and protein loss, increase the rate of epithelialization, reduce pain, and facilitate movement of joints to retain range of motion.

Allograft (homograft) skin is obtained from human cadavers that are screened for communicable diseases. Allograft is particularly useful in the coverage of surgically excised deep partial- and full-thickness wounds in extensive burns when available donor sites are limited. Severe immunosuppression occurs in massively burned children, and the allograft becomes adherent. The allograft can remain in place until suitable donor sites become available. Typically, rejection is seen approximately 3 to 4 weeks after application. The availability of tissue banks and a supply of suitable donors limit the use of allografts.

Xenograft from a variety of species, most notably pigs, is commercially available. In large burns, the porcine xenograft is commonly applied when extensive early débridement is indicated to cover a partial-thickness burn; this provides a temporary covering for the wound until an available autograft can be applied to the full-thickness areas. Pigskin dressings are replaced every 1 to 3 days. They are particularly effective in children with partial-thickness scald burns of the hands and face because they allow relatively pain-free movement, which reduces contracture formation and has the added benefit of improving appetite and morale.

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When applied early to a superficial partial-thickness injury, biologic dressings stimulate epithelial growth and faster wound healing. However, biologic dressings must be applied to clean wounds. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such infection may convert the wound to a full-thickness injury.

Synthetic skin coverings are available for the management of partial-thickness burn wounds. Ideally, the dressing should provide the properties of human skin: adherence, elasticity, durability, and hemostasis. Synthetic skin substitutes are readily available, have an indefinite shelf life, and are relatively inexpensive.

Synthetic dressings are composed of a variety of materials and can be used successfully in the management of superficial partial-thickness burns and donor sites. Examples include adherent elastic films; hydroactive materials; or colloidal suspensions that are usually permeable to air, vapor, and fluids.

Biobrane is a flexible silicone-nylon membrane bonded to collagenous peptides of porcine skin. Calcium alginate is another treatment for donor sites. As with biologic dressings, it is important that the wound be free of debris before the dressing is applied. Body temperature elevation or evidence of purulence, erythema, or cellulitis around the wound edges may indicate that the wound has become infected beneath the dressing. If this occurs, prompt discontinuance of the synthetic dressing is indicated. All synthetic dressings are reputed to hasten wound healing and reduce discomfort.

Permanent Skin Coverings.

Permanent coverage of deep partial- and full-thickness burns is usually accomplished with a split-thickness skin graft. This graft consists of the epidermis and a portion of the dermis removed from an intact area of skin by a special instrument, the dermatome (Fig. 30-20). With extensive burns it is often difficult to find enough viable skin to cover the wounds; therefore available donor sites and special techniques are used. Split-thickness skin grafts may be sheet graft or mesh graft.

Sheet Graft – A sheet of skin, removed from the donor site, is placed intact over the recipient site and sutured in place; this is used in areas where cosmetic results are most visible (Fig. 30-21).

Mesh Graft – A sheet of skin is removed from the donor site and passed through a mesher, which produces tiny slits in the skin that allow the skin to cover 1.5 to 9 times the area of the sheet graft; this results in a less desirable cosmetic and functional outcome (Fig. 30-22).

The donor site is dressed with synthetic wound coverings or fine-mesh gauze until the dressing separates at 10 to 14 days, when the wound is healed. Dressings are not changed on donor sites to avoid damage to newly healed, delicate epithelium. Healed donor sites are available for reharvesting in patients with extensive burns and limited undamaged skin, but the quality of skin is decreased when multiple grafts are taken.

Artificial Skin – The development of Integra, a product that allows the dermis to regenerate, has produced significant improvement in burn wound healing and decreased scar formation. It is applied to partial- and full-thickness burns. The two-layer membrane is made of collagen (a fibrous protein from animal tendons and cartilage) and silicone rubber (i.e., Silastic). The Silastic layer is peeled off after the dermis is formed. The application of artificial skin does not replace the grafting procedure, but it prepares the burn wound to accept an ultrathin autograft. Advantages include faster healing of the burn wound when integrity of the dermis is restored, faster healing of donor sites with the use of ultrathin grafts, and restoration of sweat glands and hair follicles. A disadvantage is its high cost.

Cultured Epithelium – When burns are extensive and donor sites for split-thickness skin grafting are limited, it is possible to culture cells from a full-thickness skin biopsy and produce coherent sheets that can be applied to clean, excised full-thickness wounds. Epithelial cell culture grafts offer the possibility of an unlimited source of autografts in patients with extensive burns. Cultured epithelial autografts are effective in early wound closure. The child's own skin is fractionated and cultured in a porcine media to form a thin epithelial layer that is applied to the burn wound. This technique offers an improved rate of survival in patients with extensive burns and limited donor sites.

Prognosis.

Children differ from adults in their responses to thermal injury, and the mortality rates in young children are significantly higher than those in older children and adults. Mortality is greatest for children younger than 48 months of age. Many children who do survive have long-term functional and cosmetic impairments.

Nursing Care Management

Because the care of burned children encompasses a broad range of skills, nursing care has been divided into segments that correspond with the major phases of burn treatment. The acute phase, also referred to as the emergent or resuscitative phase, involves the first 24 to 48 hours. The management phase extends from the completion of adequate resuspara through wound coverage. The rehabilitative phase begins once the majority of the wounds have healed and rehabilitation has become the predominant focus of the care plan. This phase continues until all reconstructive procedures and corrective measures are accomplished (often a period of months or years).

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Acute Phase.

The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. IV infusion is begun immediately and is regulated to maintain a urinary output of at least 1 to 2 ml/kg in children weighing less than 30 kg (66 pounds); an output of 30 to 50 ml/hr is expected in children weighing more than 30 kg. Urinary output and specific gravity, vital signs, laboratory data, and objective signs of adequate hydration guide the rate of fluid administration.

Children who are hospitalized with burns require constant observation and assessment for complications. Alterations in electrolyte balance produce clinical symptoms of confusion, weakness, cardiac irregularities, and seizures. Changes in respiratory function and gas exchange are reflected clinically by restlessness, irritability, increased work of breathing, and alterations in blood gas values. The loss of protective function of the skin exposes burned children to increased risk of hypothermia. Edema formation and circulatory impairment result in the loss of sensation and deep throbbing pain.

Burn units maintain a pictorial record of the wound to record progress and for legal purposes (if child abuse is suspected). The burn wound is treated according to the protocol of the specific burn facility. The burn team monitors infection control procedures and ensures that staff and visitors comply with established protocols to prevent cross-contamination in the burn unit.

Throughout the acute phase of care, the psychosocial needs of the children and their families should not be overlooked. The child is frightened, uncomfortable, and often confused. Children may be isolated from familiar persons and surroundings; the overwhelming physical needs at this time are the primary focus of the staff and parents. In addition to feeling concern for their child, the family experiences guilt, which may be related to the fact that the parents did not or could not protect their child from injury. Consistency in the information presented and in the attitude of the staff creates a sense of familiarity and stability during the acute phase of care. Consistent caregivers can also help decrease the patient's and family's anxiety and provide coordination of care. For example, when many teams of consultants and specialists are involved in the child's care, appointing one “spokesperson” decreases the confusion and enhances communication regarding the child's care.

Management and Rehabilitative Phases.

After the patient's condition is stabilized, the management phase begins. The multidisciplinary team concentrates on preventing wound infections, closing the wound as quickly as possible, and managing the numerous complications. Although the rehabilitative phase begins when permanent wound closure has been achieved, rehabilitation issues are identified on admission and are included in the care plan throughout the hospital course.

Comfort Management.

The severe pain of the wound and resultant therapies, the anxiety generated by these experiences, sleep deprivation, itching related to wound healing, and the conscious and unconscious interpretations of traumatic events contribute to the psychologic behaviors commonly observed in children with burns. It is always difficult to deal with a child in pain, and inflicting pain on a helpless child is contrary to the empathic nature of nursing. Interventions to promote comfort may include medications (including IV morphine or midazolam and short-term anesthetics such as propofol), relaxation techniques, distraction therapy, behavioral techniques, operant conditioning (e.g., tokens, star chart), and family participation.

Children need age-appropriate explanations before all procedures. When children appear to accept pain with little or no response, psychologic consultation may be needed. Consistency in caregivers is important. If this is not possible, a carefully developed, multidisciplinary care plan is necessary to provide consistency.

Care of the Burn Wound.

The nurse has a major responsibility for cleansing, débriding, and applying topical medications and dressings to the burn wound. Pain medication should be administered so that the peak effect of the drug coincides with the procedure. Children who have an understanding of the procedure to be performed and some perceived control demonstrate less maladaptive behavior. Children also respond well to participating in decisions.

Outer dressings are removed. Any dressings that have adhered to the wound can be more easily removed by applying tepid water or normal saline. Loose or easily detached tissue is débrided during the cleansing process. In dressing the wound, it is important that all areas be clean, that medication be amply applied, and that no two burned surfaces touch each other (e.g., fingers or toes; ears touching the side of the head). If they are touching, the burned surfaces will heal together, causing deformity or dysfunction.

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NURSINGALERT – Evaluate the burned extremity and check the pulse every hour. If unable to palpate, use Doppler to ascertain loss of circulation and pulse. If the pulse is lost, escharotomy may be necessary to relieve the edema causing pressure on blood vessels, to restore adequate circulation.

NURSINGALERT – Disorientation in the burned patient is one of the first signs of overwhelming sepsis and may indicate inadequate hydration. Assessment of the sensorium is another important indicator of the adequacy of hydration. With inadequate hydration, a spiking fever and diminished bowel sounds accompanied by paralytic ileus are noted and progressively increase over 48 to 72 hours, after which the temperature falls to subnormal limits. At this time the wound deteriorates, the white blood cell count is depressed, and septic shock becomes manifest.


Topical medications may be applied directly to the wound with a tongue blade or gloved hand or impregnated into fine-mesh gauze before application. Dressings are then applied to assist in exudate absorption, wound débridement, and increased patient comfort. All dressings applied circumferentially should be wrapped in a distal-to-proximal manner. The dressing is applied with sufficient tension to remain in place but not so tightly as to impair circulation or limit motion. Elastic bandages are applied over dressings to prevent epithelial breakdown, decrease edema, stimulate circulation, and improve mobility. A stable dressing is especially important when the child is ambulatory.

Standard precautions, including the use of protective garb and barrier techniques, should be followed when caring for patients with thermal injuries. Frequent hand and forearm washing is the single most important element of the infection control program. Strict policies for cleaning the environment and patient care equipment should be implemented to minimize the risk of cross-contamination. All visitors and members of other departments should be oriented to the infection control policies, including the importance of hand and forearm washing and use of protective garb. Visitors should be screened for infection and contagious diseases before patient contact.

Nutrition.

Oral feedings are encouraged unless the child is intubated or paralytic ileus persists. Because children with burns often lack an appetite, the child needs encouragement, help, and patience. Consultation between the caregiver and the dietitian helps determine food preferences. Children who are old enough to participate should be included in meal planning. In addition, many children prefer an atmosphere more nearly like that provided at home. Therefore, when possible, many children enjoy sitting at a table and interacting with other children at mealtimes. Painful procedures should not be scheduled near mealtimes, since most children will be too physically exhausted and emotionally upset to eat.

Children who require enteral supplementation must be monitored for feeding intolerance and tube malposition. The nurse should also monitor and report any abdominal distention, diarrhea, or electrolyte and metabolic deviations.

Prevention of Complications

Acute Care.

The maintenance of body temperature is important to the child with burns. Core body temperature is supported when energy is conserved with an environmental temperature of 28° to 33° C (82.4° to 91.4° F). Large areas of the body should not be exposed simultaneously during dressing changes. Warmed solutions, linens, occlusive dressings, heat shields, a radiant warmer, and warming blankets assist in preventing hypothermia.

The chief danger during acute care is infection—wound infection, generalized sepsis, or bacterial pneumonia. Accurate and ongoing assessments of all parameters that provide clues to the early diagnosis and treatment of infection are essential. Symptoms of sepsis include a change in the level of consciousness, a rising or falling white blood cell count, hypothermia or hyperthermia, a loss of the progression of wound healing, increasing fluid requirements, hypoactive or absent bowel sounds, a rising or falling blood glucose level, tachycardia, tachypnea, and thrombocytopenia.

Children are reluctant to move if movement causes pain, and they are likely to assume a position of comfort. Unfortunately, the most comfortable position often encourages the formation of contractures and loss of function. Ongoing efforts to prevent contractures include maintaining proper body alignment, positioning and splinting involved extremities in extension, providing active and passive physical therapy, and encouraging spontaneous movement when feasible. Frequent position changes are important to promote adequate bronchopulmonary hygiene and capillary perfusion to common pressure areas. Low—air loss beds are beneficial for the morbidly obese or children with posterior grafts. Special attention should be given to areas at risk for increased pressure, such as the posterior scalp, heels, sacrum, and areas exposed to mechanical irritation from splints and dressings.

Long-Term Care.

The rehabilitative phase of care begins once wound coverage is achieved. Scar formation becomes a major problem as burn wounds heal (Fig. 30-23). Contractile properties of the scar tissue can result in disabling contractures, deformity, and disfigurement.

Uniform pressure applied to the scar decreases the blood supply. When pressure is removed, blood supply to the scar is immediately increased; therefore periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Continuous pressure to areas of scarring can be achieved by elastic bandages or commercially available pressure garments. Because these custom-made garments are often worn for months, revisions may be required as the child grows. It is much easier to prevent scarring and contracture of the wound than to resolve an existing problem. Splints and appliances may also be needed until wound maturation is achieved (Fig. 30-24).

Scar tissue has certain significant properties, particularly for growing children. Intense itching occurs in healing burn wounds and scar tissue until the scar is no longer active. Itching is usually treated with a combination of H1 and H2 antagonists such as cetirizine (Zyrtec) and cimetidine (Tagamet); an H1 antagonist alone; and frequent applications of a moisturizer, such as Vaseline, Cetaphil, Aquaphor, Eucerin, cocoa butter, or Nivea. Petrolatum-based ointments (Vaseline, Aquaphor) seem to spread more easily on friable skin than thick creams do. Massage therapy during the application of moisturizers is also beneficial to stretch scar tissue and aid in contracture

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prevention. Scar tissue has no sweat glands, and children with extensive scarring may experience difficulty during hot weather. Caregivers should be alerted to this possibility and be prepared to institute alternate methods of cooling when necessary.

Scar tissue does not grow and expand, as does normal tissue, which may create difficulties, especially in functional areas such as on the hands and over joints. Additional surgery is sometimes required to allow independent functioning in daily activities, to improve cosmetic appearance, or to restore anatomic integrity.

The nursing activities in the rehabilitative phase of treatment focus on the child's and family's adaptation to the burn injury and their ability to reintegrate into the community. The psychologic pain and sequelae of severe burn injury are as intense as the physical trauma. The impact of severe burns taxes the coping mechanisms at all ages. Very young children, who suffer acutely from separation anxiety, and adolescents, who are developing an identity, are probably the most affected psychologically. Toddlers cannot understand why the parents they love and who have protected them can leave them in such a frightening and unfamiliar place. Adolescents, in the process of achieving independence from the family, find themselves in a dependent role with a damaged body. Being different from others at a time when conformity with peers is so important is difficult to accept.

Anticipation of the return to school can be overwhelming and frightening. It is essential that health care professionals recognize the importance of preparing teachers and classmates for the child's return. Teachers need to be provided with information to assist the child and family and to promote the child's optimal adjustment. Hospital-sponsored school reentry programs use a variety of methods to provide education and information about the implications of the injury, the garments and appliances, and the need for support and acceptance. Telephone calls, videotapes, information packets, and visits by members of the health care team offer opportunities to help with reintegration into the school environment'a focal point of the child's life.

Psychosocial Support of the Child.

Children should begin early to do as much for themselves as possible and to be active participants in their care. Loss of control and perceived helplessness may result in acting-out behaviors. During illness, children regress to a previous developmental level that allows them to deal with stress. As children begin to participate in their care, they gain confidence and self-esteem. Fears and anxieties diminish with accomplishment and self-confidence. If the child demonstrates nonadherence in the rehabilitative phase, a behavior modification program can be initiated to promote or reward the child's accomplishment in care.

Children need to know that their injury and the treatments are not punishment for real or imagined transgressions and that the nurse understands their fear, anger, and discomfort. They also need body contact. This is often difficult to arrange for the child with massive burns. Stroking areas of unburned skin is comforting. Even older children enjoy sitting on the parent's lap and being cuddled and hugged. This can be a reward or a comfort in times of stress, but most of all it should be kept in mind that it is a natural part of childhood.

Psychosocial Support of the Family.

Recognizing and respecting each family's strengths, differences, and methods of coping allow the nurse to respond to their unique needs by implementing a family-centered approach to care. In the acute phase, all attention is focused on the child, and the parents feel powerless and ineffectual. Most parents feel overwhelming guilt, whether or not the guilt is justified. They feel responsible for the injury. These feelings may impede the child's rehabilitation. Parents may indulge the child and allow nonadherent behaviors that affect physical and emotional recovery. Parents need to be informed of the child's progress and helped to cope with their feelings while providing support to their child. The nurse can help them understand that it is not selfish to look after themselves and their own needs to meet their child's needs. It is important to recognize the parents' need to grieve the change in their child's normal appearance as part of the grieving process. Definitive professional help may be needed for parents whose response to the injury is severe or whose response to stress is manifested in destructive behavior.

The parents are members of the multidisciplinary team and participate in the development of the care plan. It is important to facilitate their input; to consider all aspects of the physical, emotional, social, and cultural factors affecting the child and family; and to establish a realistic home therapy program. The family's willingness to assume responsibility for care and their ability to implement the therapeutic regimen are assessed. Home, school, and other environmental factors are explored; financial concerns and available community resources are discussed; and a specific care plan for the child, with an anticipated follow-up program, is developed.

Prevention of Burn Injury.

The best intervention is to prevent burns from occurring. Hot liquids in the kitchen and bathroom most commonly injure infants and toddlers. Hot liquids should be kept out of reach; tablecloths and dangling appliance cords are often pulled by toddlers, who spill hot grease and liquids on themselves. Electrical cords and outlets represent a potential risk to small children, who may chew on accessible cords and insert objects into outlets.

The Consumer Product Safety Commission recommends a reduction of water heater thermostats to a maximum of 48.9° C (120° F). The “dial-down” recommendation has been suggested by utility companies, burn treatment centers, medical personnel, and others interested in public safety. However, many water heaters continue to remain set at levels well above the safe level. Small children are especially at risk for scald injuries from hot tap

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water because of their decreased reaction time and agility, their curiosity, and the thermal sensitivity of their skin. Caregivers should never leave a child unattended in a bath and without adult supervision. Water should always be tested before a child is placed in the tub or shower.

The increased use of microwave ovens has resulted in burn injuries from the extremely hot internal temperatures generated in heated items. Baby formula, jelly-filled pastries, and hot liquids and dishes may result in cutaneous scalds or the ingestion of overheated liquids. Parents should use caution when removing items from the microwave oven and should always test the food before giving it to children.

As children mature, risk-taking behaviors increase. Matches and lighters are dangerous in the hands of the young. Adults must remember to keep potentially hazardous items out of the reach of children; a lighter, like a match, is a tool for adult use.

Education related to fire safety and survival should begin with the very young. They can practice “stop, drop, and roll” to extinguish a fire. The fire escape route, including a safe meeting place away from the home in case of fire, also should be practiced.

Community activities are also helpful in supporting burn survivors and preventing burns. The Aluminum Cans for Burned Children (ACBC) is an exemplary effort based at the Paul and Carol David Foundation Burn Institute, Akron, Ohio. Activities funded by ACBC include Burn Survivors Support Group, Burn Camp, and meetings of Juvenile Firestoppers (for children with fire-setting behavior). Adult weekend retreats and school and family education sessions are a part of this program. The burn center and fire department provide the personnel to present programs.

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FIG. 30-17: Superficial partial-thickness burns on an African-American child. A, Blisters intact. B, Blisters removed.

FIG. 30-18: Bottom to top: Deep partial-thickness burn (red area); full-thickness burn (white area); full-thickness burn with eschar (brown area).

FIG. 30-19: Full-thickness burn with muscle and fascia involved.

FIG. 30-20: Removal of split-thickness skin graft with a dermatome.

FIG. 30-21: Sheet graft

FIG. 30-22: Mesh graft

FIG. 30-23: Extensive scars from flame burn.

FIG. 30-24: Child in elasticized (Jobst) garment and “airplane” splints.

Documents

Mod 15 Burns - Wong Ch 30 p1091-1103