Dr. Dhiraj R. SheteA.P.
Burn Injury Statistics
Over 2 million burn injuries and 7,000-9,000 deaths as a result of fire and burns each yr. in the U.S.
The home is frequently where burn injuries occur.
The very young and the elderly are at greatest risk for burn injuries.
Infants and toddlers are especially prone to scald injuries.http://www.ameriburn.org/
Burn Injury Statistics
School age children may incur injury as a result of playing with matches.
Teenage boys have a high incidence of electrical injuries.
Males are more common than females to be injured by burns.
6% of burn center admissions do not survive.
Anatomy- Normal Skin Functions Maintain fluid and electrolyte
balance Protective barrier Regulation of temperature Sensory functions Immunologic functions
Anatomy of the burn wound
Superficial Thickness Epidermis only
portion affected Erythema, mild
edema, pain Peeling dead skin 2-
3 days after burn
Partial thickness
–Partial Thickness: epidermis + partial dermis–- sparing of significant portion of hair follicles, sebaceous and sweat glands + significant portion of dermis.–Blister formation
Deep partial thickness
Second degree- Deep- destruction of large portions of hair follicles, sebaceous and substantial portion of dermis. No blisters
Full thickness burns
Full Thickness:Third degree burns- entire epidermal layers. Skin grafts required.
Escharotomies – to relieve pressure
Healing takes weeks to many months.
Deep full thickness
Fourth degree burns- underlying fascia
Damage to muscle and bones, tendons- exposed.
Sensation absent. Wound blackened
and depressed.
Severity of burn related to: Depth Extent Age Parts of body burned Past Medical History Concomitant injuries and illness Presence of inhalation injury
Initial management
Goal: Limit extent of injury Stop the burning process Assess type of burn Assure adequacy of ventilation and
oxygenation. Initiate restoration of hemodynamic
stability. Look for other traumatic injuries Burn wound last priority.
Primary Survey
Methodology of ABCDEF: A- Airway/C- spine immobilization B- Breathing C- Circulation, cardiac status. D- disability, neurologic deficit E- Expose and examine F- Fluid resuscitation
Secondary Survey
AMPLE: A- allergies? M- Medications/alcohol/drugs used? P- Previous illness; PMH, last tetanus? L- Last meal or drink E- Events preceding injury (cause of
burn?, injury occur in a closed space?, chemicals involved? Related trauma?
Respiratory tract injury
Carbonaceous sputum Facial burns, singed nasal hairs Agitation, tachypnea, anxiety, stupor,
cyanosis, other signs hypoxemia. Rapid resp. rate, flaring nostrils,
intercostal retractions. Hoarse voice, brassy cough, grunting or
guttural respiratory sounds. Rales, rhonchi or distant breath sounds
Airway management
Administer O2- Give 100% oxygen to all patients with burns of 20% or more TBSA.
Give 100% O2 by mask to any patient suspected of CO +/or inhalation injury.
Endotracheal Intubation- Transnasal intubation if possible, transorally if necessary.
Obtain blood gases and carboxyhemoglobin levels ASAP.
Burns
Smoke inhalation Carbon monoxide poisoning Assess blood gas, chest x-ray. Listen for hoarseness and crackles Prepare for bronchoscopy and/or
possible intubation or tracheostomy for facial burns
Airway Management
Carbon Monoxide Poisoniong- 100% O2 until carboxyhemoglobin <15%
Transfer to a Burn Unit. Inhalation injury above or below
glottis- intubate immediately, suctioning, relieve dyspnea.
Circumferential burns of chest may require escharotomies.
Eschar
Necrotic tissue resulting from a burn wound.
Separates slowly from underlying viable tissue.
Good medium for microorganisms. Failure to treat can lead to infection Escharotomies are commonly
performed.
ABA Referral Criteria
Refer patients to a Burn Center: Partial thickness burns greater than
10% total body surface area (TBSA). Burns that involve face, hands, feet,
genitalia, perineum, or major joints. Third degree burns in any age group. Patients with pre-existing medical
disorders or trauma. Patients requiring special social,
emotional, rehab intervention
Initial treatment in ER
Establish airway Initiate IV therapy, weigh pt. Insert foley – hourly assessment of u/o Insert NG tube to remove contents. Insert CVP – hemodynamics Baseline mental status Initiate treatment of burn wounds Initiate tetanus prophylaxis. Perform a head to toe assessment
Specific Management
Flame BurnsSmother the flamesRemove smoldering clothing and all metal
objects Chemical BurnsBrush off all chemicals present on the skin
or clothing.Remove the clients clothingAscertain the type of chemical causing the
burn (acid or alkalai)
Electrical BurnAt the scene, separate the client from the
electrical currentSmother any flames that are presentInitiate cardiopulmonary resuscitationObtain an electrocardiogram Radiation BurnsRemove the client form the radiation sourceIf the client has been exposed to radiation
from an unsealed source, remove clothing (using lead protective gloves)
Burns
Determine extent of body surface burned. Rule of nines body divided into groups
equal to about 9% of BSA. Palm method- rough estimate adult palm
is equal to 0.5% to 1% of BSA. Lund- Browder classification- each section
of body has own % according to age of pt. Computerized mechanism in some burn
units.
Fluid Resuscitation
Systemic Response: Marked increase in peripheral vascular
resistance Reduced cardiac output- edema forms in
burn injury area; blood volume decreases.
Cellular response: Full thickness burn; protein coagulation causes cell death with thrombosis of small vessels and nerve necrosis.
Goal is to maintain vital organ function and avoid complications of inadequate or excessive therapy
Parkland (Baxter) Fluid Resuscitation Calculation of fluids for 1st 24 hrs: Adults: Ringer’s Lactate 4ml/kg body weight
x % TBSA burn. Children: Ringer’s Lactate 4 ml/kg body
weight x % burned. Infusion rate is regulated so 50% of
estimated volume is administered in the first 8 hours post burn.
Remaining 50% administered over next 16 hrs.
Fluid Resuscitation Response Monitoring of Response- Hourly urine
output. Adults: 0.5 – 1.0 mL/kg/hr Children: 1.0 mL/kg/hr. Fluid and electrolytes Weigh patient daily Monitor vital signs, assess lung
sounds.
Burns
NURSING DIAGNOSIS Impaired gas exchange decreased
cardiac outputInadequate tissue perfusion Fluid volume deficit or fluid volume
overload
Impaired skin integrity.Risk for infection
Burns
1. Emergent period 24-48 hours, vascular changes, shock, respiratory failure
2. Acute phase- until all wounds heal (up to several months). Risk- infection.
3. Rehabilitation phase- regain or compensate for loss- many years.
Initial management of burn wound Cool the wound within 30 minutes to
limit tissue damage and reduce edema but avoid excessive cooling.
Maintain blisters intact Cover wound with clean, dry,
occlusive dressing (sterile if possible).
Apply topical antimicrobial ointment if transfer to burn unit is to be delayed.
Burns
Cleanse wounds daily Debride eschar, dress wounds, Fine mesh gauze on
granulating, healing wounds.Promote healing to donor sites-
open to air 24 hrs. post-op.
Burns
Desire normal body temp- do not expose wounds unnecessarily.
Warm ambient temp. Warm dressing and solution to
body temp.Administer antipyretics as
needed.
Burns
Avoid infection Monitor for sepsisHand hygieneSterile dressing changesUse barrier garmentsAdminister antibiotics
Treatment methods for burns Method –open exposure Burned area cleansed and exposed
to air, no clothing or bedclothes over area.
Cradle over bed. Isolation technique Sterile linen Room temp. 85 degrees, humidity-
40-50%
Treatment methods for burns Method- closed Burned area cleansed Dressings applied and changed one
to five times a day. Standard dressing- topical antibiotics
on wound, then sterile multiple gauze layers.
Treatment method for burns
Method – hydrotherapy
Place pt. in hydrotherapy tub for 20-30 min, 2X per day.
Attendants wear gowns, gloves until wounds are healed.
Tub room kept 80-90 to prevent chilling.
Wound debridement
1. Mechanical- hydrotherapy, tub, shower, forceps to remove loose, nonviable tissues
2. Enzymatic- naturally- by autolysis, spontaneous disintegration of tissues (own cellular enzymes.
Travase (sutilains)- proteolytic agent applied
3. Surgical (within first 5 days after injury)excise burn wound, then cover with skin graft or temporary covering- reduces # hydrotherapy treatments, risk- massive blood loss.
Topical medications
Silvadene-broad antimicrobial activity, no electrolyte imbalances, can cause leukopenia.
Sulfamylon- broad, used partial and full thickness, side effects- met acidosis, causes severe pain when applied.
Silver nitrate solution- broad, applied with wet, bulky dsg., restricts mobility, causes elec. imbalances, stings when applied.
Agents used in burns
Dakin’s- dress wounds that are “soupy”, aids in debridement, may inhibit clotting, causes elec. imbalances.
Betadine- may control candida, may cause elec imbalances.
Furacin- antimicrobial- effective staph aureus, may cause contact dermatitis, renal problems if burns are extensive.
Skin grafts
Biologic- viable tissue on once living tissue To promote re-epithelialization of deep
second degree burns. To cover a wound temporarily after
wound excision. To protect granulation tissue between
autografts. Heterograft- xenograft, skin from
another species (pig), Rejection after 24-72 hours.
Skin grafts
Homograft (allograft)- From another human (cadaver usually) Rejection after 24 hours. Amniotic membrane- disintegrates 48
hrs. Artificial skin- gradually dissolves. Autograft- first debride, then transplant Transcyte grown in lab from foreskins.
Pressure dressings
After graft heals Prevents formation
of contractures and tight hypertrophic scars
Uniform pressure over burned surfaces.
Worn 23 hrs. a day.
Burns- body positions
Encourage prone and supine positions for a definite interval each day.
Frequent position changes Burns on neck and chin- encourage
position of neck hyperextension for part of the day.
Burns on hand- consult M.D. for specifics.
Burns- preventing mobility limitations Contractions – serious complication. Help to maintain range of joint motion Exercises to prevent and correct
contractures are begun ASAP- stable PT/OT, Hubbard tank Chewing gum and blowing up balloon –
prevent facial contractures.
Burns- Pain Management
Provide analgesic medication 30 minutes prior to painful treatments.
Provide clear explanations to gain patient’s cooperation.
Handle burned parts gently. Use careful sterile technique
(infection causes more pain).
Burns: Pain Management
PCA, imagery , breathing techniques, enhance coping strategies.
Pt. and family education and support Patient may need years of PT and
OT. Psych support for trauma suffered
and body image changes endured.
Burns – emotional responses Patient response- aggression Nursing approach: Acknowledge ability to cope. Provide structure; allow pt. choices
when possible. Pt. needs some control.
Burn team must be sensitive to emotional and psychological needs of patient and family.
Emotional responses
Depression- Nursing approach- support patient,
listen. Encourage verbalization of frustrations. Paranoia- Nursing approach- acknowledge c/o
fear. Investigate all complaints. Support pt. Provide reality orientation.
Teaching and Discharge Instructions Care of the healed burn wound Nutritional needs Prevention of injury Recognition of S&S of complications. Methods of re-socialization. Evaluation- Any signs of infection?,
Diet being followed?, Pt. involved? Pt. understand D/C instructions?
NCLEX TIME
Blisters are a classic sign of which classification of burn? 1. Superficial 2. Superficial partial thickness 3. Deep partial thickness 4. Full thickness
Which is your first priority when caring for a burn victim at the scene? 1. Assess for additional injuries. 2. Apply cool compresses to the
affected areas. 3. Stop the fire on the victim’s
clothing. 4. Use ice packs for swelling.
Patients with which conditions should be transferred to a burn center? 1. Burns that involve the face, hands,
feet, genitalia, perineum or major joints.
2. Second degree burns covering less than 10% total BSA.
3. Life threatening traumatic injuries. 4. Electrical burns, excluding
lightning.
During the primary survey of a burn victim, you first assess: 1. Airway. 2. Circulation. 3. Burn size. 4. Fractures of limbs.
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