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.

THANK YOU………