6/20/2018

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Emergent Burn Care

Debbie Harrell R N , M S N ,

Shriners Hospitals for Children® –Cincinnati

Cincinnati, Ohio

Speaker Disclosure

I, Debbie Harrell, MSN, RN, NE‐BC, have no financial relationships to disclose.

OBJECTIVES

1. Identify the immediate priorities of the initial stabilization following of thermal injury.

2. Discuss types of burn injuries and different degrees of burn injuries.

3. State three complexities of the burn injury and the American Burn Association criteria for referral.

At a Glance

90-year-old organization,founded in 1922 due to the polio epidemic in children

Network of 22 healthcare facilities that provide compassionate,high-quality, family-centered pediatric medical and surgical care

Spokane

Portland

Salt Lake City

Northern California

Los Angeles

Twin Cities

Chicago

CincinnatiSt. Louis

Houston

Galveston

Greenville

Lexington

Erie

Philadelphia 

Boston

Springfield

Tampa

Montreal

Mexico City

Honolulu

Shreveport

Thermal Injuries

75% of burns are 10% or less

60% of burns are children 5 and under

90% of burns can be managed on an outpatient basis

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Flame InjuriesThe use of smoke detectors has significantly reduced the severity of burn injuries.

• 80% reduction in mortality

• 74% decline in injuries from residential fires

Initial triage 

Stop the Burning Process for 3 to 5 minutes (never use ice)

Remove all clothing completely

Cover with a warm dry dressing

Prevent Hypothermia  

Increase temperature of ambient air

Keep covered as much as possible

Warm IV fluids

Bair hugger

Continuous temperature monitoring

A burn injury, even 100% may not render a victim unconscious

If the patient is unconscious or incoherent,look for a cause other than the burn.

• Head injury

• Anoxia

• Stroke

• Delay in treatment

??????

Airway Management

Assessment of Inhalation Injury

Predisposing Factors– Closed space– Decreased mentation

Diagnostic Tests– ABG, CO-Hb

– Fiberoptic Bronchoscopy

– Chest X-ray

Physical Examination– Facial burns, singed hairs– Mucosal edema of nose and mouth– Carbonaceous sputum– Hoarseness, stridor (laryngeal)– Dyspnea, wheezing (small airway)

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Inhalation Injuries

Dry gas

Orofacial surface burns

Steam

Hypoxia

Cardiopulmonary arrest <24 hrs

Atelectasis

Pulmonary edema (24-72 hrs)

Bronchopneumonia

ARDS - pulmonary parenchymal failure (1 week - 1 month)

Upper Airway

Lower Airway

Edema <24

Heat

CarbonMonoxide

Toxic Gases

SMOKE

Carbon monoxide 

Treatment for CO Poisoning is removal from source, followed

by 100% O2.

Affects of Edema on Airway

Infant

Adult

Normal Edema 1mm Resistanceincrease

DiameterDecrease

16x

3x

75%

44%

Edema & Burn Shock

Burn damage causes increased capillary permeability.

This increase in capillary permeability and the accompanying inflammatory process causes leakage into the interstitial space = edema

Small burns have localized edema – like a blister - but burns >20% will result in systemic edema including areas not burned

Post burn day 1 Post burn day 7

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Size of Burn Injury

Total Body surface Area

TBSA

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Rule of “Nines”Modified for Age

5 years 1 year

99 993636

1414

1616 1616

3636

1818

9999

1414 1414

99 99

1818 1818

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3636

99

Adult

Estimation of Small Burns

Palmar MethodPatient’s palm

including fingers

is equal to 1% of their

Total Body Surface Area

(TBSA)

Indications for Fluid Resuscitation

TBSA > 20% adults

TBSA > 20% Children

Age >65 y/o or < 2 y/o any size burn

Fluid Replacement

Large Bore IV

Crystalloid Solution– Lactated ringers

Begin as soon as possible

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Pain Control – Partial Thickness

In the ER, small incremental doses of morphinecan be given IV & titrated to effect.

Oxycodone/APAP, Tylenol, or similar analgesics, are usually effective for discharge.

Medicate 30 minutes before dressing change.

Remember that the pain is more intense when the burn is open to the air.

Managing anxiety in pediatrics is key.

Early Fluid Management 

Pre hospital/primary survey in the hospital

< 5 y/o 125ml/hr of LR

6-14 y/o 250ml/hr of LR

> 15 y/o 500ml/hr of LR

Resuscitation Calculations

Calculated Resuscitation requirement– 3ml x kg x % burn = estimated total fluids for 24

hours

Resuscitation Fluid per 8 hours– Half of total in first 8 hours

– Remaining amount in next 16 hours

Parkland Formula 

3ml x 20kg x 90% = 7200ml/24 hours

1st 8 hours 3600 = 450ml/hr

2nd 8 hours 1800 = 250ml/hr

3rd 8 hours 1800ml = 250ml/hr

Adequate Fluid Resuscitation

Based on urine output

–Pediatric .5ml to 1ml/kg/hr

–Adults (>15yr) 30ml to 50ml/hr

Urine Output

Urine output inadequate– Increase total body fluids by 10%

– Do not bolus

Urine output to high– Decrease total body fluids by 10%

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Escharotomy

Incision made into the eschar to relieve pressure on compartment

Chest escharotomies allow for easier ventilation of pt. Can be life saving

Lateral incision mid-axillary line

Across chest and abdomen if involved

Escharotomy

Vascular impairment fromcircumferential burns

Laterally & Medially

Across involved Joints

Types of Burns

Contact

Scalds

Flame

Chemical

Electrical

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Post burn day 3                                                              Post burn 20

Tar Burns Tar creates a thermal injury, not a chemical

one

Bitumen compound not absorbed, not toxic

» Cool tar to stop the burning process

» Facilitate removal with use of a petroleum based ointment or medically safe solvent to emulsify the tar

Scald Injuries

Time of contact and water temperature to cause a burn

- 120 degrees – 5 minutes- 130 degrees - 30 seconds- 140 degrees - 5 seconds- 160 degrees - instantaneous

Young children and older adult may burn deeper faster because their skin is often very thin

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Scald Burns

Accidental Splash marks present

Irregular pattern of

burn

Consistent history

Non-Accidental No splash marks

Clear demarcation

Inconsistent story

Post burn day 1                             Post burn day 10                             Post burn day 20

Non accidental 

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Flash and Flame Injuries

Flash burns– Intense heat for a short period– Clothing protective unless ignited – Generally not full thickness

Flame burns– Deep dermal or full thickness– Proportional to time of contact

Post burn day 1                            Post burn day 7     

Chemical 

Stop Burning Process

Brush Away vs. Flush Away

Flushing 20 minutes continuous

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Electrical Injuries 

Low-voltage <1,000 V– Localized to area

surrounding the area

High-Voltage >1,000 V– Deep extension and

underlying tissue damage

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High Voltage 

Monitor for Cardiac Dysrhythmias

Monitor Peripheral Pulses

Fluid Resuscitation– 3 ml X kg X %TBSA

Urine Output if myoglobin present– Adult 75-100 ml/hr

– Children 1 ml/kg/hr

Myoglobinuria

Presence of myoglobin and hemoglobin in the urine. Pigmented urine darker than light pink Indicative of significant muscle and tissue

damage Presents the risk of renal failure, it must

be cleared.– Maintain UOP at 100ml for adults 1mg/kg for kids– May add one amp sodium bicarb to each unit of

resuscitation fluid

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Other Conditions

Frostbite

Dog bite

Friction burns

Road rash

Frostbite

Area of necrosis noted to wound flap on the right side needing demarcation.

Returned to OR on June 7th for application of split thickness skin graft.

Avulsion

Friction burn Road rash

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Superficial 

1st degree

Involves epidermis

Reddened, painful,

No blisters

Heals within 3-10 Days

No scarring

Care– Lotion for comfort

Partial Thickness

2nd degree

Involves epidermis/part of dermis

Painful, red, blisters

Most often heals within 14 days

Treatment 

Administer pain medication

Remove any wet or cold dressing. Cover with a dry dressing

Wash with soap and water.

Wound care

– Transfer directly to a burn unit. Cover the burn with a clean dry dressing.

– Going home, place antibiotic ointment/vaseline/aquaphor on a dressing cover the burn.

Dressing Preparation 

1

3

2

Dressing Application

4

5 6 Post burn day 2 tx with silver sulfadiazine 

Post burn day 5 tx with Bacitracin 

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PBD 1

PBD 7

PBD14

Post burn day 2 Post burn day 14

Full Thickness

3rd degree

Epidermis/Dermis

No pain/blanching

Whitish/leathery/red

Will not heal

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Post burn day 5                         Post autograft 1                            Post autograft 3 months Sheet AutograftA strip of donor site is taken and transferred without alteration to the excised burn area. Advantages:

– more durable than mesh grafts– more cosmetic– contracts less than mesh grafts

Disadvantages:– bacteria may collect

under the graft causing graft loss.

Scar Management 

Hypertrophic Scar Keloid

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Guidelines for compression therapy

Healing time

<10 days no compression

10‐14 days monitor

>21 days compression 

Post burn 1 month

Post burn 6 months

Post Burn 14 months 

Plastic Surgery

Cleft Lip and Palate

Brachial Plexus Injury

Hand Malformations

Hairy Nevus

Port Wine Stains

Breast Deformities

Ear Deformities

Vascular Malformations

Hidradenitis

Ear Reconstruction

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Congenital Hairy Nevus

Type of mole present at birth

Often pale at birth; darken and grow with the child

Can have regular or uneven borders

Most are benign, but they do have potential to become malignant

Gynecomastia

Breast Asymmetry 

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Within the App…