BURN INJURIES

Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.

Burn size

1. Small burns: body’s response is localized to the injured area

2. Large or extensive burns: a. consist of 25% or more of the total body surface area

(TBSA)

b. body’s response to injury is systemic

c. affect all of the major systems of the body

Characteristics1. Minor Burns

a. Partial thickness burns are no greater than 15% of the TBSA in the adult

b. Full thickness burns are < 2% of the TBSA in the adult

c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum

d. There are no electrical burns or inhalation injuries

e. The client is an adult younger than 60 y.o.

f. The client has no preexisting medical condition at the time of the burn injury

g. No other injury occurred with the burn

Characteristics2. Moderate Burns

a. Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult

b. Full thickness burns are 2% to 10% of the TBSA in the adult

c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum

d. There are no electrical burns or inhalation injuries

e. The client is an adult younger than 60 y.o.

f. The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury

g. No other complicated injury occurred with the burn

Characteristics3. Major Burns

a. Partial thickness burns are > 25% of the TBSA in the adult

b. Full thickness burns are > 10% of the TBSA

c. Burn areas involve the eyes, ears, hands, face, feet, or perineum

d. The burn injury was an electrical or inhalation injury

e. The client is older than 60 y.o.

f. The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury

g. Burns are accompanied by other injuries

Estimating the extent of injury

Rule of nine Lund and Browder Method

- Modifies percentages for body segments acc. to age

- Provides a more accurate estimate of the burn size

- Uses a diagram of the body divided into sections,

with the representative % of the TBSA for ages

throughout the lifespan

- Should be reevaluated after initial wound

debridement

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Assessment of Burn Injury

Takes several weeks to heal.

Scarring may occur.

Takes several weeks to heal.

Scarring may occur.

Superficial:

Pink or red; blisters form (vesicles); weeping, edematous, elastic.

Superficial layers of skin are destroyed; wound moist and painful.

Deep dermal:

Mottled white and red: edematous reddened areas blanch on pressure.

May be yellowish but soft and elastic – may or may not be sensitive to touch; sensitive to cold air.

Hair does not pull out easily

Second degree

In about 5 days, epidermis peels, heals spontaneously.

Itching and pink skin persist for about a week.

No scarring.

Heals spont. If it does not become infected w/in 10 days - 2 weeks.

Pink to red: slight edema, which subsides quickly.

Pain may last up to 48 hours.

Relieved by cooling.

Sunburn is a typical example.

First Degree

Reparative ProcessAssessment of ExtentExtent / Degree

Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft.

For areas larger than 3-5 cm, grafting is required.

Expect scarring and loss of skin function.

Area requires debridement, formation of granulation tissue, and grafting.

Destruction of epithelial cells – epidermis and dermis destroyed

Reddened areas do not blanch with pressure.

Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar.

Destruction of epithelium, fat, muscles, and bone.

Third degree

Reparative ProcessAssessment of ExtentExtent / Degree

Assessment of Burn Injury

AGE AND GENERAL HEALTH• Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o.,

and for clients over the age of 60 years.• Debilitating disorders, such as cardiac, respiratory, endocrine, and renal

d/o, negatively influence the client’s response to injury and treatment.1. Mortality rate is higher when the client has a preexisting disorder at the

time of the burn injury

TYPES OF BURNS• Thermal Burns: caused by exposure to flames, hot liquids, steam or

hot objectsA. Chemical Burns:

a. Caused by tissue contact with strong alkali, or organic compounds

b. Systemic toxicity from cutaneous absorption can occurB. Electrical Burns:

a. Caused by heat generated by electrical energy as it passes through the body

b. Results in internal tissue damagec. Cutaneous burns cause muscle and soft tissue damage that may

be extensive, particularly in high voltage electrical injuriesd. Alternating current is more dangerous than direct current because

it is associated with CP arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures

• Radiation Burns: caused by exposure to UV light, x-rays, or radioactive source

INHALATION INJURIESA. Smoke inhalation injury

: results from inhalation of superheated air, steam, toxic fumes, or smoke

: Assessment

- facial burns - erythema

- swelling of oro / nasopharynx - singed nasal hair

- stridor, wheezing and dyspnea - flaring nostrils

- sooty sputum and cough - hoarse voice

- agitation and anxiety - tachycardia

B. Carbon Monoxide Poisoning

: CO is colorless, odorless and tasteless gas that has an affinity for Hgb 200 times greater than that of oxygen

: O2 molecules are displaced and carbon monoxide reversibly binds to Hgb to form carboxyhemoglobin

: can lead to coma and death

C. Smoke Poisoning: Caused by inhalation of by-products of combustion: A localized inflammatory reaction occurs, causing a decrease in

bronchial ciliary action and a decrease in surfactant: Assessment- mucosal edema in the airways- wheezing on auscultation- after several hours, sloughing of the tracheobronchial epithelium

may occur, and hemorrhagic bronchitis may develop- ARDS can result

D. Direct Thermal Heat Injury: Can occur to the lower airways by the inhalation of steam or

explosive gases or the aspiration of scalding liquids: Can occur to the upper airways, w/c appear erythematous and

edematous, with mucosal blisters and ulcerations: Mucosal edema can lead to upper airway obstruction, esp. during

the first 24 to 48 hours: Monitored for airway obstruction, ET intubation if obstruction occurs

PATHOPHYSIOLOGY OF BURNS

BURN

↑ Vascular permeability

↓ Cardiac output

↑ Peripheral resistance

↑ Viscosity

↑ Hematocrit

↓ IV volume

Edema

HEMODYNAMIC / SYSTEMIC CHANGESA. Initially hyponatremia and hyperkalemia occur. Followed by

hypokalemia as fluid shifts occur and K+ is not replaced.• The hematocrit level increases as a result of plasma loss; this initial

increase falls to below normal at the 3rd to 4th day postburn as a result of the RBC damage and loss at the time of injury.

A. Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid, and diuresis of the excess fluid occurs over the next days to weeks.

B. Blood flow to the GIT is diminished, leading to intestinal ileus and GI dysfunction.

C. Immune system function is depressed, resulting in immunosuppression and thus increasing the risk of infection and sepsis.

D. Pulmonary hypertension can develop, resulting in a decrease in the arterial O2 tension and a decrease in lung compliance.

E. Evaporative fluid losses through the burn wound are greater than normal, and the losses continue until complete wound closure occurs

F. If the intravascular space is not replenished with IV fluids, hypovolemic shock and ultimately death will occur.

BURN INTERVENTIONSBURN INTERVENTIONS

MAINTAIN AIRWAYMAINTAIN AIRWAY FLUID RESUSCITATIONFLUID RESUSCITATION RELIEVE PAINRELIEVE PAIN PREVENT INFECTIONPREVENT INFECTION PROVIDE NUTRITIONPROVIDE NUTRITION PREVENT STRESS ULCERATIONPREVENT STRESS ULCERATION PROVIDE PSYCHOLOGIC SUPPORTPROVIDE PSYCHOLOGIC SUPPORT PREVENT CONTRACTURESPREVENT CONTRACTURES

MANAGEMENT OF THE BURN INJURY

Phases of Management of the Burn Injury

Resuscitative phase

- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased

- the amount of fluid administered is based on the client’s weight and extent of injury

- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion

Emergent phase

- begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury

- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ functioning

- includes prehospital care and emergency room care

Rehabilitative phase

- final phase of burn care

- overlaps the acute care phase and goes well beyond hospitalization

- goals of this phase are designed so that the client can gain independence and achieve maximal function

Acute phase

- begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun

- usually begins 48 - 72 hours after the time of injury

- emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved

- the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy

FLUID SHIFTING IN BURNSFLUID SHIFTING IN BURNS

OLIGURIC PHASE – Intravascular to Interstitial

Hct increased, renal output decreased, hyper K, hypo Na, hypo CHON, metabolic acidosis

DIURETIC PHASE – Interstitial to Intravascular

Hct decreased, renal output increased, hypo K, hypo Na, hypo CHON, metabolic acidosis

FLUID RESUSCITATION Indications:

- Adults with burns involving more than 15% - 20% TBSA

- Children with burns involving more than 10-15% TBSA- Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury

The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr

Successful fluid resuscitation is evidenced by:- Stable vital signs - Palpable peripheral pulse- Adequate urine output - Clear sensorium Urinary output is the most common and most sensitive assessment

parameter for cardiac output and tissue perfusion If the Hgb and Hct levels decrease or if the urinary output exceeds

50ml/hr, the rate of IV fluid administration may be decreased Generally, a crystalloid (Ringer’s lactate) solution is used initially.

Colloid is used during the 2nd day (5% albumin, plasmate or hetastarch)

½ in 1st 8 hours

½ in next 16 hours

crystalloid only

(lactated Ringer’s)

PARKLAND (Baxter)

4ml/kg/% BSA for 24hr period

½ in 1st 8 hours

½ in next 16 hours

¾ crystalloid, ¼ colloid D5W maintenance

BROOKE

2ml/kg/% BSA + 2000ml/24hr (maintenance)

Infusion RateSolutionFormula

Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st 24hrs after a Burn Injury

PARKLAND FORMULAExample: Patient’s weight: 70 kg; % TBSA burn: 80%

1st 24 hours:

4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer’s 1st 8 hours = 11,200 ml or 1,400 ml/hour 2nd 16 hours = 11,200 ml or 700 ml/hour

2nd 24 hours:

0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period

0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W

= 117 ml colloid/hour + 84 ml D5W/hour

PAIN MANAGEMENT Administer morphine sulfate or meperidine (Demerol), as

prescribed, by the IV route Avoid IM or SC routes because absorption through the soft tissue is

unreliable when hypovolemia and large fluid shifts are occurring Avoid administering medication by the oral route, because of the

possibility of GI dysfunction Medicate the client prior to painful procedures

NUTRITION Essential to promote wound healing and prevent infection Maintain nothing by mouth (NPO) status until the bowel sounds are

heard; then advance to clear liquids as prescribed Nutrition may be provided via enteral tube feeding, peripheral

parenteral nutrition, or total parenteral nutrition Provide a diet high in protein, carbohydrates, fats and vitamins

ESCHAROTOMY A lengthwise incision is made through the burn eschar to relieve

constriction and pressure and to improve circulation Performed for circulatory compromise resulting from circumferential

burns After escharotomy, assess pulses, color, movement, and sensation

of affected extremity and control any bleeding with pressure Pack incision gently with fine mesh gauze for 24 hours after

escharotomy, as prescribed Apply topical antimicrobial agents as prescribed

FASCIOTOMY An incision is made, extending through the SQ tissue and fascia Performed if adequate tissue perfusion does not return after an

escharotomy Performed in OR under GA, after procedure assess same as above

WOUND CARE1. The cleansing, debridement and dressing of the burn wounds

2. Hydrotherapya. Wounds are cleansed by immersion, showering or spraying

b. Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress

c. Client should be premedicated prior to the procedure

d. Not used for hemodynamically unstable or those with new skin grafts

3. Debridement a. Removal of eschar to prevent bacterial proliferation under the eschar

and to promote wound healing

b. May be mechanical, enzymatic or surgical

c. Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily

Mobility limitations Prevents effective ROM exercises Wound assessment is limited

Decreases evaporative fluid and heat loss Aids in debridement

CLOSED Gauze dressings are carefully wrapped from the distal to the proximal area of the extremity to ensure circulation is not compromised No 2 burn surfaces should be allowed to touch; can promote webbing of digits, contractures, and poor cosmetic outcome Dressings are changed every 8 – 12 hours

Increase chance of hypothermia from exposure

Visualization of the wound Easier mobility and joint ROM Simplicity in wound care

OPEN Antimicrobial cream applied, and wound is left open to the air w/o a dressing Antimicrobial cream is applied every 12 hrs

DisadvantagesAdvantagesMethod

Open Method Versus Closed Method of Wound Care

TOPICAL ANTIMICROBIAL AGENTS FOR BURNSSilver sulfadiazine Most widely used agent and least common incidence of side effects May cause transient leukopenia that disappears 2-3 days of treatment Use with either open treatment, light or occlusive dressings Applied once or twice daily after thorough wound cleansing

Mafenide acetate 10% cream or 5% solution (Sulfamylon) Painful during and for a while after application May cause metabolic acidosis, not used if >20% TBSA Cream must be reapplied 12 hours to maintain therapeutic effectiveness Solution concentration is maintained with bulky wet dressings, rewet every

2-4 hours

Silver nitrate (0.5% solution) Stains everything including normal skin brown or black Monitor electrolyte balance carefully

Other topical dressings Cerium nitrate Povidone iodine Gentamycin Polymixin B – Bacitracin ointment

WOUND CLOSURE Prevents infection and loss of fluid Promotes healing Prevents contractures Performed on the 5th to 21st day, depending on the extent of the burn

AUTOGRAFTING Permanent wound coverage Surgical removal of a thin layer of the client’s own unburned skin, which is

then applied to the excised burn wound Monitor for bleeding following the graft because bleeding beneath an

autograft can prevent adherence Immobilized after the surgery for 3-7 days to allow time to adhere and attach

to the wound bed Care of the graft site Care of the donor site

TEMPORARY WOUND COVERINGSBiologicalAmnion Amniotic membranes from human placenta Dressing is changed every 48 hours

Allograft (Homograft) Donated human cadaver skin is harvested w/in 24 hrs after death Monitor for wound exudate and signs of infection Rejection can occur w/in 24 hours

Xenograft (Heterograft) Porcine skin is harvested after slaughter and preserved Rejection can occur w/in 24 – 72 hours Replaced every 2-5 days until the wound heals naturally or until closure with

autograft is complete

Biosynthetic and synthetic Visual inspection of wound is possible, as dressings are transparent or

translucent Monitor for wound exudate and signs of infection