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American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Burn Care
Carrie Wilson, RN, CPNP-PC, CPNP-AC, WCC Washington University / St. Louis Children's Hospital
St. Louis, MO
Disclosure Information
There were no financial interests or relationships or conflicts of
interest to disclose for any of the Burn Care roundtable
moderators.
Objectives
1) Describe different techniques used to assess burn size and depth of pediatric burn patients after stabilization.
2) Describe appropriate cleansing and debridement techniques of pediatric burn injuries and utilization of ancillary services (i.e. pain control, sedation, child life, therapy) for these procedures
3) Describe current topical treatment/dressings for pediatric burns that offer the best wound coverage and infection control.
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Burn Incidence
• Burn injuries that require medical treatment annually-450,000 per year.
• Burn injuries requiring hospitalization total approximately 40,000 per year.
• 60% of these patients are admitted to one of the 128 specialized burn centers in the United States.
Multidisciplinary Approach
3 Core FT RNs (Increasing)
FT Nurse clinician
FT PNP
Cross-trained 10th floor nurses
Program Assistant
Hospitalist
PT/OT
Child Life
Nutrition
Pharmacy
Physicians
CPT
Social Work
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
3
Pathophysiology: 3 Zones of Injury
(1) zone of coagulation
(2) zone of stasis
(3) zone of hyperemia
Classification
• Superficial
• Superficial partial thickness
• Deep partial thickness
• Full thickness
Size of the Burn
• Calculating Total Body Surface Area (TBSA)
• Lund Browder calculation performed at Burn dressing change
• Partial to Full thickness burns only
• Pediatrics have disproportioned body type
• Patients Palm + Fingers = 1% TBSA
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
4
Depth of the Burn
First Degree Burn
Superficial
Painful
No blistering
Pink; red
Mild edema
Blanches with pressure
Partial Thickness (2nd degree)
Pink to red
Moist
Moderate edema
Extremely painful
Vesicles
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Partial Thickness
Partial Thickness
Superficial Partial vs. Deep Partial Thickness Burns
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Hand Burn-Deep Partial Thickness
Full Thickness (3rd Degree)
Waxy-white to black
Dry leathery
Thrombosed vessels
Edema
Painless
Doesn’t blanch with pressure
Types of Burn Injury
• Thermal
• Electrical
• Chemical
• Various treatment modalities for each
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
7
Partial vs. Full Thickness
Flame Burn
Debridement
Manual
Sharps Debridement
Consent
Including Iris scissors and/or Curette
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
8
Pre-Debridement
Post-Debridement
Calculating TBSA
• Partial to full thickness burns only
• Patients Palm + Fingers = 1%
• Lund-Browder chart
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
9
Typical Dressing Change
Make child comfortable (Child Life)
Provide sedation if needed/Adminster pain meds according to institution
Transition to treatment room
Rally the troops
Consent, Timeout, Sedate
Typical Dressing Change
Radiant warmer on
Remove old dressing (note any cellulitis, foul-smelling drainage, s/s infection)
Assess wound
Debride (manually or with sharps)
Debride blisters over joints
Gentle cleansing (if burn is already post-debridement, with soap and water)
Provide education
Document
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
10
Typical Dressing Change
Measure/estimate burn size using Lund-Browder, document %
Picture (according to institution policy)
Range of Motion with PT/OT at bedside with dressings off while sedated (is optimal)
Implement dressing
Schedule f/u
Tub Time
PAWS-Experienced Wound Care
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Taking the “Ouch” Out
Nitrous
Ketamine
Versed
Tylenol
Oxycodone
Percocet
Most Common Dressings
Silvadene Cream
Antimicrobial Cream
Apply 1-2 per day
Easy to Apply
Leaves a film on wound requiring cleansing
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Silver Impregnated Foam Dressings
Foam dressing impregnated with Silver
Silver helps fight infection
Easy removal
Absorbant
Compresses
May leave on several days
Silver Impregnated Foam Dressings
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Foam Dressing
Foam dressing
Silicone contact layer
No pain or trauma upon removal
Waterproof outer layer
Silver Impregnated Dressing (Aquacel AG)
Silver impregnated dressing
Feels like felt
Absorbs exudate and forms a gel
Fills the wound and traps the bacteria
Silver Impregnated Dressing
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
14
Silver Impregnated Rope Dressing
Antibiotic Ointment
Xeroform
Petroleum based dressing
Antimicrobial
Protective dressing
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Non-Adherent Gauze (Telfa)
Tubigrip
Kerlix & Conform
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Ace wrap
Complicated Burns
Escharotomy
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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TE & Pigskin
Pigskin Graft
Oasis Wound Matrix
Small intestine submucosa (SIS)
Reduces the likelihood of patient rejection due to its natural acellular yet intact extracellular matrix composition
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
18
Muffler Burn
Muffler Burn post debridement
Pre and Post STSG
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
19
STSG
Donor Site s/p STSG
Physical and/or Occupational Therapy
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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S/P STSG
Burn Clinic
Compression
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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Severe Contracture
When to Refer to a Burn Center
1. Partial thickness burns greater than 10% total body surface area (TBSA).
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
3. Third degree burns in any age group.
4. Electrical burns, including lightning injury.
5. Chemical burns.
6. Inhalation injury.
7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
When to Refer to a Burn Center
8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols.
9. Burned children in hospitals without qualified personnel or equipment for the care of children.
10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention
(ABA, 2016)
American Pediatric Surgical Nurses Association
One Parkview Plaza, Suite 800 | Oakbrook Terrace, IL 60181 | www.apsna.org
25th Annual Scientific Conference | May 12-15, 2016 | San Diego, CA
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References
American Burn Association. Burn Incidence and Treatment in United States Fact Sheet. http://www.ameriburn.org. 2016. Accessed March.
Haines, et al. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients. Pediatric Emergency Medicine Practice. 2015: 12 (5): 1-24.
Ellison, DL. Burns. Critical Care Nursing Clinics of North America 2013: 25:273-285.
E.L. Gee Kee, R.M. Kimble, L. Cuttle, A. Khan, K.A. Stockton .(2015). Randomized controlled trial of three burns dressings for partial thickness burns in children. Burns, 41(5), 946-955. doi:10.1016/j.burns.2014.11.005
Jeschke, MG, et al. Morbidity and survival probability in burn patients in modern burn care. Critical Care Medicine 2015: 43 (4): 808-815.
Lloyd E, et al. Outpatient burns: prevention and care. Am Fam Physician. 2012;85(1):25.
Mckenna, C., Pieper, P. (2013). Chapter 31: Pediatric trauma. In N.T. Browne and others (Eds.), Nursing care of the pediatric surgical patient (3rd ed., pp. 513-538). Burlington, MA: Jones & Bartlett Learning.
Seigel, J., Wilson, C.M., McCubbins, M. (2014). Chapter 36: Burns. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (7th ed., pp. 926-950). St. Louis: Mosby.
Thank you!