9/5/20151 Burns Linda Copenhaver. 9/5/20152 Introduction Incidence of Burns 450K in U.S. seek medical care annually Approximately 45K are hospitalized.

04/19/23 1

BurnsLinda Copenhaver

04/19/23 2

Introduction

Incidence of Burns

450K in U.S. seek medical care annually

Approximately 45K are hospitalized Which setting do most burn trauma

injuries occur? How many Burn Trauma centers in

U.S.?

04/19/23 3

Types of Burn Injury

Thermal Chemical Electrical-what type considered

here? Which state has highest incidence of ____ injuries?

Radiation

04/19/23 4

Thermal Burns( Most Common) Caused by flame, flash, scald, or

contact burns

STOP & DROP Roll to shut off O2 supply to

fire Flush or immerse in cold

water DO NOT use ICE on deep

burns, just localized, superficial burns

04/19/23 5

Chemical Burns

Remove person from contact with agent

Flush with water continuously

Remove affected clothing if possible

Alkaline agents worse than acid, process keeps going

04/19/23 6

Electrical burns Coagulation necrosis Severity depends on voltage, amount of

resistance, time,

and current

pathways.

Electrical Burn–Back

Fig. 25-2 B

04/19/23 8

Frequently only entry (yellow-white) and exit (blow out) wounds are visible

Current practice: Now refer to contact points vs entry and exit points.

Extensive tissue damage is masked

How can we evaluate “masked tissue damage”???

04/19/23 9

Electrical Burns (cont) Patient at risk for arrhythmias

due to _____, metabolic acidosis due to _____, and acute tubular necrosis due to ______.

Current can be so strong to

fracture long bones and cause respiratory muscles to contract

Cross Section of Skin

Fig. 25-3

04/19/23 11

Depth of Burns Superficial Partial Thickness Burn (1st

degree) Epidermis involvedSunburn, UV light, mild radiation,Pink to redSlight edemaMild pain

04/19/23 12

Depth of Burns Deep Partial Thickness (2nd)

Epidermis and some of dermis, is painful, red, blisters

04/19/23 13

Depth of Burns

Deep Partial Thickness (2nd)

Epidermis and Dermis

Very Painful, edema, pale

Moist or dry, but more commonly wet

Blisters

04/19/23 14

Depth of Burns (cont) Full Thickness Burns (3rd)

Epidermis, Dermis, and Subcutaneous tissue burned

Nerve endings destroyed Little or no pain

04/19/23 15

Depth of Burns (cont)

Full thickness (4th degree) Involves past the 3 layers

down to the bone and/or organs

Rule of Nines Chart; quick & easy

Fig. 25-4 B

Lund-Browder Chart; More accurate

Fig. 25-4 A

Burn Unit Referral Criteria

Deep Partial Thickness burns > 10% TBSA Burns that involve the face, hands, feet,

genitalia, perineum, or major joints Full thickness burns in any age group Electrical burns, including lighting Inhalation burns requiring intubation Chemical burns that involve deep and

extensive TBSA burned

04/19/23 18

04/19/23 19

Medical/Nursing Management of Burns I. Emergent Phase

Period of time from onset of burns to the beginning of fluid remobilization

Usually lasts 24-48 hours

04/19/23 20

Emergent Phase (cont)

Also called FLUID ACCUMULATION PHASE

The greatest initial threat to a major burn victim is hypovolemic shock

Let’s do the Patho on p. 479 Lewis…this is a DING DING!

04/19/23 21

04/19/23 22

What are the Priorities in this patient??? Is this patient a candidate for a

major burn center?

04/19/23 23

Nursing Care During Emergent Phase Impaired Gas Exchange r/t

tissue hypoxia secondary to carbon monoxide poisoning

Note: CO poisoning is the MOST immediate cause of death from fire.

04/19/23 24

Signs & Symptoms of Carbon Monoxide Poisoning Edema of Airway Hoarseness Dysphagia Stridor Copius Secretions usually

black tinged Skin will appear cherry red

Cherry red skin appearance

04/19/23 25

04/19/23 26

Interventions for CO Poisoning: Assess for S&S CO poisoning (mild to

severe) Humidified O2 100% via face mask High Fowler’s Position TCDB q 1 hour Intubation & Ventilation Bronchodilators for bronchospasm One other thing…..does anyone

know???

04/19/23 27

Nursing Care during Emergent Phase (cont) Impaired Gas Exchange r/t

mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases

04/19/23 28

Interventions: Early intubation to prevent

trach placement Ventilation Humidified O2 100% ABG’s Bronchodilators

04/19/23 29

Questions to Ask Burn Victims Were you in an enclosed

space? Were you standing up? Was it a flame and chemical

fire? Are you having difficulty

breathing?

04/19/23 30

What are your #1 priorities in this patient?

Patient #1 Patient #2

04/19/23 31

Emergent Phase (cont)

Ineffective Breathing pattern r/t constriction of chest/trachea secondary to the effects of full thickness burns.Assess for signs of

constrictionEscharotomies with

circumferential burns of chest

04/19/23 32

Escharotomy of chest and arm What is the pathophysiology here?

04/19/23 33

Emergent Phase (cont)

Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spacesAssess fluid needs:

Brooke FormulaEvans Formula

Parkland Baxter Formula Most widely used

Formula

LR 4ml X kg body weight X TBSA % burned

½ total amount given 1st 8 hours ¼ total amount given next 8 hours ¼ total amount given next 8 hours

04/19/23 34

Okay Nurses Let’s Calculate

What would the fluid replacement be for a patient who weighed 60kg and had 30% TBSA burned???

1st 8 hours= _____ or ____ml/hr 2nd 8 hours= _____ or _____ml/hr 3rd 8 hours= ______ or _____ml/hr

04/19/23 35

04/19/23 36

Crystalloids used such as LR, 0.9NS, D5NS

Colloids (albumin, dextran, FFP) used to expand plasma.

Colloids not given until after capillary permeability decreases and returns to normal…..WHY?

04/19/23 37

Insert foley catheter to monitor output. What should urine output be in an adult???

Frequent vital signs SBP>100 Pulse<100 RR 16-20

04/19/23 38

Emergent Phase (cont)

Monitor Electrolytes and Hematocrit; tells you about fluid shift. What should Hct be doing as

time progresses???

04/19/23 39

Emergent Phase (cont)

Potential for Infection r/t loss of skin and micro invasion

Meticulous hand washing Sterile technique during dressing

changes & wound care Hair near burned areas shaved

04/19/23 40

Potential for Infection r/t loss of skin and micro invasion (cont)

Blisters popped or not???Tetanus Toxoid I.M. given to

all major burn victims to fight

anaerobic contamination of burn wound

04/19/23 41

Hydrotherapy in cart (water is heated to approximately 104 degrees)

< 30 minutes to prevent _____

04/19/23 42

04/19/23 43

Hydrotherapy Cart

What does hydrotherapy accomplish?

04/19/23 44

Wound Care

Open Method Apply topical chemotherapy

04/19/23 45

Topical Meds/Antimicrobials

Silvadene cream

Silver Nitrate or silver impregnated dressings such as Silverlon or Acticoat

Sulfamylon cream

04/19/23 46

Wound Care (cont) Closed Method

Apply topical chemo and wrap with gauze, fluffs, kerlix

Assess for

constriction;

circulation

checks

04/19/23 47

Emergent Phase (cont)

Elevate burned arms on pillows Give pain meds 30 minutes

prior to treatments Wrap distal to

proximal

04/19/23 48

Emergent Phase (cont) Alteration in body temp

(hypothermia) r/t loss of skin

Set thermostats at warm temp in room (~85 degrees)

Maintain body temp above 37 (98.6) degrees C; patient outcome on POC:

Patient will maintain body temp of 38 (100.4)

04/19/23 49

Emergent Phase (cont) Potential for injury r/t effects of

stress response:

Stress diabetes What is the patho here???

Curling’s ulcer (associated with burn trauma patients)

Gastroduodenal ulcer caused by increased gastric acid secretion

So which meds would nurse anticipate in the POC?

• Sliding scale and routine insulin sc

• H2 blockers for GI ulcer prevention:

• Pepcid, Protonix, Zantac04/19/23 50

04/19/23 51

Emergent Phase (cont) Potential for injury r/t effects of

stress response:Paralytic ileus (stress related)

NPO, NG tube to suctionDelirium (psychological stress)Inderal given for anxiety, pain

and tachycardia

04/19/23 52

Emergent Phase (cont) Compartment syndrome r/t the

effects circumferential burns

Circulation is impaired

Edema formation

Occluded blood supply

Ischemia

Necrosis

Gangrene

04/19/23 53

Emergent Phase (cont)

What is the treatment?Escharotomy

04/19/23 54

Emergent Phase (cont)

Renal Failure

Hypovolemia (Why?) blood flow to kidneys

Renal ischemia ARF may develop

04/19/23 55

Emergent Phase (cont) Renal Failure

Full thickness & electrical burns

Myoglobin from muscle cells released

Urine myoglobin q 6 hours Blocks renal tubules

04/19/23 56

Emergent Phase (cont)

What is the treatment for these 2 renal problems????

04/19/23 57

Emergent Phase (cont)

Cardiac Function

Arrhythmias due to electrolyte imbalance or electrical burns

Hypovolemic shock due vascular bed depletion

Important points…2 Large bore IV sites initially until central line can be placed (16 gauge preferable)

LR preferred over 0.9NS Why? ___________________

Most burn trauma patients will be conscious unless what? ______

04/19/23 58

04/19/23 59

Summary of Emergent Phase:

04/19/23 60

II. Acute Phase (weeks to months) Begins after 48-72 hours Fluid begins to shift interstitial

spaces back into bloodstream or intravascular space

Diuresis occurs Ends when TBSA burned is

<20% by grafting or wound healing

04/19/23 61

Nursing Care During Acute Phase Skin/systemic infection r/t

Loss of normal skinFormation of escharSuppression of immune

systemMetabolic/hormonal

alterations

04/19/23 62

Acute Phase Interventions for

Skin/Systemic Infection:

Hydrotherapy cart shower to debride

Open/Closed dressing changes

Topical antimicrobialsWeekly culturesSystemic antibiotics

04/19/23 63

Acute Phase (cont) Excision & Grafting

Removal of necrotic tissue Eschar is removed until viable

tissue is reached

The RN just received report on the burn unit. Which client requires the most immediate assessment or intervention? a) 22 yo old admitted 4 days previously with

facial burns due to a house fire who has been crying since recent visitors left

b) 34 yo who returned from skin graft surgery 3 hours ago and is c/o 8 out of 10

c) 45 yo with deep partial thickness leg burns who has temp of 102.6 and a bp of 98/46

d) 57 yo who was admitted with electrical burns 24 hours ago and has K+ level of 5.6mEq/L

04/19/23 65

Acute Phase (cont)

Reasons for Grafting (priorities)

Survival Function Cosmetic

Synthetic Grafts BIOBRANE

04/19/23 66

Types of Grafts

Autograft or Autologous self

Heterograft Different species

Pig, bovine Homograft

Cadaver Which are temporary vs

permanent?

New Advanced Grafts

Cultured Epithelial Autograft (CEA) Patient’s own skin cells grown in

culture dish—Permanent Cost of CEA---$145K for 15 small pieces

of CEA

Latest in Skin Grafting--More options for Permanent Grafts

New Advanced Grafts

Integra

Bovine collagen and glycosaminoglycan bonded to silicone membrane-Permanent

AlloDerm Acellular dermal matrix derived from

donated human skin-Permanent

04/19/23 69

Acute Phase (cont)

GRAFTING

04/19/23 70

Acute Phase (cont)

GRAFTING

Dermatome-harvesting donor skin from thigh

04/19/23 71

04/19/23 72

Acute Phase (cont)

Can you describe this???

04/19/23 73

Acute Phase (cont) Potential for fluid volume excess r/t

fluid shift from interstitial back to intravascular space Daily weights Monitor lab values-Which ones? Auscultate lungs Fluids as ordered Avoid free water-dilutional

hyponatremia

04/19/23 74

Acute Phase (cont)

Alteration in Nutrition r/t hypermetabolismGoals are to minimize

energy demands and to..Provide adequate calories

to promote wound healing

04/19/23 75

Acute Phase (cont)

Interventions for altered nutrition:

Monitor bowel soundsHigh Protein High CHOAssess food preferencesDaily calorie countTPN as ordered

04/19/23 76

Acute Phase (cont) Ineffective Coping r/t long rehab

process with multiple surgeries and change in lifestyle/social isolation

Include family in plan of care Assess client’s readiness to talk Allow client to work through grief

process Give honest, accurate information

A client with deep partial and full thickness TBSA burned is 28% is receiving hydrotherapy. The nurse should assess for which of the following complications?

a) hypernatremia b) dehydration c) edema d) hypothermia

04/19/23 78

Acute Phase (cont)

Self-care Deficit r/t restricted movement/contractures/muscle atrophy

04/19/23 79

Interventions

Assist with positioning ROM exercises Support O.T. & P.T. efforts Always maintain eye contact with

client

04/19/23 80

III. Rehabilitation Phase From wound closure to optimal level of

physical and psychosocial adjustment

Potential for impaired home maintenance/integration back into social and work environment

Discuss grief process, self-concept, resocialization process

Sexuality issues, will I be a productive person? Will I be a good parent/partner?

04/19/23 81

Rehabilitation Phase

Instruct client on skin care:

Skin will itch, be dry, have a tight feeling

Use Vaseline Intensive Care ES lotion, mild soaps

Use Benadryl for itchingAvoid direct sunlight (will cause

hyperpigmentation)

04/19/23 82

Rehabilitation Phase

Instruct client on skin care:

Skin may be hypo or hyper sensitive to cold/heat/touch

Diet (high protein, vitamins) Exercise to prevent contractures Instruct client on S & S of infection

04/19/23 83

Rehabilitation Phase Instruct client to wear JoBST

pressure garment up to 1 year

04/19/23 84

Rehabilitation Phase

Instruct client on skin care:Need to wear Jobst to

prevent keloid formation