Burn Injuries- Andrew

8/7/2019 Burn Injuries- Andrew

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Burn Injuries

Andrew D. Beluso, RN



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 theinjured 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

adultc. 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 aredestroyed; 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, healsspontaneously.

Itching and pink skin persist for about aweek.

No scarring.

Heals spont. If it does not become

infected w/in 10 days - 2 weeks.

Pink to red: slight edema, whichsubsides quickly.

Pain may last up to 48 hours.

Relieved by cooling.

Sunburn is a typical example.

First Degree

Reparative Process Assessment of ExtentExtent / Degree



Eschar must be removed. Granulationtissue 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 withpressure.

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 Process Assessment 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 renald/o, negatively influence the client¶s response to injury and treatment.

1. Mortality rate is higher when the client has a preexisting disorder at thetime of the burn injury



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

hot objects

A. Chemical Burns:

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

b. Systemic toxicity from cutaneous absorption can occur

B. Electrical Burns:

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

b. Results in internal tissue damage

c. Cutaneous burns cause muscle and soft tissue damage that maybe extensive, particularly in high voltage electrical injuries

d. Alternating current is more dangerous than direct current because

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

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



INHALATION INJURIES

A. Smoke inhalation injury

: results from inhalation of superheated air, steam, toxicfumes, 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 inbronchial 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 andedematous, with mucosal blisters and ulcerations

: Mucosal edema can lead to upper airway obstruction, esp. during thefirst 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 CHANGES

A. Initially hyponatremia and hyperkalemia occur. Followed byhypokalemia as fluid shifts occur and K+ is not replaced.

The hematocrit level increases as a result of plasma loss; this initialincrease falls to below normal at the 3rd to 4th day postburn as a resultof the RBC damage and loss at the time of injury.

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

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

C. Immune system function is depressed, resulting inimmunosuppression and thus increasing the risk of infection andsepsis.

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

E. Evaporative fluid losses through the burn wound are greater thannormal, 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 tonear 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 1Û goal is to prevent hypovolemic shock and preserve vital organfunctioning

- 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 gainindependence and achieve maximal function

Acute phase

- begins when the client is hemodynamically stable, capillarypermeability 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 thephase 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 InterstitialHct 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 intravenousfluid 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 assessmentparameter for cardiac output and tissue perfusion

If the Hgb and Hct levels decrease or if the urinary output exceeds50ml/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 FORMULA

Example: 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 concurrentlyover 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 CARE

1. 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 evaporativefluid and heat loss

Aids in debridement

CLOSED Gauze dressings arecarefully wrapped from the

distal to the proximal area of the extremity to ensure

circulation is not compromised

No 2 burn surfaces shouldbe allowed to touch; canpromote webbing of digits,

contractures, and poor cosmetic outcome

Dressings are changed

every 8 ± 12 hours

Increase chance of hypothermia from

exposure

Visualization of thewound

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

Disadvantages AdvantagesMethod

Open Method Versus Closed Method of Wound Care



TOPICAL ANTIMICROBIAL AGENTS FOR BURNS

Silver 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 every2-4 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 attachto the wound bed

Care of the graft site

Care of the donor site



TEMPORARY WOUND COVERINGS

Biological

Amnion

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 hoursXenograft (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 withautograft 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



Thank You!

Burn Injuries- Andrew

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