BURNS
BURNS
ContentsDefinition, Description, Types, EtiologyAnatomy of Integumentary SystemDetermining Severity of BurnAssessmentPathophysiology Management
DefinitionBurns are a result of the effects of thermal injury on the skin and other tissuesHuman skin can tolerate temperatures up to 42-440 C (107-1110 F) but above these, the higher the temperature the more severe the tissue destructionBelow 450 C (1130 F), resulting changes are reversible but >450 C, protein damage exceeds the capacity of the cell to repairAnatomy of the Skin
Anatomy of the Skin
Depth of Burns Superfacial (First-degree) burns
Involve only top skin layerEpidermis only damagedPainful to touchArea initially erythematous due to vasodilatationEpidermis sloughed off in 7 days with complete scarless healing
Depth of Burns Partial-thickness Superfacial(Second-degree) burnsInvolve epidermis and some portion of dermisCan be either superficial or deep
Partial thickness- Superfacial Second degree burn
Partial thickness Deep Second degree burnsEpidermis & deeper degrees of dermis destroyedAre pink to cherry red, wet, shiny with serous exudateVery painful when touched or exposed to airHeal in 14- 28 days with scarringMay need early excision and grafting
Partial thickness Deep Second degree burns
Depth of BurnsFull-thickness(Third-degree) burnsExtend through all layers of skin
Need better phtls
Full-thickness(Third-degree) burns
Will appear as thick, dry, leathery, waxy white to dark brown regardless of race or skin color May have a charred appearance with visible thrombosis of blood vessels Will have little to no sensation because nerve endings have been destroyed except in surrounding tissues with partial thickness burns
Full-thickness(Third-degree) burns
Depth of BurnsFourth-degree burnsExtend through all layers of skin as well as extending to underlying fat, muscle, bone or internal organs
Burn Photos
Mild Burn2nd degree Burn 1 hr2nd degree Burn 1 day2nd degree Burn 2 daysBurn Size EstimationCritical to providing adequate resuscitation
3 common guidelines used Rule of Nines Lund-Browder ChartPalmer Method
Rule of NinesIn the adult, most areas of the body can be divided roughly into portions of 9% or multiples of 9. In the child, similar portions are assigned
This division is useful in estimating the percentage of body surface damage an individual has sustained in burn.
Rule of Nines
Lund-Browder Chart
Palmer MethodThe palmer surface of the patients hand from crease at wrist to tip of extended fingers- equals ~ 1% of the patients total body surface area
Extent of Burns
24The extent of burns is expressed as percentage of the total surface area.Classification According to ExtentMild: 10%Moderate: 10-30%Severe: > 30%
Hospitalization for > 10% of body surface areaInfant Rule of Nines (for quick assessment of total body surface area affected by burns)Anatomic structureSurface areaHead18%Anterior Torso18%Posterior Torso18%Each Leg14%Each Arm9%Perineum1%Kinds of BurnsFlame Burn: due to gasoline, kerosene, liquified petroleum gas (LPG) or burning houses
Kinds of BurnsScald Burn: most frequent in home injuries; hot water, liquids and foods are most common causes; above 65o C, cell death
Kinds of BurnsChemical Burns2 types of chemical burnsacids-can be neutralizedalkaline- adheres to tissue, causing protein hydrolyses and liquefactionexamples: industrial or agricultural sites, highways and battlefields > cleaning agents, drain cleaners, lyes, and military grade agents, etc.
Chemical (Acid) BurnsChemical BurnsWith chemical burns, tissue destruction may continue for up to 72 hours afterwards.It is important to remove the person from the burning agent or vice versa.Chemicals, heat, and light rays can burn the eye.
Kinds of BurnsRadiation Burns from X-ray, radioactive radiation and nuclear bomb explosions
Kinds of BurnsElectrical Burnsworse than the other types; with entrance and exit wounds; may stop the heart and depress the respiratory center; may cause thrombosis and cataracts
Electrical Burns
Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current.Can cause tissue anoxia and deathThe severity depends on amount of voltage, tissue resistance, current pathways, and surface area in contact with the current and length of time the current flow was sustained.
External signs of an electrical burn may be deceiving.Entrance may be small, while deeper tissue damage may be massive.
Burn Photos
Electrical Burns Entrance WoundsElectrical Burns Exit WoundsEntrance wound of electrical burns from an overheated tool Severe swellingpeaks 24-72 hrs after Electrical burns mummified1st 2 fingers later removed Smoke and Inhalation InjuryCan damage the tissues of the respiratory tractAlthough damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.
The glottis (1) is the opening in the epiglottis (2). It is the dark slit in the center of the epiglottis and is evident when the tongue is pulled down toward the chest cavity.
Inhalation injuryAirway edema & Carbon deposits
3 types of smoke and inhalation injuries1. Carbon monoxide poisoning (CO poisoning and asphyxiation count for majority of deaths)
Treatment- 100% humidified oxygen-draw carboxyhemoglobin level- can occur without any burn injury to the skin
3 types of smoke and inhalation injuries (cont)2. Inhalation injury above the glottis (caused by inhaling hot air, steam, or smoke.)Mechanical obstruction can occur quickly-True ER! Watch for facial burns, signed nasal hair, hoarseness, painful swallowing, and darkened oral or nasal membranes
3 types of smoke and inhalation injuries (cont)3. Inhalation injury below glottis (above glottis-injury is thermally produced)below glottis-it is usually chemically produced.Amount of damage related to length of exposure to smoke or toxic fumesCan appear 12-24 hours after burn3 Phases of Burn ManagementEmergent (resuscitation)0 48 hours, can be up to days laterAcute (definitive care) day 3 until wounds healRehabilitationBegins during resuscitation and continues throughout lifespan
Emergent Phase (Resuscitative Phase)Lasts from onset to 5 or more days but usually lasts 24-48 hoursBegins with fluid loss and edema formation and continues until fluid motorization and diuresis beginsGreatest initial threat is hypovolemic shock to a major burn patient
Emergent Phase Initial Management/CareMAKE SURE YOU ARE SAFE !!!Remove patient from area! Stop the burn!Airway-check for patency, soot around nares, or signed nasal hair. 100% O2 via NRM @ 15L. Watch for early upper airway edema >intubate is in doubt.Breathing- check for adequacy of ventilation, consider need for early intubation or early escharotomy if ventilation is impaired
Emergent Phase Initial Management/CareCirculation-check for presence and regularity of pulses, consider early escharotomy if circulation to a limb is impairedDisability- AVPU, altered mental status in burn patient is not normal >think carbon monoxide poisoning. Check pupils. Check for movement in all extremities.Expose- Remove clothing and jewelry. Do not pull on clothing stuck to skin > Cut away clothing or soak it off. Cover with dry sterile sheet and tuck in sides.
Emergent Phase Initial Management/CareFluid Resuscitation- estimate TBSA burn percentage and weight then calculate fluids for first 24 hour period using Parkland formulaFoley catheter- to monitor urine outputSecondary survey starting with a good scene and patient history then head to toe examPain Management- early and often based on patients hemodynamic status and pain scalePsychosocial issues- consider need for religious intervention, legal consult for family affairs, etc for patients with life-threatening burns
Secondary Survey HistoryFlameHow did the burn occur?Did the burn occur outside or inside?Did the clothes catch on fire?How long did it take to extinguish the flames?How were the flames extinguished?Was gasoline or another fuel involved?Was there an explosion?Was there a building/house fire?Was the patient found in a smoke-filled room?
Secondary Survey HistoryHow did the patient escape?If the patient jumped out a window, from what floor?Were others killed at the scene?Was there a motor vehicle crash?How badly was the vehicle damaged?Was there a motor vehicle fire?Are there other injuries?Are the purported circumstances of the injury consistent with the burn characteristics?
Secondary Survey HistoryChemicalWhat was the agent?How did the exposure occur?What was the duration of contact?What decontamination occurred?Was there an explosion?
Secondary Survey HistoryElectricalWhat kind of electricity was involved?What was the duration of contact?Did the patient fall?What was the estimated voltage?Was there loss of consciousness?Was cardiopulmonary resuscitation administered at the scene?
Specific burn Treatment notes Care for Thermal Burn For myoglobulin release > protein leak clogs kidney cells >ischemia) Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.
U.S. StatisticsAbout 2.4 million people suffer burns annuallyAccount for an estimated 700,000 ER visits per year and 45,000 require hospitalizationsBetween 8,000-12,000 burn patients die, and approximately one million will sustain substantial or permanent disabilitiesFires kill about 500 children 15-20% BSA) decreases body temperature which contraindicates use of cold compress dressingsIf burn caused by hot tar, mineral oil to remove itInitial Management: ABCDEsAirwayBreathingCirculationDepth of BurnExtent of Injury(s)
Pediatric (special) issues
Initial Airway ManagementEvaluate, and ensure airway patencyDetermine the need for an artificial airwayintact airway reflexes?risk factors for airway burns/edema?Perioral burns, carbonaceous sputum subjective dysphagia, hoarseness or changes in phonationerythema to edema transition may be rapidEnsure adequate air exchange, thoracic excursion with tidal breaths
Breathing Assessment/SupportEnsure adequate oxygenationABG with carboxyhemoglobin level preferredhumidified 100% FiO2 empericallyAssess for possible inhalation injuryhistory of an enclosed space, carbonaceous sputum, respiratory symptoms, altered LOCyounger children at greater riskNMB for intubation: avoid succinylcholine
Breathing Assessment/SupportNG tube placementthoracic decompression; reduce aspiration riskVentilatory support recommended for circulatory insufficiency, or GCS10% BSA or >2% full thickness, halved for 40 yrHands, face, feet or genitalia involvedEvidence or suspicion of inhalation injuryAssociated injuries presentSuspicion that burn inflictedBurn is infectedBurn circumferentialHistory of prior medical illnessPatient is comatosePatient or family unable to cope with situationHospital ManagementGeneral assessment and cardiopulmonary stabilizationResuscitationEstablishment of IV lines and blood studiesWound care and infection controlPain relief and psychological supportNutritional supportPhysical Therapy/Occupational TherapyAirway compromise? Respiratory distress? Circulatory compromise?Intubation, 100% O2 IV access, fluidsMultiple trauma?YesNoEvaluate & treat injuriesBurns >15% or complicated burns?YesNoBurn care, tetanus prophylaxis, analgesiaIV access;fluid replacementCircumferential full thickness burns?EscharotomyYesYesNoNoInitial ProceduresFluid infusion must be started immediatelyNGT insertion to prevent gastric dilatation, vomiting and aspirationUrinary catheter to measure urine outputWeight important and has to be taken dailyLocal treatment delayed till respiratory distress and shock controlledHematocrit and bacterial cultures necessaryFluid ResuscitationFor most, Parkland formula a suitable starting guide (4 ml Ringers Lactate/kg body weight/% BSA burned), to be given over 1st 8 hr from time of onset while remaining over the next 16 hrDuring 2nd 24 hr, of 1st day fluid requirement to be infused as D5LROral supplementation may start 48 hr after as homogenized milk or soy-based products given by bolus or constant infusion via NGTAlbumin 5% may be used to maintain serum albumin levels at 2 g/dlPacked RBC recommended if hematocrit falls below 24% (Hgb
