Care of the Burn Patient Jaf

Care of the Burn PatientCathy Miller, MSN,RN & Julie Fomenko, MSN, RN MSII

Objectives Upon completion of this lecture, participants will be able to: Identify the components of a primary and secondary burn survey Apply the Rule of Nines to make an initial estimate of burn content Distinguish between partial-thickness and full-thickness burns

Prevelance of Burns 1.25 million burn injuries require medical attention in the United States every year Burns can be mild or very severe, requiring hospitalization and possibly more than one surgery

The Skin The skin is the bodys outer covering. It protects us against heat, light injury, and infection It also regulates body temperature

Burns A burn is damaged tissue caused by heat, chemicals, electricity, sunlight or nucler radiation. Burns caused by scalds, building fires, flammable liquids and gases are most common

Burn Injuries First Degree Second Degree Third Degree Fourth Degree (ABA)

Partial Thickness Full Thickness

First Degree Burns Sunburns are the best example Involve only the superficial layer of the epidermis Tenderness, redness typical Will not make you very sick Heal on own Healing time: 4-5 days OTC pain management

First Degree Burn

Another First Degree Burn

Second Degree Burns Difficult to diagnose because they vary in nature May be superficial to very deep Very moist appearance Second degree burns blister immediately Most blisters should be removed Healing time: approximately 2 weeks OCT pain management

Picture of First and Second Degree Burns

Second Degree Burn

Second Degree Burn Variability Superficial second degree: Heal on own

Deep partial thickness: Treat like third degree burns Grafting required

Second Degree Burn Variability

Second Degree Pain Factor Epidermis has been lifted off by fluid Most painful because nerve endings are preserved Scarring is minimal if healing occurs within 2-3 weeks If the wound is open for a longer period of time, grafting is indicated

Deep Partial Thickness

Third Degree Burns Epidermis and dermis are destroyed Appear whitish, charred or translucent Dry, leathery Red, white, brown, grey Coagulated vessels are often seen Full thickness

Third Degree Burns continued Require grafting If third degree burns are not excised, they will not heal Exception: small third degree burns less than 5cm can heal from the outside edges in

Third Degree Burn

Third Degree Circumferential

Third Degree to Buttocks

Third Degree to Hand

Estimating Burn Injury Rule of Nines Divide the body up into sections which equal nine percent Each arm is nine Each leg is two nines (front/back) Chest is two nines (belly button & higher, front/back) Abdomen is two nines (belly button & lower, front/back) Head is nine And the perineum is.one Area of patients palm equals one

Rule of Nines

Whats a Lund and Browder? A tool that divides the body up into smaller areas Good for estimating burns in children Kids have relatively big heads and relatively small legs compared to adults this is why this tool was developed You cannot use the Rule of Nines for children! More accurate than Rule of Nines Total Body Surface Area (TBSA)

Lund and Browder

Lund and BrowderAge Half of head Half of Thigh 09.5

18.5

56.5 4.0

105.5

154.5

Adult3.5 4.75

2.75 3.25

4.25 4.25

Half of Leg

2.5

2.5

2.75

3.0

3.25

3.5

Two Points to Remember When Estimating Burn Injury Debride the blisters before you estimate the size First degree burns do not count!! For irregular burns, the palm of the hand is about 1% of TBSA

Burn Survival

Management of a Burn Victim at the Scene STOP STOP STOP STOP STOP STOP STOP STOP THE THE THE THE THE THE THE THE BURNING BURNING BURNING BURNING BURNING BURNING BURNING BURNING PROCESS PROCESS PROCESS PROCESS PROCESS PROCESS PROCESS PROCESS

How to Stop the Burning Process Flame burns: smother the fire with water or a blanket; make sure fire is out and remove burned clothing Scald injuries: cool the area (DO NOT APPLY ICE!), then keep dry and covered Chemical injuries: flush with water, and lots of it!

Tar, Asphalt and Plastic Injuries Cool the offending element Leave it in place! Transport patient to nearest emergency facility

Tar Injury

Electrical Injuries If you are at the scene, make sure the person is not in contact with the electrical current Most people killed by electrical injuries do not die from their burn injuries they die from cardiac dysrhythmias Ventricular fibrillation is usually the culprit

Electrical Injuries continued Current density is maximum at entry and exit points (most condensed) Current enters the body through a small opening, then travels deep through the body and exits through a small opening This is why electrical burns may be deceiving damage is hidden!!!

Electrical Injury

Electrical Injury after Debridement

Typical Exit Wound

Electrical Shock Summary May result in unconsciousness, convulsions, loss of memory Orthopedic injuries common Spine fractures may result from tetanic contractions of muscles induced by high voltage current

Airway Burns Inhalation of smoke, steam, superheated air or toxic fumes Swelling can cause decrease flow of air

Initial Management: Primary Survey Treat the patient, not the burn Every burn patient is a trauma patient Immediate priorities: Airway with cervical spine protection Breathing and Ventilation Circulation Disability, Neurologic Deficit Exposure/Environmental Control

Airway Airway must be assessed immediately Compromised airway may be controlled by simple measures, including: Chin lift Jaw thrust Insertion of an oral pharyngeal airway in the unconscious patient Endotracheal intubation

Three Types of Airway Injuries Carbon monoxide poisoning Inhalation injury above the glottis Inhalation injury below the glottis Any victim found burned in a closed area should be suspected of having an inhalation injury unless proven otherwise

Extensive Facial Burns

Pediatric Facial Burns

Carbon Monoxide Intoxication By-product of incomplete combustion Oxygen competes with carbon monoxide for hemoglobin The more oxygen, the less carboxyhemoglobin Carboxyhemoglobin non-smoker Blood 0-2.3% 0-0.023 Carboxyhemoglobin smoker Blood 2.1-4.2% Most common sign is CNS change (headache, confusion, somnolence, coma) Treatment is 100% oxygen

Breathing and Ventilation Listen to the chest and verify that you hear breath sounds in each lung Assess rate and depth of respiration High flow oxygen is started on each patient at 100% using a nonrebreather Circumferential full-thickness burns

CirculationBlood pressure (manual please!) Pulse rate Skin color (of unburned skin) Insert 2 large bore IVs (may insert through burn tissue if necessary) Doppler pulses in circumferentially burned extremities

Disability, Neurologic Deficit A alert V responds to verbal stimuli P responds to painful stimuli U - unresponsive

Exposure/Environmental ControlRemove all clothing and jewelry Maintain patient temperature Room should be warm Give patients warmed intravenous fluids Dry sheets, hypothermia blankets (bear huggers), radiant barriers are all good methods to keep patients warm

Secondary Survey Completed after primary survey Consists of history and complete head-to-toe examination of patient

History Circumstances of Injury: Flame? Scald? Chemical? Electric?

Medical History: AMPLE (allergies, medication, previous illness/surgery, last meal/fluid intake, events related to injury)

Complete Physical Examination Head-to-toe examination Determine severity of burn

Other Burn Management PrinciplesStop the burning process Universal precautions Fluid resuscitation Vital signs Insert nasogastric tube (if >20% TBSA, since patients are prone to gastric dilatation due to ileus) Insert duotube (for tube feedings keep the gut going)

More Management Principles Insert urinary catheter (urinary output is vital to survival) Assess extremity perfusion Continue respiratory assessment Pain management (morphine please) Psychological assessment

Initial Laboratory Studies Baseline laboratory studies are important: Hemoglobin, hematocrit Electrolytes (initial losses usually Na, Cl and K) BUN, creatinine Urinalysis Chest x-ray

More Laboratory Studies to Consider ABGs (if inhalation injury is suspected) Carboxyhemoglobin ECG with all electric injuries or preexisting cardiac problems Glucose (in children) and diabetics

Shock & Fluid Resuscitation Fluid replacement is part of initial burn treatment Burn tissue causes capillary leaking Endothelial cells separate and become porous Huge amounts of fluid pour out into tissue Blood volume goes down as patients become more edematous (third spacing) hypovolemic shock!

Who is resuscitated? Any burn greater than 10% Depends also on age and health of patient Any inhalation injury Any trauma patient Any electircal burn When in doubt OVER TREAT

The Parkland Formula Goal is to maintain volume during period of hypovolemia ****Resuscitation time is calculated from the TIME OF INJURY, not the time the patient arrived at the hospital!!!**** Use Lactated Ringers for fluid replacement only!!!

The Parkland Formula Continued Adults: 2-4 mL x kg body weight x % burn Children: 3-4 mL x kg body weight x % burn Infants and young children should receive fluid with 5% dextrose at a maintenance rate in addition to the resuscitation fluid noted above

Give fluid in the first 8 hours Give the remaining fluid over the next 16 hours You may need to increase fluid ABOVE the formula to maintain adequate urine output

Why use LR? Isotonic Well, so is normal saline! However, normal saline contains a large amount of chloride Too much chloride to a burn patient creates a potential for metabolic acidosis This is why LR is the fluid of choice!!!

The Color of Pee Patients with electrical injuries will have a lot of myoglobin in their urine So that the myoglobin does not gum up the kidneys, these patients may require more fluid

The Foley tells the Story! If there is only one thing that you could choose to see if your burn patient was doing well, that would be the Foley!

Hourly Urinary Output Adults: 0.5 mL per Kg per hour Children weighing less than 30 kg: 1 mL per Kg per hour Remember this is the minimum amount of urine to expect!

Summary We have reviewed first, second and third degree burns We have applied the Rule of Nines We know the resuscitation formula

Care of the Burn Patient Part IIAlenka Vale, RN, MSN Edited by Jo Teichman, RN, MSN, CWOCN

Objectives Upon completion of this lecture, participants will be able to: Describe the difference between an escharotomy and a fasciotomy Recognize different methods of topical wound management

Escharotomies/Fasciotomies Both are surgical techniques used to restore circulation to an extremity Escharotomy cuts through eschar; typically does not go through the fatty layer Fasciotomy cuts through to the fascia (muscle); you will see exposed muscle

Escharotomy

Escharotomy and Fasciotomy

Escharotomy

Another Patient with Escharotomies

Why use them? Any major burn injury circumferential to an extremity or body part will swell tightly Expect compartment syndrome, especially with circumferential third degree burns As you pour fluid (from the Parkland formula) into the patient, the burns become extremely tight Circulation becomes compromised This can happen several hours after fluid resuscitation

Complications of Edema Complications of edema may effect the ability of the chest to expand This may occur even in an intubated and ventilated patient Chest needs to be able to expand in order for good oxygen exchange to occur Escharotomies in the shape of a square are part of the solution

How is an escharotomy or fasciotomy performed? Physicians may use a scalpel Most use a device called a Bovie A Bovie is a cauterizing machine that simultaenously cuts and cauterizes Potential for bleeding is great during and post-procedure

How do you take care of escharotomies and fasciotomies? Escharotomies typically use the same burn creams prescribed for the area where they are performed Fasciotomies expose muscle; the key is to keep the muscle moist Fasciotomies usually use a non adherent dressing coated with Bacitracin ointment

Topical Wound Management There are many products out on the market for burn care The products and procedures used for a specific burn patient largely reflect physician preference

Silvadene White, antimicrobial cream Sulfa derivative (watch for patients with sulfa allergies!) Has silver Will turn grey on exposure to air May cause the patient to become neutropenic Applied after debridement

Silvadene application

Sulfamylon cream White, antimicrobial cream Diffuses through devascularized areas Typically applied to cartilage (on ears) Does not turn grey like silvadene

Acticoat Is a blue sheet with several layers Contains bactericidal concentrations of silver with patented nanocrystalline technology Smells like fish

Acticoat in Action

Algae Products Many on the market Kaltostat is one popular brand Typically algae is impregnated into dressing form Algae is sterilized and does not look green Used to absorb oozy secretions Donor sites

Debriding Creams Enzymatic debridement creams help debride necrotic tissue or eschar Will also debride good tissue Practitioner needs to be careful in applying These creams are painful! Good pain management is required Santyl is a common marketed brand

The Skin Were In! Deep partial thickness and full thickness burns often require grafting to heal There are different types of grafts: Autograft Homograft Heterograft

Autografts Patients own skin is used Skin is taken from a non-burned donor site Depending on the area to be covered, the autograft may be run through a meshing machine that stretches the autograft Healed area looks like mesh An autograft not run through a mesh is a sheet graft

Donor site for graphs Taken usually from the thigh

Autograft in Action

Sheet Graft Surgery

Donor site for sheet graft

Sheet graft in place

Cultured Epithelial Autografts CEAs Biopsy is taken from the non-burned skin of the patient Cells are grown over a period of 6 weeks to form skin Meshers help expand the CEAs to cover more area on the patient Really, really, really, really, really expensive!!!!!

Homografts/Allografts Terms for skin derived from deceased humans Used as temporary coverings of burn wounds Eventually rejected because of the bodys immune reaction Some homografts are not rejected

Heterografts/Xenografts Skin taken from animals used as a temporary covering for burns Usually pigskin is used Available from commercial suppliers Often, it is impregnated with a topical antibacterial ointment Normally it is rejected, but there have been cases where pigskin has remained on the patient

General Guidelines When autografts or CEAs are to be applied, you must make sure that the patients WBC count is considered to optimize graft take Autografts are left undisturbed for a few days to optimize take Sulfamylon liquid is spritzed over the grafted site Algae-based product is applied over donor site

What happens when you dont have skin to work with? Consider Integra an artificial skin composed of 2 layers: a silicone outer layer that acts as a person's epidermis and a porous matrix that replaces the dermis The porous matrix is biodegraded and reabsorbed The epidermal layer is removed and replaced with grafted skin

Summary We now know the difference between escharotomies and fasciotomies We have discussed different wound treatment options