Initial Care of Burn patients

Initial Care of Burn patient

Zakiyeh Jafary Parvar

Nursing Student

contents

1. Early management of major burn

2. Initial care of burn wound

3. Burn unit admission criteria

EARLY MANAGEMENT OF MAJOR BURN

As described by the American College of Surgeons Committee on Trauma, evaluation of burn patient is recognized into a primary survey and a secondary survey using modification of ATLS course.

primary survey :A – airway patencyB - breathingC – circulatory

The emphasis is on detection and treatment of threatening conditions.

A – airway patency :

Heat affects primarily the oral and nasal cavity , supraglottic area of the pharynx and causes edema and mechanical airway obstruction.

Assess airway , Intubate if necessary.

Definite indications for endotracheal intubation:

1. Deep facial burns – especially of the mouth and oropharynx

2. Massive body burns , especially in the presence of circumferential chest burn

3. Severe inhalation injury.

If the patient’s hemodynamic condition tolerates, elevation of the Head by 30 degrees is helpful in reducing neck and chest wall edema.

INHALATION INJURY SHOULD BE SUSPECTED IN ALL OF THE FOLLOWING SITUATIONS:

Individuals who sustained injury in a closed spacePatients with extensive burns or with burns of the facePatients who were unconscious at the time of injuryPatients with singed nasal and facial hair , horseness or wheezingPatients who are coughing up carbonaceous sputumExplosions with burn to head and torsoCarboxyhemoglobin level >10%

B – breathing :

is evaluated for depth of respiration and effort.

detection of Wheezing or rales suggests either inhalation injury with bronchospasm or aspiration of gastric contents.

C – circulatory is evaluated with :

1. pulse rate and blood pressure when indicated venous access is established with two wide bore intravenous lines in upper limbs in unburnt area.

2. Assess hemodynamic stability and perfusion by looking for evidence of impending burn shock.

3. Remove bangles and rings to avoid constriction and hand it over to relative.

4. Assessment of distal circulation for detection of compartment syndrome in in circumferential deep partial or full thickness burns of extremities and electrical injury.

5. Draw blood samples for basic investigation like BBVS, serum electrolytes like NA, K , Bun ,Cr, Potein , Albumin , hemoglobin, estimating blood group , ABG and clotting profile.

secondary survey :

The burn specific secondary survey should include:

D – Neurological disability :

Observe level of consciousness

All patient should be assessed for responsiveness with GCS.

They may be confused because of hypoxia or hypovolemia.

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E – Exposure with environment control :

Evaluate the patient from head to foot for other injuries like Spine and Abdomen.

Check for any concomitant injuries. Patients should be covered and warmed as soon as possible.

Check for other injuries like: chest (rib fractures ,pneumothorax,..)

Assess depth and size of burn while keeping the patient warm (remove wet clothes).

High tension (>1000 Volts) injury- look for cardiac abnormalities ,entrance and exit sites and other injuries.

F – Fluid resuscitation :

The resuscitation fluid prevented the development of burn shock and eliminated acute renal failure in the early post burn period.

This is based on the estimation of the burn area.

An estimate of fluid requirement during transportation is :

15-25% BSA = 500 ml per hour R/L

25-50% BSA = 750 ml per hour R/L

> 50 % BSA = 1 liter per hour R/L

Indication:

1. In children with superficial burns of more than 10% or deeper burns of less than 10%.

2. In adults with superficial burns of more than 15% or deeper burns of less than 15%.

Extend of burn

1. Lund and Browder

2. Wallace's “Rule of Nines”

3. Palm of the patient

Check the weight / approximate weight.

Intravenous analgesics.

Monitor-temperature, pulse, respiratory rate, Spo2.

Tetanus toxoid 0/5ml IM.

Tetglobe 250 units IM .

Secure two large bore intravenous line for >20%TBSA.

Start R/L infusion at desire rate.

Nursing note Although the doctor calculates the fluid

requirement according to the formula. It is the duty of nurse to adjust the rate of infusion to maintain the urine out put a 0/5 ml to 1 ml /kg/ hour.

Intravenous access :

Choices for venous access :

First choice : peripheral vein ; unburnt area

Second choice : central vein ; unburnt area

Third choice : peripheral vein ; burnt area

Worst choice : central vein ; burnt area .

The time frame of fluid resuscitation is to be calculated from the time of burn and NOT from the time of initiation of therapy.

Remember that fluid calculation is only a basic guideline and the best guideline to say that the fluid administered is correct is the hourly urine output.

Insert nasogastric tube.

Insert F/C to monitor U/O during transport.

INITIAL CARE OF BURN WOUND Once the resuscitation procedures have been initiated ,

the burn area has to be evaluated in detail for in extent and depth.

It is preferable to shift the patient to the specific dressing room where the wound can be managed with all aseptic procedures. the technique of dressings very important for the final outcome of burn wound treatment program.

Remove all the loose nonviable tissue with minimum trauma.

Management of blisters :

1. very small blisters (< 5 cm ) may be allowed to be kept intact.

2. Larger blisters ( > 5 cm ) run the risk of rupture at the time of initial dressing or else may get ruptured in odd situations and the burn wound gets contaminated.

3. Aspirate these blisters with a needle to allow the blister membrane to stick to the wound.

4. Wash the burn area with Normal Saline to remove all the debris.

5. Shave hair to prevent infection.

6. After cleansing , the wounds are dabbed dry with sterile gauze and then the appropriate method of wound dressing ( open method or closed method ) , is selected.

open method :

it is useful for burns of face and perineum which can not be adequately dressed.

Temperature must be in the range of 28 -32 c and humidity at about 40 %.

closed method ( occlusive dressing ) :

it is avoided in burns of face and neck and perineal burns.

Advantages : 1. Reduce evaporative losses2. Absorbs exudates from the wound surface3. Provides a mechanical barrier to prevent bacteria

from contaminating the wounds.4. Maintains most environment which encourages

epithelialization.5. Patient is more comfortable6. Provides splintage to joints thus preventing

contractures.

7. Apply topical agent , Wrap in sterile clean drape . Avoid hypothermia

Topical antibiotics :

Topical antimicrobial agents have been used for decades to successfully decrease the bacterial load in wounds.

A) Silver sulfadiazine (SSD ) : Is the most common broad spectrum topical cream. It is used to minimize bacterial colonization. It is very soothing and has broad antimicrobial coverage.

Advantages : 1. Easy to apply and causes minimal to no pain on application. 2. Bacterial resistance to SSD , even after prolonged therapy ,

has not been reported.

Disadvantages of Silver sulfadiazine:1. It Should not be used in patient who have sulfa

allergies.2. It turns a gray color.3. It impairs re - epithelialization.4. It causes brief leukopenia that occur 3-5 days

after the burn.5. A macular rash is seen in <5 % patients .

B ) mafenide (11/1%) : it is active against most gram + and wide spectrum of gram – organisms including Pseudomonas.

Advantages : I. It has the best scar penetrating ability.II. It is the most useful topical antibacterial

agent for control of established or incipient burn wound sepsis.

Disadvantages of mafenide :

I. Significant painII. Application of it can be limited to no more

than 20% the BSA at any on timeIII. maculopapular rash IV. Metabolic acidosis which results from its

carbonic anhydrase inhibiting effect which decreases the reabsorption of bicarbonate from the renal tubule.

V. Hemolytic anemiaVI. Inappropriate polyuria

Despite its disadvantages , mafenide is still the best topical agent for control of established burn wound infection.

Its use should be reserved for short duration of time and withdrawn before significant side effects become evident.

c) Mupirocin: It is a popular topical agent for MRSA infection. It can be used intravenously to treat of MRSA.

c.

D) Povidone –iodine solution : It is an antiseptic used to prepare surgical wounds. It has a broad spectrum of activity covering gram positive , gram negative bacteria, yeast and fungi . It can cause contact dermatitis

in large quantities in extensive burn , it can be absorbed in the blood.

E ) Bacitracin : Despite lack of efficacy against common

gram – negative burn pathogen , Bacitracin remains popular in burn care , particularly on partial- thickness face burn.

H – history :

the history about : Nature and extent of the burn Likelihood of inhalation injury Time of burn Depth of burn Probability of other injury Medical history Previous medical history and allergies and

vaccinations patient’s smoking habits.

Be kind to the patient and relatives. Communicate with the patient and be supportive.

Talk to the relatives and brief them about condition of the patient and allow them to see the patient.

Consider all burn cases as a medicolegal case(MLC).

Check for incident report and inform the hospital.

Obtain the address and telephone number of the relatives.

BURN UNIT ADMISSION CRITERIA

Patient who need admission to the burn unit are:

Partial thickness burn > 10%TBSA

Burns that involve the face , hands , feet , genitalia , perineum or major joints.

Full thickness burn in any age group.

Electrical burn.

Inhalation burns.

Chemical burns.

Burn injury in patient with pre-existing medical disorders.

Burned children in hospitals without qualified personel or equipment for the care of children.

Those with extremes of age.

Associated other trauma , medical condition.

Burns requiring fluid resuscitation.

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THANK YOU