Metropolitan Community College Fall 2013 Jane Miller, RN MSN

Metropolitan Community CollegeFall 2013

Jane Miller, RN MSN

Objectives• Identify clinical manifestations of depth of burn injuries: superficial,

partial thickness, and full thickness and treatment modalities.• Define importance of assessment skills and gathering of important

data in determining treatment in the emergent phase of burns.• Identify burn etiology and significance in treatment• Identify vascular changes resulting from burn injuries including fluid

shifts, electrolyte changes, gastrointestinal involvement, cardiac, pulmonary, skin, metabolic changes, and immunologic changes.

• Identify prioritization of treatment of burns from emergent phase, acute phase, and rehabilitative phase of burn injury.

• Compare and contrast the Browder-Lund chart and Rule of Nines chart in calculating total body surface area(TBSA) in a burn injury.

• Apply the Parkland Formula together with the TBSA in establishing correct fluid replacement in the emergent phase

• Identify airway management in burn injury

• Identify compensatory responses to burn injury• Evaluate laboratory profiles during the emergent phase of burn

injury.• Identify the role of burn centers.• Identify surgical management of burn injury.• Identify pain management in burn injury and treatments.• Define prevention of infection interventions.• Identify would care management to include debridement,

dressings, and types of grafts.• Compare and contrast types of grafts available.• Identify nutrition requirements in burn injury.• Identify nursing interventions for prevention of complications such

as patient position, range of motion, ambulation, pressure dressings, and post-op cares utilized to prevent complications of burns.

• Identify research in the burn realm that may affect future burn interventions.

• Identify current/future therapies in the treatment of burn patients.

Burns are…• Traumatic• Painful• Dehumanizing• Embarrassing• Holistic• Disfiguring• Incapacitating• Fatal

Burn Statistics• 450,000 people received treatment for

burn injuries in 2011• 55% of the 450,000 injuries were

admitted to one of the 125 burn centers in the United States

• 70% of burn center admissions were male• The survival rate of those admitted to a

burn center was 96%• There were 3,500 fire/burn related deaths

Burn Survivor Resource Center, 2013

Burns and Children• 85% of fires that injure or kill children occur

in a residence• 2/3 of residential fires that result in the

death of a child occur in homes without a working smoke detector

• Fires kill more than 600 children per year and 47,000 are injured but survive.

• Scald and contact burns are the most common cause of burn-related injuries in children 4 years old and underBurn Survivor Resource Center, 2013

Burn Etiology• Burn injuries occur when there is direct

or indirect contact with a heat sourceo Electrical wiring, hot liquid, lightning, sun, caustic chemicals, fire

• No matter the cause, the burn injury results in loss of skin integrity

• Inhaling smoke causes injury to the lung known as an inhalation injury

Types of Burns• Thermal

o Most often from fireo Extent depends on the length of exposure and temperature of

the heat source

• Scaldo Type of thermal burn caused by hot food or liquido Extent depends on the length of exposure and temperature of

the heat source

• Electricalo Tend to be deeper than other burnso Extent depends of amount of voltage, length of exposure, type

of current, pathway of flow, and local tissue resistanceo Difficult to assess damage

• Radiationo Result from overexposure to the sun, radiation treatment,

industrial accidentso Extent depends on how close the individual was to the

source and length of exposure

• Chemicalo Occur when the skin contacts a caustic agento Extent depends on length of exposure

• Inhalation Injuryo Result from inhaled smoke and heated airo The majority of deaths from burn injuries are due to

smoke inhalationo Signs include: burns to the face and neck, singed nasal

hair, dry cough, bloody/sooty sputum, labored respiration

Burn Prevention• Keep matches and lighters out of children’s

reach• Set water heater no higher than 120o F• Lock up chemicals• Limit exposure to the sun and wear

sunscreen• Have a working smoke detector in the home• Don’t overload electrical circuits• Properly extinguish cigarettes and never

smoke in bed• Have an escape plan• Community education

Pathophysiology • When damage occurs there are 3 distinct

zones of injuryo Zone of coagulationo Zone of stasiso Zone hyperemia

Pathophysiology• Immediately after the injury third spacing

begins• Edema develops in unburned tissue and

organs away from the site of injury• This process starts at the time of injury,

peaks in 12 to 24 hours, and continues for 49 to 72 hours

Decreased Blood Volume

Decreased Cardiac Output

Decreased Venous Return

Decreased Stroke Volume

Decreased Tissue Perfusion

Vascular Dilation

• Cardiaco Heart failure o Dysrhythmias and cardiac arrest from the

release of potassium• Pulmonary

o Pulmonary edema• Gastrointestinal

o Decreased motility and nutrient absorption due to shunting of blood

o Paralytic ileuso Stress gastritis and ulcerations

• Renal o Decreased urine outputo Renal failure from blocked renal tubules

• Immuneo Impaired immune functiono Increased risk of developing opportunistic

infection and death• Integumentary

o Fingerprints may be losto Permanent loss of hair growth, perspiration,

and sensory abilitieso Impaired temperature control and protection

from infection

Emergency Phase• Begins with the injury and last 2 to 3 days• Goals

o Maintain an airwayo Treatment of concurrent injurieso Correcting fluid imbalanceso Preventing infectiono Conserving body heato Relieving paino Emotional support

Burn Centers in NE• Acute care

o The Nebraska Medical Centero Saint Elizabeth Community Health Center

• Rehabilitationo Madonna Rehabilitation Hospital

Initial Treatment• Remove the source of injury if possible• ABCDEF• Apply clean saline soaked towels• Copious irrigation of chemical burns• Apply a clean blanket• Do not use oils or salves• Give a tetanus shot

ER• Airway assessment and possible intubation• ABGs, CBC, BMP, BUN, BS, Coags• 12-lead ECG• Carotid and peripheral pulses• VS• Place 2 large bore IVs• NG tube• Assess concurrent injuries• Maintain body temperature• Prevent infection• Provide emotional support• Assess the burn

Treatment Plan• Based on five factors

o Size of the injuryo Depth of the injuryo Age of the patiento Past medical historyo Part of the body burned

Rule of Nines• Size is expressed as a percent of the total

body surface areao Head and neck = 9%o Each arm = 9%o Each leg = 18%o Trunk = 36%o Perineum = 1%

= 100%

Lund-Browder Formula

• Also assess burn size • Divides the body into smaller percentage

areas• Considered more accurate, especially for

children

Question

Burn Depth• Partial thickness

o 1st and 2nd degreeo Partial destruction of skin layerso Enough epithelial cells, hair follicles, and

sweat glands remain to provide a new dermiso Heal spontaneously in 2 weeks to 21 dayso Little to no scar or contracture formationo Characterized by:• Pink or white, pain, blanchable, thick walled

blisters, firm texture

Burn Depth• Full thickness

o 3rd degree, involves all skin layers, subcutaneous tissue, muscles, and bone

o 4th degree, some say burns that involve muscle and bone are actually 4th degree

o Requires grafting o Characterized by:• White or charred black, waxy, not

blanchable, charred vessel visible, no pain, no blisters, dry and leather like

Age• The very young and the elderly have the

highest mortality rates due to burn injuries

• Under 2 yrs of ageo Immature immune systemo High body surface area per body mass.

• Elderlyo Burns exacerbate previous medical problemso Less physiological reserves

Past Medical History• Cardiac• Respiratory• Renal• Endocrine• Substance abuse

All decrease the rate of survival

Area Burned• Burns to the head, neck, and chest are

more serious due to pulmonary complications

• Burns in the perineum and upper thigh are more prone to infection

• Burns to the hands, face, and neck require special care for both physical and psychological reasons

A general rule of prognosis

If the age of the patient + the percent of the body burned = more than 100

there is little chance for survival

65 yr old + 50% burned = 115

This patient has little chance of survival

Medical Management• Fluid resuscitation

o 0.9% NaCl or Lactated Ringerso Once stabilized begin colloidso Parkland formula

• 4ml/kg x % TBSA of burn = replacement volume• ½ given in first 8 hours, ¼ in second 8 hours, and ¼

in the third 8 hours

Example: 100kg male burned over 25% of his body

4 x 100 x 25 = 10000 ml

Fluid Resuscitation Assessment

• Monitoro Mental statuso Skin color and temperatureo Heart rateo Blood pressureo Urine outputo Specific gravityo CVPo H & Ho GI function

Pain Management• Opioids such as morphine, fentanyl, and codeine

are given on a non-pain-contingent schedule• Additional narcotics are given before dressing

changes• IM needs to be avoided due to poor absorption• Anti-anxiety meds need to be given as well• Start on stool softeners

Proper pain management is essential for improved healing

Acute Phase• Begins when the patient is hemodynamically

stable and ends with wound closure• Goals

o Wound cleansing and healingo Pain reliefo Maintaining body temperatureo Preventing infectiono Promoting nutritiono Splintingo ROM

Wound Care• Clean the burn with chlorhexidine gluconate and

gauze pads to remove dead tissue and debris• Wound debridement removes further loose tissue

and eschar• Fasciotomy may need to be performed in order

to restore blood flow to a limb• Apply temporary dressing

o Xenograft (pigskin)o Allograft (cadaver skin)o Biosynthetic dressingso Synthetic Dressings

Skin Grafting• Full thickness skin graft

o Entire thickness of skin down to the subcutaneous tissue is excised

o Use for areas that need thicker covering to prevent breakdown or improved cosmetic result• Palm of hand, bottom of foot, joints, face

o Less common• Split-thickness skin graft

o Partial layer of skin is harvested with a dermatomeo Is either used as a sheet or meshedo Most common skin graft

Maintaining Mobility• Splinting and a ROM exercise plan is

essential to maintaining function and motility

• Exercise begins on admission and goes until the scars are matured

• PT and OT are essential members of the care team

Nutrition• Burn patient experience extreme

metabolic stress• Their resting energy expenditure can

increase by as much as 150%• Oral route is preferred• Enteral and parental nutrition may be

required

Rehabilitative Phase• Begins when less than 20% of the wound is

open• Emphasis is on physical and psychological

restorative therapy• Treatments include:

o PT/OTo ROM exerciseso Increased strength and enduranceo Pain managemento Nutritiono Cosmetic reconstructiono Psychological care

Resources• Osborn, Wraa & Watson chapter 68• Burn Survivor Resource Center

o http://www.burnsurvivor.com/• Split thickness skin graft video

o http://www.youtube.com/watch?v=pvbxmm9inoo