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Burn Injuries
Andrew D. Beluso, RN
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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
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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
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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
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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
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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
9
189
18
9
18
1
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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
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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
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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
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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
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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
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PATHOPHYSIOLOGY OF BURNS
BURN
Vascular permeability
Cardiac output
Peripheral resistance
Viscosity
Hematocrit
IV volume
Edema
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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.
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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