BURN INJURIES

Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes. Burn size
1. Small burns: bodys response is localized to the injured area 2. Lar e or e!tensi"e burns: a. consist of 2#$ or more of the total body surface area %&BS'( b. bodys response to injury is systemic c. affect all of the major systems of the body Characteristics: 1. )inor Burns a. *artial thickness burns are no reater than 1#$ of the &BS' in the adult b. +ull thickness burns are , 2$ of the &BS' in the adult c. Burn areas do not in"ol"e the eyes- ears- hands- face- feet- or perineum d. &here are no electrical burns or inhalation injuries e. &he client is an adult youn er than ./ y.o. f. &he client has no pree!istin medical condition at the time of the burn injury . 0o other injury occurred 1ith the burn 2. )oderate Burns a. *artial thickness burns are deep and are 1#$ to 2#$ of the &BS' in the adult b. +ull thickness burns are 2$ to 1/$ of the &BS' in the adult c. Burn areas do not in"ol"e the eyes- ears- hands- face- feet- or perineum d. &here are no electrical burns or inhalation injuries e. &he client is an adult youn er than ./ y.o. f. &he client has no chronic cardiac- pulmonary- or endocrine disorder at the time of the burn injury . 0o other complicated injury occurred 1ith the burn 2. )ajor Burns a. b. c. d. e. f. *artial thickness burns are 3 2#$ of the &BS' in the adult +ull thickness burns are 3 1/$ of the &BS' Burn areas in"ol"e the eyes- ears- hands- face- feet- or perineum &he burn injury 1as an electrical or inhalation injury &he client is older than ./ y.o. &he client has a chronic cardiac- pulmonary- or metabolic disorder at the time of the burn injury . Burns are accompanied by other injuries

Estimating the extent of injury a. 4ule of nine b. Lund and Bro1der )ethod )odifies percenta es for body se ments acc. to a e *ro"ides a more accurate estimate of the burn size 5ses a dia ram of the body di"ided into sections- 1ith the representati"e $ of the &BS' for a es throu hout the lifespan Should be ree"aluated after initial 1ound debridement Assessment of Burn Injury: 6!tent 7 8e ree 'ssessment of 6!tent +irst 8e ree *ink to red: sli ht edema- 1hich subsides 9uickly. *ain may last up to :; hours. 4elie"ed by coolin . 4eparati"e *rocess <n about # days- epidermis peels- heals spontaneously. <tchin and pink skin persist for about a 1eek.

Sunburn is a typical e!ample.

0o scarrin . =eals spont. <f it does not become infected 17in 1/ days > 2 1eeks.

Second de ree Superficial: *ink or red? blisters form %"esicles(? &akes se"eral 1eeks to heal. 1eepin - edematous- elastic. Scarrin may occur. Superficial layers of skin are destroyed? 1ound moist and painful. Deep dermal: )ottled 1hite and red: edematous reddened &akes se"eral 1eeks to heal. areas blanch on pressure. Scarrin may occur. )ay be yello1ish but soft and elastic @ may or may not be sensiti"e to touch? sensiti"e to cold air. =air does not pull out easily &hird de ree 8estruction of epithelial cells @ epidermis and dermis destroyed 4eddened areas do not blanch 1ith pressure. 0ot painful? inelastic? coloration "aries from 1a!y 1hite to bro1n? leathery de"italized tissue is called eschar. 8estruction of epithelium- fat- muscles- and bone. 6schar must be remo"ed. Aranulation tissue forms to nearest epithelium from 1ound mar ins or support raft. +or areas lar er than 2># cm- raftin is re9uired. 6!pect scarrin and loss of skin function. 'rea re9uires debridement- formation of ranulation tissue- and raftin .

'A6 '08 A6064'L =6'L&= 1. )ortality rates are hi her for children , : y.o- particularly those , 1 y.o.- and for clients o"er the a e of ./ years. 2. 8ebilitatin disorders- such as cardiac- respiratory- endocrine- and renal d7o- ne ati"ely influence the clients response to injury and treatment. 2. )ortality rate is hi her 1hen the client has a pree!istin disorder at the time of the burn injury &B*6S C+ B540S '. &hermal Burns: caused by e!posure to flames- hot li9uids- steam or hot objects B. Chemical Burns: a. Caused by tissue contact 1ith stron alkali- or or anic compounds b. Systemic to!icity from cutaneous absorption can occur C. 6lectrical Burns: a. Caused by heat enerated by electrical ener y as it passes throu h the body b. 4esults in internal tissue dama e c. Cutaneous burns cause muscle and soft tissue dama e that may be e!tensi"eparticularly in hi h "olta e electrical injuries d. 'lternatin current is more dan erous than direct current because it is associated 1ith C* arrest- "entricular fibrillation- tetanic muscle contractions- and lon bone or "ertebral fractures 8. 4adiation Burns: caused by e!posure to 5D li ht- !>rays- or radioacti"e source <0='L'&<C0'L <0E54<6S '. Smoke inhalation injury results from inhalation of superheated air- steam- to!ic fumes- or smoke 'ssessment > facial burns > erythema

> s1ellin of oro 7 nasopharyn! > stridor- 1heezin and dyspnea > sooty sputum and cou h > a itation and an!iety

> sin ed nasal hair > flarin nostrils > hoarse "oice > tachycardia

B. Carbon )ono!ide *oisonin CC is colorless- odorless and tasteless as that has an affinity for = b 2// times reater than that of o!y en C2 molecules are displaced and carbon mono!ide re"ersibly binds to = b to form carbo!yhemo lobin can lead to coma and death C. Smoke *oisonin Caused by inhalation of by>products of combustion ' localized inflammatory reaction occurs- causin a decrease in bronchial ciliary action and a decrease in surfactant 'ssessment o mucosal edema in the air1ays o 1heezin on auscultation o after se"eral hours- slou hin of the tracheobronchial epithelium may occur- and hemorrha ic bronchitis may de"elop o '48S can result 8. 8irect &hermal =eat <njury Can occur to the lo1er air1ays by the inhalation of steam or e!plosi"e ases or the aspiration of scaldin li9uids Can occur to the upper air1ays- 17c appear erythematous and edematous- 1ith mucosal blisters and ulcerations )ucosal edema can lead to upper air1ay obstruction- esp. durin the first 2: to :; hours )onitored for air1ay obstruction- 6& intubation if obstruction occurs

=6)C8B0')<C 7 SBS&6)<C C='0A6S '. <nitially hyponatremia and hyperkalemia occur. +ollo1ed by hypokalemia as fluid shifts occur and FG is not replaced. B. &he hematocrit le"el increases as a result of plasma loss? this initial increase falls to belo1 normal at the 2rd to :th day postburn as a result of the 4BC dama e and loss at the time of injury. C. <nitially- the body shunts blood from the kidneys- causin oli uria? then the body be ins to reabsorb fluid- and diuresis of the e!cess fluid occurs o"er the ne!t days to 1eeks. 8. Blood flo1 to the A<& is diminished- leadin to intestinal ileus and A< dysfunction. 6. <mmune system function is depressed- resultin in immunosuppression and thus increasin the risk of infection and sepsis. +. *ulmonary hypertension can de"elop- resultin in a decrease in the arterial C2 tension and a decrease in lun compliance. A. 6"aporati"e fluid losses throu h the burn 1ound are reater than normal- and the losses continue until complete 1ound closure occurs =. <f the intra"ascular space is not replenished 1ith <D fluids- hypo"olemic shock and ultimately death 1ill occur. MANAGEMEN !" #E BURN INJUR$ %hases of Management of the Burn Injury

Emergent phase be ins at the time of injury and ends 1ith the restoration of capillary permeability- usually at :;>H2 hours after the injury the 1I oal is to pre"ent hypo"olemic shock and preser"e "ital or an functionin includes prehospital care and emer ency room care Resuscitative phase be ins 17 the initiation of fluids and ends 1hen capillary inte rity returns to near normal le"els and the lar e fluid shifts ha"e decreased the amount of fluid administered is based on the clients 1ei ht and e!tent of injury most fluid replacement formulas are calculated from the time of injury and not from the time of arri"al at the hospital > the oal is to pre"ent shock by maintainin ade9uate circulatin blood "olume and maintainin "ital or an perfusion Acute phase be ins 1hen the client is hemodynamically stable- capillary permeability is restored- and diuresis has be un usually be ins :; > H2 hours after the time of injury emphasis durin this phase is placed on restorati"e therapy- and the phase continues until 1ound closure is achie"ed the focus is on infection control- 1ound care- 1ound closure- nutritional support- pain mana ement- and physical therapy Rehabilitative phase final phase of burn care o"erlaps the acute care phase and oes 1ell beyond hospitalization oals of this phase are desi ned so that the client can ain independence and achie"e ma!imal function

+L5<8 46S5SC<&'&<C0 <ndications: - 'dults 1ith burns in"ol"in more than 1#$ > 2/$ &BS' - Children 1ith burns in"ol"in more than 1/>1#$ &BS' - *atients 1ith electrical injury- the elderly- or those 1ith cardiac or pulmonary disease and compromised response to burn injury &he amount of fluid administered depends on ho1 much intra"enous fluid per hour is re9uired to maintain a urinary output of 2/ > #/ ml7hr Successful fluid resuscitation is e"idenced by: - Stable "ital si ns - *alpable peripheral pulse - 'de9uate urine output - Clear sensorium 5rinary output is the most common and most sensiti"e assessment parameter for cardiac output and tissue perfusion <f the = b and =ct le"els decrease or if the urinary output e!ceeds #/ml7hr- the rate of <D fluid administration may be decreased Aenerally- a crystalloid %4in ers lactate( solution is used initially. Colloid is used durin the 2nd day %#$ albumin- plasmate or hetastarch(

Brooke and *arkland %Ba!ter( +luid 4esuscitation +ormulas for 1st 2:hrs after a Burn <njury +ormula Solution <nfusion 4ate

B4CCF6 2ml7k 7$ BS' G 2///ml72:hr %maintenance(

J crystalloid- K colloid 8#L maintenance

M in 1st ; hours M in ne!t 1. hours

*'4FL'08 %Ba!ter( :ml7k 7$ BS' for 2:hr period

crystalloid only %lactated 4in ers(

M in 1st ; hours M in ne!t 1. hours

*'4FL'08 +C4)5L' 6!ample: *atients 1ei ht: H/ k ? $ &BS' burn: ;/$ 1st 2: hours: :ml ! H/k ! ;/$ &BS' N 22-://ml of lactated 4in ers 1st ; hours N 11-2// ml or 1-:// ml7hour 2nd 1. hours N 11-2// ml or H// ml7hour 2nd 2: hours: /.#ml colloid ! 1ei ht in k ! &BS' G 2///ml 8#L runs concurrently o"er the 2: hour period /.#ml ! H/k ! ;/$ N 2;// ml colloid G 2/// ml 8#L N 11H ml colloid7hour G ;: ml 8#L7hour *'<0 )'0'A6)60& 'dminister morphine sulfate or meperidine %8emerol(- as prescribed- by the <D route '"oid <) or SC routes because absorption throu h the soft tissue is unreliable 1hen hypo"olemia and lar e fluid shifts are occurrin '"oid administerin medication by the oral route- because of the possibility of A< dysfunction )edicate the client prior to painful procedures 05&4<&<C0 6ssential to promote 1ound healin and pre"ent infection )aintain nothin by mouth %0*C( status until the bo1el sounds are heard? then ad"ance to clear li9uids as prescribed 0utrition may be pro"ided "ia enteral tube feedin - peripheral parenteral nutrition- or total parenteral nutrition *ro"ide a diet hi h in protein- carbohydrates- fats and "itamins 6SC='4C&C)B ' len th1ise incision is made throu h the burn eschar to relie"e constriction and pressure and to impro"e circulation *erformed for circulatory compromise resultin from circumferential burns 'fter escharotomy- assess pulses- color- mo"ement- and sensation of affected e!tremity and control any bleedin 1ith pressure *ack incision ently 1ith fine mesh auze for 2: hours after escharotomy- as prescribed 'pply topical antimicrobial a ents as prescribed +'SC<C&C)B 'n incision is made- e!tendin throu h the SO tissue and fascia *erformed if ade9uate tissue perfusion does not return after an escharotomy *erformed in C4 under A'- after procedure assess same as abo"e LC508 C'46 1. &he cleansin - debridement and dressin of the burn 1ounds 2. =ydrotherapy a. Lounds are cleansed by immersion- sho1erin or sprayin

b. Cccurs for 2/ minutes or less- to pre"ent increased sodium loss throu h the burn 1ound- heat loss- pain and stress c. Client should be premedicated prior to the procedure d. 0ot used for hemodynamically unstable or those 1ith ne1 skin rafts 2. 8ebridement a. 4emo"al of eschar to pre"ent bacterial proliferation under the eschar and to promote 1ound healin b. )ay be mechanical- enzymatic or sur ical c. 8eep partial> or full>thickness burns: Lound is cleansed and debrided and topical antimicrobial a ents are applied once or t1ice daily Cpen )ethod Dersus Closed )ethod of Lound Care )ethod 'd"anta es 8isad"anta es

C*60 'ntimicrobial cream applied Disualization of the 1ound <ncrease chance of and 1ound is left open to the air 6asier mobility and joint 4C) hypothermia from e!posure 17o a dressin Simplicity in 1ound care 'ntimicrobial cream is applied e"ery 12 hrs CLCS68 Aauze dressin s are carefully 8ecreases e"aporati"e fluid 1rapped from the distal to the and heat loss pro!imal area of the e!tremity to 'ids in debridement ensure circulation is not compromised 0o 2 burn surfaces should be allo1ed to touch? can promote 1ebbin of di its- contracturesand poor cosmetic outcome 8ressin s are chan ed e"ery ; @ 12 hours

)obility limitations *re"ents effecti"e 4C) e!ercises Lound assessment is limited

&C*<C'L '0&<)<C4CB<'L 'A60&S +C4 B540S Sil"er sulfadiazine )ost 1idely used a ent and least common incidence of side effects )ay cause transient leukopenia that disappears 2>2 days of treatment 5se 1ith either open treatment- li ht or occlusi"e dressin s 'pplied once or t1ice daily after thorou h 1ound cleansin )afenide acetate 1/$ cream or #$ solution %Sulfamylon( *ainful durin and for a 1hile after application )ay cause metabolic acidosis- not used if 32/$ &BS' Cream must be reapplied 12 hours to maintain therapeutic effecti"eness Solution concentration is maintained 1ith bulky 1et dressin s- re1et e"ery 2>: hours Sil"er nitrate %/.#$ solution( Stains e"erythin includin normal skin bro1n or black )onitor electrolyte balance carefully Cther topical dressin s

Cerium nitrate *o"idone iodine Aentamycin *olymi!in B @ Bacitracin ointment

LC508 CLCS546 *re"ents infection and loss of fluid *romotes healin *re"ents contractures *erformed on the #th to 21st day- dependin on the e!tent of the burn '5&CA4'+&<0A *ermanent 1ound co"era e Sur ical remo"al of a thin layer of the clients o1n unburned skin- 1hich is then applied to the e!cised burn 1ound )onitor for bleedin follo1in the raft because bleedin beneath an auto raft can pre"ent adherence <mmobilized after the sur ery for 2>H days to allo1 time to adhere and attach to the 1ound bed Care of the raft site Care of the donor site &6)*C4'4B LC508 CCD64<0AS Biolo ical 'mnion 'mniotic membranes from human placenta 8ressin is chan ed e"ery :; hours 'llo raft %=omo raft( 8onated human cada"er skin is har"ested 17in 2: hrs after death )onitor for 1ound e!udate and si ns of infection 4ejection can occur 17in 2: hours Peno raft %=etero raft( *orcine skin is har"ested after slau hter and preser"ed 4ejection can occur 17in 2: @ H2 hours 4eplaced e"ery 2># days until the 1ound heals naturally or until closure 1ith auto raft is complete Biosynthethic and synthetic Disual inspection of 1ound is possible- as dressin s are transparent or translucent )onitor for 1ound e!udate and si ns of infection &B*6S C+ SF<0 A4'+&S S*L<& &=<CF06SS Araft half of the epidermis? applied in sheets or posta e stamp>like pieces +5LL &=<CF06SS Araft consistin of epidermis and dermis? commonly used for reconstructi"e sur ery months or years after the initial injury *68<CL6 +L'* Commonly used for reconstructi"e sur ery months or years after the initial injury C5L&5468 6*<&=6L<5) 5sed of the clients unburned skin

Feratinocytes are isolated and epithelial cells are cultured in a laboratory? these cells are then attached to the burn 1ound

#E BURNE& C#I'& *ediatric 8ifferences: 1. Dery youn children 1ho ha"e been se"erely burned ha"e a hi her mortality rate than older children and adults 1ith comparable burns 2. Lo1er burn temperatures and shorter e!posure to heat can cause a more se"ere burn in a child than in an adult because a childs skin is thinner. 2. Se"erely burned children are at increased risk for fluid and heat loss- dehydration- and metabolic acidosis than an adult. :. &he hi her proportion of body fluid to mass in children increases the risk of cardio"ascular problems. #. Burns in"ol"in more than 1/$ of &BS' re9uire some form of fluid resuscitation .. <nfants and children are at increased risk for protein and calorie deficiency because they ha"e smaller muscle mass and less body fat than adults H. Scarrin is more se"ere in a child ;. 'n immature immune system presents an increased risk of infection Q. ' delay in ro1th may occur follo1in a burn 6P&60& C+ B54068 <0E54B *'4FL'08 +C4)5L' +C4 +L5<8 46S5SC<&'&<C0 : ml 4in ers lactate solution ! k b1 ! $ &BS' burned M of the total fluid is administered in the 1st ; hours postburn K of the total fluid is administered in the 2nd ; hours postburn K of the total fluid is administered in the 2rd ; hours postburn &ime is calculated from the time of injury- not the time of admission to the hospital &he criterion for successful burn- shock- and fluid resuscitation is a urine output of 1ml7k 7hr in children

R Burn 1ound care and closure is similar to adults