3-26-08 Mrs.

Batton

Burns
Goals related to Burns

• Prevention

• Lifesaving measures for the severely burned

• Early, individualized and specialized treatment to prevent disability and

disfigurement

• Rehabilitation through reconstructive surgery and rehab programs

Outlook for persons with burns

• > 70 years of age, are surviving burns of 30% TBSA burns

• 60-70 years of age, are surviving 50% TBSA burns

• 20-30 years of age, are surviving 80% TBSA burns

• 2-5 years of age, are surviving 75% TBSA burns

• Best survival over age of 5 under age of 40

• Best survival rate if no pulmonary involvement

Categories

• Thermal (includes electrical burns)

o Water burns (130 degree water only takes 15 seconds to cause full
thickness burn-dermis and epidermis destoyed)

• Radiation

• Chemical

• Tissue destruction=skin and mucous membranes (typically)

• How deep a burn ends up being depends on temperature of burning agent

and amount of time burning agent is in contact with the skin

Classification

• Depth of burn injury

o Dermis, epidermis, organs, etc.

• How much of the body surface is burned (total surface body area) TBSA

• Superficial partial thickness burn-similar to what is known as first degree burn

o epidermis and a little bit of dermis

o Usually caused from low intensity flash burn or sun burn

o Skin blanches and color comes back rapidly=good blood flow

o May have little blisters or skin can be really dry

• Deep partial thickness-similar to second degree

o Destruction of epidermis and dermis and even deeper layers of the

dermis

o Usually caused by scalds or flash flame

o Very pain

o Sensitive to cold air-keep covered

o Usually blistered or molttled- red, usually very edematous, may leak

fluid

o Do have capillary refill after blanching=good blood flow

o Not deep enough to burn hair follicles

o May result in hypertrophic scars

o Usually takes a couple of weeks

o Skin may be a different color

o If infection occurs may convert to full thickness burn

• Full Thickness burn

o Similar to 3rd degree

o Involves epidermis, dermis, and tissue, and bone

o Caused by flame or prolonged exposure to hot surface, chemicals, and

electrical current

o No pain due to deepness and destruction of nerve endings

o But other areas w/o full thickness hurt

3-26-08 Mrs. Batton

o Remember with electrical burns-look for entrance and exit

 Degree of exit wound depends on voltage

 Be concerned about trauma-can have fractures or c-spine

injuries due to voltage

Total body surface area

• Rule of nines-quick and easy- KNOW THIS

o Head (all of it) = 9%

o One arm = 9% both 18%

o Torso (anterior=18%) posterior 18%

o Genitals 1 %

o Each leg 18%

• Lund and Browder-more precise and time consuming (don’t have to know
how to do this)

• Palm method-good for scattered burns

o Take size of patients palm=1% used to measure size of burn

Initial Local Response to Burns

• Usually only a local response if burn is less than 25% TBSA

o Usually doesn’t affect cardiovascular response

o Will see a lot of edema at site due to destroyed capillaries

o If trapped in room breathing hot air might have pulmonary problems

• TBSA greater than 25% may have local and systemic response and are
considered major burns

• OVER 60% major systemic response

Systemic response to major burns

• Occurs due to release of cytokines and other mediators into the systemic
circulation

• The release of local mediators and changes in blood flow, tissue edema, and
 infections can cause progression of the burn injury

• End up with systemic hemodynamic instability

• Phase 1-decreased tissue perfusion due to decreased blood supply

(hypoperfusion of major organs-due to fluids leaving vessels therefore not
making it to heart and lungs) this is when patients die after major burn. MUST
MAINTAIN ADEQUATE PERFUSION TO MAJOR ORGANS

Systemic cardiovascular response

• Hypovolemia due to fluid loss

• Decreased perfusion and oxygen delivery

o Sats dropping

o Rapid, shallow respirations

• Cardiac output drops even before blood pressure

o Heart rate increases

• Vascular volume continues to decrease

• Even though we may be putting in IV fluids, its going into the tissue, but
continue to giving IV fluids

• Continued decreased cardiac output

• Decreased B/P (now you have burn shock)

C/V Response after onset of burn shock

• Release of catecholamines=increase in peripheral vascular

resistant=vasoconstriction

• Keep pumping in IV fluids

• Look at algarythm in 1708

• Increased pulse rate

• Capillaries begin to regain integrity

o Will see more stable blood pressure, easier to maintain

• Fluid returns to vascular compartment

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o Decrease IV fluid rate

• Blood volume increases

• Usually greatest volume of fluid lost is between 6 to 8 hours and continue to

lose some up to 24 and 36 hours

• Dieresis and will continue for 2 weeks unless kidneys are not perfused
(dialysis

Systemic Edema

• Can be massive

• Usually maximal after 24 hours

• Begins to resolve in 1-2 days post injury

• Circumferential burns can result in compartment syndrome and may require

escharotomy due to eschar (escharotomy on extremeties and around the
chest)

Systmeic effects of fluid electrolytes and blood volumes

• Circulating blood volume decreases

• Cardiac output decreases

• Serum sodium level decreases due to fluid leaving capillaries

• Serum potassium level increases immediately after injury due to cells losing
integrity, later on it may decrease

• Hemoconcentration – thick blood

• 11-12L of fluid in adult 6L is blood and 3L is plasma

• Increased blood viscosity

• Anemia

• Hematacrit may be elevated due to loss of plasma

• Thrombocytopenia due to decreased platelets causes clotting issues

• Prolonged clotting times

• Decreased urine output due to poor kidney perfusion

 • Metabolic acidosis

Pulmonary response

• Leading cause of death in fire victims

• Inhalation injury negatively impacts survival of burn client

• 1/3 of all burn victims have pulmonary injury

• Deterioration of burn client may occur without evidence of smoke inhalation

• Anyone with possible pulmonary involvement must be observed for 24 hours

may take 48 hours to show signs on pulmonary involvement

Indicators of pulmonary problem

• Dyspnea, Tachypnea

• Singed nasal hair-always indicates pulmonary problem

• Burn that occurred in enclose area

• Burns of face and neck

• Hoarseness, dry cough

• Bloody sputum

• Blistering of oral or pharyngeal mucosa

• Carbonatious sputum (black stuff)

Categories of Pulmonary Injuries

• Upper airway injury

• Inhalation injury below the glottis (includes carbon monoxide poisoning)

• Restrictive defects

Upper airway injury

• Results from direct heat or edema

• Mechanical obstruction of the upper airway (includes the pharynx and larynx)

• Treated by early nasotracheal or endotracheal intubation

Inhalation injury below the Glottis

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• Results from inhaling the products of incomplete combustion or noxious

gases

• Leads to chemical irritation of pulmonary tissue at alveolar level

• Cardinal sign (expectoration of carbon particles)

• Impaired gas exchange

• Carbon monoxide poisoning needs 100% oxygen

Restrictive pulmonary injury

• Escharotomy

Other Systemic Response

• Altered renal function due to inadequate perfusion and free hemoglobin

o Acute tubular necrosis

• Decreased resistance to infection. Sepsis remains leading cause of death in

burn victims

• Inability to regulate body temperature

• Not unusual for burn victims to have decreased body temperature –warm IV
fluids, then they might spike a temp due to hypermetabolism

• Paralytic ileus-NG tube

• Curling’s ulcer-protonix to decrease acidity of secretions in stomach

Phases of burn care

• Emergent /resuscitative phase

o From onset to completion of fluid resuscitation

o On the scene care-the burn is not the first priority (fire-make sure you
don’t get burned and no one else gets burns)

o Must first prevent injury to the rescuer

o Then airway, breathing, circulation for the victim-cervical spine

immobilization for all high voltage electrical injuries or otherwise
indicated and cardiac monitoring

o At the scene continued

  Assess circulatory, apical pulse and blood pressure

 Assess neurological status

 Secondary head to toe survey to determine other life

threatening problems

 Establish large bore IV access

 Cool, cover the wound

 NOTHING by mouth

o IN the ER

 Assure ABC’s

 Assure IV access

 Fluid resuscitation is initiated

 Obtain baseline vital signs, ht, wt, ABG’s, electrolytes

 Pain control

 IF TBSA > 25% insert NG tube for decompression

 Check/ Remove contact lenses

 Insert foley

 Tetanus injection

 Obtain history (enclosed area) of the accident

 When stable can then treat the burn itself

 Assess and clean the burn

 Reassure client and family

 Management of fluid loss and shock

o Hemodilution

o Increased urinary output (hopefully)

o Sodium deficit- due increased fluid

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o Potassium deficit- going back into the cells

o Metabolic acidosis

• Survival depends on adequate fluid resuscitation

• Next to respiratory problems the most urgent need is to

prevent irreversible shock

• Common formulas

o Consensus formula

 2-4ml. X kg. wt. X TBSA

o Evan’s formula

o Brooke army formula

o Parkland Baxter formula

o Hypertonic saline formula

• Assessment of fluid replacement

o Urine output

o Systolic greater than 100

o Heart rate less than 100

o H &H and serum sodium level

o Diagnosis

 Gas exchange

 Airway clearance

 Volume deficit

 Hypothermia

 Respiratory failure

 Pain

• Acute/intermediate phase

o From beginning of dieresis to near closure of wounds

o Begins 48-72 hours after burn

o Assessment and maintenance of respiratory, circulatory status, fluid

and electrolytes and GI function

o Temperature management

o Pain control-give plenty of morphine if they are on a ventilator

 Often very severe pain- it is intense and of long duration

 Partial thickness have exposed nerve endings with severe pain

when exposed

 With full thickness margins of wound are hypersensitive and

regenerating nerves become entrapped in scar tissue

 IV Morphine is Drug of choice- titrated to pain relief

 Fentanyl goo for procedural pain monitor cardiac and respiratory

o Nutritional support

 Hypermetabolism

 Must provide adequate nutritional support and calories to

decrease catabolism

 Must provide a state of positive nitrogen balance by matching

nutritional utilization to nutritional support

 Enteral feedings are superior to parenteral feedings

 High protein, high calorie, and have supplements if oral route

 Risk of curling’s ulcer continues in acute phase

o Infection prevention

 Septic shock is major cause of death in clients who have

survived the first few days post major burns

 Primary source of bacterial infection is the clients intestinal tract

• Tube feed as soon as they have bowel sounds to prevent

septicemia

 Wound is also cause of infection

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 The environment is also source of secondary infection

o Topical antibacterial agents

 Silver sulfadiazine 1% (silvadene)

• Most bactericidal

• Poor eschar penetration

• Observe for leucopenia 2-3 days after initial treatment

(resolve after that)

• Soothing

• Remove proteinaceous gel after 72 hours

• Apply 1-3 times a day

 Sulfamylon

• Good against gram negative and positive organisms

• Goes through eschar

• 10% best for burns

• Monitor for acidosis

• Always premedicate, very painful, severe burning pain for

up to 20 minutes after application. May leave wound
open

 Silver nitrate- turns everything colors

• Bacteriostatic and fungicidal

• Does NOT penetrate eschar

• Monitor sodium and potassium

• Protect bed linen

• Apply to gauze/ cover wound/ remoisten every 2 hours

and redress 2 times a day

 Acticoat

• Effective against gram negative and positive

 • Silver based

• Delivers a uniform application of silver to wound

• Moisten with sterile water ONLY- NEVER use normal saline

• Apply to wound and cover

• Can leave in place 3-5 days or up to 7 days

o Wound Care

 Hydrotherapy

• May be with showers or total immersion

• Make sure tubs are decontaminated

• Temperature of water = 100 degrees

• Temperature of room =80-85 degrees

• Limit to 20-30 minutes, very stressful

• Pre-medicate them before treatment

 After cleaning burned areas pat dry lightly

• Topical agent applied with dressing

• Light dressing over joints to allow mobility

• Circumferential dressings go from distal to proximal

• Do not let open skin touch open skin-wrap fingers and

toes individually

• Occlusive dressings- frequently used with skin grafts

• Pre medicate always

 Wound debridement

• To remove contaminated tissue to prevent spread of

bacteria, remove devitalized tissue or eschar in
preparation for grafting

• Types
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o Natural-dead tissue separates liquefies

o Mechanical

o Surgical

 Wound Dressings/ Grafts

• Biological dressing

o Homografts (allografts)-obtained from living or

recently deceased humans

o Heterografts –skin taken from animals, usually pigs

• Biosynthetic (Biobrane)

o Semitransparent and sterile

o Protects wound from evaporative loss and bacteria

o Silastic membrane combined with collagen

derivative

o Can remain in place 3-4 weeks

o Not to be used over necrotic or infected wounds

• Dermal Substitutes (Integra and Alloderm)

o Integra

 Less hypertrophic scarring

 Minimal contracture formation

 After 203 weeks outer silicone removed and

replaced with thin epidermal graft of patients
skin

o Alloderm

 Processed dermis from cadaver

 Permanent dermal layer replacement

 Less scarring

• Autografts
 o Preferred material for burn wound closure following
excision

o Are clients own skin and will not be rejected

o Position and turn carefully to prevent dislodgement

o Dressing removed in 3-5 days unless s/s of

infection before

o Donor site must be kept clean, dry and free of

pressure

o Disorders of Wound healing

 Hypertrophic scars

• Wear compression garments keep scars from forming

incorrectly

• Worse in children and with dark complexions

• May result in contractures in joint areas

 Keloids

• Mass of scar tissue may mass beyond area of where

wound was

 Failure to heal

• Due to not meeting nutritional needs

 Contractures

• Rehabilitation phase

o Begins immediately after burn has occurred and often extends for
years after injury

o Psychological support

o Emotional support

o Referrals are needed

o Prevention of hypertrophic scarring-compression dressings

o Improvement of activity tolerance, body image, self concept

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• Prevent hypertrophic scarring- Jobst Stockingj