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SEVERITY OF BURN
Severity of burn is determined by :
Age of the patient
Depth of the burn
Burned surface area
The presence of inhalation injury and other
injuries
Location of the injury in special care areas such
as the face, the perineum, hands, or feet
The presence of a past medical history.
Age
Young children and the elderly continue to
have increased morbidity and mortality
when compared to other age groups with
similar injuries and present a challenge for
burn care.
BURN DEPTH
Burns are classified according to the
depth of tissue destruction as
1.superficial partial-thickness injuries,
2.deep partial- thickness injuries, or
3.full-thickness injuries
Burn
Superficial partial-thickness burn:
The epidermis is destroyed and a portion of
the dermis may be injured.
A deep partial-thickness burn:
destruction of the epidermis and upper
layers of the dermis and injury to deeper
portions of the dermis.
Capillary refill follows tissue blanching.
Hair follicles remain intact.
BURN
A full-thickness burn
Total destruction of epidermis and dermis
Destruction of underlying tissue, muscle, and
bone.
Wound color ranges widely from pale white to red,
brown, or charred black.
The burned area is painless and lacks sensation
because nerve fibers are destroyed.
The wound appears leathery; hair follicles and
sweat glands are destroyed
Wounds require skin grafting for healing.
Skin
Involvement
Symptoms
Wound
Appearance
Recuperative
Course
Superficial
PartialThickness
Epidermis;
possibly a
portion of
dermis
Tingling
Hyperesthesia
(supersensitivit
y) Pain that is
soothed by
cooling
Reddened;
blanches with
pressure; dry
Minimal or no
edema
Possible
blisters
Complete
recovery within
a week; no
scarring
Peeling
Pain
Hyperesthesia
Sensitive to
cold air
Blistered,
mottled red
base; broken
epidermis;
weeping
surface
Edema
Recovery in 2
to 4 weeks
Some scarring
and
depigmentation
contractures
Infection may
convert it to full
thickness
Sunburn
Low-intensity
flash
portion of
deeper dermis
Skin
Involvement
Symptoms
Wound
Appearance
Recuperative
Course
FullThickness
(Similar to
Third Degree)
Epidermis,
entire dermis,
and sometimes
subcutaneous
tissue; may
involve
connective
tissue,
muscle, and
bone
Pain free
Shock
Hematuria
(blood in the
urine) and
possibly
hemolysis
(blood cell
destruction)
Possible
entrance and
exit wounds
(electrical
burn)
Dry; pale
white,
leathery, or
charred
Broken skin
with fat
exposed
Edema
Eschar
sloughs
Grafting
necessary
Scarring and
loss of
contour and
function;
contractures
Loss of digits
or extremity
possible
Flame
Prolonged
exposure to
hot liquids
Electric
current
Chemical
Contact
Rule of Nines
The rule of nines is a
quick way to estimate
the extent of burns in
adults.
The system divides the
body into multiples of
nine.
The sum total of these
parts equals the total
body surface area.
Palmer Method
In patients with scattered burns, or for a
quick prehospital assessment, the palmer
method may be used to estimate the extent
of the burns.
The size of the patients palm, not including
the surface area of the digits, is
approximately 1% of the TBSA.
The patients palm without the fingers is
equivalent to 0.5% TBSA and serves as a
general measurement for all age groups
Pathophysiology of Burns
Burns are caused by a transfer of energy
form a heat source to the body.
Tissue destruction results from coagulation,
protein denaturation, or ionization of cellular
contents
The skin and the mucosa of the upper
airways are sites of tissue destruction
Thermal (includes electrical)
Radiation
Chemical
Physiologic Changes
Burns less than 25% TBSA produce primarily a local
response.
Burns more than 25% may produce a local and
systemic response, and are considered major burns.
Systemic response includes release of cytokines and
other mediators into systemic circulation.
Major burns cause Fluid shifts and shock result in
tissue hypoperfusion and organ hypofunction related
to decrease cardiac output followed by hyperdynamic
and hypermetabolic phases..
Cardiovascular effects
Hypovolemia is the immediate consequence of fluid loss
and results in decreased perfusion and oxygen delivery.
As fluid loss continues and vascular volume decreases,
cardiac output continues to decrease and the blood
pressure drops (This is the onset of burn shock.)
the sympathetic nervous system releases
catecholamines, resulting in an increase in peripheral
resistance (vasoconstriction) and an increase in pulse
rate.
Peripheral vasoconstriction further decreases cardiac
output.
Pulmonary injury
Results from the inhalation of superheated air and noxious gas
Bronchoconstriction caused:
- release of powerful vasoconstrictor (histamine, serotonin, and
thromboxane)
- chest constriction secondary to circumferential full-thickness
chest burns.
hypoxia may be present as a result:
- catecholamine release resulting alters peripheral blood flow
and thereby reducing oxygen delivery to the periphery.
- hypermetabolism
Pulmonary injuries:
- Upper airway: results from inhalation of direct heat
results in severe upper airway edema, which can cause obstruction of
the upper airway, including the pharynx and larynx,
- Inhalation below the glottis: results from inhaling the products of
incomplete combustion or noxious gases.
Tissue hypoxia is the result of carbon monoxide inhalation. It combines
with hemoglobin to form carboxyhemoglobin.
This cause loss of ciliary action, hypersecretion, severe mucosal
edema, and possibly bronchospasm.
- The pulmonary surfactant is reduced, resulting in atelectasis (collapse
of alveoli).
- Expectoration of carbon particles in the sputum is the main sign of this
injury
Management of ShockFluid
Resuscitation
Maintain blood pressure of greater than
100 mm Hg systolic and urine output of
3050 mL/hr, maintain serum sodium at
near-normal levels
Consensus formula
Evans formula
Brooke Army formula
Parkland Baxter formula
Hypertonic saline formula
Note: Adjust formulas to reflect initiation of
fluids at the time of injury
Question
Formulas are only a guide for burn care fluid
resuscitation. How often must the patient s
response to fluid therapy (heart rate, blood
pressure, and urine output) be evaluated?
A.1 hour
B.2 hours
C.3 hours
D.4 hours
Answer
A
The patient s response to fluid therapy
(heart rate, blood pressure, and urine
output) should be evaluated at least
hourly.
Pain Management
Burn pain has been described as one of
the most severe forms of acute pain
Pain accompanies care, and treatments
such as wound cleaning and dressing
changes
Types of burn pain
Background or resting
Procedural
Breakthrough
Pain Management
Analgesics
IV use during emergent and acute phases
Morphine
Fentynal
Other
Nutritional Support
Burn injuries produce profound metabolic
abnormalities, and patient with burns have great
nutritional needs related to stress response,
hypermetabolism, and requirement for wound
healing.
Goal of nutritional support is to promote a state of
nitrogen balance and match nutrient utilization.
Nutritional support is based upon patient preburn
status and % of TBSA burned.
Enteral route is preferred. Jejunal feedings are
frequently utilized to maintain nutritional status with
lower risk of aspiration in a patient with poor
appetite, weakness, or other problems.
Rehabilitation phase
From wound closure to return to optimal
physical and psychosocial adjustment
Impaired
exchange
Ineffective airway clearance
Fluid volume deficit
Hypothermia
Acute Pain
Anxiety
Acute respiratoryCollaborative
failure
Complications/
Problems
Distributive shock
Acute renal failure
Compartment syndrome
Paralytic ileus
Curlings ulcer
Rehabilitation Phase
Rehabilitation is begun as early as possible in the
emergent phase and extend for a long period after
the injury.
Focus is upon wound healing, psychosocial
support, self-image, lifestyle, and restoring maximal
functional abilities so the patient can have the best
quality life, both personally and socially.
The patient may need reconstructive surgery to
improve function and appearance.
Vocational counseling and support groups may
assist the patient.
Question
Is the following statement True or False?
Breathing must be assessed and patent
airway established immediately during the
initial minutes of emergency burn care.
Answer
True
Breathing must be assessed and patent
airway established immediately during the
initial minutes of emergency burn care.