Burns Lecture

BURNSBURNS

Sonny M. Moreno, RNSonny M. Moreno, RN

CoverageCoverage

• PreventionPrevention• SafetySafety• Immediate CareImmediate Care• AssessmentAssessment

• Emergency ManagementEmergency Management• 11stst Phase Phase• 22ndnd Phase Phase• 33rdrd Phase Phase• RehabilitationRehabilitation

PREVENTIONPREVENTION

MAJORITY OF BURN MAJORITY OF BURN CASESCASES

ARE DUE TO ARE DUE TO NEGLIGENCENEGLIGENCE

SO HAZARD SO HAZARD PRECAUTIONSPRECAUTIONS

MUST BE OBSERVED.MUST BE OBSERVED.

MNEMONIC IN THE EVENT OF MNEMONIC IN THE EVENT OF FIREFIRE

RR ESCUE remove ESCUE remove clientclient

AA LARM activate LARM activate fire alarm, reportfire alarm, report

CC ONFINE close ONFINE close doors and doors and windowswindows

E E XTINGUISH fire XTINGUISH fire

SafetySafety

Don’t panicDon’t panic Drop to the floorDrop to the floor Look for the exitLook for the exit Cover face with wet clothCover face with wet cloth Immerse into cool water or running water Immerse into cool water or running water

immediately if you get burned to prevent immediately if you get burned to prevent further injury.further injury.

Extinguish any remaining fire by dropping Extinguish any remaining fire by dropping and rolling onto the floor. and rolling onto the floor.

INHALATION INJURIESINHALATION INJURIES Heat Inhalation-Heat Inhalation-

HOT AIR OR FLAMESHOT AIR OR FLAMES

Systemic Toxins-Systemic Toxins-ENCLOSED FIRE-CO IS ENCLOSED FIRE-CO IS INHALEDINHALED

Smoke Inhalations-Smoke Inhalations-FREQUENTLY HIDDEN FREQUENTLY HIDDEN BY MORE VISIBLE BY MORE VISIBLE INJURIES (60-80% INJURIES (60-80% FATALITIES)FATALITIES)

Indications of Inhalation InjuryIndications of Inhalation Injury

Usually appears within 2-48 hours Usually appears within 2-48 hours after burn occurred. after burn occurred.

Indications may include: Indications may include: • The patient faints The patient faints • Fire or smoke present in a closed area Fire or smoke present in a closed area • Evidence of respiratory distress or upper Evidence of respiratory distress or upper

airway obstruction airway obstruction • Soot around the mouth or nose Soot around the mouth or nose • Nasal hairs, eyebrows, eyelashes have Nasal hairs, eyebrows, eyelashes have

been singed been singed • Burns around the face or neck Burns around the face or neck

ASSESSMENTASSESSMENT

AA IRWAYIRWAY BB REATHINGREATHING CC IRCULATIONIRCULATION DD ISABILITIESISABILITIES EE XPOSEXPOSE

A A airwayairway - check nose, face and neck - check nose, face and neck (priority) singed and sooty hair of (priority) singed and sooty hair of the nosethe nose

B B breathingbreathing – – rise and fall of chestrise and fall of chest C C circulationcirculation - if there is no breathing - if there is no breathing

and circulation start CPRand circulation start CPR D check for D check for disabilitydisability and manage and manage

accordinglyaccordingly E E exposeexpose to determine extent of to determine extent of

injuryinjury

Types of BurnsTypes of Burns

Thermal – dry flames, moist and heatThermal – dry flames, moist and heat Mechanical – friction or abrasionMechanical – friction or abrasion Chemical – acid or alkaliChemical – acid or alkali Electrical – most fatalElectrical – most fatal Radiation – sunlightRadiation – sunlight

ClassificationsClassifications 1st degree – partial 1st degree – partial

thickness thickness painful, no blisters, pink painful, no blisters, pink and red, epidermisand red, epidermis

2nd degree – deep partial 2nd degree – deep partial thickness thickness painless, with blister, (+) painless, with blister, (+) blanch and refill epidermis blanch and refill epidermis and dermis and dermis

3rd degree – full thickness 3rd degree – full thickness

painless, leathery, fascia painless, leathery, fascia and muscle, F&E and muscle, F&E imbalanceimbalance

4th degree – bones and 4th degree – bones and visceral organs are visceral organs are affected affected

Layers of SkinLayers of Skin

Extent of InjuryExtent of Injury

Sunburn, 1Sunburn, 1stst degree degree

Epidermis OnlyEpidermis Only

All Skin LayersAll Skin Layers

Skin, SQ, Fascia, MusclesSkin, SQ, Fascia, Muscles

44thth Degree Degree

Emergency RoomEmergency Room

ABCDE assessmentABCDE assessment Airway and fluid resuscitation Airway and fluid resuscitation

(priority)(priority) Strict I and O monitoring Strict I and O monitoring Give TIG/TAT and TTGive TIG/TAT and TT Prophylactic antibioticProphylactic antibiotic Sterile dressing for wound Sterile dressing for wound

EXPOSEEXPOSE

To check other injuriesTo check other injuries Determine TBSADetermine TBSA Rule of Nines “Berker Formula”Rule of Nines “Berker Formula”

Parkland Formula Parkland Formula (4ml x TBSA x BWkg) (4ml x TBSA x BWkg)

1st 8H 1st 8H give ½, give ½, 2nd 8H 2nd 8H give ¼ and for the give ¼ and for the 3rd 8H 3rd 8H give give the last partthe last part

Repeat ABCDE assessmentRepeat ABCDE assessment

Parkland FormulaParkland Formula

(4ml x TBSA x BWkg)(4ml x TBSA x BWkg) 1st 8H 1st 8H give ½ give ½

2nd 8H 2nd 8H give ¼give ¼

3rd 8H 3rd 8H give ¼ give ¼

TBSATBSA

Entire trunk = A1Entire trunk = A1 Both upper extremities = A2Both upper extremities = A2 Face = A3Face = A3 Entire back = B1Entire back = B1 Anterior left upper extremity = B2Anterior left upper extremity = B2 Right and left lower extremities = B3Right and left lower extremities = B3

Parkland FormulaParkland Formula A1+A2+A3 = A4A1+A2+A3 = A4 Total Volume of Infusion = A5Total Volume of Infusion = A5 11stst 8 hours = A6 8 hours = A6 22ndnd 8 hours = A7 8 hours = A7 33rdrd 8 hours = A8 8 hours = A8 B1+B2+B3 = B4B1+B2+B3 = B4 Total Volume of Infusion =B5Total Volume of Infusion =B5 11stst 8 hours = B6 8 hours = B6 22ndnd 8 hours = B7 8 hours = B7 33rdrd 8 hours = B8 8 hours = B8

QuestionsQuestions

Most common type of burns = A9Most common type of burns = A9 Fatal type of burns = B9Fatal type of burns = B9 s/sx of head injury = A10s/sx of head injury = A10 s/sx of spinal cord injury = B10s/sx of spinal cord injury = B10

1st Phase 1st Phase Fluid Accumulation Fluid Accumulation

IV to IT and ICIV to IT and IC

most critical periodmost critical period 36-48H post burn, FVD or 36-48H post burn, FVD or

hypovolemiahypovolemia 3rd fluid shift3rd fluid shift edema on the injured area (IV to IT) edema on the injured area (IV to IT)

fatal form is circumferential edema fatal form is circumferential edema from chest injuryfrom chest injury

11stst Phase Con’t Phase Con’t

hyponatremia (IV to outside from it)hyponatremia (IV to outside from it) hyperkalemia (cell injury) hyperkalemia (cell injury)

11stst Phase Con’t Phase Con’t

urine output to RF (dec. BV)urine output to RF (dec. BV) myoglobinuria destroys the kidney to myoglobinuria destroys the kidney to

RF (muscle destruction) RF (muscle destruction) rhabdomyolysisrhabdomyolysis

BV - BV - TP - TP - H - H - pH – AcidosispH – Acidosis

11stst Phase Con’t Phase Con’t

BV – curling’s ulcer or paralytic ileus BV – curling’s ulcer or paralytic ileus (dec. BV), NPO, NGT lavage, TPN (dec. BV), NPO, NGT lavage, TPN

Infection may set in (isolation)Infection may set in (isolation)

2nd Phase 2nd Phase Fluid RemobilizationFluid Remobilization

IT/IC to IVIT/IC to IV

May last 48-60HMay last 48-60H FVE (CHF) FVE (CHF) Hypokalemia Hypokalemia Diuresis phase (oliguria may signifies Diuresis phase (oliguria may signifies

RF)RF)

22ndnd Phase Con’t Phase Con’t

Hyponatremia due to fluid loss from Hyponatremia due to fluid loss from diuresis phasediuresis phase

Infection may set in (isolation)Infection may set in (isolation) Anemia may linger up to recovery Anemia may linger up to recovery

periodperiod Complications from immobility may Complications from immobility may

set in (Circulo-O-electric bed) set in (Circulo-O-electric bed) Anemia may lingerAnemia may linger

3rd Phase to Recovery Period3rd Phase to Recovery Period

Infection may set in Infection may set in (isolation, Sulfadiazine (isolation, Sulfadiazine application)application)

Healing process to scar Healing process to scar formation and formation and contracturescontractures

Surgery (Reconstructive Surgery (Reconstructive or Plastic) STSG auto-or Plastic) STSG auto-graftgraft

33rdrd Phase Con’t Phase Con’t

Debridement and EscharotomyDebridement and Escharotomy Diet: high caloric high CHONDiet: high caloric high CHON Psychological Aspect: dec. self Psychological Aspect: dec. self

esteem, stigma, perceived body esteem, stigma, perceived body changes, isolation, depression, loss changes, isolation, depression, loss of identity these are all related to of identity these are all related to physical disfigurement.physical disfigurement.

RECAPRECAP

• PreventionPrevention• SafetySafety• Immediate CareImmediate Care• AssessmentAssessment

• Emergency ManagementEmergency Management• 11stst Phase Phase• 22ndnd Phase Phase• 33rdrd Phase Phase• RehabilitationRehabilitation

Short QuizShort Quiz

1. Fluid accumulation1. Fluid accumulation A. FVEA. FVE 2. Fluid remobilization2. Fluid remobilization B. FVDB. FVD 3. Hypokalemia3. Hypokalemia C. 1C. 1stst

PhasePhase 4. Hyperkalemia4. Hyperkalemia D. 2D. 2ndnd Phase Phase 5. Priority during 15. Priority during 1stst phase? phase?

A. fluidA. fluid C. infectionC. infectionB. I&OB. I&O D. all of the aboveD. all of the above

6. diuresis6. diuresis A. 1A. 1stst Phase Phase 7. oliguria7. oliguria B. 2B. 2ndnd Phase Phase 8. tetany8. tetany 9. anemia9. anemia 10. infection10. infection 11. T wave elevation11. T wave elevation 12. T wave inversion 12. T wave inversion

13. STSG?13. STSG? 14. type of dressing? (debridement)14. type of dressing? (debridement) 15. diet? (recovery)15. diet? (recovery)

Full thickness, circumferential chest Full thickness, circumferential chest burns cause difficulty breathing. burns cause difficulty breathing. Which of the following surgical Which of the following surgical intervention can correct this?intervention can correct this?A. intubationA. intubationB. thoracentesisB. thoracentesisC. escharotomyC. escharotomyD. chest tube insertionD. chest tube insertion

An adult woman arrives in the ER 20 An adult woman arrives in the ER 20 minutes after sustaining a major burn minutes after sustaining a major burn injury. IV line was inserted, which of the injury. IV line was inserted, which of the following intervention would the nurse do following intervention would the nurse do next?next?A. insert an indwelling catheterA. insert an indwelling catheterB. apply silvadene creamB. apply silvadene creamC. shave the hair around the burn woundC. shave the hair around the burn woundD. obtain culture from the deepest burned D. obtain culture from the deepest burned areaarea

During the fluid accumulation phase During the fluid accumulation phase of major burn injury, fluids shift from of major burn injury, fluids shift from the:the:A. intravascular to outside from itA. intravascular to outside from itB. intracellular to intravascularB. intracellular to intravascularC. interstitial to intracellularC. interstitial to intracellularD. any of the aboveD. any of the above

When the nurse is completing an When the nurse is completing an assessment of a burned client, second assessment of a burned client, second degree burns (deep partial thickness) degree burns (deep partial thickness) would appear as:would appear as:A. injury is extended to the muscles and A. injury is extended to the muscles and bonesbonesB. with edema and redness no vesicleB. with edema and redness no vesicleC. thickness involving the epidermis and C. thickness involving the epidermis and dermis showing edema and vesiclesdermis showing edema and vesiclesD. full thickness with dry, waxy or leathery D. full thickness with dry, waxy or leathery appearanceappearance

Hypervolemia can occur during the fluid Hypervolemia can occur during the fluid remobilization phase as a result of:remobilization phase as a result of:A. giving too much fluidA. giving too much fluidB. fluids shifting back into the intracellular B. fluids shifting back into the intracellular spacespaceC. fluids shifting back into the interstitialC. fluids shifting back into the interstitialD. none of the aboveD. none of the above

Using Berker Formula or Rule of Using Berker Formula or Rule of Nines, an injury affecting the anterior Nines, an injury affecting the anterior chest, anterior abdomen and entire chest, anterior abdomen and entire right arm would be estimated at how right arm would be estimated at how many percent?many percent?A. 18%A. 18% C. 27%C. 27%B. 45%B. 45% D. 50%D. 50%

During the fluid accumulation phase During the fluid accumulation phase the nurse would expect to see signs the nurse would expect to see signs of which electrolyte imbalance?of which electrolyte imbalance?A. hyperkalemiaA. hyperkalemia C. hypercalcemiaC. hypercalcemiaB. hypernatremiaB. hypernatremia D. hypokalemiaD. hypokalemia

What is your parameter in assessing the What is your parameter in assessing the degree of burn?degree of burn?A. count the presence of blisters or A. count the presence of blisters or vesiclesvesiclesB. observe presence of soot and singed B. observe presence of soot and singed hair of the nosehair of the noseC. Check the location of injuryC. Check the location of injuryD. assess the rate and extent of burned D. assess the rate and extent of burned areaarea

Using Berker Formula, which has the Using Berker Formula, which has the largest percent of burns?largest percent of burns?A. face and neckA. face and neck C. upper trunkC. upper trunkB. both thighsB. both thighs D. all limbsD. all limbs

In relation to post burn injury, you In relation to post burn injury, you would expect that doctor will order:would expect that doctor will order:A. foley catheter insertionA. foley catheter insertionB. intermittent catheterizationB. intermittent catheterizationC. straight catherterizationC. straight catherterizationD. none of the aboveD. none of the above

During the initial phase of burn During the initial phase of burn management, the type of fluid that management, the type of fluid that would be given is:would be given is:A. hypotonicA. hypotonic C. hypotonicC. hypotonicB. isotonicB. isotonic D. whole bloodD. whole blood

Which of the following would be Which of the following would be appropriate in managing post burn?appropriate in managing post burn?A. Circul-O-electric bedA. Circul-O-electric bedB. Stryker frame bedB. Stryker frame bedC. Cradle bedC. Cradle bedD. Bed with egg crate mattressD. Bed with egg crate mattress

Priority nursing action 16 hours after Priority nursing action 16 hours after major burn injury would be:major burn injury would be:A. watchout for infection A. watchout for infection B. hourly urine outputB. hourly urine outputC. ROM every 3 hoursC. ROM every 3 hoursD. give high caloric dietD. give high caloric diet

Burn clients require continuous emotional Burn clients require continuous emotional support. The nurse will know that he will support. The nurse will know that he will receive therapeutic support by which of receive therapeutic support by which of the following nursing actions?the following nursing actions?A. keeping his room neat and cleanA. keeping his room neat and cleanB. reacting to him as individual by B. reacting to him as individual by spending timespending timeC. keeping family members aware of his C. keeping family members aware of his conditionsconditionsD. rotate the staff nurse so he could have D. rotate the staff nurse so he could have varied interactionsvaried interactions

An electrical worker has come in contact An electrical worker has come in contact with a live power line. He is unconscious with a live power line. He is unconscious and is lying across the power line, the best and is lying across the power line, the best initial action is to:initial action is to:A. flush him with waterA. flush him with waterB. grab him and pull awayB. grab him and pull awayC. cover him with blanketC. cover him with blanketD. use a wooden pole and pull him awayD. use a wooden pole and pull him away

Nursing intervention during the Nursing intervention during the emergent phase would be, except;emergent phase would be, except;A. obtain an IV lineA. obtain an IV lineB. assess the degree and typeB. assess the degree and typeC. administer antacidsC. administer antacidsD. maintain an open airwayD. maintain an open airway

ENDEND

SCAR

Scar tissue forms as skin heals after an injury (such as an accident) or surgery. The amount of scarring may be determined by the size, depth, and location of the wound; the age of the person; heredity; and skin characteristics including color (pigmentation).

SURGERY

Surgery to revise scars is done while the patient is awake, sleeping (sedated), or deep asleep and pain-free (local anesthesia or general anesthesia).

MEDICATIONS

Medications (topical corticosteroids, anesthetic ointments, and antihistamine creams) can reduce the symptoms of itching and tenderness. Scars shrink and become less noticeable as they age, therefore, immediate surgical revision is delayed until the scar lightens in color, which is usually several months or even a year after a wound has healed.

KELOID A keloid is an abnormal scar that is thicker, different color

and texture, extends beyond the edge of the wound, and has a tendency to recur. It often creates a thick, puckered effect simulating a tumor. Keloids are removed at the point where they meet normal tissue.

Massive injuries (such as burns) can cause loss of a large area of skin and may form hypertrophic scars. A hypertrophic scar can cause restricted movement of muscles, joints, and tendons (contracture). Surgical repair includes removing excessive scar tissue and a series of small incisions on both sides of the scar site, which creates V-shaped skin flaps (Z-plasty) may be used. The result is a thin, less noticeable scar because the wound closure following a Z-plasty more closely follows the natural skin folds.

GRAFTING

• Skin grafting involves the taking a thin (split thickness) layer of skin from another part of the body and placing it over the injured area. Skin flap surgery involves moving an entire thickness (full thickness) of skin, fat, nerves, blood vessels, and muscle from a healthy part of the body to the injured site. These techniques are planned when a considerable amount of skin has been lost in the original injury, when a thin scar will not heal, and when improved function (rather than aesthetic reasons) are the primary concern. Secondary procedures may later be necessary to achieve appropriate aesthetic results.

First Aid for Minor BurnsFirst Aid for Minor Burns If the skin is not broken, run cool water over the burned If the skin is not broken, run cool water over the burned

area or soak it in a cool water (NOT ICE WATER) bath. Keep area or soak it in a cool water (NOT ICE WATER) bath. Keep the area in the bath for five minutes. If the burn occurred in the area in the bath for five minutes. If the burn occurred in a cold environment, DO NOT apply water. A clean, cold, wet a cold environment, DO NOT apply water. A clean, cold, wet towel will also help reduce pain. towel will also help reduce pain.

Burns can be extremely painful, reassure the victim and Burns can be extremely painful, reassure the victim and keep them calm. keep them calm.

After flushing or soaking the burn for several minutes, After flushing or soaking the burn for several minutes, cover the burn with a sterile non-adhesive bandage or clean cover the burn with a sterile non-adhesive bandage or clean cloth. cloth.

Protect the burn from friction and pressure. Protect the burn from friction and pressure. Over-the-counter pain medications may be used to help Over-the-counter pain medications may be used to help

relieve pain; they may also help reduce inflammation and relieve pain; they may also help reduce inflammation and swelling. swelling.

Minor burns will usually heal without further treatment. Minor burns will usually heal without further treatment.

First Aid for Severe BurnsFirst Aid for Severe Burns DO NOT remove burnt clothing (unless it comes off easily), but do ensure DO NOT remove burnt clothing (unless it comes off easily), but do ensure

that the victim is not in contact with burning or smoldering materials. that the victim is not in contact with burning or smoldering materials. Make sure the victim is breathing. If breathing has stopped or the victim's Make sure the victim is breathing. If breathing has stopped or the victim's

airway is blocked then open the airway and if necessary begin CPR. airway is blocked then open the airway and if necessary begin CPR. If the victim is breathing, cover the burn with a cool moist sterile bandage If the victim is breathing, cover the burn with a cool moist sterile bandage

or clean cloth. DO NOT use a blanket or towel; a sheet is best for large or clean cloth. DO NOT use a blanket or towel; a sheet is best for large burns. DO NOT apply any ointments and avoid breaking blisters. burns. DO NOT apply any ointments and avoid breaking blisters.

If fingers or toes have been burned, separate them with dry sterile, non-If fingers or toes have been burned, separate them with dry sterile, non-adhesive dressings. adhesive dressings.

Elevate the burned area and protect it from pressure or friction. Elevate the burned area and protect it from pressure or friction. Take steps to prevent shock. Lay the victim flat elevate the feet about 12 Take steps to prevent shock. Lay the victim flat elevate the feet about 12

inches, and cover the victim with a coat or blanket. DO NOT place the inches, and cover the victim with a coat or blanket. DO NOT place the victim in the shock position if a head, neck, back, or leg injury is suspected victim in the shock position if a head, neck, back, or leg injury is suspected or if it makes the victim uncomfortable. or if it makes the victim uncomfortable.

Continue to monitor the victim's vital signs (breathing, pulse, blood Continue to monitor the victim's vital signs (breathing, pulse, blood pressure). pressure).

DO NOTDO NOT DO NOT apply ointment, butter, ice, medications, DO NOT apply ointment, butter, ice, medications,

fluffy cotton dressing, adhesive bandages, cream, fluffy cotton dressing, adhesive bandages, cream, oil spray, or any household remedy to a burn. oil spray, or any household remedy to a burn. This can interfere with proper healing. This can interfere with proper healing.

DO NOT allow the burn to become contaminated. DO NOT allow the burn to become contaminated. Avoid breathing or coughing on the burned area. Avoid breathing or coughing on the burned area.

DO NOT disturb blisters or dead skin. DO NOT disturb blisters or dead skin. DO NOT apply cold compresses and DO NOT DO NOT apply cold compresses and DO NOT

immerse a severe burn in cold water. This can immerse a severe burn in cold water. This can cause shock. cause shock.

DO NOT place a pillow under the victim's head if DO NOT place a pillow under the victim's head if there is an airway burn and they are lying down. there is an airway burn and they are lying down. This can close the airway. This can close the airway.