7/29/2019 BURN .docx

1/4

BURN

A burnis damage to your bodys tissues caused by heat, chemicals, electricity, sunlight or radiation. Scaldsfrom hot liquids and steam, building fires and flammable liquids and gases are the most common causes ofburns.

Types of Injury:A. According to cause:

Thermal burns Thermal burns constitute almost 90% of burn injuries. Skin that comes in contact witha source of increased temperature results in a thermal burn. Flame, scalding liquids, steam, and hotobject are common sources of thermal burns. Severity of the burn is related to heat intensity andduration of contact (the higher the temperature and longer the contact with the heat source = deeper,more severe burn.) Thermal burns occur at temperatures above 40 degree Celsius (111.2 degreesFahrenheit). Full thickness tissue destruction can happen in as little as 3 to 5 seconds withtemperatures of 60 degrees Celsius (140 degrees Fahrenheit). Extremities of age, children and theelderly, are at greater risk of burn wound injury due to thinner skin and.

Chemical burns Chemical burns are the cause of less than 10% of all burn injuries. Injury can becaused by contact, inhalation of fumes, ingestion, or injection of chemicals. The result of a chemicalburn can have both local and systemic effects on the body. Severity is related to type, volume, durationof contact, quantity of the chemical, extent of tissue penetration, and concentration of the agent.Tissue damage continues until chemical is removed or neutralized. Categories of chemical burnsinclude:

Strong acids: sulfuric and muriatic acid Alkalis: lime (cement), ammonia, caustics

Vesicants: Dimethyl sulfoxide, chemical warfare agents

Corrosives: phenol, lye, white phosphorus

One of the main concerns for healthcare providers when caring for chemical burns is to provide protection forself first prior to treating the injured burn patient. Dry chemical are brushed-off and liquid chemicals are flushedwith copious amounts of water. All clothing should be removed and thrown away.

Electrical burns Electrical burns are associated with less than 10% of burn injuries. Contact with householdcurrent, car batteries, electrosurgical devices, high-tension electrical wires, and lightening are common causesof electrical injury. Electrical injuries are classified as either a high-voltage, greater than 1,000 volts of energy,or low-voltage, less than 1,000 volts of energy. Injury from electrical burns is a result of the type of electricalcurrent pathway, duration of contact, environmental conditions, and resistance of body tissues. Electricityfollows through the path of least resistance. Generally, nerves, blood vessels, and muscles have the highestrisk of damage. Nerve tissues have the least resistance and bone tissue has greater resistance. It is expectedthat electrical burn injuries will have both entrance and exit wounds. Presence of both entrance and exitwounds should be assessed on every burn suspected of being caused by electricity. It is not always possible toassess total burn surface area due to the unknown amount of internal injury. Total body surface area of a burnmay not be known calculation of resuscitation volume may be difficult. Often, electrical burns require largervolumes of fluid resuscitation due to myoglobinuria due to muscle damage and breakdown. Urine output shouldbe maintained at 75100ml/hour when myoglobin is detected in the urine. There is a high risk of hypoxia dueto paralysis of respiratory muscles and continuous cardiac monitoring is essential for the detection ofdysrhythmias or ectopy. A high risk of cardiopulmonary arrest is associated with electrical burns. Goals oftreatment are aimed at maintaining peripheral circulation. Assessment of skin color, sensation, capillary refill,and peripheral pulses is essential. Remove rings, watches, and other jewelry due to the swelling that oftenaccompanies fluid resuscitation. Muscle compartment syndrome is a known complication of electrical burninjuries and any detected decrease in blood flow to extremities or central body area (i.e. the chest) should elicitprompt assessment for whether an escharotomy or fasciotomy needs to be initiated.

Radiation Burns Radiation burns include nuclear sources (some ultraviolet light has radiation). In addition todetermining the method of a burn, determining the degree of the burn is also an important assessment in orderto develop an appropriate plan of care. Determining the extent of a burn is also important in order to evaluatethe potential for infection, the tissue exposure and invasion of the circulatory system.

Inhalation injury Inhalation injury is observed in 20% to 50% of patients admitted to burn centers. Lung injuryis secondary to the inhalation of smoke and products of incomplete combustion. Incomplete combustion ofsmoke products can produce carbon monoxide. Carbon monoxide poisoning occurs because carbon monoxidehas an affinity for hemoglobin 200 times greater than that of oxygen. When carbon monoxide is combined withhemoglobin oxygen cannot be transported via red blood cells and the body tissues do not receive the requisiteoxygen for cell metabolism; the result is hypoxia. Inhalation injury includes injury above the glottis and injurybelow the glottis. Injury above the glottis is referred to upper airway injury. Upper airway injury causes edema

7/29/2019 BURN .docx

2/4

and has a high risk of airway obstruction. A patient may present with hoarseness, dry cough, labored or rapidbreathing, difficulty swallowing, or stridor. Injury below the glottis can cause extensive damage to alveoli.Carbonaceous sputum is a hallmark sign injury below the glottis. Bronchial constriction and spasms can occurwithin several minutes to hours after injury and can lead to acute respiratory failure and acute respiratorydistress syndrome within the first few days. Respiratory tract mucosal sloughing may occur within 4 to 5 days.Bronchoscopy can be used to definitively diagnose injury below the glottis.

B. According to depth:

Superficial burns affect the first layer of skin only, the epidermis, and typically heal in 3 to 5 days

without treatment. No calculation of burn size is needed. Partial-thickness burns involve the dermal layer of skin and are divided into superficial partial-thickness

burns, deep partial-thickness burns, and full-thickness burns.

Superficial partial-thickness affects the epidermis and a limited portion of the dermis and is pink to redin color. Slight edema may be visible with pain upon touch. Healing should occur in 3 to 5 days.

Deep partial-thickness affects epidermis and most of the dermis. These burns may heal spontaneouslywithin 3 to 6 weeks and skin grafting may necessary.

Full-thickness burns lead to destruction of all layers of the skin down to or past the subcutaneouslayer, fascia, muscles, or bone. Full-thickness burns have thick, leathery, non-elastic, coagulated layerof eschar. Nerves are destroyed, so the burn at this depth may be painless. Skin grafting is alwaysrequired for permanent closure with longer than 1 month healing time. Accurate depth assessmentmay be difficult to determine initially during the first 48 to 72 hours.

STAGES OF BURN (Please see Udan book)

1. Shock Phase/Fluid Accumulation Phase/Emergent Phase

First 48 hours post-burns Fluid shifts from IVC to ISC Hypovolemia Hemoconcentration, increased hematocrit Oliguria Hyperkalemia and hyponatremia Metabolic acidosis

2. Diuretic/Fluid Remobilization Phase

After 48 hours post-burns Fluid shifts from ISC to IVC Hypervolemia, hemodilution, decreased hematocrit Diuresis Hypokalemia and hyponatremia Metabolic acidosis

3. Recovery Phase

Fifth day onwards Fluid shifts from IVC to ISC Hypocalcemia Negative nitrogen balance

Hypokalemia

NURSES ROLE IN THE TEAM APPROACH TO BURN CARE

A DISTINCTIVE MULTIDISCIPLINAR APPROACH is required for the care of a patient with burninjury. The members of the bun care team needs close collaboration in which the positive patient outcomesdepend.

The BURN NURSE is the center of the team that coordinates all the patient care activities. He mustpossess a broad-knowledge of multisystem organ failure, critical care techniques, diagnostic studies andrehabilitative and psychosocial skills. He oversees the total care of the patient and coordinates activities withother disciplines. Also, he is a specialist on wound care and is responsible for wound care and noting changesthat may require attention, prevention and management.

7/29/2019 BURN .docx

3/4

Practice Guidelines:

These evolved from the evidence-based practice revolution. Provide recommendations based on critical reading and interpretation of current literature for

managing specific problems. Define the most cost-effective treatment. Help minimize practice variances that lead to poor patient outcomes and high health care costs.

ASSESSMENT1. Zones of thermal injury explain the relationship of depth and extent of injury.

Zone of hyperemia: Outermost area of minimal injury, similar to a superficial burn and heals rapidly,there is no cell death. Tissue is red but blanches.

Zone of coagulation: Greatest area of tissue necrosis and is at the core of the wound. The tissue in thisarea reached at least 45 degrees Celsius (113 degrees Fahrenheit). Protein coagulation and cell deathhas occurred. Tissue is expected to be black, gray, or khaki to white and does not blanch withpressure.

Zone of stasis: Area directly next to the zone of coagulation with vascular damage (reduced bloodflow) and potentially reversible injury. Tissue is red but does not blanch with pressure. Adequateresuscitation to correct hypovolemia and restore blood flow is essential for recovery.

2. Rules of Nine

Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% Each palm = 1% Groin = 1% Each leg = 18% total (front = 9%, back = 9%)

3. LUND AND BROWDER METHOD

A more precise method of estimating the extent of a burn. This recognizes the percentage of TBSA ofvarious anatomic parts.

4. PALM METHOD

MANAGEMENT (Please see Udan book)

1. Promote respiratory function.

Assess for sooty sputum and singed hair Open airway Oxygen therapy

2. Promote fluid-electrolyte and acid-base balance.

Assess vital signs, urine output, CVP, LOC, weight and percentage of burns

3. Relieve pain.

Administer Morphine Sulfate per IV Monitor for respiratory depression Bed cradle Avoid exposure of affected areas to draft

4. Prevent infection.

7/29/2019 BURN .docx

4/4

Asepsis Reverse isolation Tetanus immunization Irrigation

5. Maintain adequate nutrition.

Do not give oral fluids for the first 48 hours

High-calorie, high-carbohydrate, high-protein diet Diet rich in vitamins A, B, and C

6. Provide wound care.

Methods of wound care

Open method Semi-open method Closed method

Antimicrobials

Furacin Sulfamylon (Mafenide Acetate) Silvadene (Silver sulfadiazine) Silver Nitrate

Hydrotherapy Debridement

Surgical/Mechanical Debridement

Skin graft

Isograft or syngeneic graft

Autograft Homograft/Allograft Heterograft or Xenograft

Care of graft site

7. Promote GI support.

NGT as indicated

8. Fluid replacement.

Types

Colloids Electrolytes Non-electrolytes

Baxter and Parkland Formula

9. Rehabilitation.

Minimize scarring