Burn Manual pdf

8/20/2019 Burn Manual pdf

1/69

BURN CARE MANUAL FAHC 1

FAHC Burn Care Manual

Complied by:Peter Igneri, PA-C, Jennifer Gratton, RN


2/69


FAHC BURN CARE MANUAL – 2008

Table of ContentsINTRODUCTION................................................................................ 4

INITIAL ASSESMENT........................................................................ 5

INHALATION INJURY ....................................................................... 8

ESTIMATING TOTAL BODY SURFACE AREA OF BURNS.......... 12

TYPES OF BURNS AND TREATMENTS........................................ 15

DRESSING CHANGES.................................................................... 22

DRESSING TYPES FOR BURNS.................................................... 25

TOPICALS FOR BURN DRESSINGS ............................................. 29

EXCISION AND BURN GRAFTING ................................................ 31

MANAGEMENT OF SPECIFIC BURN AREAS............................... 35

CHEST...................................................................................................................... 35AXILLA.................................................................................................................... 35

NECK AND BREAST.............................................................................................. 36

LOWER EXTREMITIES......................................................................................... 36UPPER EXTREMITIES........................................................................................... 37

HANDS..................................................................................................................... 37

BACK ....................................................................................................................... 38PHASES OF GRAFT MATURATION........................................................................ 39

LONG TERM COMPLICATIONS.............................................................................. 41

BURN NUTRITION........................................................................... 44

BURN NUTRITION - PEDIATRIC .................................................... 50

BURN REHABILITATION................................................................ 53


3/69


HYPOTHERMIA AND FROSTBITE................................................. 58

Frostbite protocol .......................................................................................................... 60

PEDIATRIC BURNS: SPECIAL CONSIDERATIONS..................... 61

PSYCHOSOCIAL ASPECTS OF BURNS ....................................... 64

BURN CARE REMINDERS ............................................................. 65

WEBSITE REFERENCES................................................................ 67

BURN (Dressing change) CART INFORMATION ......................... 68


4/69


INTRODUCTION

This burn care document was developed by the burn committee as aresource for Fletcher Allen staff that may have questions in regards tocaring for the burn patient.

Although there are advances in burn treatments most of thedocuments in this binder remain the standard of care for the patient.

As new treatment develops the manual can easily be updated.Thanks to all of the people that researched information for the manualfor all there time and effort.

Fletcher Allen Burn Commit teeJennifer Gratton, RN Trauma Program Supervisor

Peter Igneri, PA Trauma ServiceLori Camp, RN Trauma Case ManagerJess Langer, RN Care Coordinator Baird 6Pam Kupiec, RN Baird 6Marie Zebertavage, RN Baird 6Tracey Wagner, RN Baird 5Carole Richards, RN Baird 5Gail Tuscany, RN SICUPatrick Delaney, RN SICUPatty Crease, RN SICUGil Helmken, RN EDRay Scollins, RN FACTKristen Brewster Occupational TherapyBarb Blokland Occupational TherapyKaryann Bombardier Physical TherapyJulie Jacob, SW Trauma Social Worker


5/69


Burn Care

INITIAL ASSESSMENT

Primary Survey

A – Airway.• Secure the airway first.

• Get history as much as reasonably possible before intubation

• Soot or singed nasal hairs?

B – Breathing;

• High flow Oxygen for all.

• Escharotomy? - Monitor chest wall excursion in presence of FT torsoburns

• Listen: verify breath sounds

• Assess rate & depth

C – Circulation

• Monitor BP,

• pulse rate,

• skin color

• Establish IV access,

• Warm IV fluids

• Monitor peripheral pulses in circumferential burns.

D - Disability;

• Associated Injuries?• CO poisoning?

• Substance abuse?

• Hypoxia?

• Pre-existing medical condition

E – Exposure;

• Remove all clothing and jewelry

• Ensure warm environment

• Clean DRY blankets

• It is OK to use water to stop the burning process and clean but not at the

expense of reducing body core temperature.

Secondary surveyRepeat Primary

Complete head to toe evaluationStart after resuscitation fully established


6/69


Complete the HPI

• What type of burn (flame, chemical, scald)

• Duration of exposure

• What time did burn occur?

• What treatment already provided.(chemical brushed off, water to cool, etc)• Did burn occur in house fire/enclosed space (think inhalation injury)

Order labs and x rays

• CBC, BUN, Cr, Lytes

• Carboxyhemoglobin

• CXR

• Blood gas

• Insert Foley

• EKG (especially in electrical injury)

Special considerations;• Abuse patterns

o Children, elderly

• Concomitant traumao C-spine precautionso Trauma protocols if trauma is majority of injuries

Determine TBSA

• Use Lund Browder chart.

• Can start with patients palm = 1% of patients BSA

• A good online program is sagediagram.com. Need patient weight andheight and age for this program. Can print out a graphic with parklandcalculations.

Initiate resusci tation strategy – DO NOT need on


7/69


Pediatric calculation example23 Kg child with 20% deep burn

♦ Resuscitation (Ringer’s Lactate)3 ml X 23 Kg X 20% Burn = 1380 mls½ in 1st 8 hrs post burn = 86 cc/hr

♦ Maintenance (D5LR)• 1st 10 Kg: 100 cc/kg/24hr = 1,000 cc/24 hr• 2nd 10 Kg: 50 cc/kg/24hr = 500 cc/24 hr• Remaining 3 Kg: 20cc/kg/24hr = 60 cc/24 hr

1560 cc/24 hr = 65cc/hr

Cleaning & Debridement –

• Whenever possible, clean using mixture of Hibiclens and sterile water (notsaline – it stings more when mixed with Hibiclens).

• If picking patient up at OSH, remove wet dressings and place bacitracinand fluffs or Exu-Dry for transport.

• If transporting out to MGH or other larger Burn center, contact them and

find out what they like for dressings on transferred patients. (i.e. MGHtypically wants a dry sterile dressing)

• Assemble team to view at same time to avoid time consuming dressingremoval and reapplication.

• Take picture(s) if possible – print color pictures for chart.

• Involve resident physicians to teach when possible.

• First cleaning should take place in the ED if possible. Set a plan for thenext cleaning/shower time and let other team members know.

• Use reverse isolation precautions to clean and débride when

• TBSA>15%

•

Associated inhalation injury• Immunocompromised patient.

Dressings/Supplies:

• There is a burn care cart in the ED that requires a key from PIXIS system.Keep track of supplies in order to replace on cart ASAP.

• The SICU does not stock burn dressings. If needed for the SICU orderburn cart through distribution/transport tracking.

• Please ensure IBM card used to deal with cost center issues when gettingsupplies from another unit.

• Mepilex Ag dressing is available only in CSR as of May 2008. It may be

stocked in the patient floors in the future.


8/69


INHALATION INJURY The three injury processes, resulting from smoke exposure, are presented in theorder in which peak symptoms occur.

• Carbon Monoxide Toxicity- peak symptoms immediate

• Upper Airway Injury with Potential Obstruction – peaksymptoms can be delayed for an hour or more

• Lower Airway Injury with Impaired Gas Exchange- peaksymptoms can be delayed for hours

Carbon Monoxide Toxici ty

Pathophysiology:

Carbon Monoxide binds to the hemoglobin molecule displacing oxygen therebydecreasing the oxygen delivered to tissue. The affinity of CO to hemoglobin is

much higher than O2.

Risk Factors • Any exposure to smoke• Any exposure to fumes

Diagnosis• Pulse oximeter may be completely normal value as it only measures O2 level.• A high index of suspicion in any fire victim with a history of smoke exposure• A carboxyhemoglobin level exceeding 10% total (Morbidity is related to

peak level at scene not the fi rst value obtained)

• Unexplained metabolic acidosis

Hgb Level Carbon MonoxideIntoxication

CO High Symptoms

0-5 Normal Value

15-20 Headache, Confusion

20-40 Disorientation, fatigue,nausea, visual changes

40-60 Hallucination,combativeness, coma,shock, shock state

60 orabove

Cardiopulmonary arrest,Death

*CO Hgb - carboxyhemoglobin


9/69


Table 2: Treatment of Carbon Monoxide and Cyanide Toxicity

Carbon Monoxide Cyanide

Awake Obtunded Metabolic Acidosis

High flow by maskoxygen (Fi02 100%)untilcarboxyhemoglobin< 10%

Intubate

100% oxygen viapositive pressureventilation

Hyperbaria used ifpatient notresponding to 100%oxygen (specificindications remainundefined)

Cardiovascular support

Sodium nitrite followed by sodiumthiosulfate if there is a highlikelihood of toxicity (unexplainedmetabolic acidosis)

Upper Airway Injury:

Pathophysiology:

Direct heat injury caused by the inhalation of air heated to a temperature (150° Cor higher) ordinarily results in burns to the face, oropharynx, and upper airway(above the vocal cords). Even superheated air is rapidly cooled before reachingthe lower respiratory tract because of the tremendous heat-exchanging efficiencyof the oropharynx and nasopharynx.


10/69


Pathophysiology of Airway Injury: The initial response to smoke is usually that caused by intense airways irritation,and airways edema producing increased airways resistance. The late response,typically seen 2 to 5 days after the insult, is the result of the initial mucosal injuryleading to mucosal slough, increased secretions, intense airways inflammation

and impaired immune function.

The Lung Injury: Lower airway

The degree of initial and late injury will, in large part, be related to the status ofthe pre-injured lung. A lung with any element of reactive airway disease orchronic changes from smoke, for example, will likely react more severely to asmoke exposure than a healthy lung. In addition, the inflammatory responsecaused by the injury will lead to much of the subsequent damage. Oxidants insmoke and those released by inflammatory cells play a critical role in the airways


11/69


injury. A decrease in lung anti-oxidants is also seen further increasing thedegree of injury.

The mechanism of the airway and parenchymal injury is complex. The cell toxicagents, present on the particulates lead to a number of pathologic events. First,

there is direct mucosal injury, loss of ciliary activity with subsequent impairmentof particulate and mucous clearance and later bacterial clearance. Second,there is a marked, early increase in bronchial blood flow, as well as increasedbronchial vessel permeability, leading to submucosal edema and vascular-engorgement narrowing of the airway lumen. Third, there is tissue destructiondue to the above response, as well as a secondary inflammatory response. Theresult is a slough of mucosa in both large and small airways, and a markedincrease in mucous production.

Lower Airway Injury:

Closely resembles the same signs and symptoms as upper airway, especiallyduring the acute phase of burns.

3030

Signs and SymptomsSigns and Symptoms

•• Burns of face, mouth or neck Burns of face, mouth or neck •• Singed nasal /facial hairSinged nasal /facial hair•• Red & dry mucosaRed & dry mucosa•• Edema of tongue or pharynxEdema of tongue or pharynx•• Chest tightnessChest tightness•• Hoarseness, wheezing,Hoarseness, wheezing, stridorstridor•• Cough orCough or dyspneadyspnea•• Profuse secretions, sooty sputumProfuse secretions, sooty sputum

Inhalation Burns


12/69


ESTIMATING TOTAL BODY SURFACE AREA OF BURNS

Total Body Surface area, TBSA, for burns is calculated based on the partial andfull thickness burns (not superficial, first degree burns)

It is important to make an initial calculation early on, and follow up with updatedestimates in the following days to see the progression/regression of the burns.

All Admitted patients to FAHC should have a Lund Browder or Sage diagram placed in the front of the clinical records of the chart.

Lund Browder –


13/69


It takes into account the age of the patient as it relates to the TBSA.SAGE diagram

Another tool to use is the Sage Diagram. This is available via the internet at:

www.sagediagram.comThis is a free service which permits the user to draw in the areas burned on adiagram, and based on the patient’s height and weight will provide an estimatedtotal body surface area of burns. This diagram can be printed for charting.


14/69


Following the RULE OF NINE’S Adults: Each arm is 9%, each leg is 18%, the front of the torso is 18%, the Backis 18%, the head and neck are 9%, and the perineum is 1%Children: Modified due to larger head proportionately: Each arm is 9%, each legis 14%, Front and back are 18% each, and the Head is 18%

Estimating the size of the Burn as a % of the Total Body Surface (TBSA)


15/69


TYPES OF BURNS AND TREATMENTS

First Degree Burns- superficial burns A f irst degree burn is confined exclusively to the outer surface and is not

considered a signif icant burn. No skin barrier funct ions are altered. Themost common form is sunburn which heals by itself in less than a weekwithout a scar.

TreatmentTopical antimicrobial (Bacitracin) applied several times a day

Second Degree Burns- partial thickness burns

Second degree burns cause damage to the epidermis and por tions of thedermis. Since it does not extend through both layers, it is termed partialthickness. There are a number of depths of a second degree or partialthickness burn which are used to characterize the burn.

Superficial Second Degree

Involves the entire epidermis and no more than the upper third of the

dermis is heat destroyed. Rapid healing occurs in 1-2 weeks, because ofthe large amount of remaining skin and good blood supply. Scar isuncommon. Init ial pain is the MOST SEVERE of any burn, as the nerveendings of the skin are exposed to the air.


16/69


Appearance

The micro vessels perfusing this area are injured resulting in theleakage of large amounts of p lasma, which in turn lif ts off the heat-destroyed epidermis, causing blis ters to form. The blisters often increase

in size even after the burn. A light pink, wet appearing very painful woundis seen as the blisters are disrupted. ** Frequently, the epidermis does notlift o ff the dermis for 12 to 24 hours and what initially appears to be firstdegree is actually a second degree burn.

Treatment

Debridement of affected skin to expose underlying wound. Debrideblisters that are limiting joint movement.

Clean wound and apply antimicrobial ointment such as bacitracin.Excellent alternative is the use of skin subst itute which seals the woundand decrease pain. Below is an example of Biobrane application-usuallyput on in the Emergency Department setting.

Must débride blisters prior to placing to allow firm adhesion


17/69


Also can apply closed dressing of gauze for absorbency and wrap.This will need to be changed daily.

Healing

This type of burn heals in 10-12 days without scarring. There is a lowrisk of infection.

Mid-Second degree-Mid partial thickness burn

In this type of burn, destruction to about half the dermis occurs. Healing is

slower due to the fact that there is less remaining dermis and less of ablood supply. Pain can be severe but is usually less intense than thesuperficial due in part by nerves that are destroyed.


18/69


Appearance

The burn surface may have blisters but is redder and less wet.

Treatment

Treatment is typically Silvadene cream and occlusive dressing with aclosed dressing technique. A temporary skin substitute is also a treatmentof choice.

Healing

This type of burn usually heals in 2 to 4 weeks. The longer thehealing time, the more chance of scarring.

Deep Second Degree-Deep partial thickness

In this type of burn most of the skin is destroyed except a small amount ofremaining dermis. The wound looks white or charred indicating deadtissue. Blood f low is compromised and a layer of dead dermis or escharadheres to the wound surface. Pain is much less as the nerves are actuallydestroyed by the heat. Usually, it is di fficult to d istinguish a deep dermalburn from a full thickness burn by visualization. The presence of sensationto touch usually indicates the burn is a deep partial injury.


19/69


Appearance

The wound surface may be dry and red in appearance with whiteareas in the deeper parts. There is marked decrease in blood flow makingthe wound very prone to conversion to a deeper injury and to infection.

Direct contact with flames is a common cause. The appearance of the deepdermal burn changes dramatically over the next several days after burn asthe area of dermal necrosis along with surface coagulated protein turns thewound a white to yellow color. This resembles the third degree burn anddifferentiation sometimes is dif ficu lt. The presence of some pain can assistin diagnosis because the pain is usually absent in full thickness injury.

Treatment

Wash wi th antimicrobial soap and water. Apply silvadene closeddressing. Often grafting is needed to speed healing. Monitor for infection.Often converts to full thickness injury.


20/69


Note how fingers are wrapped separately to maintain mot ion

Healing

This type of burn may heal in 2-3 months. If it heals scarring isusually severe.

Full thickness burns

Both layers of skin are completely destroyed leaving no cells to heal. Anysignificant burn will require skin grafting. Small burns will heal with scar.

Entire destruction of the epidermis and dermis, leaving no residualepidermal cells to repopulate.

Appearance

A characterist ic in it ial appearance of the avascular burn tissue is awaxy white color. If the burn produces char or extends into fat as withprolonged contact with a flame source, a leathery brown appearance canbe seen along wi th surface coagulation veins. The burn wound is painlessand has a coarse non-pliable texture to touch.


21/69


Treatment

Wash wi th antimicrobial soap and water. Apply Silvadene cream with aclosed dressing. Grafting is treatment of choice. High risk for infection.


22/69


DRESSING CHANGES

FULL THICKNESS AND DEEP PARTIAL THICKNESS (PRE-GRAFT)

For the Bedside nurse/provider:1) Gather necessary supplies (order burn cart via transport tracking)2) Ensure adequate quantities of burn creams.3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Ker

clean white gloves, and other items4) Have adequate pain medicine available5) Connect with PT/OT, BST to establish time of burn care

PREPARATION:

1) Gather all materials prior to starting burn care2) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff

participating in care3) Remove dressings, exposing a minimal amount of body surface area to prevent

hypothermia4) In sterile fashion, cleanse area with equal amounts of Hibiclens and sterile saline

using lap sponges5) Débride areas of loose skin and eschar with sterile scissors6) Allow to air dry7) Apply ordered creams to affected areas, usually Silvadene to torso and limbs,

Bacitracin to face, and Sulfamylon to cartilaginous area

8) Cover wounds with Exu-Dry, contain Exu-Dry with Kerlix wraps if needed

SUPERFICIAL (FIRST DEGREE) AND HEALED DONOR SITES

For the Bedside nurse/provider:1) Gather necessary supplies (order burn cart via transport tracking)2) Ensure adequate quantities of burn creams3) Have adequate dressing supplies, including Exu-Dry, gauze, Fluffs, Xeroform, Kerlix

clean white gloves, and other items4) Have adequate pain medicine available5) Connect with PT/OT, BST to establish time of burn care

Procedure:1) Wash and/or have patient help wash all affected areas with anti-bacterial soap and

water


23/69


2) Pat dry with clean cloth3) Apply Eucerin Cream to areas, remembering that with application, “Some is good, M

is better”4) Cover, if ordered, with loose dressing, or with clean white shirt if on torso, or clean

white gloves (turned inside-out) if on hands

5) Reinforce dressings, and reapply creams as ordered and PRN to keep skin well-coa

NEWLY GRAFTED BURNS AND DONOR SITES

For the Bedside nurse/provider:1) Gather necessary supplies (order burn cart via transport tracking)2) Ensure adequate quantities of burn creams3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Ker

clean white gloves, and other items

4) Have adequate pain medicine available5) Connect with PT/OT, BST to establish time of burn care

PROCEDURE:1) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff

involved with procedure2) Maintain integrity of newly grafted burn sites for 5 days, or unless directed otherw

by house staff3) Minimize areas uncovered during burn care to maintain euthermia4) Remove dressings from donor sites to Xeroform- remove via sterile scissors only

the areas peeling back or loose5) Cleanse with equal amounts of Hibiclens and Sterile Saline6) Allow to air dry7) Apply generous amounts of Bacitracin over Xeroform, remembering that with

creams, “Some is good, More is better”8) Cover with Telfa and Kerlix, making sure distal circulation is not constricted9) ** Newly grafted burn dressings must be removed initially by house staff, to asse

successful take of grafted skin**

DRESSING CHANGESPARTIAL THICKNESS AND DONOR SITES

For the Bedside nurse/provider:1) Gather necessary supplies (order cart via transport tracking)2) Ensure adequate quantities of burn creams3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Ker

clean white gloves, and other items4) Have adequate pain medicine available


24/69


5) Connect with PT/OT, BST to establish time of burn care

PROCEDURE:1) Have staff wear gown, gloves, and mask for burn isolation2) Cleanse wounds with sterile Hibiclens and Saline (mixed in equal amounts), washin

with lap sponges if available3) Note: gentle scrubbing will help with light debriding of partial thickness burns, andremove previous creams

4) Clip any loose or pealing Xeroform from donor sites, using sterile scissors5) Allow to air dry6) Cover areas affected with Bacitracin, unless otherwise directed. Remember: When

applying creams, “Some is good, More is better”7) Apply Exu-Dry dressing over partial thickness burns, Telfa pads covered by Kerlix, o

dressed as ordered ** Be sure dressings are not constrictive to peripheral/distalcirculation


25/69


DRESSING TYPES FOR BURNS

EXU-DRY- non-adherent dressing made upof multiple layers. It is designed to conform readily and comfortably to contouredareas. It is highly absorbent and has an anti shear layer. It is compatible withtopical agents. Mainly used with first and second degree burns and after grafting.It comes in gloves and jackets and pants also.

FLUFFS-these are woven gauze dressings used over thirddegree burns to assist in debriding prior to grafting. These canbe used out of package or a Kerlix can be opened all the wayup to use as a fluff. It is often used as a padding layer toprotect grafts postop and to apply soft but constant pressureonto the grafts to facilitate imbibition.

CONFORM - this is slightly elastic cotton roll gauze dressing. Itis good for use on fingers and anywhere that mobility isimportant as it flexes easily. It comes in 1 inch and up sizes.

KERLEX- this is used to wrap burns andassist in keeping underlying dressings inplace. Often used over Exu-Dry to keep inplace.


26/69


Coban – this is an elastic self adherent dressing that is used tohelp with reduction in the amount of swelling in an extremity burn.

It is used over and in conjunction with other dressings mentionedherein.

ACE - these commonly found elastic wraps areused over dressings to help with swelling andsometimes just used to keep materials in place.

MEPITEL-Mepitel is a porous, semi-transparent,low-adherent wound contact layer, consisting of a flexible polyamide net coatedwith soft silicone. The silicone coating is slightly tacky, which facilitates theapplication and retention of the dressing to the peri-wound area. This gentleadhesion also tends to prevent maceration by inhibiting the lateral movement ofexudate from the wound on to the surrounding skin. The nature of the bond thatforms between Mepitel and the skin surface is such that the dressing can beremoved with minimum pain and without damaging delicate new tissue. Mepitel

is not absorbent, but contains apertures or pores approximately 1mm in diameterthat allows the passage of exudate into a secondary absorbent dressing.Depending on the nature and condition of the wound, Mepitel may be left in placefor extended periods, up to 7-10 days in some instances, but the outer absorbentlayer should be changed as frequently as required. When Mepitel is used for the


27/69


fixation of skin grafts and protection of blisters, it is recommended that thedressing should not be changed before the fifth day post-application. It can beused under a wound vac. It can be removed and cleaned with mild soap andwater and reused. Washing will restore the stickiness to the material.

XEROFORM - Xeroform Petrolatum Gauze is a sterile dressing composed of 3%Bismuth tribromophenate in a petrolatum blend on fine mesh gauze. TheXeroform gauze patch is a medicating and deodorizing, occlusive and non-adhering dressing packaged in sterile convenient peel-open, tamper-proofpackages. Xeroform has a bacteriostatic action.Its property is 3% Bismuth Tribromophenate in a special petrolatum blend on finemesh gauze. It is non-adherent and conforms to body contours.

We often use Xeroform to cover an open wound inthe days right after a graft is taken down and thestaples taken out, and occasionally over a donor

site. When used as a donor site covering, do notpeel off! Allow neoepitheliazation to ‘push’ thedressing off. Trim the edges that are not longeradherent. Sometimes bacitracin is used to addanother layer of moisture and no stick to the finemesh gauze dressing.

MEPILEX AG-The new Mepilex Ag is a novel antimicrobial dressing since itcombines silver with Safetac soft silicone technology. It targets bacteria andprotects the skin. This dressing will release silver for up to 7 days. It may belifted and adjusted without losing its adherent properties. It also can be cut to sizeand is easy to apply. . In order for the silver to activate, there must be activeserous discharge from the wound. It will not provide antimicrobial protectionwithout being moist.


28/69


Tubigrip – stretching cotton dressing used to apply pressure to swollen area orsometimes just used to keep dressing in place. Can make a shirt out of largersizes.

White cotton Gloves – these are simply white cotton gloves used as a dressing.It allows for increased mobility while still protecting the burn. Hands and glove

are coated in appropriate topical agent (usually bacitracin). These gloves can becleaned and dried and used again. Turn gloves inside out so seems are on theoutside (more comfortable).

BandNet – (Spandage)

Tubular mesh netting type dressing that allows contactlayers to stay in proximity to the wound. Sometimes usedon the OR in order to apply pressure to the dressing andkeep graft in place. When used over a graft will be stapledin place.


29/69


TOPICALS FOR BURN DRESSINGS

FOR ALL TOPICALS: Some is good, more is better! Too much can causereactions. Thin coat of topical directly on burn and then more topical

applied to the dressing material prior to placing over burn is best.

SILVADENE (Silver Sulfadiazine): Initial cream for suspected partial and full-thickness burns (2nd and 3rd degree).

Action : Contains Silver Sulfadiazine in micronized form which has broadmicrobial activity. It is bactericidal against many gram-negative and gram-positivebacteria as well as being effective against yeast. This is also used to help partialand deep partial-thickness burns to slough off eschar.The patient may have pain, burning and itching at the site of application.Precautions: Use cautiously if patient has a sulfa allergy.Because sulfonamide therapy is known to increase the possibility of kernicterus,

Silvadene Cream 1% should not be used on pregnant women approaching or atterm, on premature infants, or on newborn infants during the first 2 months of life.

SULFAMYLON (mafenide): Used for its anti-infective and antimicrobial agents,primarily over cartilage, such as ears in 2 deep second and third degree burns.

Action : Sulfamylon Cream, applied topically, produces a marked reduction in thebacterial population present in the avascular tissues of second- and third-degreeburns. Reduction in bacterial growth after application of Sulfamylon Cream hasalso been reported to permit spontaneous healing of deep partial-thicknessburns, and thus prevent conversion of burn wounds from partial-thickness to full-thickness. It should be noted, however, that delayed eschar separation has

occurred in some cases. Frequently associated with increased pain at theapplication site.Precautions: Sulfamylon and its metabolite, inhibit carbonic anhydrase, whichmay result in metabolic acidosis, usually compensated by hyperventilation. In thepresence of impaired renal function, high blood levels of Sulfamylon and itsmetabolite may exaggerate the carbonic anhydrase inhibition. Therefore, closemonitoring of acid-base balance is necessary, particularly in patients withextensive second-degree or partial-thickness burns and in those with pulmonaryor renal dysfunction. Some burn patients treated with Sulfamylon Cream havealso been reported to manifest an unexplained syndrome of markedhyperventilation with resulting respiratory alkalosis (slightly alkaline blood pH, low

arterial pCO2, and decreased total CO2); change in arterial pO2 is variable. Theetiology and significance of these findings are unknown.Mafenide acetate cream should be used with caution in burn patients with acuterenal failure.Sulfamylon Cream should be administered with caution to patients with history ofhypersensitivity to mafenide. It is not known whether there is cross sensitivity toother sulfonamides.


30/69


Fungal colonization in and below eschar may occur concomitantly with reductionof bacterial growth in the burn wound. However, fungal dissemination through theinfected burn wound is rare.

SILVER NITRATE: Used in liquid form as a wet dressing over partial and full

thickness burns, for patients with sulfa allergies. Requires frequent re-applicationto keep area moist. Action: Silver Nitrate is a topical solution agent with bacteriostatic propertiesagainst staph aureus, E. Coli, and Ps. Aeruginosa. It is most effective with thewound is clean and débrided of all dead tissue.Precautions: May cause hyponatremia, monitor electrolytes closely.Will cause discoloration of skin, clothes and equipment.

BACITRACIN: Used with partial thickness burns, with grafted areas initially afterdressing removed, with donor sites until nearly healed, and with facial burns.

Action: Bacitracin is produced by a strain of the bacterial species Bacillus

subtilis. It is widely used for topical therapy such as for skin and eye infections; itis effective against gram-positive bacteria, including strains of staphylococcus.Precautions: May cause burning, redness or a rash at which time the ointmentshould be stopped.

EUCERIN: Used for first degree (superficial) burns and for healing partialthickness burns, grafted burns, and donor sites to keep area moist.

Action: Moisturizing lotion


31/69


EXCISION AND BURN GRAFTING

A skin graft is surgical procedure in which a piece of skin from one area of thepatient's body is transplanted to another. Skin from another person or animal

may be used as temporary cover for large burn areas in order to decrease fluidloss. The skin is taken from a ‘donor site’, which has healthy skin and implantedat the damaged ‘recipient site’. Skin graft and flaps are more serious than otherscar revision surgeries such as dermabrasion. They are usually performed in ahospital under general anesthesia. The treated area depending on the size of thearea and severity of the injury will determine the amount of time needed forhealing. This time may be 6 weeks or a few months. Within 36 hours of thesurgery new blood vessels will begin to grow from the recipient area into thetransplanted skin. Most grafts are successful, but some may require additionalsurgery if they do not heal properly.

There are several types of skin grafts: p inch, spli t-thickness, full -thickness,and pedicle grafts.• Pinch grafts - Quarter inch pieces of skin are placed on the injured site.

These small pieces of skin will then grow to cover injured sites. These willgrow even in areas of poor blood supply and resist infection.

• Split-thickness grafts - consists of sheets of superficial and some deeplayers of skin. The grafts removed from the donor sites may be up to 4inches wide and 10 to 12 inches long. The grafts are then placed at therecipient site. Once the graft is in place, the area may be covered with acompression dressing or the area maybe left exposed. Split-thicknessgrafts are used for non-weight-bearing parts of the body.

• Full-thickness grafts - are used for weight-bearing portions of the bodyand friction prone areas such as, feet and joints. A full-thickness graftcontains all of the layers of the skin including blood vessels. The bloodvessels will begin growing from the recipient area into the transplantedskin within 36 hours.

• Pedicle grafts - with a pedicle graft a portion of the skin used from thedonor site will remain attached to the donor area and the remainder isattached to the recipient site. The blood supply remains intact at the donorlocation and is not cut loose until the new blood supply has completelydeveloped. This procedure is more likely to be used for hands, face or

neck areas of the body.

The success of a skin graft can be determined within 72 hours of the surgery. If agraft survives the first 72 hours without an infection or trauma the body, in mostcases, will not reject the graft. Before the surgery, the recipient and donor sitesmust be free of infection and have a stable blood supply. Following the proceduremoving and stretching the recipient site must be avoided. Dressings need to besterile and antibiotics may be prescribed to avoid infection.


32/69


EXCISIONThere are two types of excisions when skin grafting, fascial and tangential.

• Fascial: burn eschar is excised down to muscle fascia. Good graft take,decreased bleeding, fast. Cosmetic and functional results worse than withtangential excision. Perform where burn depth is deep into subcutaneoustissue, person may not tolerate blood loss, or where reduced blood loss

and stress outweigh cosmetic and functional advantages of tangentialexcision

• Tangential: burn débrided to briskly bleeding dermis or glistening fat.Bleeding and operative time increased. Improved functional and cosmeticresults. Blood loss much higher.


33/69


EXCISION PROS CONS

Tangential Improved functionImproved cosmesis

High blood lossNeed more skinTakes longerRisk over/under excisionEnd points hard to define

Fascial RapidDefined endpointsWide-mesh graftsGood graft takeSkin substitutes

Cosmetic defectRisk of nerve injuryRisk of joint exposureDistal edema

FASCIAL EXCISION

TANGENTIAL EXCISON

Good, brisk bleeding used at guide to depth of excision

Early excision and grafting (2-5 days post injury) is associated with improvedoutcomes. After one week there is and increased dermal blood flow and


34/69


granulation is forming under eschar. This results in an increased blood loss withexcision.It is best to only excise up to 18-25%TBSA in the first operation and never morethan 18% in a single operation after that.

Monitor the patient’s temperature closely and if unable to maintain normothermiathe operation should be stopped.

Post operatively patients may experience periods of hypotension and decreasedurine output. This is due to vasodilatation, re-warming and loss of the tourniqueteffect after the constricting eschar is removed.

EXCISION AND GRAFTING IMPORTANT POINTS:-harder than you think-requires planning ahead to figure out what you want to accomplish and how youare going to accomplish it

-what are you going to use for back up skin (cadaver, Biobrane, Integra)-what type of excision-what type of graft-what is the best position for the patient

-make sure you have enough help before you go the to OR-If burn requires splinting, make sure to coordinate with therapists in advance

Surgical Approach Based on Burn Size-Must Priorit ize1. Life

2. Limb

3. Looks


35/69


MANAGEMENT OF SPECIFIC BURN AREAS

CHEST

Management Based on Specific Burned Area-Chest

• Chest/abdomen highpriority in large andmoderate sized burn.

• If FT burn excise tofascia (spareumbilicus andnipples), 3:1 graft.

• Skirt axilla, do notexcise to fascia.

AXILLA

Management Based on Specific Burned

Area- Axilla

• Skirt axilla, do notexcise to fascia.

• Need to excise andgraft chest or shoulderfirst.

• Wait untilchest/shoulder healed

to tangentially exciseaxilla; allows anchoringof grafts.

• Axilla takes high priorityin smaller burns andshould be grafted afterhands.


36/69


NECK AND BREAST


Area-Neck & Breast

• Neck low priority inmassive burns, but ahigh priority in smallburns.

• Thick sheet grafts(20/1000s in) or 1:1 meshpreferred for neck.

• Breast burns in youngerwomen tangentiallyexcised. In elderlyconsider mastectomy.

LOWER EXTREMITIES


Area-Lower Extremities

• 2nd priority after chest inmassive burns. Exciseto fascia if full thickness.

• In moderate burnsexcise FT leg burns tofascia if there are hand,neck, or face burns thatrequire lots of skin.

• For small burns prefertangential excision withsheet grafts over joints.


37/69


UPPER EXTREMITIES


Area-Upper Extremities

• Lower priority to excise tofascia in massive burns(9%TBSA). Cover with3:1 except 1.5:1 overelbow, wrist, hands.

• Small burns tangentiallyexcise and use 1.5:1 overarm and sheet grafts overelbow and hands.

HANDS


Area- Hands

• Lower priority in massiveburns. Need a lot of skin .May need to pare downeschar and wait untilgranulation forms to graft.

• Small burns hands apriority. Tangentiallyexcise and use 1:1orsheet graft.


38/69


BACK


Area- Back

• Very thick skin so will

often heal. Delay in

massive burns unless

absolutely sure is FT,

then excise to fascia,

graft 3:1.

• Smaller burns: wait to do

back until priority areas

closed.

GRAFTING IMPORTANT POINTS Sheet grafts or unopened 1:1 meshed graft should be used for functional

areas such as hands, neck or elbows

Secure grafts with clips, staples, or absorbable sutures. Remember theclips and staples have to come out so use these judiciously

Immobilize seams

Wound-vacs are often used to keep graft in place

Cover grafts with Xeroform or Adaptic and staple in place

Use large bulky absorbent dressing to protect grafts

Take down occurs post operative day 5

Use Eucerin once grafts healed to keep from drying out

DONOR SITES IMPORTANT POINTS

Bleed vigorously, use thrombin and epinephrine for immediate hemostasis Cover with Xeroform, will separate from donor site when healed

Healing occurs in 10-14 days

Deep donor sites (>0.016 inch) should be grated with a thin (0.005 inch)graft to speed healing and minimize scarring

Use Eucerin over healed donor sites to keep moist


39/69


PHASES OF GRAFT MATURATION

Three phases:1. Adherence: fibrin bonds between graft and excised bed form

immediately. Fibrovascular ingrowth by 3 days.

2. Imbibition: Cell swelling in first 48 hours, may nourish graft.

3. Revascularization: vascular connections form in 4-7 days, lymphaticconnections one week

5 DAYS POST GRAFTING


40/69





41/69


LONG TERM COMPLICATIONS

HYPERTROPHIC SCARRING

• Hypertrophic scar

more common after

spontaneous closure

of DPT burns or

healing of widely

meshed grafts.

• Deep donor sites.

HYPERTROPHIC SCARRING

• Compressiongarments can helpcontrol hypertrophicscarring.

• Restrict capillaryblood flow.

• Garments worn 12-18months for 23 hours aday, 7 days a week.


42/69


CONTRACTURES

• Grafts andspontaneouslyhealing burns maydevelop contractures.

• Splinting, aggressiveOT/PT, and earlygrafting may preventcontractures.

HETERTROPHIC

OSSIFICATION• Bone deposition outside of bone. X-rays

show calcifications in soft tissues.

• ? Causes• Often occurs in joints injured by burns or in

grafted or healed burns.

• May show up months-years after injury.

• Symptoms pain, limitation of mobility.

• Treatment PT, analgesics, surgery.


43/69


Marjolin’s Ucer

• Squamous cellcarcinoma that can

occur in an area of

healed or grafted

burns.

• May develop decades

after the original

injury.


44/69


BURN NUTRITION

Characteristics:

Nutrition needs are altered in patients with burns. Energy (calorie) and proteinneeds are elevated and remain high after a burn and during subsequenttreatment. If other injuries accompany the burn, the additional injuries alsoincreases calorie needs. Protein losses and energy expenditure are directlyrelated to the size of the burn. Nutrition support for the burn patient requiresmeeting energy and protein needs. Periodic re assessment of calorie needsduring recovery prevents complications from overfeeding. Providing enoughcalories and protein can help minimize loss of lean body mass and enablehealing.

Calorie needs:

Energy needs surge 7 to 10 days post burn. Calorie needs may change due tochange in patient status. Injuries and infections can also increase calorierequirements.Best practice is to re assess calorie needs weekly, taking into considerationchanges in condition including extubation, activity, infection, surgery andfrequency of dressing change. Indirect calorimetries, or metabolic carts, providethe most accurate evaluation of calorie needs when compared to predictiveequations.

Calorie needs will be high before grafting and decrease afterwards. Goodnutrition is needed to heal the donor sites along with the grafted burns.

The metabolic cart can measure energy expenditure (MEE) over a brief period oftime. This information can be extrapolated to twenty four hour caloricrequirements. The results of the metabolic carts can be multiplied by 1.1 to 1.3 ifthe patient is active with physical therapy or dressing changes. The timing of themetabolic cart is key in getting an accurate study. It is helpful for the patient to betolerating tube feedings at goal as the metabolic cart is performed.

Predictive equations are another way of assessing calorie needs. Ireton Jonesand Harris-Benedict are two of the predictive equations commonly used inassessing calorie needs of burn patients. In intubated patients periodic metaboliccarts will give more accurate and useful information when compared to apredictive equation in determining the calorie needs of burn patients.


45/69


Assessment of energy needs:

Key to assessing calorie needs is to get an accurate weight that reflects thepatient’s weight at the time of injury; it may be a stated weight.Ireton Jones in ventilator dependent patients:

EEE=1784-11(age) +5(weight in kg) +244(if male) +239(if trauma) +804(burn)

Harris Benedict equation (HBE). BEE=Basal Energy Expenditure. The result ofthis equation is then multiplied by a stress factor.

Men: BEE=66.5+13.7(wt in kg) +5 (height in cm)-6.8(age years)Women: BEE=655+9.6(wt in kg) +1.75(height in cm)-4.7(age in years)

Stressors Stress factors

Activity factor:

Confined to bed 1.2Out of bed 1.3

Injury factor:

Minor operation 1.2

Skeletal trauma 1.3

Major Surgery 1.4

Sepsis 1.6

Burn factor:


46/69


stay will decrease ventilator days and length of stay. Patients may also eat ifgetting tube fed.

Tube feeds should be initiated in all patients with:

• Burns >20% of TBSA

• Burns >10% with other significant injuries• Elderly patients

• Patients who will frequently be NPO for surgery/dressingchanges/procedure requiring sedation.

• Patients with baseline nutrition compromise such as a history ofunintentional weight loss.

In patients lacking in safe enteral access Total Parenteral Nutrition (TPN) can beused as a nutrition source until the patient can be fed enterally. TPN solutionsare customized to the patient individual needs. The TPN is monitored to maintainit’s safely and usefulness.

Enteral nutrition:

The tube feed of choice for the burn patient on formulary at FAHC now is Crucial.Crucial is a high protein, high calorie enteral formula. It contains hydrolyzedcasein as a protein source which has been shown to be better absorbed incritically ill patients. The primary fat source is marine oil. The omega 3 fats inmarine oil act as immunomodulators. It does contain arginine, another nutrientassociated with wound healing. It is supplemented with elevated levels of keynutrients associated with wound healing. It can be fed into the stomach or smallbowel. Details of the nutrient content of this product are posted on the nutrition

services web site.

http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_Guide.pdf

Typically when tube feedings are started they are run continuously, they can berun over shorter periods of time to allow time off for meals or therapy. Tubefeedings can act as a sole source of nutrition or as a supplement to a regulardiet.

Crucial is contraindicated in:

• Patients who are septic

• Patients who are pregnant

• Patients with elevated potassium and renal failure or insufficiency

• Patients with liver failure

• Patients who are HIV positive

Other tube feed options are available for these populations.


47/69


Diet by mouth:If the patient is able to eat, a regular, high calorie high protein diet is best choice.In addition to the patients meals, snacks and supplements can provide additioncalories. The supplements available at FAHC are posted on the nutrition services

web site. The best choice supplement is the one the patient will take on a regularbasis. Low sugar supplements are available for patients with diabetes. Lactosefree supplements are also available. The diet tech can assist patient with mealselection and indicate high protein options on the menu. They will also offersnacks and supplements.

A complete list of high calorie supplements is available at:

http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_Guide.pdf

The dietitian will also meet with the patient and their family and discussed thereason for high protein high calorie diet and suggest options from the menu andsupplement on the formulary. At least 3 meals and 2 snacks per day areencouraged. Nutrition services will accommodate patient’s special requests asable. Typically patients receive a supplement at every meal.

The aim of providing high calorie supplements to burn patients is to provideaddition calories and protein for healing. The supplements are intended to beconsumed in addition to meals; typically they are not a meal substitute. Forpatients who can’t tolerate solid food or are only drinking ensure plus, four to fivecans of ensure plus are needed per day to prove close to adequate calories.Supplements such as ensure or mighty shakes can be consumed between mealsand in the evenings to avoid interfering with meal time appetite. This is a goodstrategy for patients who have a poor appetite or feel full quickly.

Patients often fatigue if consuming the same supplement for a long time, varyingthe type of supplement can help patients continue to drink supplements. The bestchoice of supplement is the one the patient is willing to consume on a regularbasis. Although ensure plus is the highest in calories, some patients may prefermighty shakes or CIB (a fruit juice based supplement).

High protein foods include chicken, turkey, beef, fish, eggs, milk and other dairyproducts, and nuts. Good snack choices are sandwiches, yogurt, cottage cheese,milk, peanut butter or cheese and crackers, egg, tuna or chicken salad. All areavailable as between meal snacks.

Other high calorie, high protein foods are available on the patient menu. Thepatient will be encouraged to choose these. Also burn patients will be offeredbetween meal snacks. The overall goal is to allow the patient to maximize calorie


48/69


and protein intake for healing. FAHC nutrition services will try to accommodatespecial requests.

Supplemental vitamin and nutrients:

Supplemental vitamins are required when healing burns to provide specificnutrients for healing and to compensate for losses via the burns. Vitamin C is acomponent of collagen formation. Zinc is lost when skin or gastrointestinal fluidsare removed/lost. Glutamine is a nutrient that acts as an immunomodulator.

Arginine has been shown to enable wound healing in some studies. Arginine iscontraindicated in septic patients.

In patients taking a regular diet with small burns, likely there is no benefit ingiving supplemental vitamins except a multivitamin and mineral and vitamin D.Listed below are commonly given supplements, dose and who will most benefit.

Nutrient Tube fed only Tube feedcombined withdiet

Diet only,large burn Diet only,small burn

Vitamin C 500 mg perday

1000 mg perday

1000 mg perday

None

Zinc (ZNSO4) 220 mg perday

220 mg perday for 14days

220 mg perday for 14days

None

Multivitaminand mineral

One chewabletablet daily




Vitamin A None None if tube

fed > 1 literper day

10,00 iu po

Monday,Wednesdayand Friday

none

Vitamin D None 400 IU perday

400 IU bid 400 IU daily

Argininesupplement

None None Two packetsdaily

None

Glutamine 10 grams 3times per day

10 grams 3times per day

10 grams 3times a day astolerated

None

Monitor:

Monitoring the patients response to nutrition support allows for changes to bestprovided nutrition for healing. Nutrition services will review the bedside flow sheetto see the amount of TPN or tube feed the patient receives. Also, patients eatingby mouth are closely monitored using the flow sheets. Calorie counts can beimplemented in patients who are eating poorly and are candidates for


49/69


supplemental tube feeds. Weekly weights are needed to evaluate if the patient isconsuming enough calories.

Labs:

Prealbumin is affected by acute stress and will be low early in the hospitalcourse. It is not a good indicator of response to nutrition therapy early in thehospital stay. It can be helpful when the patient is no longer acutely stressed.

Actual nutrient intake is the best way to evaluate nutrition status. Patients, whoare eating poorly, or not at all, either have a nutrition problem or will soondevelop one.

Electrolytes, magnesium and phosphorus should be followed daily in patientsreceiving nutrition support.

Close monitor of blood sugars, at least initially, even in non diabetic patients isneeded.

Prepared byKaren Tufano RD CDBonnie Beynnon RD CD CNSD


50/69


BURN NUTRITION - PEDIATRIC

Burned children pose a special challenge to meet their growth needs. Aburned child has more limited endogenous reserves and greater calorie and

protein needs/kg than an adult so they can more quickly reach negative nitrogenbalance with a smaller burn area than an adult. Also the immaturity of an infant’ssystem makes them more susceptible to diarrhea, dehydration and malnutrition.

Children follow the same Ebb and Flow phase as adults after a burn with theEbb phase lasting about 3-5 days which is characterized by hypometabolism,and the flow phase which occurs during the 6-10th days is characterized byhypermetabolism.

Caloric NeedsThe degree of hypermetabolism is directly related to the size of the burn.

Studies in burned children at Shriners Hospitals for Children show that energy

needs approximate the RDA for children, as the increased energy needs for theburns are offset by decreased activity. This is the calculation generally usedhere at FAHC.

RDAInfantsBirth to 6 months 108 kcal/kg6-12 months 98 kcal/kg

Children1-3 years 102 kcal/kg

4-6 years 90 kcal/kg7-10 years 70 kcal/kg

Male11-14 years 55 kcal/kg15-18 years 45 kcal/kg

Female11-14 years 47 kcal/kg15-18 years 40 kcal/kg

Another formula which is also for children with burns is the Curreri formula.This formula is generally not used at this facility.

Monitoring the burned pediatric patient A nutrition assessment protocol depending on the severity of the patient’s burn

and alertness would include the following:- A diet history


51/69


- Meeting with the patient/family to obtain food preferences, initiatehigh calorie, high protein snacks, and possibly supplemental ageappropriate shakes, and/or the addition of modular ingredients tofood foods to boost calorie and protein intake.

- Monitoring of calorie and protein intake whether on PO feeds, tube

feeds parenteral nutrition or combination of the above.- Glucose levels may need to be monitored.- Monitoring of Prealbumin.- Vitamin and mineral supplementation may need to be provided.- Bi-weekly weights or more often as deemed necessary.- Nitrogen balance studies if thought that nutrition intake may be

inadequate.

Protein Needs:Protein needs are elevated in burned pediatric patients, and it is recommended

that 20-23% of the calories be provided as protein with >10% BSA burns which

translates to about 2.5-4.0 grams protein/kg.

Micronutrient Needs:Micronutrient needs increase based on the severity of the burn, and stores of

micronutrients are lower in a young child. The following are recommendationsfor vitamins and mineral supplementation in the burned child: (3)

Children and adolescents (3 years and older)1. Major burn

- one multivitamin daily- 500 mg ascorbic acid twice daily- 10,000 IU vitamin A daily- 220 mg zinc sulfate daily

2. Minor burn (


52/69


the preferred method, but if the patient is unable to tolerate enteral feeds,parenteral nutrition may be needed.

References:

1. Young VR, Motil KJ, Burke JF. Energy and protein metabolism in relation torequirements of the burned pediatric patient. Textbook of PediatricNutrition. New

York, Raven Press; 1981: 309-340.2. Curreri PW, Richmond D, Marvin J, et al. Dietary Requirements of patients

with major burns. J Am Diet Assoc. 1974; 65: 415-417.3. Samour PQ, Helm KK, Lang CE, Handbook of Pediatric Nutrition (2nd

edition). Aspen Publishers, Inc. Gaithersburg, Maryland 1999: pg 502.

Prepared by Patty McKibben MS, RD, CDEdited by Carlie Geer MS, RD, CD and Linda LaShure RD, CD


53/69


BURN REHABILITATIONBurn rehabilitation is a

24 hour a day process!! !! The ultimate goal of burn rehabilitation is to return the patient back to society in

as near to their normal functional capacity as what existed prior to the burn injury,through prevention and treatment of burn scar contracture deformity andhypertrophy scarring. This goal is achieved through functional activities, exerciseprograms, splinting, positioning, and scar management.

Functional ActivitiesOutcomes: Prevent loss of function during hospitalization or prevent

secondary complications. Reinforce carry over of ROM and strengtheningexercise programs.

Exercise Programs

Outcomes: Maximize functional ROM and strength through exerciseprograms to be carried out by the patient and or caregivers.

SplintingOutcomes: Protect joints and tendons, provide optimal positioning for

wound and graft healing, maximize and maintain ROM (see photos on followingpages).


54/69


S:\Groups\Rehab Therapies\ACUTE\Burn Rehabilitation.doc


55/69


Positioning “The position of comfort is the position of contracture”Outcomes: Edema control; prevent tissue destruction.

Maintain burned tissue in and elongated state (see diagram)*These positions are not indicated for all patients, please review therapistrecommendations closely.


56/69


Timelines for development of tissue restrictions

• Burn scar contracture 1 - 4 days

• Tendons and sheaths 5 - 21 days

• Adaptive muscle shortening 2 - 3 weeks

• Ligament and joint capsule 1 - 3 months

Effects of Compression Therapy

• Flattens the scar

• Increases pliability

• Decreases blood flow

• Accelerates scar maturation

• Realigns collagen bundles

• Decreases edema

• Decreases the rate of collagen synthesis

• Compression is mandatory on all burn wounds that require >21 days or skingrafting to heal

• Compression is required until the scar is mature

• Compression should begin within 2 weeks of wound closureFrequency of Wear

• All the time except bathing and cream application• Not off for more than 30 minutes to 1 hour at a time

Duration of Use• Until scar maturation• Minimum of 6-8 months; usually 9-12 months; longer in children

As long as a scar is red, it is vascular. It can contract and hypertrophy

Amount of Compression

•Reported clinical improvement with 5 - 15 mm Hg – Elastic bandage: (coban)•Extremity: 10-15 mmHg (may need 2 layers)•Trunk: 3-4 mmHg

– Tubular support bandage: 10-20 mmHg•Use 2 layers

– Pressure Garment: 25 mm Hg

Elastic Tubular Support Bandages

Advantages

•Used on healed burns that can not tolerate shearing forces•Interim pressure device•Comfortable•Can be placed over dressing•Controls edema

Disadvantages

•Limited to cylindrical body parts


57/69


•Improper application or bunching can cause skin breakdown or edema•Some patients are allergic to elastic•Same diameter through out a tapered extremity

Custom Made Elastic Compression GarmentsAdvantages

•Can be fit for every part of the body•Customized closures, materials, styles•Multiple options•Variety of colors•Multiple companies

Disadvantages

•Expensive• Not all insurances reimburse

•Fit - dependent on accurate measurements•Difficult to don/doff•May cause skin breakdown•May retard/alter bone growth•Weight gain/loss should be stableProper Fit of Custom Garments

•Extend garment 2-3“ beyond scar•Avoid stopping garment over muscle belly or joint•Anchor garment so it does not slip•Avoid zippers when possible•If zippers are needed, avoid placing them over scar and bony prominences

•Initial fitting should not be done by patient at home•Should be tight enough that it’s difficult to pull away from skin, but does notcompromise neurovascular status•Avoid wrinkles


58/69


HYPOTHERMIA AND FROSTBITE

HypothermiaHypothermia, or exposure, exists when the body core temperature falls below

98oF. The heart rate, cardiac output, respiratory rate, and blood pressure fall. Asthe muscles cool, shivering begins, become violent, and then gradually ceasesbelow 86oF as the muscles become stiff. Central nervous system cooling leadsto a decrease in cerebral blood flow, dilation of the pupils, stupor, and then coma.

Hypothermia may be classified by duration into acute (several minutes to a fewhours), sub-acute (several hours to a day), and chronic (one to many days).

Acutely, there is a large difference between body core and outside temperatures.In sub-acute and chronic hypothermia, the differences between body core andshell temperatures are smaller.In general, hypothermia occurs in one of the following four (4) clinical settings:

Immersion Hypothermia is usually acute or sub-acute and results fromimmersion in cold water. A similar hypothermia can be due to exposure tocold rain and high winds.Field Hypothermia occurs in previously healthy individuals such asskiers, climbers, hunters, and hikers and may accompany injuriesoccurring outdoors in cold weather.Urban Hypothermia occurs in individuals with a physical predisposition,disability, or illness. Predisposing conditions include those which increaseheat loss (premature infants and newborns with relatively large surfaceareas), or interference with heat production, i.e., the elderly with impairedcirculation.

Hypothermia occurs when the body core is accidentally cooled to below98oF. It can be caused by exposure to cold, snow or ice. Hypothermiarequires medical attention as soon as possible. First aid should be appliedto prevent further heat loss and re-warm the body core and extremities.Patients with hypothermia should be treated gently to avoid heartproblems.

Frostbite:The term "frostbite" refers to actual localized of body parts to variable depthdepending on the temperature, length of exposure, amount of insulation andother factors. Frostbite requires temperatures of freezing or below. The most

commonly involved body parts are on an exposed position (face, ears, hands,and feet). In addition, the body's tendency to protect itself from cold by restrictingperipheral circulation predisposes to frostbite of the extremities.Localized cold injury results from local freezing and interference with circulation.Intra-cellular and extra-cellular ice crystals appear and as they grow in sizecause cellular damage.Superficial frostbite involves only the outer layers of the skin and causes burningor tingling followed by numbness. Inspection shows a grayish-white patch of skin,


59/69


usually on the face or extremities. The deeper tissues remain soft and pliable. After thawing, the area becomes red and sensitive, and slight edema with a fewsmall blebs may appear. A few days later, the skin may peel.Deep frostbite, a much more serious injury, usually occurs in the hands and feet.Inspection shows a cold, waxy, pale, or cyanotic member, solid and unyielding,

which resembles a piece of chicken just out of the freezer. After thawing, blistersof various sizes usually develop. A relatively favorable sign is the occurrence ofhuge blisters filled with pinkish fluid, extending close to the tips of the affecteddigits. In more severe frostbite, the blisters tend to be smaller and filled with adarker fluid, the part remains numb and cool, and the joints remain stiff. In themost severe cases, the frozen area is completely numb, cold, and bloodless,without blisters or edema, and gangrene develops rapidly. The amount ofdamage tends to be overestimated in the early stages, and amputation should bedelayed if possible until clear demarcation occurs.

Signs & Symptoms of Frostbite

Tingling and burns are early symptoms and a warning to get out of the coldimmediately. If this isn't possible, vigorously move the affected part to increasecirculation.The next stage is numbness. By this time, you probably have frostbite.In the third stage, skin may appear pale or white and cold to the touch.In the final stages, there is a swelling and blisters may form after the skin thaws.

A physician should examine all frostbite as soon as possible. Prompt treatmentwill increase the chance for complete recovery.

Initial ManagementSuperficial frostbite can be thawed by direct body heat, such as a warm hand ona frozen cheek, or by general body warming indoors.The preferred initial treatment for deep frostbite is rapid re-warming on a waterbath at a temperature of 104 - 108oF. Rapid re-warming should not be performedin the field if there is a danger that the extremity might be frozen. The re-warmingflushing process is quite painful, and narcotics may be required for relief of pain.Vasodilatation in the affected member is encouraged by raising the body coretemperature with direct heat to other parts of the body and hot drinks.

After thawing, the once frozen part is wrapped in clean, soft material. Toes andfingers are separated with cotton pledgets, and the limb is elevated to minimizeswelling. Patients should not be allowed to walk on a thawed foot. Smoking isprohibited.Tissue loss will be less with rapid re-warming even if the part has been frozen forseveral days.


60/69


Frostbite protocol

Admission/ED: Rewarm affected areas rapidly in warm water (40-42°C) for 15to 30 minutes or until thawing is complete.

On completion of re-warming: treat the affected parts as follows:1. Débride white blisters and institute topical treatment with aloe Vera every

6 hours.2. Leave hemorrhagic blisters intact and institute topical aloe Vera every 6

hours.3. Elevate affected parts with splinting as indicated.4. Administer anti-tetanus prophylaxis (toxoid or Ig).5. Provide analgesia: opiate IV/PO PRN.6. Administer ibuprofen 4-600 mg orally Q 12 hours.7. Administer penicillin 500 mg PO Q 6 hours for 48 to 72 hours.8. Begin ASAP QD hydrotherapy (PT consult) for 30 to 45 min. @40°C. Until

devitalized tissue sloughs. Less benefit if delayed >48 hr.9. Documentation: obtain photographic records at

a. Admissionb. 24 hoursc. Every 2 to 3 days until discharge.

10. Smoking: Prohibit the patient from smoking/nicotine.11. After hydrotherapy has reached maximal benefit, switch to

bacitracin/Sulfamylon/silvadene as indicated.12. Debridement is carried out PRN in the office setting or in the OR over the

next 1-2 months.13. Consider contacting interventional radiology or vascular for possible tPA,

reserpine, or other angiographic revascularization of cold, insensate butnot necrotic extremities (i.e. early intervention). There is some literatureshowing benefit. Consult Drs. Morris, Najerian, Bhave or Sartorelli forguidance if unsure if patient is candidate for angiographic intervention.

Adapted from Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesisand treatment. J Trauma 2000;48(1):171-8; Gentilello LM, Rifley W. Continuousarteriovenous rewarming: report of a new technique for treating hypothermia. JTrauma 1991;31:1151-4; Reduction of the Incidence of Amputation in FrostbiteInjury With Thrombolytic Therapy. Bruen, K. J., MD, et al. ArchSurg. 2007;142:546-553.


61/69


PEDIATRIC BURNS:SPECIAL

CONSIDERATIONS

Highlights of ABA Burn Admission Criteria related to children

• Age < 10 with greater than 10% TBSA burns- second and third degree

• Age > 10 with 20% TBSA burns

• Third degree burns > 5%

• Burns to face , hands, feet, genitalia, or overlying major joint

• Suspected Abuse: Mechanism of injury is consistent with developmentalstatus and must match clinical picture

It bears repeating:

• < 10% Burns- start on maintenance with fluid bolus as needed

• Pediatric Parkland formula for 2nd and 3rd degree

o 2-4 ml RL X kg X % BSA burno ½ in 1st 8 hrso ¼ in 2nd 8 hrso ¼ in 3rd 8 hrs o In children, must add dextrose containing maintenance IV fluids in

addition to resuscitation: – use D5LR100cc/kg for 10 kg of weight 50 cc/kg next 10 kg of weight 20cc/kg remaining weight

Goals: Urine output of 0.5 cc/hr (1-2 cc/kg/hour for children)Reverse base deficit

Restore blood pressure

Caring for Children

Children’s needs and understanding of the injury will differ based upon theirstage of development.


62/69


Key developmental considerations include:

• Infants: Learn through sensory stimulation and movement, includingtouch, may experience separation anxiety

• Early Childhood: At risk for developing low self-esteem as they may viewthe injury as punishment for being “bad’, coordinate procedures around

daily routines• School-Age: Decrease anxiety by educating child and involving in care as

much as possible

• Adolescence: Concern with body image, at increased risk of depressionhowever, may not share feelings with others. Consider psychologicalcounseling

Support for the child and family is critical. When children are frightened anduncomfortable, they may regress to the developmental level that allows them todeal with the stress of the injury. They may be confused by the intensity of

concern given to their physical needs and care. All children need reassurancethat they are “all right” and that they will get better.

General Care Guidelines include:

• Tell child first before doing anything

• Allow for choices whenever possible

• Give descriptions of sensations that may be felt as well as what child cando to cope with them

• Do not use words such as “done” or “finished” until burn care is completed

• Avoid emotional words such as “pain”, “scream” or “hurt”

• Utilize treatment rooms or spaces other than child’s bedroom for dressing

changes and interventions -in order to maintain a “safety zone”• Establish ground rules before procedure. For example, agree on an

allotted time for dressing change or to identify who may perform whatpiece of dressing change

• If child refuses to focus on dressing change or refuses to activelyparticipate- continue to encourage cooperation. Reinforce with praise andgradually increase expectations for child’s participation in care

• If child cannot help- encourage child to count 1-10 or 20 as fast aspossible, rest for agreed upon time ( another 1-10 or 20), then continueburn care work , repeating pattern as indicated

Child Life Specialists are available throughout FAHC to provide proceduralsupport and medical play opportunities for children and families, includingsiblings.


63/69


Managing Pain

Children can enter a “shock like” state after an injury that can mask theirexpressive ability. It is critical to remember that the child’s initial experiencewith pain sets the stage for the rest of the hospitalization.

Barriers:

• Younger children have difficulty conceptualizing or quantifying pain.

• Older children have difficulty in describing pain due to lack of experience

• Often non-pharmacologic techniques are under -used.

Developmentally Appropriate Interventions Ages 0-2 Distraction Ages 2-6 Deep Breathing, Distraction Ages 6 and older Deep Breathing, Distraction, Imagery, Progressive

Muscle Relaxation

It is sometimes difficult to predict the most effective pain management forchildren with new burns, but providing a dose that gives the maximum coveragefor pain and anxiety is optimal.

Pharmacological Support:

• Give IV doses immediately before interventions

• Give PO doses 45 minutes to 1 hour before

Frequently used medications and dosages:

Morphine IV 0.1 mg/kg/dose

Fentanyl IV 1-5 mcg/kg/doseVersed IV 0.05 mg/kg/dose

Oxycodone PO 0.15-0.4 mg/kg/dose

Versed PO 0.5-1 mg/kg/dose

Tylenol 10-15mg/kg/dose

Ibuprofen 10mg/kg/dose

• Assess the need for anesthesia support for Propofol or additionalmedications

• Consider PACT team consult for complex pain management


64/69


PSYCHOSOCIAL ASPECTS OF BURNSPsychosocial aspects of the burn survivor –

Patients with burn injuries are a very unique population not only in terms of thephysical treatment and recovery but also the psychosocial aspects of recovery.The first challenge that a patient with a burn injury faces is survival. Their focuschanges to the psychosocial aspects of recovery as the rate of survivalincreases.

Burn patients go through various stages of emotional recovery as their physicalrecovery continues to progress. Each patient is an individual and their emotional

journey through recovery will be unique. Many factors determine how someonewill respond and cope with the traumatic injury including the events surroundingthe trauma, fatalities involved, and preexisting psychosocial issues.

The emotional responses that one has to such events will span the spectrum andvary with each individual. There is no right, wrong or “appropriate” way forindividuals to react it is their process.Some emotional responses you might observe are anxiety, depression, sleepdisturbances and grief, all of which are very normal.The best way we can support individuals is to honor and respect where they are& try to meet their emotional and physical needs.There are very valuable resources within our hospital including social work,medical psychology and child life specialists, all of whom have knowledge, skillsand expertise in supporting individuals and their families through this process.


65/69


BURN CARE REMINDERSBurn clin ic number 802-847-3790

WOUND CARE1. Shower daily with a mild soap.

2. Pat all areas dry.3. Apply prescribed topicals and/or lotions per discharge summary. Cover

all areas so that you cannot see any burn or healed areas through it.Don’t forget to reapply!

4. Once topicals and/or lotions have been applied, bandage burns ifdirected.

5. **Remember new skin is fragile and may tear, bruise, or blister ifbumped. Apply bacitracin to these areas & watch this area closely. **

ITCHING1. Itching is a common problem in the wound healing process.

2. Tips to relieve itching include:a. Applying Eucerin or other non-perfume moisturizing cream more

frequently, especially before bed time.b. Cool compressesc. Benadryl may help to decrease discomfort. Apply more ointment

as a first step. **If using must read label & follow directions.d. Loose fitting clothing.

AVOID EXPOSURE TO HOT AND COLD, DIRECT SUNLIGHT1. Hot Weather: Your new skin is less able to tolerate extreme

temperature:

a. Deep burn tissue has a decreased ability to sweat so you mayexperience more heat discomfort. Stay indoors in a cool room ifthis occurs.

b. Go outside in the evening when it is cooler out.c. Stay in the shade if outdoors during warm weather.d. Keep burned skin covered while outdoors (long sleeves, pants,

hat, gloves, etc.)e. New skin will burn and blister if exposed to direct sunlight. Must

use a sunscreen with the highest SPF you can find.f. The risk of scarring increases with exposure to extremes of hot,

cold and direct sunlight. This risk lasts up to one year on

burned skin and on skin grafts.2. Cold Weather: Your burned skin is very sensitive to cold and is at high

risk for frostbite. Dress warmly!a. If you experience numbness, tingling or change in the color of

your skin, get out of the cold.b. Wear gloves or mittens. If your face is burned, cover it with a

scarf.


66/69


SCARRING1. Initially it is very difficult to tell how much scarring will be permanent. It

is difficult to predict how much scarring any one person will have sincethe amount of scarring is determined on an individual basis and by thedepth of your burn. When you return to clinic you will be evaluated for

the possible need for pressure garments. If you have been grafted(split thickness skin graft) you will almost always require pressuregarments, all others will be evaluated on an individual basis.

EXERCISE1. Per physical and occupational therapy instructions.

DIET1. A healthy, high protein diet is preferable and will promote wound

healing. You may need to supplement your diet with Ensure, CarnationInstant Breakfast, or other protein shakes.

a. High Protein Food- Dairy (milk, cheese, yogurt, eggs), Poultry, Beef,Fish (tuna, etc), certain nuts, or Peanut butter.

EMOTIONAL READJUSTMENT1. If you are having anxiety, sadness, or sleep issues related to this injury

please do not hesitate to call the burn clinic (847-3790) or discuss thisat your next appointment.

FOLLOW-UP1. Keep all appointments. Burn clinic is located on the 5th Floor of the ACC

building. 847-3790


67/69


WEBSITE REFERENCES

www.ameriburn.org American Burn Association

www.burnprevention.org Burn Prevention Foundationwww.burntalk.com Burn Talkwww.nfpa.org National Fire Protection

Associationwww.burntherapist.com Burn Therapistwww.firefightersburninstitute.com Firefighters Burn Institutewww.cdc.gov Centers for Disease Controlwww.traumaf.org The Trauma Foundationwww.shrinershq.org/Hospitals Shriners Hospitals for

Children

www.burnsurgery.org Burn Surgerywww.sagediagram.com Sage Diagramwww.wounds1.com Wounds1-burn dressingswww.phoenix-society.org Phoenix Society for Burn

Survivors


68/69


BURN (Dressing change) CART INFORMATION

The burn cart was developed as a need for patient care units to get burn supplies

they normally do not stock on their units. The cart is located in distribution andwill be re-stocked by distribution when returned.

To request the cart;The unit enters the request in transport tracking and distribution is notified tobring the cart to that particular unit. Please give plenty of notice before you wishto have the cart ready. It can be obtained through this mechanism 24 hours aday.

The cart should be kept outside the room.

To return the cart:The cart is returned through transport tracking as soon as burn care iscompleted.

Record items used on PAR sheet in top drawer of cart.

Restocking of the cart only occurs during regular business hours. If you needadditional items contact distribution through your normal channels

Currently the Mepilex, Mepitel and large Telfa are kept in CSR. Unit staff willneed to go to CSR to get these products.

The large burn jacket is a patient charge and should be charged accordingly.See attached sheet for contents


69/69

Burn Cart Charge Master Form

Floor Name: CC#

Approver Name: M#:

Time Cart Deliveredto Dept.

Time CartReturned:

Exp. Date Item #New

Item # ProductPAR ONCART Unit of Measure

Write Down Qtyused

01/01/2010 009291 Hibiclens 16 oz 4 bottles

001988 Sterile Bowls 2 each

55408 Telfa 3 X 8 2 boxes

001777 Telfa 3 X 2 2 boxes

001763 Ace Bandage 2" non sterile 2 rolls




001839 Kerlix 20 rolls

55418 Lap Sponges 6 packs

01/01/2001 001872 Exu-dry dressing 24x36 2 each

05/01/2010 001873 Exu-dry dressing 15x24 6 each

08/01/2010 001874 Exu-dry Dressing 9x15 15 each

001875 Exu-dry Jacket Large 2 each

001878 Exu-dry gloves Small 2 each

001880 Exudry Buttock Dressing Adult 2 each

001881 Exu-dry Jacket Small 1 each

08/01/2010 001882 Exu-dry gloves Medium 2 each

001903 59036 Bandnet Size # 3 1 box



001907 59039 Bandnet Size # 10 1 box

002044 Exu-dry gloves Large 4 each

12/01/2010 020217 Burn Fluff Dressing/large 12 packs

001771 Conform - kling 2" 1 box

001772 Conform - kling 3" 1 box