Burns Prepared

Aseem.B,MBA,MSN, PGDHA

Assistant Professor,

SP Fort College of Nursing, Trivandrum

Definition

• Burns are a result of the effects of thermal injury on the skin and other tissues

• Human skin can tolerate temperatures up to 42-440 C (107-1110 F) but above these, the higher the temperature the more severe the tissue destruction

• Below 450 C (1130 F), resulting changes are reversible but >450 C, protein damage exceeds the capacity of the cell to repair

• A burn injury occurs as a result of destruction of the skin from direct or indirect thermal force.

• Burn are caused by exposure to heat, electric current, radiation or chemical.

• Scald burn result from exposure to moist heat (steam or hot fluids) and involve superficial.

Types

1. Thermal burns.2. Chemical burns3. Electrical burns 4. Radiation burns

Mammootty's kind hearted gesture gives hope to acid attack victim.

incidence• About 2.4 million people suffer burns annually• Account for an estimated 700,000 ER visits per

year and 45,000 require hospitalizations• Between 8,000-12,000 burn patients die, and

approximately one million will sustain substantial or permanent disabilities

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Classification According to Depth

• First-degree Burns (mild): epidermis Pain, erythema & slight swelling, no blisters Tissue damage usually minimal, no scarring Pain resolves in 48-72 hours

• Superficial Second-degree Burns: entire epidermis & variable dermis

Vesicles and blisters characteristic Extremely painful due to exposed nerve

endings Heal in 7-14 days if without infection

Superficial

Partial thickness (second degree)

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Full thickness (3°burn)

• Midlevel to Deep Second-degree Burns: Few dermal appendages left There are some fluid & metabolic effects

• Full-thickness or Third-Degree: • entire epidermis and dermis, no residual

epidermis Painless, extensive fluid & metabolic deficits Heal only by wound contraction, if small, or if

big, by skin grafting or coverage by a skin flap

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Blister may ↑size because continuous exudation and collection of tissue fluid

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Eschar:composed of denatured protein

Burn Photos

Chemical (Acid) Burns

Radiation (Flash) Burns

Burn Photos

Electrical Burns Entrance Wounds

Electrical Burns Exit Wounds

Entrance wound of electrical burns from an overheated tool

Severe swellingpeaks 24-72 hrs after

Electrical burns mummified1st 2 fingers later removed

Chemical Burn

Pathologic Features

• Zone of coagulation (necrosis): Superficial area of coagulation necrosis and cell death on exposure to temperatures >450 (primary injury)

• Zone of stasis (vascular thrombosis): Local capillary circulation is sluggish, depending on the adequacy of the resuscitation, can either remain viable or proceed to cell death (secondary injury)

• Zone of hyperemia (increased capillary permeability)

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Zone of injury

Burns Assessment/Physiology/ Classification

Based on:• Depth/Degree of injury,• Percent of body surface areas involved,• Location of the burn, • Association with other injuries.

Classification According to Extent

• Mild: 10%• Moderate:

10-30%• Severe: > 30%

• Hospitalization for > 10% of body surface area

• Rule of nines-An estimated of the TBSA involved as a result of a burn.

• The rule of nines measures the percentage of the body burned by dividing the body into multiples of nine.

• The initial evaluation is made upon arrival at the hospital.

Rule of nine

For small children, the head represents a greater portionof the body mass than adults. Lund and Browder first described a method for compensating for the differences and the Lund and Browder Chart is used to calculate Body Surface Area (BSA) in children.

If the chart is unavailable, one can estimate body surface area and adjust for age, as :follows

.

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Factors determining severity of burns

• Size of burn• Depth of burn• Age of victim• Body part involved• Mechanism of injury• History of cardiac, pulmonary, renal, or

hepatic disease • Injuries sustained at time of burn.

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Effects of a severe burn

1. Cardiovascular2. Respiratory3. Immune4. Integumentary5. Gastrointestinal6. Urinary

Cardiovascular system

• Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein)

• Hypotension• tachycardia• Blood flow in intravascular is concentrated and

cause static.• Cardiac output ↓, • Due to that tissue perfusion ↓,

Hematologic changes

• Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, deficit plasma clotting factors.

• Life span ↓RBC.• Blood loss during diagnostic and therapeutic

procedure.

Respiration system

• Majority of deaths from fire are due to smoke inhalation.

• Pulmonary damage can be from direct inhalation injury or systemic respond to the injury.

• Damage to cilia and cell in the airway-inflammation.

• Mucociliary transport mechanism not functioning-bronchial congestion and infection.

• Pulmonary edema, fluids escape to interstitial. • Airway obstruction

Gastrointestinal

• Burn >20% experience ↓peristalsis, gastric distention and ↑risk of aspiration.

• Paralytic ileus due to secondary to burn trauma.• Stress ulcer (stomach/duodenum) due to burn

injury.• Indication of stress ulcer-malena stool or

hematemesis.• These signs suggest gastric or duodenal erosion

(Curling`s ulcer)• Gastric distention and nausea may lead to vomiting.

CURLING’S ULCER

• Acute ulcerative gastro duodenal disease• Occur within 24 hours after burn• Due to reduced GI blood flow and

mucosal damage• Treat clients with H2 blockers,

mucoprotectants, and early enteral nutrition

• Watch for sudden drop in hemoglobin

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Immunologic changes

• Skin barrier to invading organisms s destroyed, circulating levels of immunoglobulins are ↓

• Changes in WBC both quantitative and qualitative.

• Depression of neutrophil, phagocytic and bactericidal activity is found after burn injury.

• All this changes in the immune system can make the burn patient more susceptible to infection

PHASES OF BURN INJURIES

• Emergent (24-48 hrs)• Acute• Rehabilitative

MANAGEMENT OF THE BURN INJURYPhases of Management

Emergent phase - begins at the time of injury and ends with the

restoration of capillary permeability, usually at 48-72 hours after the injury

- the 1˚ goal is to prevent hypovolemic shock and preserve vital organ functioning

- includes prehospital care and emergency room care

Acute phase

- begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun

- usually begins 48 - 72 hours after the time of injury- emphasis during this phase is placed on restorative

therapy, and the phase continues until wound closure is achieved

- the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy

Resuscitative phase

- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased

- the amount of fluid administered is based on the client’s weight and extent of injury

- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion

Resuscitative phase

- begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased

- the amount of fluid administered is based on the client’s weight and extent of injury

- most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital

- the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion

Rehabilitative phase

- final phase of burn care- overlaps the acute care phase and goes well

beyond hospitalization- goals of this phase are designed so that the

client can gain independence and achieve maximal function

Diagnosis

• A detailed history and physical examination is the first step. The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection.

• Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.

Lab Tests

• Routine blood work for a patient with a burn injury includes a complete blood count, platelet count, clotting studies, liver function studies, and carboxyhemoglobin, electrolyte, blood urea nitrogen, glucose and creatinine levels.

• Urinalysis may reveal myoglobinuria and hemoglobinuria.

• If pt. is 35 or older, he’ll also need an electrocardiogram.

• Chest x-rays and arterial blood gas levels allow the evaluation of alveolar function.

BURN INTERVENTIONS

•Maintain Airway• Fluid Resuscitation• Relieve Pain• Prevent Infection• Provide Nutrition• Prevent Stress Ulceration• Provide Psychologic Support• Prevent Contractures

Management

PAIN MANAGEMENT• Administer morphine sulfate or meperidine

(Demerol), as prescribed, by the IV route• Avoid IM or SC routes because absorption

through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring

• Avoid administering medication by the oral route, because of the possibility of GI dysfunction

• Medicate the client prior to painful procedures

FLUID IMBALANCES

• Occur as a resul t of f lu id sh i f t and ce l l damage

• Hypovolemia• Metabol ic ac idos is• Hyperkalemia• Hyponat remia• Hemoconcent ra t ion (e levated b lood

osmolar i ty, hematocr i t /hemoglobin) due to dehydrat ion

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Formula for estimating fluid replacement

• Brooke (Modified) : lactated ringers solution : 2..0ml/kg/% TBSA burn: half given during first 8 hours and half given during next half hour

• Parkland (Baxter) lactated ringers solution 4ml /kg/% TBSA burn; half given first 8 hr, ¼

• Given each next 8 hr

ESCHAROTOMY

• A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation

• Performed for circulatory compromise resulting from circumferential burns

• After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure

• Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed

• Apply topical antimicrobial agents as prescribed

NUTRITION

• Essential to promote wound healing and prevent infection

• Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed

• Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition

• Provide a diet high in protein, carbohydrates, fats and vitamins

ESCHAROTOMY&FASCIOTOMY

FASCIOTOMY• An incision is made, extending through the SQ

tissue and fascia• Performed if adequate tissue perfusion does

not return after an escharotomy• Performed in OR under GA, after procedure

assess same as above

Hydrotherapy cart shower

Hubbard Tank (old method)

Dermatome-harvesting donor skin from thigh (courtesy : google images)

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courtesy : google images

• For graft to SURVIVE and be effective:

– Recipient bed must have adequate blood supply

– Graft must be in close contact with recipient bed

– Graft must be firmly fixed or immobile– Free from infection

Acid attack survivor laxmi courtesy : google images