Download - Initial Care of Burns
Initial Care of Burns
Connie Handel RNUniversity of Wisconsin Hospital and Clinics
Objectives
Discover who’s getting burned? Discuss Burn pathophysiology. Understand why some treatments are better
than others. Review treatment options.
Skin Structures
Epidermis – outermost layer of keratinized cells Dermis – contains skin appendages, vascular supply
and nerve endings Subcutaneous Tissue
Functions of the Skin
Barrier to infection
Protection from external injury
Temperature control
Control of body fluids
Sensory organ
Determines identity
What is a burn?
Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.
Burn Depth
First Degree Burns
Epidermis affected only Red or pink, dry, painful,
blanches to touch Epidermis is intact Spontaneous healing
within 7 days. Outer injured epithelial cells peel
Seldom clinically significant
Superficial Partial Thickness
Entire epidermis & portion of dermis (Papillary dermis)
Homogenous pink Painful Blisters Blanches Hair usually intact Does not scar, may pigment
differently
Sup 2nd degree
Deep partial thickness
Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft
Deep Partial Thickness
Deep dermal
Full Thickness: 3rd degree
May go into fat or deeper
Red, white, brown, black
Inelastic and leathery painless or numb Heals only from the
periphery Always excise and graft
Full-thickness
Etiology
Types of burns
Circumstances of injury
Where do burns occur
Admissions by age
% of admissions vs. burn size
Inhalation Injury
Exposure to heat and toxic products of combustion
50% of fire deaths are related to inhalation injuries Asphyxia/Carbon Monoxide displacement of oxygen
Inhalation injury diagnosis
Closed-space fire Face burns
Terminology
Inhalation injury “nonspecific”– Thermal injury
Upper airway Heat and toxic fumes
– Local chemical irritation Throughout airway Primarily toxic fumes
– Systemic toxicity CO
Signs and symptoms
Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing
Conjunctivitis Carbonaceous
sputum Singed hairs Stridor Bronchorrhea
Pathophysiology
The main factor responsible for mortality in thermally injured patients
Carbon monoxide the most common toxin– 200 times greater affinity– Competitive inhibition with cytochrome P-450
Poison management = CO
500 unintentional deaths each year Persistent Neurologic Sequelae
– May improve over time
Delayed Neurologic Sequelae– Relapse later
Carbon Monoxide Poisoning
10% COHb – asymptomatic, seen most often in smokers, truck drivers, traffic police
20% COHb - headache, nausea, vomiting, loss of dexterity
30% COHb - confusion & lethargy, possible ECG changes
40-60% COHb - coma 60% + - usually fatal
Poison management = CO
Treatment– CO level means nothing to predict outcome– Length of hypoxia is the determining factor– Oxygen– HBO
No studies show benefit in treatment
Reduction of CO
0
20
40
60
80
0 20 40 60 80
Time in Minutes
% C
O
Room Air100% Oxygen3 ATM
Determine Burn Severity
% BSA involved Depth of injury Age Associated/pre-existing
disease or illness Burns to face, hands,
genitalia
Difficulties with accurate initial assessment of burn size & depth
Soot, blisters, adherent clothing or debris obscure wound
Burns are dynamic…Progression is always a risk
Burn Extent
Total Body Surface Area (TBSA)?
Rule of nines Lund and Browder chart Patients palm = about 1% TBSA
Extent of Burn :“Rule of Nines”
Adult anatomical areas = 9% BSA (or multiple)
Not accurate for infants or children due to larger BSA of head & smaller BSA legs.
Burn diagrams illustrate adult – child differences
Lund & Browder Chart
Extent of Burns
Patient’s palmar surface (hand + Patient’s palmar surface (hand + fingers) = 1% TBSAfingers) = 1% TBSA
Burn Depth
Factors
Temperature Duration of contact Dermal thickness Blood supply Special Consideration: Very young and
very old have thinner skin
Burns begin at 44 degrees C
6 hours for burns to occur at
111 degrees F (44 C)
1 second of burns to occur at
140 degrees F (60 C)
Time For Full Thickness Burns To Occur In Scalds
5 seconds in water @ 140 F (60 C)
30 seconds in water @ 130 F (55 C)
5 minutes in water @ 120 F (49 C)
Pain control
Ice Pack-----DO NOT USE EVER
DOES NOT– Reverse temperature– Inhibit destruction– Prevent edema
DOES– Delay edema– Reduce pain
Non-medication methods
Cover burns with plastic wrap– Wet dressings will stick and cause more pain– Other burn dressings are expensive and not
necessary– Quik Clot is expensive and will not provide any
patient benefit
Medication
Medications– Opioids– Narcotics– Pain medications– IV Analgesia
Resuscitation
IV access
< 15% TBSA – oral resuscitation 15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s IV’s should be in the upper extremities Suture IV’s started through burns
Field resuscitation
Start IV with LR, through burn OK
– < 6 years = 125mL/hr– 6-13 years = 250mL/hr– >13 years = 500mL/hr
Contact
Contact Burn
Scald Burn
Flame Burn
Grease Burn
ABA Burn Referral Criteria
The ABA identifies the following as injuries requiring a Burn Center referral:
2nd degree burns > 10% TBSA Burns to face, hands, feet, genitalia, perineum, major joints 3rd degree burns Electrical injury Chemical burns Inhalation injuries Burns accompanied by pre-existing medical conditions Burns accompanied by trauma, where burn injury poses greatest
risk of morbidity or mortality. Burns to children in hospitals without pediatric services. Patients with special social, emotional or rehabilitative needs.
UWHC Burn CenterVerified by the American Burn Association
7 ICU beds General care bed
expansion available as needed
Open to all burns, all ages, all times
Capability of providing specialized care for all patients, from pediatrics to geriatrics
Full time Surgical
Staff, House Staff, Nursing, Respiratory, Occupational and Physical Therapists, Social Worker, Nutritionist, Health Psychologist, Child Life and Pharmacist
UWHC Burn CenterVerified by the American Burn Association
Closely integrated inpatient, rehabilitation and outpatient services
Outreach programs– Burn Support Group– Burn Camp– Burn Buddies– Juvenile Fire Starters
Program– School Reintegration– Burn Education to School
and Community Groups