unit 2 management of patients with burn

MANAGEMENT OF PATIENTS WITH BURN

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Pathophysiology of BurnsCauses of Burn

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Burns are caused by a transfer of energy from a heat source to the body.

Heat may be transferred through conduction or electromagnetic radiation.

Burns are categorized as thermal (which includes electrical burns), radiation, or chemical.

Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents.

Pathophysiology of Burns cont’d

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The skin and the mucosa of the upper airways are the sites of tissue destruction.

Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source.

Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image.

Pathophysiology of Burns cont’d

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The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent.

For example, in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis, causing a fullthickness (third-degree) injury.

Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar full-thickness injury.

Temperatures less than 111°F are tolerated for long periods without injury.

CLASSIFICATION OF BURNS

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Burn injuries are described according to the depth of the injuryand the extent of body surface area injured.

Burn Depth Burn depth determines whether

epithelialization will occur. Determining burn depth can be difficult

even for the experienced burn care provider.

CLASSIFICATION OF BURNS cont’d

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Burns are classified according to the depth of tissue destruction as:

1. Superficial partial-thickness injuries (first degree burn):

In a superficial partial-thickness burn, the epidermis is destroyed or injured

and a portion of the dermis may be

injured. The damaged skin may be painful and

appear red and dry, as in sunburn, or it may blister (very minimal).


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Typical Characteristics for Superficial thickness burn Mild to severe erythema (pink to red) NO BLISTERS Skin blanches Painful, tingling Pain responds well to cooling Lasts about 48 hours; healing in 3-7

days


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2. Deep partial-thickness injuries (second degree burn):

A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis.

The wound is painful, appears red, and exudes fluid.

Capillary refill follows tissue blanching. Hair follicles remain intact.

Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars.


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Typical Characteristics for deep partial thickness burn Large blisters over an extensive

area Edema Red base with broken epidermis Wet, shiny and weeping Sensitive to cold air Healing in 2-3 weeks Grafts MAY be needed

Partial-Thickness Burn to the Hand

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Partial-Thickness Burns Due to Immersion in Hot Water11


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3. Ful-thickness injuries (third degree burn):

A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well.

Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed.

The wound appears leathery; hair follicles and sweat glands are destroyed


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Typical Characteristics for Full-thickness burn

Deep, red, black, white, yellow, or brown area

Edema Tissue open with fat exposed Little to no pain* Requires removal of eschar and skin

grafting Scarring and contractures are likely Takes weeks to months to heal

Full-Thickness Thermal Burn

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The following factors are considered in determining the depth of the burn: How the injury occurred Causative agent, such as flame or

scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS

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Thermal Burns Caused by flame, flash, scald, or contact with hot objects

It is the most common type of burn

Chemical Burns Result from tissue injury and

destruction from necrotizing substances

(chemicals) Most commonly caused by acids

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d17

Chemical Burns cont’d Respiratory and systemic problems

Eye injuries Clothing containing the chemical should be removed

Tissue destruction may continue for up to 72 hours after a chemical injury


Smoke Inhalation Injuries Result from inhalation of hot air or noxious chemicals Cause damage to respiratory tract Important determinant of mortality in fire victims


Smoke Inhalation Injuries cont’d Three types:

• Carbon monoxide poisoning

• Inhalation injury above the glottis

• Inhalation injury below the glottis


Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning

CO is produced by the incomplete combustion of burning materials

Inhaled CO displaces oxygen 200 x more powerful than oxygen

CO is colorless, odorless and tasteless


Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning

can cause:• Hypoxia in tissues• Carboxyhemoglobinemia• Death


Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning Treat with 100% humidified oxygen CO poisoning may occur in the

absence of burn injury to the skin Skin color described as “cherry red” in

appearance Hot air, steam, or smoke can cause:

mechanical obstruction quickly May lead to hemorrhage in the bronchus

ARDS


Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoningSigns and Symptoms

Presence of facial burnsSinged nasal hairHoarseness,painful swallowingDarkened oral and nasal membranes


Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoningSigns and Symptoms cont’d

Wheezing on auscultationEdema is the nose and airways

FlushingNausea/vomitingSyncope, coma, death


Smoke Inhalation InjuriesInjury below the glottis -

Pathophysiology Injury is related to the length of

exposure to smoke or toxic fumes Pulmonary edema may not appear

until 12 to 24 hours after the burn Decrease is surfactant production Decrease in ciliary action


Electrical Burns Intense heat generated from

anelectrical current May result from direct damage to

nerves and vessels causing tissue anoxia and death

Severity of injury depends on the amount of voltage, tissue resistance, current pathways, surface area, and on the length of time of the flow

Electrical Burn- Hand27

Electrical Burn- Back28


Electrical Burns cont’d Electrical sparks may ignite the

patient’s clothing, causing a combination of thermal and electrical injury


Cold Thermal Injury (Frostbite)• Usually affects fingers, toes, nose, and ears

• Numbness, pallor, severe pain, swelling, edema

• Blistering in a warm environment

• Handle the tissue carefully!


Cold Thermal Injury (Frostbite) Interventions – Frostbite

Warm rapidly and continuously for 15-20 minutes

AVOID slow thawing Do not debride blisters

CLASSIFICATION OF BURNS BY EXTENT OF BSA INJURED

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Extent of Body Surface Area Injured

Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are: the rule of nines, the Lund and Browder method, and the palm method.


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RULE OF NINES An estimation of the TBSA involved in a

burn is simplified by using the rule of nines.

The rule of nines is a quick way to calculate the extent of burns.

The system assigns percentages in multiples of nine to major body surfaces.

Rule of Nines Chart34

Rule of Nines Chart35


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LUND AND BROWDER METHOD A more precise method of estimating the

extent of a burn is the Lund and Browder method,

It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth.

By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned.

The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then.

Lund-Browder Chart37


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PALM METHOD In patients with scattered burns, a method

to estimate the percentage of burn is the palm method.

The size of the patient’s palm is approximately 1% of TBSA.

Criteria for Classifying the Extent of Burn Injury(American Burn Association)Minor Burn Injury

Second-degree burn of less than 15% total body surface area(TBSA) in adults or less than 10% TBSA in children

Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints)

Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease)

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Criteria for Classifying the Extent of Burn Injury(American Burn Association)Moderate, Uncomplicated Burn Injury

Second-degree burns of 15%–25% TBSA in adults or10%–20% in children

Third-degree burns of less than 10% TBSA not involving special care areas

Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease)

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Criteria for Classifying the Extent of Burn Injury(American Burn Association)Major Burn Injury Second-degree burns exceeding 25% TBSA

in adults or 20% in children All third-degree burns exceeding 10%

TBSA All burns involving eyes, ears, face, hands,

feet, perineum, joints All inhalation injury, electrical injury,

concurrent trauma, all poor-risk patients

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LOCAL AND SYSTEMIC RESPONSESTO BURNS42

Burns that do not exceed 25% TBSA produce a primarily local response.

Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries.

These systemic responses are due to the release of cytokines and other mediators into the systemic circulation and include the following:

LOCAL AND SYSTEMIC RESPONSESTO BURNS cont’d43

tissue edema effects on fluid, electrolytes and blood

volume cardiovascular responses (decreased

cardiac out put, hypovolumia, decresed BP, increased PR)

pulmonary responses (inhalation injury to air ways, broncho-constriction-major cause of death,acute respiratory failure or respiratory distress syndrome )

altered immunological defenses renal dysfunction, etc


Pathophysiologic changes resulting from major burns during the initial burn-shock period include: tissue hypoperfusion organ hypofunction secondary to

decreased cardiac output, Hyperdynamic and hypermetabolic

phase.


The incidence, magnitude, and duration of pathophysiologic changes in burns are proportional to the extent of burn injury, with a maximal response seen in burns covering 60% or more TBSA.

The initial systemic event after a major burn injury is hemodynamic instability, resulting from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces.

Management of the Patient With a Burn Injury46

Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response.

Burn care then proceeds through three phases: Emergent/resuscitative phase (on-the-scene care), Acute/intermediate phase, and Rehabilitation phase.

Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.

Table: phases of burn care

47Phase Duration Priorities

Emergent or immediateresuscitative

From onset of injury to completionof fluid resuscitation

First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant

injuries Wound assessment and initial care

Acute From beginning of diuresis to nearcompletion of wound closure

Wound care and closure Prevention or treatment of

complications, including infection Nutritional support

Rehabilitation

From major wound closure to returnto individual’s optimal level of physicaland psychosocial adjustment

Prevention of scars and contractures Physical, occupational, and vocational

rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

Emergent/resuscitative phase mgt Emergency Procedures at the

Burn Scene Extinguish the flames Cool the burn Remove restrictive objectives Cover the wound Irrigate chemical burns

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Emergent/resuscitative phase mgt Emergency Medical Management The patient is transported to the nearest

emergency department. The hospital nurses (staff) and physician

are alerted that the patient is in route to the emergency department so that life-saving measures can be initiated immediately by a trained team.

Initial priorities in the emergency department remain airway, breathing, and circulation.

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Emergent/resuscitative phase mgtEmergency Medical Management cont’d For mild pulmonary injury, inspired air is

humidified and the patient is encouraged to cough so that secretions can be removed by suctioning.

For more severe situations, it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents.

If edema of the airway develops, endotracheal intubation may be necessary.

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Emergent/resuscitative phase mgt

Emergency Medical Management cont’d Continuous positive airway pressure and

mechanical ventilation may also be required to achieve adequate oxygenation.

A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not inserted earlier).

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Emergent/resuscitative phase mgtEmergency Medical Management

cont’d Assessment of both the TBSA burned

and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound.

An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns.

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Management of fluid loss and shockFluid Replacement Therapy: The total volume and rate of

intravenous fluid replacement are gauged by the patient’s response.

The adequacy of fluid resuscitation is determined by: Output totals of 30 to 50 mL/hour systolic blood pressure exceeding 100

mm Hg and/or pulse rate less than 110/minute.

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Conditions Leading to Burn Shock

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Management of fluid loss and shockFluid Requirements: The projected fluid requirements for the

first 24 hours are calculated by the clinician based on the extent of the burn injury.

Some combination of fluid categories may be used: Colloids (whole blood, plasma, and plasma

expanders) and Crystalloids/electrolytes (physiologic

sodium chloride or lactated Ringer’s solution).

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Management of fluid loss and shock

Fluid Requirements: Adequate fluid resuscitation results in

slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours.

Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA.

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Guidelines and Formulas for Fluid Replacement in Burn Patients

Consensus Formula Lactated Ringer’s solution (or other

balanced saline solution): 2–4 mL× kg body weight × % total body surface area (TBSA) burned.

Half to be given in first 8 hours; remaining half to be given over next 16 hours.

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The following example illustrates use of the formula in a management of a 70-kg patient with a 50% TBSA burn:

Steps 1, Consensus formula: 2 to 4

mL/kg/% TBSA 2, 2 × 70 × 50 = 7,000 mL/24 hours 3, Plan to administer: First 8 hours =

3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour

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Guidelines and Formulas for Fluid Replacement in Burn PatientsEvans Formula

1. Colloids: 1 mL × kg body weight × % TBSA burned 2. Electrolytes (saline): 1 mL × body weight × % TBSA

burned 3. Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over

next 16 hours Day 2: Half of previous day’s colloids and electrolytes; all of

insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and third-

degree (partial- and full-thickness) burns exceeding 50% TBSA are

calculated on the basis of 50% TBSA.

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Brooke Army Formula 1. Colloids: 0.5 mL × kg body weight ×

% TBSA burned 2. Electrolytes (lactated Ringer’s

solution): 1.5 mL × kg body weight × % TBSA burned

3. Glucose (5% in water): 2,000 mL for insensible loss

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Brooke Army Formula cont’d Day 1: Half to be given in first 8 hours;

remaining half over next16 hours Day 2: Half of colloids; half of

electrolytes; all of insensible fluid replacement.

Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.

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Parkland/Baxter Formula Lactated Ringer’s solution: 4 mL × kg

body weight × % TBSA burned Day 1: Half to be given in first 8

hours; half to be given over next16 hours

Day 2: Varies. Colloid is added.

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Hypertonic Saline Solution Concentrated solutions of sodium chloride

(NaCl) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output.

Do not increase the infusion rate during the first 8 post burn hours.

Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and

osmolality to reduce edema and prevent pulmonary complications.

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Nursing Management

Includes: infection prevention, wound cleansing and administering topical antibacterial drugs

like: Silver sulfadiazine 1% (Silvadene) watersoluble cream, Silver nitrate 0.5% aqueous solution, Mafenide acetate 5% to 10% (Sulfamylon)

hydrophilic-based cream, Acticoat, etc

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Acute Phase management

Hemodynamically stable through diuresis

Capillary permeability is restored 48-72 hours after injury Goal is restorative therapy Focus on infection control, wound

care and closure, nutritional support, pain management, PT

Concluded when the burned area is completely covered by skin grafts or when the wounds are healed

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Pathophysiology Diuresis from fluid mobilization occurs,

and the patient is no longer grossly edematous

Bowel sounds return Healing begins Formation of granulation tissue A partial-thickness burn wound will

heal from the edges Full-thickness burns must be covered

by skin grafts

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• Wound Care Daily observation Assessment Cleansing Debridement Appropriate coverage of the graft:

Fine-mesh gauze next to the graft followed by middle and outer dressings

Sheet skin grafts must be kept free of blebs (small blisters)

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Excision and Grafting Eschar is removed down to the

subcutaneous tissue or fascia Cultured Epithelial Autographs (CEA):

CEA is grown from biopsies obtained from the patient’s own skin

Artificial Skin: used when life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable

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Acute Phase management Pain Management Opioid every 1 to 3 hours for pain Several drugs in combination Morphine with haloperidol Nonpharmacologic strategies • Relaxation tapes

• Visualization, guided imagery • Meditation

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Acute Phase management Debriding Full-Thickness Burn

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Acute Phase managementSurgeon Harvesting Skin71

Acute Phase managementDonor Site After Harvesting

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Acute Phase managementHealed Split-Thickness Skin Graft

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Acute Phase managementApplication of Cultured Epithelial Autograft74

Rehabilitation Phase

The rehabilitation phase is defined as beginning when the patient’s burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity

Complications Skin and joint contractures Hypertrophic scarring

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Contracture of the Axilla76

Rehabilitation Phase

Both patient and family actively learn how to care for healing wounds

Cosmetic surgery is often needed following major burns

Role of exercise cannot be overemphasized

Constant encouragement and reassurance

Address spiritual and cultural needs Maintain a high-calorie, high-protein

diet Occupational therapy

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unit 2 management of patients with burn

Education