MANAGEMENT OF PATIENTS WITH BURN*

Pathophysiology of BurnsCauses of Burn*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 contd*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 contd*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 68.9C (156F) 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 56.1C (133F) results in a similar full-thickness injury. Temperatures less than 111F are tolerated for long periods without injury.

CLASSIFICATION OF BURNS*Burn injuries are described according to the depth of the injuryand the extent of body surface area injured.Burn DepthBurn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider.

CLASSIFICATION OF BURNS contd*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).

CLASSIFICATION OF BURNS contd*Typical Characteristics for Superficial thickness burnMild to severe erythema (pink to red)NO BLISTERSSkin blanches Painful, tinglingPain responds well to coolingLasts about 48 hours; healing in 3-7 days

CLASSIFICATION OF BURNS contd*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.

CLASSIFICATION OF BURNS contd*Typical Characteristics for deep partial thickness burnLarge blisters over an extensive areaEdemaRed base with broken epidermisWet, shiny and weepingSensitive to cold airHealing in 2-3 weeksGrafts MAY be needed

Partial-Thickness Burn to the Hand*

Partial-Thickness Burns Due to Immersion in Hot Water*

CLASSIFICATION OF BURNS contd*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

CLASSIFICATION OF BURNS contd*Typical Characteristics for Full-thickness burnDeep, red, black, white, yellow, or brown areaEdemaTissue open with fat exposedLittle to no pain*Requires removal of eschar and skin graftingScarring and contractures are likelyTakes weeks to months to heal

Full-Thickness Thermal Burn*

CLASSIFICATION OF BURNS contd*The following factors are considered in determining the depth of the burn:How the injury occurred Causative agent, such as flame or scalding liquidTemperature of the burning agentDuration of contact with the agentThickness of the skin

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS*Thermal BurnsCaused by flame, flash, scald, or contact with hot objectsIt is the most common type of burnChemical BurnsResult from tissue injury and destruction from necrotizing substances (chemicals) Most commonly caused by acids

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Chemical Burns contdRespiratory and systemic problems Eye injuriesClothing containing the chemical should be removedTissue destruction may continue for up to 72 hours after a chemical injury

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation InjuriesResult from inhalation of hot air or noxious chemicals Cause damage to respiratory tractImportant determinant of mortality in fire victims

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contd Three types: Carbon monoxide poisoning Inhalation injury above the glottis Inhalation injury below the glottis

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contdCarbon monoxide (CO) poisoningCO is produced by the incomplete combustion of burning materialsInhaled CO displaces oxygen 200 x more powerful than oxygenCO is colorless, odorless and tasteless

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contdCarbon monoxide (CO) poisoning can cause: Hypoxia in tissues Carboxyhemoglobinemia Death

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contdCarbon monoxide (CO) poisoningTreat with 100% humidified oxygenCO poisoning may occur in the absence of burn injury to the skinSkin color described as cherry red in appearanceHot air, steam, or smoke can cause: mechanical obstruction quickly May lead to hemorrhage in the bronchus ARDS

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contdCarbon monoxide (CO) poisoningSigns and SymptomsPresence of facial burnsSinged nasal hairHoarseness,painful swallowingDarkened oral and nasal membranes

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation Injuries contdCarbon monoxide (CO) poisoningSigns and Symptoms contdWheezing on auscultationEdema is the nose and airwaysFlushingNausea/vomitingSyncope, coma, death

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Smoke Inhalation InjuriesInjury below the glottis - PathophysiologyInjury is related to the length of exposure to smoke or toxic fumesPulmonary edema may not appear until 12 to 24 hours after the burnDecrease is surfactant productionDecrease in ciliary action

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Electrical BurnsIntense heat generated from anelectrical currentMay result from direct damage to nerves and vessels causing tissue anoxia and deathSeverity 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- Hand*

Electrical Burn- Back*

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Electrical Burns contdElectrical sparks may ignite the patients clothing, causing a combination of thermal and electrical injury

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Cold Thermal Injury (Frostbite)Usually affects fingers, toes, nose, and earsNumbness, pallor, severe pain, swelling, edemaBlistering in a warm environmentHandle the tissue carefully!

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS contd*Cold Thermal Injury (Frostbite)Interventions FrostbiteWarm rapidly and continuously for 15-20 minutesAVOID slow thawingDo not debride blisters

CLASSIFICATION OF BURNS BY EXTENT OF BSA INJURED*Extent of Body Surface Area InjuredVarious 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.

CLASSIFICATION OF BURNS contd*RULE OF NINESAn 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 Chart*

Rule of Nines Chart*

CLASSIFICATION OF BURNS contd*LUND AND BROWDER METHODA 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 patients 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 Chart*

CLASSIFICATION OF BURNS contd*PALM METHODIn patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patients palm is approximately 1% of TBSA.

Criteria for Classifying the Extent of Burn Injury(American Burn Association)Minor Burn InjurySecond-degree burn of less than 15% total body surface area(TBSA) in adults or less than 10% TBSA in childrenThird-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)*

Criteria for Classifying the Extent of Burn Injury(American Burn Association)Moderate, Uncomplicated Burn InjurySecond-degree burns of 15%25% TBSA in adults or10%20% in childrenThird-degree burns of less than 10% TBSA not involving special care areasExcludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease)*

Criteria for Classifying the Extent of Burn Injury(American Burn Association)Major Burn InjurySecond-degree burns exceeding 25% TBSA in adults or 20% in childrenAll third-degree burns exceeding 10% TBSAAll burns involving eyes, ears, face, hands, feet, perineum, jointsAll inhalation injury, electrical injury, concurrent trauma, all poor-risk patients*

LOCAL AND SYSTEMIC RESPONSESTO BURNS*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 contd*tissue edemaeffects on fluid, electrolytes and blood volumecardiovascular 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

LOCAL AND SYSTEMIC RESPONSESTO BURNS contd*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.

LOCAL AND SYSTEMIC RESPONSESTO BURNS contd*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 Injury*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, andRehabilitation 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 *

Phase Duration Priorities Emergent or immediateresuscitativeFrom onset of injury to completionof fluid resuscitationFirst aidPrevention of shockPrevention of respiratory distress Detection and treatment of concomitant injuriesWound assessment and initial careAcuteFrom beginning of diuresis to nearcompletion of wound closureWound care and closurePrevention or treatment of complications, including infectionNutritional supportRehabilitationFrom major wound closure to returnto individuals optimal level of physicaland psychosocial adjustmentPrevention of scars and contracturesPhysical, occupational, and vocational rehabilitationFunctional and cosmetic reconstructionPsychosocial counseling

Emergent/resuscitative phase mgtEmergency Procedures at the Burn SceneExtinguish the flamesCool the burn Remove restrictive objectives Cover the wound Irrigate chemical burns

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Emergent/resuscitative phase mgtEmergency Medical ManagementThe 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 contdFor 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 mgtEmergency Medical Management contdContinuous 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 contdAssessment 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.*

Management of fluid loss and shockFluid Replacement Therapy: The total volume and rate of intravenous fluid replacement are gauged by the patients 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*

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 Ringers solution).

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Management of fluid loss and shockFluid 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 PatientsConsensus FormulaLactated Ringers solution (or other balanced saline solution): 24 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.*

Guidelines and Formulas for Fluid Replacement in Burn PatientsThe 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/% TBSA2, 2 70 50 = 7,000 mL/24 hours3, 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 Formula1. Colloids: 1 mL kg body weight % TBSA burned2. Electrolytes (saline): 1 mL body weight % TBSA burned3. Glucose (5% in water): 2,000 mL for insensible lossDay 1: Half to be given in first 8 hours; remaining half over next 16 hoursDay 2: Half of previous days colloids and electrolytes; all of insensible fluid replacementMaximum of 10,000 mL over 24 hours. Second- and third-degree(partial- and full-thickness) burns exceeding 50% TBSA are calculatedon the basis of 50% TBSA.

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Guidelines and Formulas for Fluid Replacement in Burn PatientsBrooke Army Formula1. Colloids: 0.5 mL kg body weight % TBSA burned2. Electrolytes (lactated Ringers solution): 1.5 mL kg body weight % TBSA burned3. Glucose (5% in water): 2,000 mL for insensible loss*

Guidelines and Formulas for Fluid Replacement in Burn PatientsBrooke Army Formula contdDay 1: Half to be given in first 8 hours; remaining half over next16 hoursDay 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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Guidelines and Formulas for Fluid Replacement in Burn PatientsParkland/Baxter FormulaLactated Ringers solution: 4 mL kg body weight % TBSA burnedDay 1: Half to be given in first 8 hours; half to be given over next16 hoursDay 2: Varies. Colloid is added.*

Guidelines and Formulas for Fluid Replacement in Burn PatientsHypertonic Saline SolutionConcentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250300 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.*

Nursing ManagementIncludes: 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 diuresisCapillary permeability is restored48-72 hours after injuryGoal is restorative therapyFocus on infection control, wound care and closure, nutritional support, pain management, PTConcluded when the burned area is completely covered by skin grafts or when the wounds are healed

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Acute Phase management PathophysiologyDiuresis from fluid mobilization occurs, and the patient is no longer grossly edematousBowel sounds returnHealing beginsFormation of granulation tissueA partial-thickness burn wound will heal from the edgesFull-thickness burns must be covered by skin grafts

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Acute Phase management Wound CareDaily observationAssessment CleansingDebridementAppropriate coverage of the graft:Fine-mesh gauze next to the graft followed by middle and outer dressingsSheet skin grafts must be kept free of blebs (small blisters)

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Acute Phase management Excision and GraftingEschar is removed down to the subcutaneous tissue or fasciaCultured Epithelial Autographs (CEA): CEA is grown from biopsies obtained from the patients own skinArtificial 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 ManagementOpioid every 1 to 3 hours for painSeveral drugs in combinationMorphine with haloperidolNonpharmacologic strategies Relaxation tapes Visualization, guided imagery Meditation*

Acute Phase management Debriding Full-Thickness Burn*

Acute Phase managementSurgeon Harvesting Skin*

Acute Phase managementDonor Site After Harvesting*

Acute Phase managementHealed Split-Thickness Skin Graft*

Acute Phase managementApplication of Cultured Epithelial Autograft*

Rehabilitation PhaseThe rehabilitation phase is defined as beginning when the patients burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activityComplicationsSkin and joint contracturesHypertrophic scarring

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Contracture of the Axilla*

Rehabilitation PhaseBoth patient and family actively learn how to care for healing woundsCosmetic surgery is often needed following major burnsRole of exercise cannot be overemphasizedConstant encouragement and reassuranceAddress spiritual and cultural needsMaintain a high-calorie, high-protein dietOccupational therapy

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