BURNS

by: Mark Christian M. Gonzaga

Nature
A burn injury can affect people all age groups, in all socioeconomic groups. 500,000 people are treated for minor burn injury annually Males have greater then twice the chance of burn injury than women, and the most frequent age group for contact burn is between 20-40 years of age.

Function of skin
Protection and regulation in many ways -temperature -warm-coldness -moist-keeping -infections -water proof

Function of skin
Epidermis
Protection from desiccation Protection from bacterial entry Protection from toxins Fluid balance; prevents excess evporative loss Neurosensory Social interactive

Dermis
Protecion from trauma ( due to elasticity and durability properties of the dermis) Fluid balance through regulation of skin blood flow Thermoregulation Through control of skin blood flow Growth factor for epidermal replication and dermal repair

Determining Severity
Size (surface area) Depth Age Prior status of health of victim Location of burn Severity of associated injury

Rule of 9: Estimating % Burns

Different kinds of burns

Thermal-flame, radiation or excessive heat from fire, steam, hot liquids and hot objects Chemical burns Electric burns Light by intensive light sources Radiation

Depth of Burn and Causes

Characteristic of Burn According to Depth

Skin Involvement Symptoms Wound appearance

Recuperative Course

Superficial PartialThickness (similar to 1st Degree) -Sunburn -Low-intensity flash Deep Partial Thickness (similar to 2nd Degree) -Scalds -Flash Flame -Contact Full Thickness (similar to 3rd Degree ) -Flame -Prolonged exposure to hot liquids -Electric current -Chemical -Contact

Epidermis; possibly portion of dermis

-Tingling -Hyperesthesia (sensitivity) -Pain the is soothed by cooling -Pain -Hyperesthesia -Sensitive to cold air

-Reddened; blanches with pressure; dry -Minimal or no edema -Possible blisters -Blistered, mottled red base; broken epidermis; weeping surface -Edema -Dry; pale white, leathery, or charred -Broken skin with fat exposed -Edema

-Complete recovery within a week; no scarring -Peeling Recovery in 2-4 weeks -Some scarring and depigmentation contractures -Infection may convert it to full thickness -Eschar sloughs -Grafting necessary -Scarring and loss of contour and function; contractures -Loss of digits or extremity possible

Epidermis, upper dermis. Portion of deeper dermis

Epidermis, entire dermis, and sometimes subcutaneous tissue; may involve connective tissue, muscle and bone

-Pain free -Shock -Hematuria (blood in urine) -Possible hemolysis ( blood cell destruction) -Possible entrance and exit wounds (electrical burns)

Electrical Burn
The devastating effects of an electrical injury can cause neurovascular problems Tissue and bone destruction often results in amputations and possible loss of life as the result of cardiac and respiratory abnormalities A true electrical injury results when a current of electricity travels through the body and exits to the ground

Electrical Burn
The amount of damage depends on the strength of the current and the length of the duration of contact with the source An arc injury is the result of the electricitys traveling on the outside of the body or arcing around it

Electrical Burn
Low voltage injury (500v exposure) generally does no cause significant damage or medical problems Midrange (200-1000v) can cause local destruction to the tissue High-voltage Exposure (greater than 1000v) can cause loss of consciousness, fractures compartment syndrome, arrythmias, and is often associated with falls.

Midrange

High Voltage

Gerontologic Consideration
-this are the reasons why elders are at higher risk for burn injury Reduced mobility Coordination Strength Sensation Vision place elderly people

Gerontologic Considerations
Pre disposing factors and health history in the older adult influence the complexity of care the patient. Pulmonary function is limited in the older adult, therefore : - airway exchange, lung elasticity and ventilation can be affected - this can be further affected by a history of smoking

Gerontologic Considerations
Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus or other endocrine disorders present nutritional challenges and require close monitoring.

Gerontologic Consideration
The skin of elderly is thinner and less elastic, which affects depth of injury and its ability to heal

Pathophysiology- burn injury

Burn injury is a result of heat transfer from one site to another Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents Skin and mucosa of the upper airways are sites of tissue destruction Deep tissues, including viscera, can be damage by electrical burn or by prolonged contact with a heat source

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

Pathophysiology
The depth of injury depends on the temperature of the burning agent and the duration of contact with the agent. -1 sec. contact w/ hot tap water at 68.9 oC may result in a burn that destroys both the epidermis and the dermis, causing a full thickness(3rd degree) -15 sec. Contact to hot water at 56.1 oC results in full thickness

Pathophysiology
44 oC can be tolerated for long periods without injury

Pathophysiology

Pathophysiology
Zone of coagulation- where cellular death occurs Zone of Stasis- compromised blood supply inflammation and tissue injury Zone of hyperemia- sustain least damage

PathophysiologyAlterations Cardiovascular Alterations- Hypovolemia is the immediate consequence of fluid

loss and results in decreased perfusion. Cardiac output decreases and change in blood volume is evident, cardiac output continues to decrease and BP drops Fluid and Electrolyte Alterations- edema forms rapidly after a burn injury a 1st degree burn will cause edema for 4 hours and will continue up to 18 hours. Pulmonary Alterations- patients admitted to burn centers have an inhalation injury. This occurs when a person is trapped inside a burning structure or involved in an exposion that leads to the inhalation of superheated air an noxious gas. Renal Alterations- destruction of RBC at the injury site results in free hemoglobin in the urine. If muscle damage occurs e.g. Electrical burn myoglobin is released from the muscle cells and excreted by the kidneys.

Thermoregulatory Alterations- Loss of skin results to inabilty to regulate body temperature therefore, exhibit low body temperature.

Gastrointestinal Alteration-2 GI complications may occur. -Paralytic ileus(absence of intestinal peristalsis)

Phases of Burn Care

Emergent phase- from onset of injury to completion of fluid resuscitation Acute phase- from beginning of diuresis to near completion of wound closure Rehabilitation- from major wound closure to return individuals optimal level of physical and psychosocial adjustment

Emergency Procedures
Extinguish the flames -(stop, drop and roll) Cool the burn -soak with cool water to cool the wound, never apply ice directly to the burn, never wrap the person in ice and never use cold soaks, such procedures may worsen the tissue damage and may lead to hypothermia Remove restrictive objects - Remove all clothing and jewelry to prevent constriction secondary to rapidly developing edema Cover the wound - Cover to minimize bacterial contamination, to maintain body temperature and decrease pain. Ointments and salves should not be used. Irrigate chemical burns -Most chemical lab have a high pressure shower for such emergencies, remove clothes and all areas of the body that have come in contact with chemical.

Medical Management-Emergent Phase

Transfer to a burn center Management of fluid loss and shock Fluid Replacement Therapy Fluid Requirements

Pathophysiology-Emergent phase 24-48hrs postburn

Burn injury is a result of heat transfer from one site to another Release of chemical mediatorsHistamines Bradykinins Prostaglandins

a. b. c.

Cappillary permeability, edema, redness & pain. Fluid will seep to surrounding tissues. Develops 1826 hrs post burn

edema results to decreased circulating intravascular volume; pulmonary edema for pts. with burns of the face and neck.

Pathophysiology-Emergent phase 24-48hrs postburn

Fluid losses, (approx 3-5l from burn wound alone) decreased organ perfusion, hypovolemia, cardiac output decreases, hypotension and cellular destruction develops, hemolysis (resulting to anemia and thrombocytopenia)

With cellular destruction, hyponatremia (due to massive fluid shift from intravascular to interstitial and hyperkalemia (due to massive cellular destruction) occurs,18.hematocrit levels increases due to Fluid losses and due to red cell damage but decreases on the 3rd to 4th day

As an adaptive mechanism, the body shunts blood away from the kidneys, decreasing urine output,

Pathophysiology-Emergent phase 24-48hrs postburn

Renal function is diminished and destruction of red blood cells results to freeing RBC debris in the tubules leading to obstruction.

Evaporative losses thru the burn wound continues until wound closure happens but that time, more fluids had been lost

Blood flow to the gastrointestinal system decreases leading to paralytic ileus and distention, immune system is depressed increasing the risk of

sepsis the most common cause of death after 24 hours.

EMERGENCY ROOM CARE

monitor for respiratory distress, ensure patent airway and administer O2 monitor arterial blood gases and assess the need for intubation initiate peripheral access preferably two lines or CVP line as prescribed. Administer fluids as prescribed. Weigh pt. daily This maybe at a fast rate using large bore needles monitor v/s closely, assess for difficulty in respirations and decreasing blood pressure insert a NGT to prevent aspiration and measure gastric aspirate. An acidic gastric ph necessitates antacids and H2 blockers. These medications reduces possible stress ulcerations and gastric acidity. Early enteral feeding prevents increased intestinal activity and prevent endotoxin translocation, the main source of bloodtream infections

EMERGENCY ROOM CARE

Blood levels of serum electrolytes, hemoglobin and Hematocrit must be monitored. Tetanus administration and monitoring IV fluid therapy are the major responsibilities of the nurse Neurological Assessment focus on the pts level of consciousness, level of anxiety and pain. Use intensity scale to assess pain level. Administer Opioid analgesics and monitor for respiratory arrest Maintain adequate body temp. Work quickly, provide blankets and lamps. These interventions minimize heat loss insert a foley catheter maintaining an output of 30-50cc/hr measured hourly and carefully. Burgundy - colored urine indicates myoglobin and hemochromogen, indicating muscle tissue injury. Glucosuria , a common finding in the early post burn hours. This is due to the excessive release of glucose by the liver

Nx responsibilities-Emergent Phase
Monitor VS-RR closely monitored and apical, carotid,femoral pulses are evaluated and cardiac monitoring for pt. Has a hx of cardiac disease. If all extremities are burned, sterile dressing applied under bp cuff to prevent contamination, Doppler UTZ or non invasive electronic BP device may be helpful,arterial catheter is used for collecting blood sample

Nx responsibilities-Emergent Phase
Large bore IV catheters and indwelling urinary catheter are inserted for close monitoring I & O and urine output and the first urine obtained was recorded for preburn and renal function and fluid status Burgundy colored urine suggest the presence of mochromogen and myoglobin resulting from muscle damage

-Glycosuria- a common finding in the early postburn hours, results from the release of stored glucose from the liver in response to stress. Body temp,body weight,preburn weight and hx of allergies,tetanus immunization, past medical and surgical disorders, current illnesses and a list current medications are essential to help guide medication needs for pt.

Head-toe assessment is performed focusing on S & S of concomitant, associated injury or any developing complications. If pt has facial burns eyes should be examined for any injury to cornease, opthalmologist is consulted for complete asssessment via flourescent staining

Nx responsibilities-Emergent Phase

Fluid and Electrolyte change in the emergent phase

-Generalized dehydration-plasma leaks through damage capillaries -Reduction of blood volume- secondary to: plasma loss, fall of BP and diminished cardiac output -Decreased UO- secondary to: fluid loss, decrease renal blood flow, sodium and water retention caused by increased adrenocortical activity, Hemolysis of RBC, causing hemoglobinuria and myonecrosis or myoglobinuria

Fluid and Electrolyte change in the emergent phase

-Potassium excess- massive cellular trauma cause release of potassium into extracellular fluid (ordinarily,most of pottasium is intracellular) -Sodium deficit- Large amount of sodium is lost in trapped edema fluid and exudate and by shift into cells as potasium is released from cells

PARKLAND FORMULA
Example: Patients weight: 70 kg; % TBSA burn: 80% 1st 24 hours: 4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringers 1st 8 hours = 11,200 ml or 1,400 ml/hour 2nd 16 hours = 11,200 ml or 700 ml/hour 2nd 24 hours: 0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period 0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W = 117 ml colloid/hour + 84 ml D5W/hour

Medical Management-Acute Phase

This phase begins 48-72 hours after burn injury Focus of care towards: a.continous assessment b.respiratory and cardiovascular care c.fluid and electrolyte balance d. gastrointestinal functions e. wound care and infection prevention

Pathophysiology- Acute Phase- 48-72 hours after burn injury

Capillary regains integrity Fluids move from interstitial to intravascular Diuresis begins

Fluid volume increases, if the pts CV/Renal is not stable, he can develop CHF or fluid overload Hypokalemia (K+ shifts intravascular to the cells) and Hyponatremia (Na is lost in the urine. It is also diluted with influx of water in the intravascular) Resetting of core temperature begins. The presence of fever is seen. Bacteremia and septicemia may also be the cause of fever. The infection that starts at the burn site may spread to the blood. However, because of destroyed intestinal barriers, there may also be a translocation of bacteria from that site (the primary source of infection)

WOUND CARE 1. The cleansing, debridement and dressing of the burn wounds 2. Hydrotherapy
a. b.
c. d.

Wounds are cleansed by immersion, showering or spraying Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress Client should be premedicated prior to the procedure Not used for hemodynamically unstable or those with new skin grafts
Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing May be mechanical, enzymatic or surgical Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily

3.

Debridement
a. b. c.

Medical Management-Acute Phase

WOUND CLOSURE
Prevents infection and loss of fluid Promotes healing Prevents contractures Performed on the 5th to 21st day, depending on the extent of the burn AUTOGRAFTING
Permanent wound coverage Surgical removal of a thin layer of the clients own unburned skin, which is then applied to the excised burn wound Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed Care of the graft site Care of the donor site

TEMPORARY WOUND COVERINGS Biological

Allograft (Homograft)
Donated human cadaver skin is harvested w/in 24 hrs after death Monitor for wound exudate and signs of infection Rejection can occur w/in 24 hours Porcine skin is harvested after slaughter and preserved Rejection can occur w/in 24 72 hours Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete

Xenograft (Heterograft)

Biosynthetic and synthetic

Visual inspection of wound is possible, as dressings are transparent or translucent Monitor for wound exudate and signs of infection

Healed Skin Grafting

Medical Management-Acute Phase

Pain Management Nutritional Support Restoring Normal Fluid Balance Preventing Infection Maintaining Adequate Nutrition Promoting Skin Integrity Promoting Physical Mobility

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

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

Medical Management-Acute Phase

Relieving Pain and Discomfort Strengthening Coping Strategies Supporting patient and family processes Monitoring and Managing Potential Complications -Heart Failure and Pulmonary Edema -sepsis -Acute Respiratory Failure and RSD

Medical Management-Rehabilitation Phase

Psychosocial Support Abnormal Wound Healing -Hypertrophic and Keloid Scars Prevention and Treatment of Scars

THE END