BURNS CARE
Assistant lecturer / Hussam Abbas Adult Nursing / Second Stage
I. The Skin:
A. Functions:
1. Protection against infection
2. Prevents loss of body fluids
3. Regulation of body temperature
4. Principle sensory organ
5. Identification
B. Skin Layers
1. Epidermis:
a. Outer most layer
b. Composed of epithelial cells
c. Capable of quick regeneration
d. Contains nerve receptors
2. Dermis
a. Lies below the epidermis
b. Two layers of fibrous connective tissue
c. High proportion of collagen and elastin
d. Highly vascular
e. Contains
1) Lymphatics
2) Nerves
3) Appendages: hair, nails, sebaceous/sweat glands
4) Capable of regeneration
3. Subcutaneou
s a. Protective function
b. Energy store
c. Does not regenerate
Burns :
destruction of epidermis ,dermis and subcutaneous layers of skin .
Depth of Burn Injury
A. Superficial (First Degree)
1. Involves epidermis only
2. Like sunburn
3. Red, dry, painful
4. Not included in body surface area computation
5. Heals in 3 to 7 days
B. Partial Thickness (second degree):
Involves Epidermis and Dermis
1. Superficial partial thickness
a. Moist, weeping
b. Vesicles
c. Sensitive and painful
d. Usually heals in three weeks
e. Hair follicles, sweat glands intact
2. Deep partial thickness (deep dermal injury)
a. Painful b. Color varies
c. Heals without grafting if protected from drying, infection, injury
C. Full Thickness: Down to Subcutaneous Fat (third degree; may involve muscle and bone)
1. Translucent
, 2. Leathery, inelastic, unyielding (ESCHAR)
3. Dry, thrombosed vessels beneath surface of skin
4. Anesthetic to touch (experience no pain)
5. Requires grafting III Types of Burns
A. Thermal Burn Injuries
3. Causes
a. Heat/flame
b. Hot liquid: includes tar and plastics
B. Electrical Burn Injuries Causes
a. Lightning b-electric wires
C. Chemical Burn Injurie
s Classification of chemicals:
a. Alkal
i b. Acids
c. Organic compounds .
Treatment
a. Remove all clothing involved
b. Brush off dry powder before water application
c. Do not attempt neutralization
d. CAUTION: be very careful when dealing with chemicals in the eye that you don’t lavage the chemical out of the effected eye, across the bridge of the nose, into the unaffected eye. d Inhalation Injury . Three Types 1. Asphyxiants: carbon monoxide poisoning – competes with oxygen 2. Smoke poisoning: chemical lung injury secondary to the irritant. 3. Thermal injury Above the glottis injury due to inhalation of heated air. The mucosa appears erythematous with edema, blisters, ulceration. V. Determining the Extent of Burns A. Rule of Nines: body areas divided into 9% body surface areas B. Lund and Browder Chart : more precise, especially in pediatrics C. Rule of Palm: 1. A patient’s palm size (1%) compared to burn area 2. Used to estimate spot burns VI. Prehospital and Emergency Room Care A. Stop the Burning Process 1. Extinguish all flames, remove from environment 2. Once flames are out, DO NOT keep patient wet as hypothermia ensues quickly. a. Protect yourself b. Airway (C-spine), breathing, circulation, disability, expose c. Secondary survey, look for associated injuries d. Pain management 3. Transport to an Emergency Room B. Emergency Room Care 1. ABCs 2. Remove all clothing 3. Large bore peripheral IVs well secured 4. Fluid resuscitation 5. Initial blood studies, CO level 6. Chest x-ray 7. Foley catheter, I&O 8. NGT to suction 9. Pain medication 10. Transfer/transport 11. Burn severity and need for hospitalization determined by: a. Size b. Depth c. Body areas d. Burning agent e. Age f. Medical history G. Significant associated injuries 1. Inhalation injuries 2. Circumferential burns of extremity or chest 3. Burn injuries in patients with pre-existing medical problems 4. Burn injured patients with additional traumatic injuries VIII. Physiologic Changes and Management A. Circulatory changes 1. Inflammatory response initiated by tissue injury 2. Mediators, enzymes released; complement system activated 3. Increased capillary permeability, vasodilatation 4. Fluid and protein move from vascular to interstitial spaces 5. Results in: a. Decreased intravascular volume and edema (capillary leak) b. Increased false high HCT, RBC sludging c. Stress response, high catecholamine output d. Decreased cardiac output (cardiac depressant factor and ?vol.) e. Metabolic acidosis 2? tissue ischema related to hypovolemia and inadequate perfusion f. Hyperkalemia 6. Unless fluids lost are replaced early, hypovolemia and shock results 7. Severity of hypovolemia dependent on size/depth of burn 8. Goal: prevent or reverse hypovolemic shock using resuscitative fluid 9. Capillary wall begins to regain some integrity after 12 hr 10. However, fluid leak continues up to 48 hours B. Treatment-Fluid Resuscitation 1. Goal: Maintain vital organ function while avoiding complications of inadequate or excessive therapy at the least physiologic cost 2. Formula: Consensus Formula a. First 24 hours post burn: 1) Lactated ringers c) Children also require maintenance fluids for insensible water losses in addition to burn resuscitation fluids 2) Administration of fluids: a) Give ½ calculated total amount first 8 hours b) Give ¼ calculated total amount second 8 hours c) Give ¼ calculated total amount third 8 hours d) Titrate fluids according to monitored response b. Adult fluid requirements – second 24 hours 1) ½ of first 24 hour requirement 2) Dextrose solution 3) Calculate colloid needs (0.3—0.5cc per Kg/body wt) 3. Monitor for adequate volume restoration a. Urine output 1) Adults: /Kg body wt0.5cc /hr (30-50 cc/hr) 2) Children: 1cc/Kg body wt/hr (under three years of age) 3) Electrical injuries: 1.5 cc/Kg/hr until myoglobin cleared b. Vital signs c. Evidence of peripheral perfusion d. Laboratory results e. Body weight f. Level of consciousness and orientation 4. As long as wounds are open, fluid and electrolytes are a daily challenge C. Compromise of perfusion with circumferential full thickness burn: compartment syndrome 1. Areas of concern: limbs, thorax, abdomen 2. Limbs a. Circumferential full thickness injury ? ? skin elasticity and 3rd spacing ? ? tissue pressure ? ? venous return ? ?tissue pressure ? arterial perfusion b. Use doppler—ultrasonic flow meter to determine adequacy of arterial pulses distal to circumferential eschar of the extremities 3. If circumferential thorax and abdominal burns, the same restrictive 3rd spacing reduces cavity space, pressures decrease vital capacity and ability to ventilate. Also may compromise abdominal cavity blood flow 4. Intervention: escharotomy a. Indications 1) Cyanosis, cold 2) Impaired capillary filling 3) Progressive neurologic changes (paresthesia) 4) Loss of doppler pulses b. Preferred escharotomy sites 1) Medial plane of extremity 2) Lateral plane of extremity 5. Fasciotomy is done to muscle compartments when involved, often a problem with electrical injury D. Pulmonary 1. Response: a. Pulmonary vascular resistance increases b. Pulmonary hypertension c. Decrease in O2 tension d. Decrease in lung compliance 2. Treatment/nursing care a. Frequent assessments b. Ventilation management c. Monitor ABGs, SaO2 E. Gastrointestinal Changes 1. Very high risk for Curling’s stress ulcers 2. Neutralize gastric pH with antacids and H2 blockers, a. Stress response ? GI vasoconstriction and ? motility/absorption 1) Generally vomit any PO intake 2) Potential for ileus b. NGT to suction F. Pain management 1. Pain depends on depth, extent, and stage of healing 2. As long as wounds are open, exposed nerve endings can be stimulated and pain will occur 3. Goal: reduce pain to a tolerable level rather than eliminate it completely 4. Combination of continuous analgesia and sedation is most effective 5. Narcotics: Monitor respiratory response until tolerance established G. Thermal control 1. Loose body heat due to skin loss and open, evaporative wound 2. Require a warm ambient temperature 3. Desired body temperature is 100—101 degrees Fahrenheit 4. Protect from all cooling mechanisms H. Immune compromised 1. Significant immune compromise due to strong stress response 2. Strict reverse isolation 3. Staff and visitor protocols 4. Prevention of cross contamination 5. Hand washing is the most effective method of infection control 6. Necrotic tissue is infectious reservoir I. Wound care 1. Daily bid cleansing/inspection 2. Careful, thorough documentation of size, color, drainage, odor, wound edges, pain 3. Debridement—removing necrotic tissue promotes healing and reduces risk of infection 4. Topical agents: Silvedene and Sulfamylon 5. Goal: Prevent further injury, promote healing J. Nutrition 1. Very hypermetabolic a. May be twice baseline b. Peaks day 6-10 post injury 2. Catabolism associated with weight loss, retarded wound healing, negative nitrogen balance 3. Caloric needs are carefully calculated, early feeding imperative 4. Hierarchy of alimentation: oral, oral w/supplement, enteric, hyperalimentation K Psychological/Emotional Considerations 1. Acute phase – survival, PTSD common 2. Intermediate phase – pain, depression, regression 3. Recuperative phase – acceptance, adjustment 4. Adjustment depends on coping mechanisms/ego strength 5. Support of significant others essential IX. Aero medical Transport of Burn Patients – General Principles A. Achieve stabilization B. Control of hemodynamic/respiratory parameters C. Continuation of resuscitation by relatively simple measures during evacuation D. Movement at earliest moment E. Accompanied by adequately trained personnel Complications of burn:- 1-Curlings ulcer 2-Acute renal failure 3-pneumonia 4-Cogestive heart failure 5-Septicemia 6-Hypovolemic shock 7-pulmonary edema 8 1