Burns

functions of skin

• protection

• thermoregulation

• fluid + electrolyte balance

• metabolism

• neurosensory

• psychosocial, interactive → HIGHLY CONNECTED TO HOW YOU FEEL

_____ make up majority of burn pts in all age categories (except 80+)

men

nearly ___% of all burn injuries occur in children under age 15

25%

74% of burn injuries occur where?

at home

burn center referral criteria

most burns are what type of injuries?

thermal

thermal injuries

• who is at greatest risk?

• skin comes in contact w/ something hot enough to cause cell injury

• flames, scalding liquids, steam, direct contact w/ heat source

• children and elderly at greatest risk → b/c they are reliant on other ppl; skin gets thinner as you get older; babies also have thinner skin

chemical injuries

• what kind of effects?

• severity related to ?

• caused by what 3 agents?

• contact, inhalation of fumes, ingestion, or injection

• local and SYSTEMIC effects

• severity related to type, volume, duration of contact, and concentration of agent

• tissue damage continues UNTIL CHEMICAL completely REMOVED or neutralized

• caused by 3 agents:

  • alkalis (oven cleaners, fertilizers, wet cement, lye—in different soaps) → MORE SEVERE THAN ACIDS b/c they denature proteins in your skin

  • acids (bathroom cleaners, rust removers, pool chemicals) → injury more limited b/c do NOT denature proteins in skin

  • organic compounds (gasoline, kerosene, ethanol) → CNS effects b/c they dissolve the lipid barrier in cells → can enter bloodstream quicker → to brain

are chemical injuries caused by alkali or acidic compound typically more severe?

alkali (oven cleaners, fertilizers, wet cement, lye—in different soaps) → MORE SEVERE b/c they denature proteins in your skin

what is special about chemical burns caused by organic compounds?

CNS effects b/c they dissolve the lipid barrier in cells → can enter bloodstream quicker → to brain

• gasoline, kerosene, ethanol

electrical injuries

• ___ injuries have HIGHER risk of cardiopulmonary arrest by VFib compared to DC injuries

• what impacts severity?

• almost all electrical injuries cause ?

• caused by contact w/ electrical sources

• AC (alternating current) injuries have HIGHER risk of cardiopulmonary arrest by VFib compared to DC injuries

  • AC can cause tetany → keeps circulating through

• things that impact severity: type and pathway of current, duration of contact, environmental conditions, body tissue resistance

• electroporation → your body cells are an excellent conduit for electricity to travel through your body → entry and exit wound!

• wound can appear superficial!!!

electroporation

inc in conductivity and permeability of cell membranes

inhalation injuries

• __ mortality rate

• classifications?

• dx based on what 3 things?

• caused by inhalation of smoke, chemical toxins, and products of incomplete combustion

• INC MORTALITY RATE (very high b/c airway is getting burned → impacts your ability to oxygenate your body)

• classifications:

  • systemic injury caused by exposure to toxic gas

  • supraglottic injury

  • subglottic injury

• dx based on hx, clinical signs, and bronchoscopy findings

carbon monoxide poisoning

• what type of injury is this?

• PaO2 and SaO2 ?

• tx?

• inhalation injury

• released when organic compounds (wood, coal) are burned or in heavy smoking

• CO has 200x higher affinity for Hgb than O2 → forms carboxyhemoglobin → leads to tissue hypoxia

  • normal carboxyHgb level in practice = 2% or less

• PaO2 and SaO2 suspiciously high/normal (b/c these tests simply test if something is bound to Hgb, not necessarily O2

• tx: 100% O2 (to try to push CO off Hgb)

• more common in ppl who smoke → they have baseline carboxyHgb level of 9-11%

cyanide poisoning

• caused by ?

• impairs ?, leads to ?

• suspect w/ what 3 S&S?

• antidote = ?

inhalation injury

• caused by combustion of household synthetics (upholstery, carpet, plastic, vinyl)

• impairs cellular respiration, leads to anaerobic metabolism → inc in serum lactate

• suspect w/ unexplained hypotension, hypoxemia, and lactic acidosis

• sx similar to CO poisoning (HA, dizzy, N)

• antidote = hydroxocobalamin (CyanoKit)→ **causes RED discoloration of urine and body fluids

  • form of vit B12

supraglottic inhalation injury

• usually caused by what type of injury?

• S&S?

• usually caused by thermal injury

• heat absorption and damage occur mostly in pharynx and larynx

• may cause airway obstruction

• hoarseness, dry cough, labored breathing, difficulty swallowing, stridor (signs associated w/ upper airway obstruction)

subglottic inhalation injury

• usually caused by what type of injury?

• extensive damage to ?

• hallmark sign?

• usually a chemical injury that produces impaired ciliary activity, erythema, hypersecretion, edema, ulceration of mucosa, inc blood flow, bronchospasm

• extensive damage to alveoli and impaired pulm. function

• hallmark sign = carbonaceous sputum = sputum looks sooty (dark, specks of ash)

• can develop ARF and ARDS

clinical indicators of inhalation injuries

• hx of exposure in confined or enclosed spaces

• facial burns

• singed nasal hairs

• carbonaceous suptum

• hypoxemia

• abnormal breath sounds

• signs of resp distress

• elevated carboxyHgb levels

• abnormal ABG values

bronchoscopy of normal larynx

• pretty nice and pink, can visualize vocal cords

• nice little triangle

bronchoscopy — inhalation injury — edema

• very difficult intubation

• 8-12hrs post burn injury

bronchoscopy — inhalation injury

• edema has resolved, but now lots of scarring

burn severity is determined by

• type

• characteristics

• concomitant injuries

• pt age

• preexisting health status

extent and depth of burn injury is affected by

• duration of contact

• temp

• amt of tissue exposed

• ability of agent and tissue to dissipate thermal injury

superficial burn

• involves ?

• what does it look like?

• on dark skin?

• healing time?

aka 1st degree

• involves ONLY EIPDERMAL LAYER

• area pink to red; slightly edematous, usually NO BLISTERING

• on dark skin: appears reddish-brown

• healing time: 3-5 days

partial thickness burns

• involves ?

• what does it look like?

• further broken down into?

2nd degree burns

• involves ENTIRE epidermal layer AND varying depths of DERMAL LAYER

• BLISTERS!!

• further broken down into superficial partial thickness burns and deep partial thickness burns

superficial partial thickness burns

• looks like?

• cap refill?

• blisters?

• heal time?

• pain?

type of 2nd degree — not as far into dermis

• hair follicles, sebaceous and sweat glands typ intact

• bright red, edematous

• near normal cap refill

• blisters appear w/in MINUTES (ALWAYS)

• heal time: 7-10 days

• MORE PAINFUL (b/c all of your nerve endings are still intact)

deep partial thickness burns

• looks like?

• cap refill?

• blisters?

• heal time?

• pain?

type of 2nd degree

• damaged nerve cells

• white and waxy; surface can be wet or dry

• dec cap refill

• may see blisters

• heal time: 2-4 wks

• typ less painful

full thickness burns

• what layers of skin are damaged?

• cap refill?

• what’s it look/feel like?

• pain?

• heal time?

aka 3rd degree

• destruction of ENTIRE epidermis AND dermis

• little to no cap refill

• thrombosed blood vessels (essentially cauterized) may be visible

• surface firm, dry, leathery

• NO pain or sensation

• does not heal on its own — will require skin grafting

total body surface area (TBSA)

rule of nines

• only used for partial and full thickness burns

what is used to calculate extend of burn injuries in burn centers (more detailed)

Lund and Browder chart

physiologic response of getting burned

significant changes in almost every body system — local AND systemic!!

• intravascular coagulation from thermal damage

• inflamm mediators released from damaged cells

• inc cap permeability (leak) → edema and intravascular fluid depletion (RELATIVE hypovolemia)

• burn shock — combination of distributive and hypovolemic shock

phases of burn care

1. resuscitative phase

2. acute phase

3. rehabilitative phase

phase 1 of burn care: resuscitative phase

• when?

• tx priorities?

begins at time of injury - 48hrs until fluid and protein shifts stabilized

• ABCs and prevention of burn shock

  • correct someone’s fluid balances and correcting relative hypovolemia

phase 2 of burn care: acute phase

• when?

• tx priorities?

48-72hrs until wound closure occurs

• burn center — weeks, months

• focus on: wound healing, prevention of infections, lots of psychological support

phase 3 of burn care: rehabilitative phase

• when?

• tx priorities?

could be lifelong

• improve function and ROM

• minimize scarring

• restore ADLs

resuscitative phase tx

• pre-hospital

• hospital / burn center

pre-hospital:

• remove pt from scene

• stop burning process

• triage injuries

• avoid heat loss

• secondary survey

hospital / burn center:

• primary survey

• IV narcotics

• prevent burn shock

• ABCs — monitor ventilation w/ circumferential full-thickness burns to thorax

• DVT / PE prophylaxis

• nutrition w/in 24 hrs (need ntrn to heal)

procedure to treat full-thickness circumferential burns

escharotomy

• full-thickness burns will act like a tourniquet → super tight → your diaphragm and lungs cannot expant and contract

• prophylactically or to release pressure and facilitate circulation

• incision through eschar to expose subQ layer → incision will widen substantially b/c of all the pressure that’s being released

fluid resuscitation — ONE OF THE BIGGEST PARTS OF RESUSCITATIVE PHASE

b/c pt has relative hypovolemia

• myocardial depression leads to massive fluid shifts and low CO

• central line or 2 large-bore IVs or IO

• oral hydration for smaller burns

• IV hydration for burns >20% TBSA

  • Parkland formula!!

  • LR

Parkland formula

• first ____ hrs give 50% of total fluid

• administer remaining 50% over _____ hrs

IV hydration for burns >20% TBSA

• (4mL) x kg x (% TBSA)

• first 8 hrs give 50% of total fluid

• administer remaining 50% over 16 hrs

Patient weighs 75kg and has 55% TBSA

1. How many mL in first 8 hours?

2. How many in 16 hours?

3. How would you set pump for first 8 hours?

4×75kg*55% = 16,500mL total

1. 8250mL in first 8 hrs

2. 8250mL in next 16 hrs

3. pump rate for first 8 hrs: 1031 mL/hr

why does it matter if a pt has inhalation injuries when considering the amt of fluids to give them?

if pt already has an inhalation injury, then their pulm circulation is already damaged and impaired → if you’re giving them a ton of fluids on top of that, then you have to be very careful to not send them into flash pulm edema b/c they’re already having pulm issues

how do yk that fluid resuscitation was successful?

• adequate urine output (30 mL/hr or 0.5mL/kg/hr for adults)

• BP / MAP (want MAP to be 65)

• HR (<120bpm)

acute phase tx specific

pt should be stabilized w/in 48-72 hrs, good urine output and VS

• goals: promote wound healing, prevent complications, and improve function of body systems

• wound care VERY important

  • ensure up-to-date on tdap vaccine

  • prevent hypothermia — burn units are super hot

  • cleaning and debriding wounds to prevent infection

    • VERY PAINFUL — give IV narcotics

  • surgical intervention needed?

  • dressing change protocol

  • topical ointments / dressings — silver sulfadiazine, mafenide acetate, bacitracin, Xeroform gauze

• ntrn promotes healing!! — high proteins, high calories, high fat

what diet should pts on the burn unit (acute phase) be on?

high protein, high calories, high fat — ntrn promotes healing!!

rehabilitation phase specific tx

• wound and scar management

• preventing wound complications

• pain — very high risk of developing substance use disorders

• psychosocial support

  • disfigurement, chronic pain, social support, safety concerns, pre-existing psychiatric disorders, high risk behaviors (substance/alcohol use), PTSD

deep partial thickness burns

• skin is a bit wet

• red

• aren’t all the way down to third layer

deep partial thickness

• blisters

• white, waxy skin underneath — burned through wet layers

superficial / 1st degree burn

blister!! → second degree

• superficial partial thickness burn

full thickness / 3rd degree burn

4th degree burn → fingers are gonna be amputated

2nd degree — superficial partial thickness burn

2nd degree — superficial partial thickness

• intact blisters

some 2nd and 3rd degree

A pt was rescued from a house fire and is suspected of having an inhalation injury. Which clinical finding is the most immediate priority for the nurse to report to the healthcare provider?

Agitation and bright red skin 

The nurse is applying silver sulfadiazine to a pt’s burn wounds. Which lab value should the nurse monitor specifically for a common side effect of this med?

WBC count

a pt w/ an electrical burn from a high-voltage wire is admitted to the ICU. The nurse observes that the pt’s urine is dark and reddish-brown. Which nursing intervention is the priority?

inc IV fluids to maintain a urine output of 75-100 mL/hr

A pt is admitted to the ED w/ deep partial-thickness burns to the entire left arm, the anterior chest, and the anterior left leg. Using the Rule of Nines, the nurse should calculate the Total Body Surface Area (TBSA) burned as

27%

• left arm (9%) + anterior CHEST (9%) + anterior left leg (9%)

during the emergent (resuscitative) phase of a major burn injury, which electrolyte imbalance is the nurse most likely to observe due to cellular destruction?

hyperkalemia — when cells are burned and rupture, they release their intracellular contents (K⁺) into the bloodstream

which nutritional intervention is most appropriate for a pt in the acute phase of recovery from a 50% TBSA burn?

high calorie, high-protein diet w/ early enteral feedings

A nurse is caring for a firefighter w/ full-thickness circumferential burns to the right arm. The nurse notes that the right hand is cool to the touch, and the radial pulse is no longer palpable w/ a doppler. Which procedure should the nurse anticipate first?

escharotomy

An adult weighing 70kg has sustained 40% TBSA burns. Using the Parkland Formula, the nurse calculates the total fluid resuscitation required for the first 24hrs. At what rate (mL/hr) should the nurse set the infusion pump for the first 8 hrs?

700 mL/hr