Complex Exam 3: Burns/Injury from Explosions

Burn

• an injury to the skin or other tissue of the body caused by heat, chemicals, electric current, or radiation

Resulting effects if burns

• influenced by the temperature and type of burning agent, duration of contact, and type of tissue that is injured

Pts with a burn injury have a multitude of problems

• difficulty maintaining an airway and adequate circulation, affecting perfusion

• fluid and electrolyte imbalances are common

• give attention to preventing malnutrition and infection

Nursing assessment with burns/ injury from explosions

• ABCS

• lungs sounds

• external injury and recognition of possible internal injury

Common sources of burn injuries: Kitchen and bathroom

• microwaved food

• steam, hot grease or liquids from cooking

• hot water heaters set at 140 degrees F or higher

Common sources of burn injuries: General household

• heat lamps

• fireplaces

• open space heaters

• radiators

Common sources of burn injuries: Occupational Hazards

• tar

• cement

• chemicals

• hot metals

• steam pipes

• combustable fluids

• fertilizers, pesticides

• electricity from power lines

• sparks from live electric sources

Thermal burns

• caused by a flame, flash, scald, or contact with hot objects

• severity depends on temperature of the burning agent and duration of contact time

• scald injuries often occur in bathrooms and kitchens

• flash, flames or contact burns can occur while, cooking, smoking, or burning things

Chemical burns

• result of contact with

  • acids

    • bathroom cleaners, rust removers, acidifiers for home swimming pools

  • alkalis

    • oven cleaners, lye, wet cement, fertilizers

  • organic compounds

    • phenols(chemical disinfectants)

    • petroleum products

Electrical burns

• result from intense heat generated from an electric current

• direct damage to nerves and vessels, causing tissue anoxia and death, can occur

• severity depends on the amount of voltage, tissue resistance, current, pathways, surface area in contact with the current, and length of time that the current flow was sustained

• tissue densities offer varius amounts of resistance to electric current

  • fat and bone offer the most resistance

  • nerves and blood vessels offer the least resistance

• electrical current passes through vital organs (brain, heart, kidney) produces more life-threatening sequelae than that which passes through other tissues

Smoke and Inhalation injuries

• breathing noxious chemicals or hot air can damage the respiratory tract

• major predictor of mortality in burn patients

• rapid initial and ongoing assessment is critical

• airway comprise and pulmonary edema can quickly develop within hours of injury

What are the three types of smoke and inhalation injuries that can occur

• upper airway injury

• lower airway injury

• metabolic asphyxiation

Metabolic Asphyxiation

• most deaths at a fire scene are the result of inhaling certain smoke elements, primarily carbon monoxide or hydrogen cyanide

• oxygen delivery to or consumption by tissues is impaired resulting in hypoxia

Upper airway Injury

• resulting from an inhalation injury to the mouth, oropharynx, and/or larynx

• mucosal burns of the oropharynx and larynx are manifested by redness, blistering, and edema

• the swelling can be massive and the onset rapid

• Burns to the neck and chest may make breathing more difficult bc of the burn eschar

  • becomes tight and constricting

Lower airway injury

• an inhalation injury to the trachea, bronchioles and alveoli is usually caused by breathing in toxic chemicals or smoke

• tissue damage is related to the duration of exposure to toxic fumes or smoke

• carefully asses the pt for facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum(burned saliva), history of being burned in an enclosed space, and clothing burns around the neck and chest

• pulmonary edema may not appear until 12 to 48 hours after the burn

  • then it may manifests as ARDS

Classification of Burn Injury: Extent of Injury

• Total Body Surface area(TBSA) determines morbidity and mortality

• The quickest way to initially calculate the percentage of TBSA is utilizing the Rule of Nines

Extent of Burns

• Lund-Browder chart and rule of nines

• First degree burns= to a sunburn, are not included when calculating TBSA

• The Lund-Browder chart is considered more accurate bc it considers the pts age in proportion to the relative body-area size

• Rule of Nines is often used for initial assessment of bur n pts bc it is easy to remember

• For irregular-or odd-shaped burns, the pts hand is 1%TBSA

Location of Burn

• the location of the burn injury influences the severity

• burns to the face and neck and circumferential burns to the chest or back may interfere with breathing bc of obstruction from edema or leathery, devitalized burn tissue(eschar)

• these burns may indicate possible smoke or inhalation injury

Classification of Burn Depth: Superficial (first degree)

• destruction of epidermis only

• healing time:

  • 3-5 days

• wound characteristics

  • pink or red, dry, painful

Classification of Burn Depth: Superficial partial thickness (second degree)

• destruction of epidermis and some dermis

• healing time

  • 7-10 day

• wound characteristics

  • moist, pink or mottled red; very painful; blisters; blanches briskly with pressure

Classification of Burn Depth: Deep partial-thickness (second degree)

• destruction of epidermis and most of dermis; some skin appendages remain

• healing time

  • 2-4 weeks

• wound characteristics

  • pale, mottled, pearly red/white; moist or somewhat dry, typically less painful; blanching decreased and prolonged; difficult to distinguish from full-thickness injury

Classification of Burn Depth: Full-thickness (third degree)

• destruction of epidermis, dermis, and underlying subcutaneous tissue

• healing time

  • does not heal, requires skin grafting

• wound characteristics

  • thick, leathery eschar, dry; white, cherry-red, or brown-black; painless; does not blanch with pressure; thrombosed blood vessels

Classification of Burn Depth: Full thickness (fourth degree)

• involves underlying fat, fascia, muscle, tendon, and/or bone

• healing time

  • does not heal; may require amputation or extensive debridement

• wound characteristics

  • black, charred, thick, leathery eschar may be present; bone, tendon, or muscle may be visible

Burn management

• Initial management of the burn has a dramatic impact on the long0term outcome of the pt

• Caring for the pt with a burn injury will require fluid resuscitation, early excision and closure of the wound, tissue debridement and healing, respiratory support, metabolic demand management, and intense microbial surveillance and infection control practices

• watch for an assess for Abuse and Neglect in vulnerable populations

Fluid therapy

• obtaining IV access is critical for fluid resuscitation and drug administration

  • at leats 2 large-bore IVs must be in place for pts with burns that ate 15% TBSA or more

• it is critical to obtain IV access that can handle large volume of fluid

• for pts with burns greater than 30% TBSA, consider a central line for fluid and drug administration and blood sampling

• an arterial line is often placed is frequent ABGs or invasive BP monitoring is needed

• assess the extent of the burn wound using a standerized tool

  • then use a standardized formula to estimate the pts fluid resuscitation

    • parkland formula

• fluid replacement is achieved with crystalloid solutions(LR), colloids(albumin), or a combination of the two

  • IV saline is usually started during the prehospital phase

• assess for the adequacy of fluid resuscitations horuly using clinical parameters

  • UOP most often used parameter, and cardiac parameters

Wound care

• one a patent airway, effective circulation, and adequate fluid replacement have been achieved, priority is given to care of burn wounds

• you can perform cleansing and gentle debridement(using scissor and forceps) on a shower chart, can take place in a regular shower, or on a pts bed or stretcher

• pts find the first wound care to be both physically and mentally demanding

• infection can cause further tissue injury and possible sepsis

• two approaches to burn wound treatment

  • open method

    • limited to facial burns

  • multiple dressing changes

• when the pts open burn wounds are exposed, always wear personal protective equipment (PPE) (e.g., disposable hat, masks, gown, gloves)

Respiratory System

• vulnerable to 2 types of injuries

  • upper and lower airway burns

• pt mat beed a fiberoptic bronchoscopy and carboxyhemoglobin blood levels to confirm a suspected inhalation injury

Cardiovascular system

• dysrhythmias and hypovolemic shock

Inflammation and healing

• burn injury to tissues and vessels cause coagulation necrosis

Immunologic Changes

• burn injury challenges the body’s immune system

Clinical manifestations

• the pts with severe burns is likely to be in shock from hypovolemia

Endocrine system

• watch for transient increases in the pt’s blood glucose levels bc of stress-mediated cortisol and catecholamine release

Sign and symptoms of infection

• hypothermia or hyperthermia

• increased HR/RR

• Decreased BP

• decreased UOP

• early s/sx

  • chills

  • malaise

  • loss of appetite

Burn management: Fluid resuscitation

• critical intervention for burn management

• The parkland formula is one of the most widely used nurn resuscitation fluid formulas

• Monitor and report abnormal Lab values

  • sodium and potassium

  • increased BUN

  • Increased Lactate

    • anaerobic metabolism

  • Glucose

Burn management: Resuscitative phase

• begins at the time of injury and continues for approximately 48 hours until the massive fluid and protein shift have stabilized

• main concerns are the onset of hypovolemic shock and edema formation

• ends when fluid mobilization and diuresis begin

Burn management: Acute phase

• begins with the onset of diuresis at approx. 48-72 hours after injury and continues until wound closure occurs

• this phase typically occurs in a burn center and may last for weeks or months

Burn management: Pathophysiology

• a healing burn injury causes many pathophysiologic changes in the body

• diuresis from fluid mobilization occurs, and the pt is less edematous

• bowl sounds return

• depth of burn wounds may be more apparent as they “declare” themselves as partial or full thickness

pathophysiology-Fluid and Electrolyte Shifts

• the greatest initial threat to a pt with a major burn is hypovolemic shock

• it is caused by a massive shift of fluids out of the blood vessels bc of increased cap permeability can begin as early as 20 minutes after the burn

Burn management: Nursing care

• focuses on the promotion of wounds healing

• the prevention of infections and complication

• provision of psychosocial support

Rehabilitation phase

• the formal rehabilitation phase begins when the pts wounds have nearly healed and they are engaging on some level of self care

Primary Goals in the rehabilitative phase

• to improve function and range of motion

• ti minimize scarring and contractures

• restore pts ability to participate in society and return to an established

Emergency Management of Thermal Burns: Etiology

• hot liquids or solids

• flash flame

• open flame

• steam

• hot surface

• Ultraviolet rays

Emergency Management of Thermal Burns: Assessment findings: Partial Thickness (superficial; first degree) Burn

• redness

• pain

• moderate to severe tenderness

• minimal edema

• blanching with pressure

Emergency Management of Thermal Burns: Assessment findings: Partial-thickness(deep; second-degree) Burns

• moist beds, blisters

• mottled white, pink to cherry-red

• hypersensitive to touch of air

• moderate to severe pain

• blanching with pressure

Emergency Management of Thermal Burns: Assessment findings: Full-thickness(third and fourth-degree) Burns

• dry

• leathery eschar

• waxy white, dark brown, or charred apperance

• strong bum odor

• impaired sensation when touched

• absence of pain with severe pain in surrounding tissues

• lack of blanching with pressure

Emergency Management of Thermal Burns: Initial

• If unresponsive, assess ABC

• If responsive, monitor ABC

• Stabilize cervical spine

• Assess for inhalation injury

• Provide supplemental O2 therapy PRN

• Anticipate ET intubation and mechanical ventilation with circumferential full-thickness burns to the neck and chest or large TBSA burn

• Monitor vital signs, LOC, respiratory status, O2sat, and heart rhythm

• Remove nonadherent clothing, shoes, watches jewelry, glasses or contacts

• Cover any concurrent thermal burns with dry dressings or clean sheet

• Establish 2 IV access

• Begin fluid replacement

• Insert cath

• elevate limbs above heart to decrease edema

• Give Iv analgesia and assess the effectiveness

• Identify and treat other associated injuries

  • fractures, injuries

Emergency Management of Thermal Burns: Ongoing Monitoring

• Monitor ABC

• Monitor vital signs, O2sat, heart rhythm, and LOC

• Monitor pain

• Monitor UOP

Emergency Management of Inhalation Injury: Etiology

• exposure of respiratory tract to intense heat or flames

• inhalation of noxious chemicals, smoke, or CO

Emergency Management of Inhalation Injury: Assessment Findings

• History of being trapped in an enclosed space, being in an explosion, ir having clothing catch fire

• rapid, shallow resps

• increasing hoarseness

• coughing

• singed nasal or facial hair

• smoky breath

• carbonaceous sputum

• productive cough with black, grey, or bloody sputum

• irritation of upper respiratory or burning pain in throat or chest

• difficulty swallowing

• cherry-red skin color

• restlessness, anxiety

• altered mental status; coma, confusion

• decreased O2 sat

• dysrhythmias

Emergency Management of Inhalation Injury: Interventions: Initial

• If unresponsive, assess circulation, airway, and breathing.

• If responsive, monitor airway, breathing, and circulation.

• Stabilize cervical spine.

• Assess for concurrent thermal burn.

• Provide 100% humidified O₂.

• Anticipate endotracheal intubation and mechanical ventilation with significant inhalation injury.

• Monitor vital signs, level of consciousness, O₂ saturation, and heart rhythm.

• Remove nonadherent clothing, jewelry, glasses, or contact lenses (if face was exposed).

• Establish IV access with two large-bore catheters if burn >15% TBSA.

• Begin fluid replacement.

• Insert indwelling urinary catheter if burn >15% TBSA.

• Elevate burned limb(s) above heart to decrease edema.

• Obtain arterial blood gas, carboxyhemoglobin levels, and chest x-ray.

• Give IV analgesia and assess effectiveness frequently.

•  Identify and treat other associated injuries (e.g., fractures, pneumothorax, head injury).

• Cover concurrent burned areas with dry dressings or clean sheet.

• Anticipate need for fiberoptic bronchoscopy or intubation.

Emergency Management of Inhalation Injury: Interventions: Ongoing Monitoring

• Monitor airway, breathing, and circulation.

• Monitor vital signs, O₂ saturation, heart rhythm, and level of consciousness.

• Monitor pain level.

• Monitor urine output.

Emergency Management of Electrical Burns: Etiology

• electric wires

• utility wires

• lighting

• defibrillator

Emergency Management of Electrical Burns: Assessment Finding

• Leathery, white, or charred skin

• Burn odor

• Loss of consciousness

• Impaired touch sensation

• Minimal or absent pain

• Dysrhythmias

• Cardiac arrest

• Location of contact points

• Diminished peripheral circulation in injured extremity

• Thermal burns if clothing ignites

• Fractures or dislocations from force of current

• Head or neck injury if fall occurred

• Depth and extent of wound difficult to visualize.

  • Assume injury greater than what is seen.

Emergency Management of Electrical Burns: Interventions: Initial

• Remove patient from electrical source while protecting rescuer.

• If unresponsive, assess circulation, airway, and breathing.

• If responsive, monitor airway, breathing, and circulation.

• Stabilize cervical spine.

• Provide supplemental O₂ as needed.

• Monitor vital signs, heart rhythm, level of consciousness, respiratory status, and O₂ saturation.

• Check pulses distal to burns.

• Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed).

• Cover burned areas with dry dressings or clean sheet.

• Establish IV access with two large-bore catheters if burn >15% TBSA.

• Begin fluid replacement.

• Obtain arterial blood gas to assess acid-base balance.

• Insert indwelling urinary catheter if burn >15% TBSA.

• Elevate burned limb(s) above heart to decrease edema.

• Give IV analgesia and assess effectiveness frequently.

• Identify and treat other associated injuries (e.g., fractures, head injury, thermal burns).

Emergency Management of Electrical Burns: Interventions: Ongoing Monitoring

• Monitor airway, breathing, and circulation.

• Monitor vital signs, O₂ saturation, heart rhythm, level of consciousness, and neurovascular status of injured limbs.

• Monitor pain level.

• Monitor urine output.

• Monitor urine for development of myoglobinuria secondary to muscle breakdown and hemoglobinuria secondary to RBC breakdown.

• Anticipate possible administration of NaHCO₃ to alkalinize the urine and maintain serum pH >6.0.

Emergency Management of Chemical Burns: Etiology

• acids

• alkalis

• organic compounds

Emergency Management of Chemical Burns: Assessment findings

•  Burning

• Redness, swelling of injured tissue

• Degeneration of exposed tissue

• Discoloration of injured skin

• Localized pain

• Edema of surrounding tissue

• Tissue destruction continuing for up to 72 hr

• Respiratory distress if chemical inhaled

• Decreased muscle coordination (if organophosphate)

• Paralysis

Emergency Management of Chemical Burns: Interventions: Initial

• If unresponsive, assess circulation, airway, and breathing before decontamination procedures.

• If responsive, monitor airway, breathing, and circulation.

• Stabilize cervical spine.

• Provide supplemental O₂ as needed.

• Brush dry chemical from skin before irrigation.

• Remove nonadherent clothing, shoes, watches, jewelry, glasses or contact lenses (if face was exposed).

• Flush chemical from wound and surrounding area with copious amounts of saline solution or water.

• For chemical burn of the eye(s), flush from inner to outer corner of eye with water or lactated Ringer's (if available).

• Cover burned areas with dry dressings or clean sheet.

• Establish IV access with two large-bore catheters if burn >15% TBSA.

• Begin fluid replacement.

• Insert indwelling urinary catheter if burn >15% TBSA.

• Elevate burned limb(s) above heart to decrease edema.

• Give IV analgesia and assess effectiveness frequently.

• Contact poison control center for assistance.

Emergency Management of Chemical Burns: Interventions: Ongoing Monitoring