burns lecture

skin function

• prevent infection

• regulate body temperature

• prevent excessive fluid loss

• sensory and excretory functions

• provide body image and personal identity

  • these are lost when they’re are burns

pathophysio of thermal burns: Zone of hyperemia

• inflammation (the outermost zone)

• area of vasodilation from release of inflammatory mediators

  • blood vessels open up because of inflammation to bring in healing factors

• remains viable

  • tissue is still alive

• tissue should recover

  • should heal on its own

pathophysio of thermal burns: Zone of stasis

• area of ischemia

• blood vessels constrict causing ischemia

  • can potentially be salvaged

• can become necrotic due to edema, infection, hyoperfusion (low blood flow)

• tissue can remain viable with good perfusion

pathophysio of thermal burns: Zone of coagulation

• area of necrosis

• this is the central area of the burn

• complete capillary occlusion (blood vessels completely blocked)

• area of most tissue damage

• debridement required! (dead tissue must be removed)

1st degree burn

• superficial

• involves epidermis

• red, dry, painful

• heals in 3-4 days

• no scarring or slough

• kertinocytes regenerate from basal layer

• think sunburn

2nd degree burn

• superficial partial thickness injury

• involves epidermis and upper dermis

• if superficial

  • only upper layers of epidermis damaged

  • blisters develop within minutes

  • pink, moist, painful

  • heals within 2-3 weeks with no scarring

  • possibly swollen

• if deep

  • dermis probably need debridement

  • tend to have waxy white or mottled appearance with margins of superficial involvement

  • painful

  • possible swelling

3rd degree burn

• full thickness injury

• involves epidermis and dermis

  • extends through dermis to sub-cutaneous tissue

• can be white or black

• dry, leathery

• non-painful because nerves are damaged

  • only in areas of worst damage

4th degree burn

• involves tendon, bone, and muscle

• usually from flames or chemicals

treatment of superficial (1st degree burns)

• frequent application of a water-soluble lotion (aloe vera)

• pain relievers

• hydration - if appears with symptoms of chills, headache, N/V

treatment of partial thickness (2nd degree) burns

• observe for demarcation (may take up to 1 week)

• debride burned tissue

• cover with moist wound dressing (topical antimicrobials)

• deep areas may require skin grafts

• pain management

• usually heals in 3-8 weeks

• epithelium will appear from hair follicles in 7-10 days

• healing may involve scarring, contraction, loss of function

treatment of full thickness (3rd degree) burns

• initially evaluate airway, breathing, circulation

• escharotomy of constricted extremities or chest burns that restrict breathing

• excision of burned tissue

• application of antimicrobial dressing

• closure with skin grafts or flaps

• replacement of fluid and nutrition

estimation of burn size: Rule of Nines

• this is a quick estimation of percent of body burned

  • The body is divided into sections that equal 9% (or multiples of 9)

  • You add up the burned areas to get Total Body Surface Area

• Different scale for children

• used for partial of full thickness burns (superficial not included)

• head & neck = 9%

• trunk anterior = 18%; trunk posterior = 18%

• arm = 9% each

• genitalia = 1%

• leg = 18% each

estimation of burn size: Lund Browder chart

• more accurate; especially for kids

• this adjusts for body proportions based on age

• children

  • different body sizes compared to adults

  • head generally larger

  • legs smaller

estimation of burn size: rule of palm

• patient’s palm represents 1% of body size

  • Ex: 3 palms = 3% of body size or total body surface area

American Burn Association (ABA) Burn Center Transfer Criteria

• partial thickness burns on >10% of total body surface area (TBSA)

• full thickness burns on any age group

• any deep partial or full thickness burn to face, hands, feet, genitalia, perineum, or joints

• electrical or lightning burns

• chemical burns

• inhalation injury

• burn in patients with preexisting conditions that could complicate management, prolong recovery, or effect mortality

• all pediatric burns

• patients whose pain is poorly controlled

smoke inhalation injury

• major determinant in mortality

• bronchoscopy may be used to detect carbon debris, ulceration, or redness

• if suspect airway compromised, intubate!

ABGs of CO levels in smoke inhalation injury

• carboxyhemoglobin

  • non-smokers - <2-3%

  • smokers - 2-9%

  • >10% - give 100% oxygen

    • indicative of carbon monoxide poisoning

  • >25% - consider hyperbaric oxygen

Fluid/electrolyte balance

• recommended for adults with >15% and children >10% TBSA

burn wound care management

• dissipate the heat

• control pain

• maintenance of oxygen perfusion

how to dissipate the heat of burn

• remove heat source (flame, hot liquid, etc.)

• even after injury, the tissue being >44 degrees C continues to burn

• use cool tap water or saline at 8 degrees C

  • limit to 10% TBSA

how to control pain of burn

• partial thickness wounds are most painful

• use oral or IV pain meds

  • topicals not recommended for burn wounds

how to maintain oxygen perfusion in burn

• this is imperative for wound healing

• first, fluid resuscitation

  • important aspect in early treatment

  • we give fluids to maintain circulation + deliver oxygen to tissue

• appropriate fluid management to avoid burn shock

• avoid vasoconstriction

  • maintain warm environment

  • control pain and anxiety

what can PT do to the actually wound itself (local wound care)

• debride loos devitalized tissue

• for blisters

  • leave intact for 1st weeks

  • leave skin intact if blister ruptures

  • if still intact after 7-10 days - indicative of deep partial thickness or full thickness burn

• cleansing

  • use room temp water

  • use antiseptic solutions

  • avoid skin trauma

position for dressing

• may help to splint

  • hand/fingers are wrapped in full extension

metabolic function of dressings

• prevent vapor loss

• prevent desiccation

• maintain optimal tissue temp

• manage exudates

protective function of dressing

• occlude environment flora

• protect from trauma

xeroform

• topical antimicrobial choice for burns

• used to cover flat superficial 2nd degree burns and split-thickness skin graft sites

• does not adhere to wound bed

• retains moisture and is painless to remove

Silvadene

• topical antimicrobial and antifungal choice for burn

• impedes epithelialization

• does not penetrate eschar

• use to be most frequently used anitmicrobial (slow-release dressings now more common)

• can cause transient neutropenia that peaks on day 3-4

• can cause pseudoeschar over granulation tissue

• CONTRAINDICATED on pregnant women, nursing mothers, and infants <2 months