Burn Injuries

The skin is The largest organ

So important. When the integrity of this organ is compromised by a burn injury, the consequence can be very serious! A burn injury results when “the tissues of the body are damaged by a heat source.” Clearly, this can involve tissues deeper than skin level, but most often, the skin is involved. let’s

Epidermis

Top layer. Protective barrier. Replaced about every 30 days. Pigment. Vitamin D synthesis!

Dermis

90% of the skin’s thickness. Strength and elasticity. Contains roots of hair follicles and nerve endings. Oil and sweat producing glands. Blood vessels (nutrient delivery to the epidermis).

Hypodermis

Fatty layer. Cushions muscle and bone. Contains connective tissue. Helps regulate temperature. Nerves and vessels pass through (both are larger in this layer).

problems with burn injuries

Inflammation (vasodilation, vascular permutability), Perfusion, Infection and sepsis, Clotting (DIC), Acid base imbalance, Electrolyte imbalance Nutrition compromise (loss of protein and increased demand for healing) Rhabdomyolysis, Compartment syndrome, Paralytic ileus , ARDS

What do nurses most need to know about burn management?

Basic understanding of mechanisms and classification, How to stabilize a patient with burn injury and provide initial emergency management, When it is appropriate to transfer a patient to a burn center! (Box 51.1)

Classification of Burns based on

Etiology, Burn depth, Total body surface area (TBSA) percentages, Severity

Burn Etiology Thermal

(flash, scald, contact) temperature and duration of contact

Burn Etiology Electrical,

the “grand masquerader!”, Potential for multiple organ involvement depending on the “path” of the electricity. “Contact points” must be identified. (ender and exit) , Patients may also present with trauma, cardiac and/or neurologic problems! Associated Cardiac and/or pulmonary arrest are possible!

Burn Etiology Electrical

Continuous cardiac monitoring for at least 24-48 hours!, (seizure, respiratory and cardiac arrest potential) Fluid resuscitation needs will be significant! Rhabdomyolysis (myoglobinuria) potential!

Burn Electrical Rhabdomyolysis

Brown urine, Elevated Creatinine Kinase (CK), Elevated K and phosphorous, Low serum calcium, Positive urine myoglobin, Watch BUN and creatinine, Metabolic acidosis potential, lactic acidosis, Aki can worsen E lytes too

Chemical (acids,

bathroom cleaners, drain cleaners, rust removers, glass etching, home swimming pools

Chemical alkalines,

oven cleaners, drain cleaners, wet cement, fertilizers, heavy industrial cleaners, Alkali burns tend to penetrate deep

Chemical organic compounds

can be systemically absorbed! (phenols, creosote, and

petroleum products (gasoline)) , Renal injury (bun creat), Hepatic injury

Chemical Burns

Safety of health care team must be considered! May need protective equipment

Early recognition and continuous irrigation! Irrigate until

Decrease in pain. temp cannot tolerate., Transfer to burn unit.

Radiation (least common type)

Sun Poisoning” Prolonged full body exposure to ionizing radiation can cause - n/v, diarrhea, fatigue, h/a, and fever

Superficial Tissue involvement

Minimal damage to the epidermis

Superficial Wound characteristics

Dry, no blisters; pink or red; blanches easily

Superficial Pain assessment

Hypersensitive

Superficial Healing

3–7 days with no scarring, (medical mngmt most often not needed), do Ice, aloe, cool compress, NSAIDs, and fluids

Superficial partial thickness Tissue involvement

Entire epidermis and minimal damage to the dermis

Superficial partial thickness Wound characteristics

Blisters that may be closed or open and weeping; pink or red; mild edema; blanches easily

Superficial partial thickness Pain assessment

Hypersensitive

Superficial partial thickness Healing

7–14 days with no scarring, keep clean, (conflicting on popping blisters) Topical Abx ointment

Deep partial thickness Tissue involvement

Entire epidermis and deeper layers of the dermis

Deep partial thickness Wound characteristics

Blisters that may be closed or open; waxy appearance; cherry red, mottled, or pale in the center; edema; sluggish or no blanching

Deep partial thickness Pain assessment

Hypersensitive around the wound edges but may be sensitive to pressure only in the center

Deep partial thickness Healing

may take 3–6 weeks and may leave some scarring, or the wound may have to be surgically excised and grafted. Will need referral to Burn Center

Full thickness Tissue involvement

Destruction of entire epidermis and dermis have; may involve subcutaneous fat, muscle, and/or bone

Full thickness Wound characteristics

Dry, leathery; pale, white, brown, tan, black, charred; no blanching; may be contracted if muscle involvement

Full thickness Pain assessment

No pain in the center of the wound but may be sensitive to pressure

Full thickness Healing

Will not heal without surgical excision and grafting Will need referral to Burn Center

Determination of exact depth is often

impossible on initial inspection! Burns often “evolve” within the first 24-72 hrs—frequent reassessment is needed!

Coagulation ZONE

(most contact, most damage)

Stasis ZONE

(most at risk for conversion)

Hyperemia ZONE

(increased blood flow--delivering nutrients

Fluid resuscitation to promote perfusion is so important

8-36 hours, 24 hr peak of fluid resection, (trying to prevent conversion)

Total body Surface Area (TBSA) Percentages

Guide for fluid resuscitation! Over and underestimation of fluid needs can be harmful to the patient!

fluid resuscitation! Underestimation

Shock, renal failure, other organs fail, Conversion of burns

fluid resuscitation Overestimation

Fluid volume overload, pulmonary edema (ards)

Methods for assessing surface area

Lund and Browder Classification (hospital setting, most accurate) Completed after a full and thorough debridement has been done

Rule of Palm (quick, useful in pre-hospital settings)

Use the PATIENT’s hand and ENTIRE palmar surface, Good for TBSA <15% Pediatric Entire palmar surface- 1%, Adult Entire palmar surface- 0.8%

Rule of Nines (most used method pre-hospital) 9%,

Chest/upper trunk (front), Abdomen/lower trunk (front), Upper back, Lower back/buttocks, Each leg, front (2 total), Each leg, back (2 total)

4.5%

Head (front), Head (back), Each arm, front (2 total), Each arm, back (2 total)

1%

Genitalia/perineum

Rule of Nines Concerns

A problem is the assumption that adults, regardless of weight and body shape, have the same distribution of body surface area percentages, AND different in pediatrics

Burns that involve 20% or less of TBSA

local inflammatory response.

Burns that involve greater than 20% TBSA

burn injury with both local and systemic inflammatory effects!

Severity

Presence of inhalation injury(burn to face, soot, soot in airway, may not be external) , Patient age and past medical history, Presence of concomitant injury, Anatomical location of the burns

burns to certain areas should trigger referral to a burn center

face, hands, feet, genitalia, perineum, over major joints

Management of Patient’s with Major Burn Injuries

Emergent care MUST begin at the scene! Initial priorities - STOP the burn process, manage the airway, begin fluid resuscitation, prevent hypothermia!

Is this patient being kept warm? Where are the IV fluids?

Initial Burn Care

Initial Burn Care Airway Management (top priority!)

100% NRB mask on all patients, Pulmonary assessment, ABGs, Sat monitoring, Assist with intubation if indicated. ARDS potential

intubation indicated

Respiratory injury—above the glottis? below the glottis? CO poisoning? Respiratory distress, facial burns, changes in voice, carbon in sputum, enclosed space during fire (inhalation!)

Major Burn Injuries intubation if

Special care to secure ET tube. (cant always secure regularly may need increase sedations, restrains, well inflated cuff), Tracheostomy supplies at the bedside.

Major Burn Injuries Assess for possible inhalation injury

(significant mortality risk) Can occur even when no cutaneous burns!, Initial X-rays are often normal—bronchoscopy is needed!

inhalation injury Physical manifestations

Facial burns, Singed nasal and facial hairs, Carbonaceous sputum (soot), hypersecretion, Naso- or oropharynx erythema, Excessive agitation/anxiety (hypoxia),Tachypnea, intercostal retractions, flaring nostrilsl Inability to swallow, Hoarseness, grunting, brassy voice, Rales, rhonchi, diminished breath sounds

Major Burn Injuries Obtain serum carboxyhemoglobin level!

(Carbon monoxide level!, Pulse oximeter useless with CO poisoning! (cant use Sao2 either)

Clinical manifestations of CO poisoning

Mild headache and confusion, Severe headache, flushing, vision changes, Disorientation, nausea, Irritability, dizziness, vomiting, Tachypnea, tachycardia, Coma, seizures, death

CO poisoning Treatment

get serum Coox, 100% Oxygen, Possible Hyperbaric Oxygen (pressurized chambers, gradual, cant always do initiality as there is no quick access avabile)

Initial Burn Care Fluid Resuscitation (crucial to survival with major burns) “Burn shock” risk! (distributive and hypovolemic)

Fluid shift first 8-36 hrs after injury, peak around 24 hrs, Watch for manifestations of shock!, With resolution of shock, mobilization of fluid (diuresis), Evaporative loss of up to 5 L per day! (no skin and fat to protect)

Burn Injuries Fluid Resuscitation

Two large bore (at least 20 gauge) IVs (can go through burned tissue if necessary), intraosseous (IO) can be used, central line useful ( use LR )

Burn Injuries Fluid Resuscitation Parkland Formula

2-4 mL LR X kilogram (kg) body weight X %TBSA, Half of the total volume given within the 1st eight hrs. ,(8 hours begins from the time the burn injury occurs., Ask in report for amount of pre-hospital volume and subtract amount already given from your eight-hour total.) Remaining half over the next 16 hrs.

Burn Injuries Fluid Resuscitation

Possible inclusion of colloids, Indwelling urinary catheter to monitor output.,

Burn Injuries Fluid Resuscitation Monitor for myoglobinuria

(brownish discoloration)—especially with electrical burns! (give Bicarb with fluids for kidneys

Burn Monitor response to fluid delivery Urine output

0.5 mL/kg/hr (1 mL/kg/hr if myoglobin is present)

Burn Monitor response to fluid delivery Systolic blood pressure

Greater than 100 mm Hg

Burn Monitor response to fluid delivery Heart rate

Less than 120 bpm

Burn Monitor response to fluid delivery Central venous pressure (CVP)

5-10 mm Hg

Burn Monitor response to fluid delivery Pulmonary

Lungs sound clear, blood pH within normal range (7.35-7.45)

Burn Monitor response to fluid delivery Gastrointestinal

Abdomen soft and non-tender; no nausea, vomiting, or ileus; bladder pressure less than 10 mm Hg

Burn Monitor response to fluid delivery Level of consciousness

Clear, alert, and oriented to person, place, and time (keep in mind any narcotics that may have been administered for pain)

More Fluids May Be Needed for

Inhalation and/or electrical injuries, associated trauma, alcohol/drug dependency, poor health, delay in starting fluid resuscitation

Electrical injury fluid resuscitation

ALL AGES 4 ML/KG with formula

IAP obstain

through bladder pressure, (cath), if too high can cause difficultly breathing and reduces BP

IAP

5-7 mm Hg is normal

Initial Burn Care Prevention of Hypothermia Patient temp at least

37 c (98.6 F)—up to ~ 100 F (38 c)

Prevention of Hypothermia

Keep the patient covered, Monitor temperature, Increase ambient room temperature(28-33 C, 82-91 F!!! ) Other external heat sources

Initial Burn Care Wound Care (NOT highest priority during the emergent phase)

Cover with clean, DRY blankets, More significant care may be delayed for several hours, Circumferential burns make wound care a higher priority!, Circumferential burns make wound care a higher priority

Compartment syndrome (extremity)

Rhabdo/myoglobinuria potential, P’s of neurovascular compromise, Pain and parathesia are intial (pain with passive movements, pain not prophoical to injury, pain not relived with narcotics

Abdominal compartment syndrome

Initial Burn Care Pain Management

IV narcotics, avoid IM route., Possible use of anxiolytic drugs, Monitor for respiratory depression. (constipation)

Initial Burn Care Keep an eye on renal function!

Decrease in circulating volume/potential perfusion compromise, Destruction of RBCs leads to free Hgb which can damage tubules, Muscle damage can lead to myoglobinuria which can damage tubules. (hydration, may need CRRT)

Initial Burn Care Additional labs Complete blood count (CBC)

Hematocrit (H), WBCs with differential (H) , Blood glucose(H), DIC profile

Initial Burn Care Additional labs Electrolytes

Sodium (L) loss + shifting , (H) Potassium (cellular trama), Serum proteins

Initial Burn Care ABGs

Respiratory acidosis (inhalation injury), Metabolic acidosis, Mixed acidosis

Electrical burn extras Labs

12 lead EKG, Troponin, CK-MB

Intermediate Phase of Care

After resuscitation and stabilization have been achieved. Priorities shift to- wound healing and closure, pain management, ensuring optimal nutrition, continued infection prevention. Must continue to assess and manage any respiratory and circulatory issues!

Intermediate Phase GI tract health and nutritional support (SUPER important!)

Increased metabolic needs! Decrease in nutrient absorption and motility.

Intermediate Phase Ileus potential s/s

abdominal distension, decrease Bowel sounds, bowel movement, nasusa, may need NFT to rest and decompress

Intermediate Phase Use of prokinetic medications

Metoclopramide (Reglan) (TD risk)m Erythromycin

Intermediate Phase Gi protection

PPIs and H2 Blockers