Study Notes on Burn Injuries

Chapter 24: Burn Injuries

Thermal Burns
- Caused by heat from flames, hot liquids, steam, or contact with hot objects.
Chemical Burns
- Result from contact with acids, alkalis, and organic compounds.
- Acids: cause tissue necrosis.
- Alkalis: adhere to tissues, causing protein hydrolysis and subsequent "liquefaction necrosis."
- Common household and industrial chemicals can lead to burns.
- Examples of Acids: Lye, sulfuric acid (often used in drain cleaners).
- Examples of Alkalis: Wet cement, oven cleaners.
- Contact or Systemic Toxicity: Organic compounds (e.g., phenols, petroleum products, tetrahydrozoline in eyedrops) can cause burns as well.
Smoke Inhalation Injury
- Damage to the respiratory tract from inhaling noxious chemicals or hot air.
- Upper Airway Injuries: Results in thermal burns leading to edema and obstructed airway.
- Lower Airway Injuries: Damage dependent on exposure duration to fumes or smoke.
- Inhalation of carbon monoxide (CO) or hydrogen cyanide results in metabolic asphyxiation.
- Indicators: Carboxyhemoglobin levels >20% in blood prevent oxygen absorption to tissues.
Electrical Burns
- Result from intense heat generated by an electric current.
- Directly damages nerves and blood vessels, leading to tissue anoxia and cell death.

Amount of Voltage
Tissue Resistance: Fat and bone have greater resistance than blood and nerves.
Current Pathways: Pathway determined by contact points affects severity.
Surface Area and Duration: Larger areas and longer exposures lead to more severe injuries.
Cold Thermal Injury: Injury caused by exposure to cold, such as frostbite.

Ranges from mild to life-threatening.
Burn injuries affect multiple body systems, highlighting the need for careful management.
Common risks associated with burn injuries include:
- Fluid and electrolyte imbalances.
- Full-thickness burns altering limb perfusion.
- Malnutrition and immobility.
- High risk of infection.

Severity Determinants:
- Depth of Burn: Classified by degree (first, second, third, and fourth).
- Extent of Burn: Measured in total body surface area (TBSA) percentages.
- Location of the Burn: Certain areas (face, neck, circumferential torso) increase severity due to complications like airway obstruction.
- Patient Factors: Age and pre-existing health conditions can compound risk.

First-Degree Burns (Superficial): Affect only the epidermis. Symptoms include erythema, blanching with pressure, pain, and swelling.
Second-Degree Burns (Partial Thickness): Include both the epidermis and part of the dermis. They present with fluid-filled vesicles, red shiny appearance, severe pain, and potential for regeneration.
Third-Degree Burns (Full Thickness): Involve destruction of the epidermis and dermis. Characterized by dry, waxy, white, leathery skin. Patients may experience pain insensitivity due to nerve destruction.
- Eschar: Nonviable burn tissue that cannot regenerate, requiring grafts for healing.
Fourth-Degree Burns: Extend further into fat, muscle, or bone.

To assess the extent, two common tools are utilized:
- Lund-Browder Chart: More accurate as it considers age and proportional size.
- Rule of Nines: Quick, initial assessment tool for adults, less accurate, and can lead to fluid overload if overestimated.
- Patient Hand (with fingers): Represents 1% TBSA.

Areas of Concern:
- Face, Neck, Circumferential Torso: Risk for gas exchange interference.
- Hands, Feet, Joints: May limit mobility and function.
- Ears, Nose, Buttocks, Perineum: High infection risk due to thin skin.

Scene Safety: Priority is to remove the victim away from the source of the burn.
Stop the Burning Process: Flush wounds with copious amounts of water to minimize injury depth, followed by wrapping the person in a clean, dry sheet.
Moist Dressings: Used carefully due to potential hypothermia risks.
If a chemical burn, remove affected clothing and flush with water for up to 72 hours.

Emergent Phase: Focus on life-threatening issues and fluid resuscitation.
- Hypovolemic shock and edema formation are primary concerns.
- Ends when fluid mobilization occurs, and diuresis begins.
Acute Phase: Begins after fluid shifts and lasts until wounds heal.
Rehabilitative Phase: Focuses on regaining function and addressing psychological needs.

Cardiovascular Complications: Dysrhythmias, shock, impaired circulation leading to ischemia.
Respiratory Complications: Inhalation injury, with assessments of breathing patterns and airway management required.
Renal Complications: Acute kidney injury due to ischemia or myoglobin blockage from injury.

Fluid Therapy: Calculated based on Parkland formula: 4 mL * % TBSA * body weight (kg).
- Administer half within the first 8 hours, with remaining fluid divided over the next 16 hours.
Wound Care: Utilize appropriate personal protective equipment for dressing changes and apply antimicrobial agents as needed.
Psychological Support: Address emotional needs of patients and caregivers, encourage open communication.

Opioids for pain management, with regular assessments to adjust doses as needed.
Tetanus immunization for infection prevention.
Monitor and manage electrolyte imbalances, especially sodium and potassium.

Addressing the hypermetabolic state prevalent in burn patients, enteral feeding becomes critical for healing and preventing complications.

Older patients have distinct risk profiles due to thinner skin, potential for existing comorbidities, and generally poorer healing rates.

Emotional and psychological impact is significant, emphasizing the importance of appropriate support and care during recovery.

Nurses require support to cope with the emotional toll of caring for burn victims, emphasizing self-care and healthy boundaries.

The Parkland formula is essential for determining fluid resuscitation needs after a burn.
Example:
- Patient weight of 154 lbs with 50% TBSA burned:
- Total fluid for the first 24 hours = 4 ext{ mL} imes 70 ext{ kg} imes 50 ext{ (})
- Provide appropriate distribution of this fluid across initial hours as prescribed by guidelines.