Burns

Overview of Burn Injuries

  • Burn injuries result from damage to skin or tissues from heat, chemicals, electricity, or radiation.

  • Men are twice as likely to have burn injuries than women.

  • Adults between 20 to 30 years old have the highest prevalence of burn injuries.

  • long length

Types of Heat Injuries

  • Dry heat injuries result from open flames or explosions.

  • Moist heat injuries result from contact with hot liquid or steam.

  • Thermal burns occur when clothing ignites from heat or flames.

Types of Burns

  • Chemical burns result from exposure to caustic agents.

  • Electrical burns occur when electrical current passes through the body, causing severe damage.

  • Radiation burns can result from therapeutic treatment for cancer or sunburn, causing thermal effects or damage to cellular DNA.

Factors Affecting Burn Injury Severity

  • Age of the patient, depth of burn, amount of surface area burned, presence of inhalation injury, other injuries, location of injury, and comorbid conditions.

Burn Depth Classification

  • First-degree (superficial) burns involve the epidermis and have appearances like redness (blanches w/pressure), minimal/no edema and possible blisters. Sensation and healing involve tingling, hyperesthesia, pain that’s soothed by cooling, peeling, itching

  • Second-degree (partial thickness) burns involve the epidermis and a portion of the dermis, with appearances of pink, red, white, possible blistering and mild-moderate edema. Sensation/healing involve pain, hyperesthesia, sensitive to air currents, & may require grafting.

  • Third-degree (full thickness) burns affect the epidermis, dermis, and sometimes subcutaneous tissue, may involve connective tissue and muscle and nerve damage. Appearance with red, black, brown, yellow or white, can appear leathery or charred, severe edema and no blisters. Sensation/healing involves minimal or absent sensation, scarring, and grafting.

  • Fourth-degree burns damage all layers of skin, extending to deep tissues, muscles, and bones. Appearance includes black/charred, no edema or blisters. Sensation/healing include no pain, scarring, grafting and amputations are likely.

Burn Depth Assessment

  • Ability of burn to heal depends on the burn depth

  • Factors like how the burn occurred, causative agent, temperature &duration of contact with agent, and skin thickness at the injury site determine burn depth.

Burn Center and Extent of Body Surface Area

  • Burn centers are specially equipped to treat burn patients from injury through rehabilitation.

  • Patients may need transfer to a burn center for third-degree burns, burns face/hands/feet/genitalia/perineum/major joints, electrical burns, inhalation injuries, and other severe conditions.

  • Methods like the Rule of Nines, Lund and Browder method, and Palmar method are used to estimate total body surface area affected by burns.

Rule of Nines and Calculation

  • The Rule of Nines is a common method based on anatomic regions to estimate burn extent.

  • Calculation involves summing up zones to determine the percentage of total body surface area burned.

  • Lund & Browder Method- more precise, uses percentage of surface area of specific anatomic parts

  • Palmar Method- quick method to approximate scattered burns, palm of patient’s hand (including fingers) = 1% TBSA

Management of Burn Injury

  • Management of Electrical Burns: serum creatinine kinase levels, risk for myoglobinuria, patient may require multiple surgeries.

  • Cardiovascular alterations: third spacing (capillary leak syndrome), “burn shock”, fluid resuscitation.

  • Fluid & Electrolyte Alterations- edema (forms rapidly after burn), circumferential burns, treatment (escharotomy/fasciotomy). Electrolyte abnormalities: sodium and potassium

  • Pulmonary Alterations: inhalation injuries- upper /lower airway injury

    • Clinical Manifestations: singed facial hair, sooty sputum, hoarseness, wheezing, stridor.

    • Dx: bronchoscopy

    • Upper airway injury- severe airway edema from direct thermal injury or secondary edema from face/neck burns. Possible tx: protective intubation

    • Lower Airway Injury- pt inhales smoke or noxious gases; possible carbon monoxide poisoning. Tx: 100% oxygen

  • Escharotomy/fasciotomy:

    escharotomy:

fasciotomy:

Emergent/Resuscitative Phase

  • Phase begins with burn injury & ends with completion of fluid resuscitation.

  • PRIORITIES: ABC’s, prevention of shock/respiratory distress, detection & tx of associated injuries, wound assessment/initial care

    • transport to nearest ED

    • focus on ABC’s

    • continuous monitoring of airway patency

    • calculation TBSA burned

    • fluid resuscitation initiated AFTER urgent respiratory needs addressed

  • ABA Fluid Resuscitation Formulas

    • For adults with thermal or chemical burns:

      • 2 mL LR (x) patient’s weight in kg (x) % TBSA

    • For adults with electrical burns:

      • 4 mL LR (x) patient’s weight in kg (x) % TBSA

    • The total volume calculated will be administered over the initial 24hr post-burn period

      • One half of total calculated will be administered in first 8 hours post-burn injury

      • Second half of calculated volume is administered over the next 16 hours

  • Nursing/Collab Management- Fluid Resuscitation:

    • Urinary Output- desired 0.5 - 1 mL/kg/hr

      • Gold standard for monitoring response to fluid resuscitation

      • indwelling (foley) cath inserted

  • Nursing Interventions:

    • monitor temp

    • monitor resp. status

    • assess pulses

    • cardiac monitoring

    • potential difficulties w/ obtaining vital signs

    • elevation of burned extremities

    • assess pain level

Acute/Intermediate Phase

  • Phase begins with diuresis to ends with wound closure

  • Begins 48-72 hr after burn

  • Priorities of Acute/Intermediate Phase:

    • Wound care and closure

    • Prevention or treatment of complications, including infection

    • Nutritional support

  • Upper airway edema can lead to airway obstruction

  • Complications:

    • Endotracheal intubation, ventilator-associated pneumonia (VAP)

    • Potential for fluid overload

    • Hyperthermia

    • Surgical excision of necrotic tissue

Infection Prevention & Control

  • Burn injuries cause dysregulation of immune system

  • Clinical signs of infection

  • PPE for staff

    • gown, gloves, eye protection, mask

  • Wound cultures

  • Avoid prophylactic antibiotics

Wound Cleaning

  • Goal of wound care:

    • remove nonviable tissue/wound exudate/previously applied topical agents

  • Patients who are:

    • Hemodynamically unstable- wash wounds at bedside

    • Ambulatory- pt may shower independently or w/ assistance.

    • Non-ambulatory- can be bathed/receive wound care using shower cart

Wound Dressing

  • Application of several dry dressings after prescribed topical agents

  • Circumferential dressings- apply distally to proximally

  • Wrap fingers/toes individually

  • Facial burns

  • Dressings after new skin grafts

  • Nursing interventions:

    • dressings that adhere to wound bed

    • documentation

Wound Debridement

  • Removal of devitalized tissue to prepare site for healing & possible grafting

  • 4 types of debridement: natural, mechanical, chemical, surgical

  • Natural Debridement

    • devitalized tissue spontaneously separates from underlying viable tissue

    • bacteria present between devitalized & viable tissues gradually liquifies the fibrils of collagen that hold eschar in place

  • Mechanical Debridement

    • uses tools to separate & remove eschar

    • usually performed w/ routine dressing changes

    • “wet-to-wet” or “wet-to-moist” dressings

  • Chemical Debridement

    • use of topical enzymatic agents to debride burn wounds

    • can be combined w/ topical abx therapy

    • topical agents containing silver can deactivate chemical debriding agents

  • Surgical Debridement

    • Timeframe- may be performed ASAP after injury

    • post-Procedure Interventions- wound covered immediately w/ skin graft (if necessary) or dressing. Temporary biologic or synthetic dressing possibly

    • Risks- extensive blood loss. Anemia related to blood loss

    • Benefits- shorter length of hospitalization. Granulation tissue creates barrier to bacteria

Wound Grafting

  • Use for deep partial- or full-thickness burns

  • permits earlier function

  • reduces scar contractures

Autograft Types and Characteristics

  • preferred autologous method for burn wound closure

  • not rejected by pt’s immune system

  • Types of Autografts:

    • Split-thickness Autografts

      • most common

      • remaining donor site retains sweat glands/hair follicles

      • Application- sheets; expanded by meshing

      • scar formation

      • graft loss

    • Full-thickness Autograft

      • donor site includes dermis & epidermis

      • consider cautiously

    • Cultured Epithelial Autograft (CEA)

      • used w/ massive burns (>90% TBSA burned)

      • availability of non'-burned skin as donor sites

      • cultures grown from full-thickness biopsies that were obtained from pt’s unburned skin (culture)

      • about 3 weeks for final product to be ready

      • Disadvantages-

        • fragile, prone to graft loss. Expensive. Requires long length of stay

SHEET GRAFT

MESHED GRAFT

Care of Graft Site

  • Post-op goals: protection & immobility

  • 1st dressing change

  • early graft loss

  • careful patient positioning/turning

  • elevating grafted extremities

Care of Donor Site

  • Dressing applied to site after hemostasis is obtained

  • Painful wound

  • potential site of infection

  • very susceptible to pressure injury

  • should heal spontaneously 7-14 days

Temporary Wound Coverage

  • Body’s immune response will eventually reject

  • provide temporary wound coverage until autografting is possible

  • stay in place for varying lengths of time

  • removed for bacterial colonization, infection, rejection

  • Temporary Wound Coverage:

    • Homografts:

      • avail from “skin banks”

      • revascularization occurs within 45H

      • may be left for several weeks

      • Advantages: best infection control of all biologic/biosynthetic dressing

      • Disadvantages: most expensive biologic dressing

    • Xenografts:

      • avail from commercial suppliers

      • used for temp covering of clean wounds

      • Advantages: provides pain control, allows underlying wound to re-epithelialize

      • Disadvantages: does not vascularize

    • Biosynthetic & Synthetic Dressings:

      • may eventually replace biological dressings

      • many products on the market

      • tend to be expensive

Pain Management

  • burn injuries are considered one of the most painful types of trauma

  • pain management plan should address background, breakthrough & procedural pain

    • Background Pain:

      • a continuous level of discomfort experienced even when pt is inactive/not undergoing procedures

      • Goal: to provide long-acting analgesic agent that will provide uniform coverage for long-term discomfort

      • Use small, escalating doses when initiating analgesia to reach acceptable level of pain control

      • PCA

    • Breakthrough Pain:

      • acute, intense & episodic pain. Generally related to an activity/movement of affected area

      • Goal: to achieve PRN pain control using short-acting agents

    • Procedural Pain:

      • discomfort that occurs w/ procedures such as daily wound tx, invasive line insertions, PT/OT

      • Goal: plan proper analgesia to facilitate comfort for pt throughout procedure

  • Pharmacologic treatment:

    • opioids, NSAIDS for pain

    • benzos for anxiety

    • antipruritic agents, water/silica-based lotion for itching

  • Nonpharmacological therapies:

    • relaxation techniques, distraction, guided imagery, therapeutic touch

Nutritional Therapy

  • Early nutritional support

  • Nasogastric tube placement if needed

  • High-protein, high-calorie meals if able to take PO

  • Dietary consult

Promoting Physical Mobility

  • Deep breathing, turning, and proper positioning

  • Passive & active ROM exercises

  • Splints/functional devices

  • PT/OT consults

Other Nursing Interventions

  • Daily weight

  • Strict I&O

  • Monitor sodium levels

  • Regular bathing & linen changes

  • Documentation: nutritional intake, wound status

  • report any significant changes in wound to provider

Potential Complications

  • Acute respiratory failure/acute resp. distress syndrome

  • Heart failure

  • Sepsis

  • Delirium

Rehabilitation Phase

  • Phase begins after wound closure & ends at pt’s return to optimal level of physical/psychosocial adjustment

  • Priorities:

    • prevention & tx of scars & contractures

    • physical, occupational & vocational rehab

    • functional & cosmetic reconstruction

    • psychosocial counseling