Burns

1. Classification of Burns

Burns are tissue injuries caused by heat and can be classified by their type, size, and depth.

• Types of Burns:

• Thermal: Caused by dry or moist heat.

• Chemical: Caused by acidic or basic agents.

• Electrical: Resulting from electrical force passing through the body, always with an entrance and exit wound.

• Ultraviolet/Radiation: Such as sunburn or radiation treatment.

• Inhalation: Injury to the airway.

• Classification by Size: The extent of the burned area is expressed as a percentage of Total Body Surface Area (TBSA). Two methods for determination are:

• Rule of Nines: A "Rapid Estimation Method" where body parts are assigned percentage values of 9 or multiples of 9.

• Lund and Browder Method: A more accurate method that divides the body into smaller sections with percentages assigned based on the patient's age.

• TBSA helps determine the amount of fluid needed for hemodynamic stability.

• Classification by Depth: There are four types of burn depth:

• 1st Degree (Superficial): Involves the epidermis only. Symptoms include a "Dry red surface," blanching, pain, and sensitive edema, but "No Blisters." Healing occurs in 7-10 days (e.g., sunburn).

• 2nd Degree (Partial Thickness): Affects the epidermis and dermis. Characterized by "Blisters," moist and "Mottled pink or red skin," and is "Painful." Healing time is 14-21 days and may require grafting.

• 3rd Degree (Full Thickness): Affects the epidermis, dermis, and subcutaneous tissue. The skin appears "Tough, Leathery," "Dry, Hard," and can be "Snow white, black, tan." It "Does not blanch," and there is "No pain…why?" due to nerve damage. Requires grafting for complete healing.

• 4th Degree (Full Thickness): Extends to muscle and bone. Similar characteristics to 3rd-degree burns with deeper tissue involvement.

2. Classification by Severity (Adult)

Burn severity takes into account size, depth, location, age, health status, and mechanism of injury. Adult classifications are:

• Minor:

• Partial thickness burn less than 15% TBSA.

• Full thickness burn less than 2% TBSA.

• No preexisting disease or injuries.

• Does not involve special care areas (face, eyes, ears, hands, feet, perineum).

• Moderate:

• Partial Thickness Burns 15-25% TBSA.

• Full Thickness Burns less than 10% TBSA.

• No special care areas, preexisting disease, or injuries.

• "Usually requires hospitalization, but an uncomplicated injury."

• Major:

• Partial thickness burn greater than 25% TBSA.

• All full thickness burns greater than 10% TBSA.

• Inhalation and electrical injuries.

• Disability injuries to special care areas.

• Significant influence of age and health status.

3. Physiological Changes in Burn Injury

Burn injuries lead to both local and systemic physiological changes.

• Local Effects:

• Increased capillary permeability causes fluid to move out of cells and blood to leak into the interstitial compartment, leading to "local edema and decreased cardiac output."

• Fluid evaporates through the wound surface, "Decreases blood volume."

• Capillary permeability typically normalizes within 18-36 hours, leading to fluid reabsorption and a return of cardiac output to normal.

• Systemic Effects:

• Fluid Loss: Fluid shift due to capillary permeability decreases blood volume, potentially leading to "Hypovolemic SHOCK" and kidney failure. "Fluid replacement is critical," and urine output should be monitored (at least 30-50ml/hr).

• Fluid and Electrolyte Balance:Hyponatremia: Occurs commonly in the first week post burn as injured cell membranes allow sodium (NA+) to enter the cells, decreasing blood levels. Symptoms include "Dizziness," "Headache," "Lethargy," "N/V," "Cramping," "Cold/Clammy skin," and "Dry mucous membranes."

• Hyperkalemia: Typically occurs in the first 48 hours due to tissue destruction causing potassium (K+) to escape into the blood. Symptoms include "Muscle weakness," "Confusion," "Dysrhythmias," and "Numbness/tingling."

• Metabolic Acidosis: Can occur due to severe volume depletion and insufficient bicarbonate.

• Renal Failure: A potential complication of fluid loss and hypovolemia.

• Hypokalemia: May occur after 48 hours as increased fluid absorption dilutes potassium in the blood. Symptoms include "Constipation," "Palpitations," "Fatigue," "Muscle weakness," and "Tinginling/numbness."

• GI Function: Decreased blood flow to the intestines can lead to ileus. "Stress ulcers common," specifically "Curling’s Ulcer" which presents with GI distention, N/V. Preventative measures include H2 blockers and PPIs.

• Immune System: Immune suppression follows burns due to the loss of the protective skin barrier, increasing the risk for infections like "MRSA," "VRE," and "CRE." Patients may need "reverse isolation."

• Respiratory System: Inhalation injuries from carbon monoxide, smoke poisoning, and thermal damage are significant concerns. Signs include "Singed nasal hair," "Facial burns," "Stridor, wheezes, cyanosis," "Sooty Sputum," and "Respiratory distress/hypoxia."

• Myocardial Depression: Decreased cardiac output can occur due to increased capillary permeability. Lab studies are used to measure function.

4. Contractures

• Contractures are "A condition of shortening and hardening of muscles, tendons, and other tissues."

• Prevention is crucial and includes: "Keep in functional positions!," exercises starting 24-48 hours post-injury, "Splinting devices," and "Pressure Garments."

• Circulation issues may arise from taut burned tissue that doesn't stretch with edema.

5. Psychological Effects

• Psychological responses to burn injury are "Highly individualized."

• A "Psychiatric specialist should be involved ASAP."

• Four stages are identified: Impact, Retreat/Withdrawal, Acknowledgement, and Reconstruction.

6. Pain and Nutrition

• Pain: Burn injury is "Considered one of the most painful trauma." "Morphine drug of choice," administered IV initially, then PO (give PO 1 hour before treatment). "No IM/SQ initially."

• Nutrition: Basal Metabolic Rate (BMR) can be "2x normal rate" due to the body's increased energy demands for healing. Enteral or parenteral nutrition is often required to meet increased caloric needs, sometimes "Greater than 5,000/day."

7. Stages of Burn Injury

• Emergent: Begins at the time of injury and ends when fluid shift is stabilized.

• Acute: Begins with fluid stabilization and ends when all wounds are closed.

• Rehabilitation: Begins as the acute stage ends and lasts as long as needed to promote adjustment. The "Goal: To return the patient to an optimum level of physical and psychosocial function." Therapy starts in the acute phase and continues through rehabilitation.

8. Wound Care – Grafting

• Grafts are used for 2nd and 3rd-degree burns to promote healing, earlier functional ability, and decrease contractures, infection, and scar formation.

• Types of Grafts:Allografts: From a cadaver.

• Heterografts: Skin from a pig.

• Synthetic: Substitutes like Biobrane.

• Autograft: "Human skin used to cover a burn site." Can be the patient's skin or from a donor (usually thigh or buttocks).

• Full thickness: Epidermis and all of the dermis.

• Split thickness: Leaves some dermis.

• Post-Care: Protecting grafts is key. "Occlusive dressing helps immobilize graft – 1st changed 2-5 days following surgery." Autograft donor sites are immobilized for 3-7 days and inspected for bleeding. Donor sites are covered with gauze or synthetic dressings, "Removed after 24 hours to allow drying." Graft failure typically occurs within the first 2 weeks.

9. Wound Care – Open and Closed Dressings

• Open Dressings: Topical agent without a dressing. Advantages include easy wound assessment and less restriction. Disadvantages include the need for strict isolation, frequent reapplication of topical agents (as they tend to rub off), and the necessity of using antimicrobial ointment. "Gold Standard Topical: Silver sulfadiazine (Silvadene)," a broad-spectrum antibiotic.

• Closed Dressings: Involve the use of occlusive dressings. While clinical trials haven't shown a definitive advantage over open dressings, the thought is that they protect the wound and keep the ointment in place. Non-stick layers (Telfa, Xeroform, Vaseline gauze) are used with supportive layers like Kerlix or Kling.

10. Principles of Dressings

• "Never wrap skin-to-skin surfaces."

• "Wrap fingers individually."

• Choose dressings based on wound size, protection needed, absorption, and type of debridement required.

• Elevate affected extremities.

• Limit dressing bulk to facilitate Range of Motion (ROM).

11. Support Garments

• Used to decrease scarring.

• Patient teaching includes the necessity for the garment to be tight for effectiveness and the importance of massaging the area and performing facial exercises for facial burns.

• "Jobst Pressure Stocking" is often used for 1-2 years, "23 hours/day."

12. Wound Care – Whirlpool/Debridement

• Used for the removal of dead tissue or debris (eschar) from the wound.

• Types:Mechanical: Using scissors, scalpels, or forceps.

• Surgical: Primary excision down to the fascia or shaving of layers down to viable tissue.

• Enzymes: Debridement agents (chemicals, not maggots) used with antimicrobials.

13. Wound Care – Medications

• Antibiotics!

• Silver nitrate: Bacteriostatic and fungicidal, but does not penetrate eschar.

• Silvadine: Cream ("gold standard"), broad-spectrum, but does not penetrate deep eschar.

• Sulfamylon: Effective against gram-positive and gram-negative organisms, penetrates deep eschar, but "burns for about 20 min after application."

14. Nursing Care – Emergency Care

• "Prevent further injury!" "#1 priority: stop the burning process!"

• Thermal Burn: "Stop drop and roll."

• Chemical Burn: "Irrigate with copious amounts of water or NS." Try to ID the substance. "Better outcomes when flushing is rapid and immediately at the scene."

• Electrical Burn: "Initiate CPR if needed." Estimate voltage. Assess cardiac status with "Continuous monitoring: EKG" and "Serial cardiac enzymes."

15. Nursing Care – Superficial and Partial Thickness

• First aid: Rinse with cool water.

• "STOP the burning process."