Unit 2 management of patients with burn

MANAGEMENT OF PATIENTS WITH BURN

Pathophysiology of Burns Causes of Burn Burns are caused by a transfer of energy from a heat source to the body. Heat may be transferred through conduction or electromagnetic radiation. Burns are categorized as thermal (which includes electrical burns), radiation , or chemical . Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents.

Pathophysiology of Burns cont’d The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image.

Pathophysiology of Burns cont’d The depth of the injury depends on the temperature of the burning agent and the duration of contact with the agent. For example, in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis , causing a fullthickness (third-degree) injury. Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar full-thickness injury. Temperatures less than 111°F are tolerated for long periods without injury.

CLASSIFICATION OF BURNS Burn injuries are described according to the depth of the injuryand the extent of body surface area injured. Burn Depth Burn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider.

CLASSIFICATION OF BURNS cont’d Burns are classified according to the depth of tissue destruction as: 1. Superficial partial-thickness injuries (first degree burn) : In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister (very minimal).

CLASSIFICATION OF BURNS cont’d Typical Characteristics for Superficial thickness burn Mild to severe erythema (pink to red) NO BLISTERS Skin blanches Painful, tingling Pain responds well to cooling Lasts about 48 hours; healing in 3-7 days

CLASSIFICATION OF BURNS cont’d 2. Deep partial-thickness injuries (second degree burn) : A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars.

CLASSIFICATION OF BURNS cont’d Typical Characteristics for deep partial thickness burn Large blisters over an extensive area Edema Red base with broken epidermis Wet, shiny and weeping Sensitive to cold air Healing in 2-3 weeks Grafts MAY be needed

Partial-Thickness Burn to the Hand

Partial-Thickness Burns Due to Immersion in Hot Water

CLASSIFICATION OF BURNS cont’d 3. Ful-thickness injuries (third degree burn) : A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed

CLASSIFICATION OF BURNS cont’d Typical Characteristics for Full-thickness burn Deep, red, black, white, yellow, or brown area Edema Tissue open with fat exposed Little to no pain* Requires removal of eschar and skin grafting Scarring and contractures are likely Takes weeks to months to heal

CLASSIFICATION OF BURNS cont’d The following factors are considered in determining the depth of the burn: How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS Thermal Burns Caused by flame, flash, scald, or contact with hot objects It is the most common type of burn Chemical Burns Result from tissue injury and destruction from necrotizing substances (chemicals) Most commonly caused by acids

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Chemical Burns cont’d Respiratory and systemic problems Eye injuries Clothing containing the chemical should be removed Tissue destruction may continue for up to 72 hours after a chemical injury

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries Result from inhalation of hot air or noxious chemicals Cause damage to respiratory tract Important determinant of mortality in fire victims

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Three types: • Carbon monoxide poisoning • Inhalation injury above the glottis • Inhalation injury below the glottis

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials Inhaled CO displaces oxygen 200 x more powerful than oxygen CO is colorless, odorless and tasteless

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning can cause: • Hypoxia in tissues • Carboxyhemoglobinemia • Death

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning Treat with 100% humidified oxygen CO poisoning may occur in the absence of burn injury to the skin Skin color described as “cherry red” in appearance Hot air, steam, or smoke can cause: mechanical obstruction quickly May lead to hemorrhage in the bronchus ARDS

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning Signs and Symptoms Presence of facial burns Singed nasal hair Hoarseness, painful swallowing Darkened oral and nasal membranes

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries cont’d Carbon monoxide (CO) poisoning Signs and Symptoms cont’d Wheezing on auscultation Edema is the nose and airways Flushing Nausea/vomiting Syncope, coma, death

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Smoke Inhalation Injuries Injury below the glottis - Pathophysiology Injury is related to the length of exposure to smoke or toxic fumes Pulmonary edema may not appear until 12 to 24 hours after the burn Decrease is surfactant production Decrease in ciliary action

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Electrical Burns Intense heat generated from anelectrical current May result from direct damage to nerves and vessels causing tissue anoxia and death Severity of injury depends on the amount of voltage, tissue resistance, current pathways, surface area, and on the length of time of the flow

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Electrical Burns cont’d Electrical sparks may ignite the patient’s clothing, causing a combination of thermal and electrical injury

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Cold Thermal Injury ( Frostbite) Usually affects fingers, toes, nose, and ears Numbness, pallor, severe pain, swelling, edema Blistering in a warm environment Handle the tissue carefully!

CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS cont’d Cold Thermal Injury ( Frostbite) Interventions – Frostbite Warm rapidly and continuously for 15-20 minutes AVOID slow thawing Do not debride blisters

CLASSIFICATION OF BURNS BY EXTENT OF BSA INJURED Extent of Body Surface Area Injured Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are: the rule of nines , the Lund and Browder method , and the palm method .

CLASSIFICATION OF BURNS cont’d RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines . The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

CLASSIFICATION OF BURNS cont’d LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth. By dividing the body into very small areas and providing an estimate of the proportion of TBSA accounted for by such body parts, one can obtain a reliable estimate of the TBSA burned. The initial evaluation is made on the patient’s arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then.

CLASSIFICATION OF BURNS cont’d PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA.

Criteria for Classifying the Extent of Burn Injury(American Burn Association) Minor Burn Injury Second-degree burn of less than 15% total body surface area(TBSA) in adults or less than 10% TBSA in children Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints) Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease)

Criteria for Classifying the Extent of Burn Injury(American Burn Association) Moderate, Uncomplicated Burn Injury Second-degree burns of 15%–25% TBSA in adults or10%–20% in children Third-degree burns of less than 10% TBSA not involving special care areas Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients (eg, extremes of age, concurrent disease)

Criteria for Classifying the Extent of Burn Injury(American Burn Association) Major Burn Injury Second-degree burns exceeding 25% TBSA in adults or 20% in children All third-degree burns exceeding 10% TBSA All burns involving eyes, ears, face, hands, feet, perineum, joints All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients

LOCAL AND SYSTEMIC RESPONSES TO BURNS Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. These systemic responses are due to the release of cytokines and other mediators into the systemic circulation and include the following:

LOCAL AND SYSTEMIC RESPONSES TO BURNS cont’d tissue edema effects on fluid, electrolytes and blood volume cardiovascular responses (decreased cardiac out put, hypovolumia, decresed BP, increased PR) pulmonary responses (inhalation injury to air ways, broncho-constriction-major cause of death,acute respiratory failure or respiratory distress syndrome ) altered immunological defenses renal dysfunction, etc

LOCAL AND SYSTEMIC RESPONSES TO BURNS cont’d Pathophysiologic changes resulting from major burns during the initial burn-shock period include: tissue hypoperfusion organ hypofunction secondary to decreased cardiac output, Hyperdynamic and hypermetabolic phase.

LOCAL AND SYSTEMIC RESPONSES TO BURNS cont’d The incidence, magnitude, and duration of pathophysiologic changes in burns are proportional to the extent of burn injury, with a maximal response seen in burns covering 60% or more TBSA. The initial systemic event after a major burn injury is hemodynamic instability , resulting from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces.

Management of the Patient With a Burn Injury Burn care must be planned according to the burn depth and local response , the extent of the injury , and the presence of a systemic response . Burn care then proceeds through three phases: Emergent/resuscitative phase (on-the-scene care), Acute/intermediate phase, and Rehabilitation phase. Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.

Table: phases of burn care Phase Duration Priorities Emergent or immediate resuscitative From onset of injury to completion of fluid resuscitation First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Wound assessment and initial care Acute From beginning of diuresis to near completion of wound closure Wound care and closure Prevention or treatment of complications, including infection Nutritional support Rehabilitation From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment Prevention of scars and contractures Physical, occupational, and vocational rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

Emergent/resuscitative phase mgt Emergency Procedures at the Burn Scene Extinguish the flames Cool the burn Remove restrictive objectives Cover the wound Irrigate chemical burns

Emergent/resuscitative phase mgt Emergency Medical Management The patient is transported to the nearest emergency department. The hospital nurses (staff) and physician are alerted that the patient is in route to the emergency department so that life-saving measures can be initiated immediately by a trained team. Initial priorities in the emergency department remain airway, breathing, and circulation.

Emergent/resuscitative phase mgt Emergency Medical Management cont’d For mild pulmonary injury, inspired air is humidified and the patient is encouraged to cough so that secretions can be removed by suctioning. For more severe situations , it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. If edema of the airway develops, endotracheal intubation may be necessary.

Emergent/resuscitative phase mgt Emergency Medical Management cont’d Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation. A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not inserted earlier).

Emergent/resuscitative phase mgt Emergency Medical Management cont’d Assessment of both the TBSA burned and the depth of the burn is completed after soot and debris have been gently cleansed from the burn wound. An indwelling urinary catheter is inserted to permit more accurate monitoring of urine output and renal function for patients with moderate to severe burns.

Management of fluid loss and shock Fluid Replacement Therapy: The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. The adequacy of fluid resuscitation is determined by: Output totals of 30 to 50 mL/hour systolic blood pressure exceeding 100 mm Hg and/or pulse rate less than 110/minute.

Conditions Leading to Burn Shock

Management of fluid loss and shock Fluid Requirements: The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. Some combination of fluid categories may be used: Colloids (whole blood, plasma, and plasma expanders) and Crystalloids/electrolytes (physiologic sodium chloride or lactated Ringer’s solution).

Management of fluid loss and shock Fluid Requirements: Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours. Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA.

Guidelines and Formulas for Fluid Replacement in Burn Patients Consensus Formula Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL× kg body weight × % total body surface area (TBSA) burned. Half to be given in first 8 hours; remaining half to be given over next 16 hours.

Guidelines and Formulas for Fluid Replacement in Burn Patients The following example illustrates use of the formula in a management of a 70-kg patient with a 50% TBSA burn: Steps 1, Consensus formula: 2 to 4 mL/kg/% TBSA 2, 2 × 70 × 50 = 7,000 mL/24 hours 3, Plan to administer: First 8 hours = 3,500 mL, or 437 mL/ hour; next 16 hours = 3,500 mL, or 219 mL/hour

Guidelines and Formulas for Fluid Replacement in Burn Patients Evans Formula 1. Colloids: 1 mL × kg body weight × % TBSA burned 2. Electrolytes (saline): 1 mL × body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of previous day’s colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.

Guidelines and Formulas for Fluid Replacement in Burn Patients Brooke Army Formula 1. Colloids: 0.5 mL × kg body weight × % TBSA burned 2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss

Guidelines and Formulas for Fluid Replacement in Burn Patients Brooke Army Formula cont’d Day 1: Half to be given in first 8 hours; remaining half over next16 hours Day 2: Half of colloids; half of electrolytes; all of insensible fluid replacement. Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.

Guidelines and Formulas for Fluid Replacement in Burn Patients Parkland/Baxter Formula Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned Day 1: Half to be given in first 8 hours; half to be given over next16 hours Day 2: Varies. Colloid is added.

Guidelines and Formulas for Fluid Replacement in Burn Patients Hypertonic Saline Solution Concentrated solutions of sodium chloride (NaCl) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. Do not increase the infusion rate during the first 8 post burn hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications.

Nursing Management Includes: infection prevention, wound cleansing and administering topical antibacterial drugs like: Silver sulfadiazine 1% (Silvadene) watersoluble cream, Silver nitrate 0.5% aqueous solution, Mafenide acetate 5% to 10% (Sulfamylon) hydrophilic-based cream, Acticoat, etc

Acute Phase management Hemodynamically stable through diuresis Capillary permeability is restored 48-72 hours after injury Goal is restorative therapy Focus on infection control, wound care and closure, nutritional support, pain management, PT Concluded when the burned area is completely covered by skin grafts or when the wounds are healed

Acute Phase management Pathophysiology Diuresis from fluid mobilization occurs, and the patient is no longer grossly edematous Bowel sounds return Healing begins Formation of granulation tissue A partial-thickness burn wound will heal from the edges Full-thickness burns must be covered by skin grafts

Acute Phase management • Wound Care Daily observation Assessment Cleansing Debridement Appropriate coverage of the graft: Fine-mesh gauze next to the graft followed by middle and outer dressings Sheet skin grafts must be kept free of blebs (small blisters)

Acute Phase management Excision and Grafting Eschar is removed down to the subcutaneous tissue or fascia Cultured Epithelial Autographs (CEA): CEA is grown from biopsies obtained from the patient’s own skin Artificial Skin: used when life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable

Acute Phase management Pain Management Opioid every 1 to 3 hours for pain Several drugs in combination Morphine with haloperidol Nonpharmacologic strategies • Relaxation tapes • Visualization, guided imagery • Meditation

Acute Phase management Debriding Full-Thickness Burn

Acute Phase management Surgeon Harvesting Skin

Acute Phase management Donor Site After Harvesting

Acute Phase management Healed Split-Thickness Skin Graft

Acute Phase management Application of Cultured Epithelial Autograft

Rehabilitation Phase The rehabilitation phase is defined as beginning when the patient’s burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity Complications Skin and joint contractures Hypertrophic scarring

Rehabilitation Phase Both patient and family actively learn how to care for healing wounds Cosmetic surgery is often needed following major burns Role of exercise cannot be overemphasized Constant encouragement and reassurance Address spiritual and cultural needs Maintain a high-calorie, high-protein diet Occupational therapy

Unit 2 management of patients with burn

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Unit 2 management of patients with burn