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IN THE NAME OF GOD IN THE NAME OF GOD

#BURNS #BURNS

BURNS INCIDENCE n n n Approx. 140 Burn Centers in U. S. Approx. 1. BURNS INCIDENCE n n n Approx. 140 Burn Centers in U. S. Approx. 1. 25 million people suffer a burn injury in the U. S. each year. About 5, 500 people die from burns and related inhalation injuries annually Young people and elderly are high risks Most injuries occur at home 75% of patients are victims of their own actions

Burns n n n Devastating Heals slowly Disfiguring Long months of rehabilitation Occupational therapy Burns n n n Devastating Heals slowly Disfiguring Long months of rehabilitation Occupational therapy n Nurse’s role: n n n Be knowledgeable of the pathophysiology of burns Help meet biopsychosocial needs Carry out measures to meet physical needs

Phases of Burn Care n Emergent/Resuscitative Phase (onset of injury to n Acute/intermediate Phase Phases of Burn Care n Emergent/Resuscitative Phase (onset of injury to n Acute/intermediate Phase (beg. of diuresis to n Rehabilitation Phase (wound closure to optimal completion of fluid resuscitation) n On the scene care (ABC, initial wound care, injury) n Management of fluid loss & shock near completion of wound closure) n Maintenance of resp. & circulatory status, fluid & electrolyte balance, GI function n Infection prevention, wound care, pain management, nutritional support level) n Wound healing, restoring maximal functional activity, alterations in self-image & lifestyle

Burns n Emergency management n n n n cold wet towels, cool water, no Burns n Emergency management n n n n cold wet towels, cool water, no direct ice, cover with sterile dressing don’t break blisters lotion only after a burn is completely cooled wrap loosely to avoid putting pressure on burned skin ABC Prevent shock Fluid replacement Flush area thoroughly with water or saline (chemical burns)

Burns n Short term effects of burns n n fl volume deficit hypovolemic shock Burns n Short term effects of burns n n fl volume deficit hypovolemic shock infection Long term effects of burns n n scarring (full thickness burns) contraction

Burns n Minor burns n n <15% TBSA with <2% full thickness Moderate burns Burns n Minor burns n n <15% TBSA with <2% full thickness Moderate burns n partial thickness burns 15 -25% TBSA with 2 -10% full thickness

Burns n Major Burns n n >25% TBSA or >10% full thickness involvement of Burns n Major Burns n n >25% TBSA or >10% full thickness involvement of hands, feet, face or genitalia Survival due to refinement of fluid resuscitation management and early transfer to burn unit.

Burns n n n Facial burns have the possibility of airway impairment Important to Burns n n n Facial burns have the possibility of airway impairment Important to know the circumstance of burn: greater risk of airway involvement if burn occurred in closed space Always suspect a head injury if a patient had an electrical burn which resulted from a fall

Mechanism of Burn Injuries n flame (thermal) 55% n n contact with fire etc. Mechanism of Burn Injuries n flame (thermal) 55% n n contact with fire etc. (smoke inhalation can be as damaging as thermal) get pt. Supine to decrease facial burn (STOP, DROP, ROLL) prolonged exposure to cold considered thermal burn

Mechanism of Burn Injuries n Scald 33% n n most common for children chemical Mechanism of Burn Injuries n Scald 33% n n most common for children chemical 10% n n severity depends on duration of contact, conc. Strength of chemical, amt. Of tissue exposed alkaline more serious than acid irrigate area immediately (most chem labs have high pressure showers) powder-brush off; do not inhale

Mechanism of Burn Injuries n chemical con’t n n n chemical burns destroy tissue Mechanism of Burn Injuries n chemical con’t n n n chemical burns destroy tissue through protein coagulation rather than heat some acids (sulfuric and muriatic) also destroy tissue through heat production in chemical reaction with tissue first aid n take of clothes (chemical on clothes)

Mechanisms of Burn Injuries n First aid of Chemical con’t n n if powder, Mechanisms of Burn Injuries n First aid of Chemical con’t n n if powder, dust off before irrigate so not attempt to neutralize agent (takes valuable time) running water will dilute the chemical Electrical <10% n voltage running through body can do a lot of damage (leaves an exit wound as well as entrance wound); evaluate internal damage along the path of the current

Mechanisms of Burn Injuries n Electrical con’t n n n as electrical current goes Mechanisms of Burn Injuries n Electrical con’t n n n as electrical current goes through tissue, it produces heat causing thermal coagulation necrosis immediate extent of injury unknown (electrical current pathway) deep muscle burn-burgundy color urine

Classification of Burns n Burn injuries are described according to: n n Depth of Classification of Burns n Burn injuries are described according to: n n Depth of injury Extent of body surface area (BSA) injured n Depth n n Superficial Partialthickness Deep partial-thickness Full-thickness BSA n n n Rule of nines Lund & Bowder method Palm method

Classification of Burns n First degree (superficial partialthickness) n n eg. Sunburn involvement: usually Classification of Burns n First degree (superficial partialthickness) n n eg. Sunburn involvement: usually epidermis only symptoms: tingling, hypersthesia (inc. sensitivity to pain), skin reddened, blanched with pressure, minimal or no edema how it heals: some peeling over a week, no scar

Types of Burns n Second degree burn (partial-thickness) n n eg. Scalding burns involvement: Types of Burns n Second degree burn (partial-thickness) n n eg. Scalding burns involvement: epidermis and part of dermis symptoms: hyperesthesia, sensitivity to cold, blistered mottled red base, broken epidermis , weeping surface how it heals: new epidermis grows in 1 -3 weeks

Types of Burns n Third degree (full thickness) n n eg. Fire burn, prolonged Types of Burns n Third degree (full thickness) n n eg. Fire burn, prolonged exposure to hot liquid involvement: epidermis, entire dermis, and sometimes subcutaneous tissue, muscle, and bone symptoms: painless, s/s shock, hematuria, hemolysis of blood likely, skin and fat exposed edema, skin (dry, pale white, or charred) how it heals: needs skin grafting unless very small

Burns n Rules of nine (total equals 100%) n n n arms 9 each Burns n Rules of nine (total equals 100%) n n n arms 9 each (4 1/2 front, 4 1/2 back) legs 18 each (9 front, 9 back) trunk 36 (front 18 and back 18) head and neck 9 (41/2 front, 4 1/2 back) perineum 1 A superficial burn can bring on a severe systemic reaction when it covers a large body surface area

Burns n n Suspect inhalation injury if victim has burns on head, neck, or Burns n n Suspect inhalation injury if victim has burns on head, neck, or anterior chest s/s inhalation injury n dyspnea, carbonaceous sputum, wheezing. Hoarseness (caused by laryngeal edema), altered mentation

Burns n Pain n n continuous problem with second-degree burns but not third degree Burns n Pain n n continuous problem with second-degree burns but not third degree because nerves have not completely been destroyed as with third degree when eschar removed from third degree, other pain mechanisms become operative

Burns n Assessing a patient with burns n ABCs n n history and physical, Burns n Assessing a patient with burns n ABCs n n history and physical, rules of nine, pulmonary status, check peripheral pulses on burned extremities, vital signs, urine output, labs fluid replacement, prevention of infection, psychological needs temp usually hypothermic

Physiologic Changes con’t n Pulmonary n n carbon monoxide most common cause of inhalation Physiologic Changes con’t n Pulmonary n n carbon monoxide most common cause of inhalation injury because it is a byproduct of the combustion of organic materials and therefore present in smoke (need 100% O 2 due to cell hypoxia upper airway injury, pulmonary edema, etc

Physiologic Changes in Burn Injury n Cardiovascular n n outpouring of catecholamines from SNS Physiologic Changes in Burn Injury n Cardiovascular n n outpouring of catecholamines from SNS (sympathetic nervous system) with injury which leads to peripheral blood vessel constriction and increase pulse rate vessels become more permeable due to injury and allow fluid and colloids to leak into surrounding tissues (third spacing)

Physiologic Changes con’t n Cardiovascular n n peripheral vascular vasoconstriction further decreases cardiac output Physiologic Changes con’t n Cardiovascular n n peripheral vascular vasoconstriction further decreases cardiac output with third spacing less intravascular fluid which leads to low blood volume and low cardiac output which contributes to inadequate tissue perfusion

Physiologic Changes con’t n Renal n n decreased renal blood flow which leads to Physiologic Changes con’t n Renal n n decreased renal blood flow which leads to glomerular damage GI n n hypovolemia leads to gastric dilatation and paralytic ileus Curling’s ulcer-stress ulcer

Physiologic Changes con’t n Fluid and Electrolytes n n n hyponatremia (first week of Physiologic Changes con’t n Fluid and Electrolytes n n n hyponatremia (first week of acute phase) as water shifts from interstitial to the vascular space hyperkalemia (immediate after burn) results from massive cell destruction hypokalemia may occur later with fluid shifts and inadequate potassium intake

Burns n Pyschosocial n n n self-concept body image There is a rapid fluid Burns n Pyschosocial n n n self-concept body image There is a rapid fluid and electrolyte change taking place n fluid loss leads to decreased blood volume which leads to thicker blood and decreased efficiency of circulation. There is a inc cellular elements of blood which leads to inc Hct

Burns n What happens in third spacing n n burns produce a dilatation of Burns n What happens in third spacing n n burns produce a dilatation of capillaries and the small vessels in the area of the burn leading to increase capillary permeability. The plasma seeps out into the surrounding tissues which produce blisters and edema. . The capillary walls that are damaged permit plasma proteins to move into interstitial (extracellular) spaces

Burns n Third spacing con’t n n the developed capillary permeability allows plasma proteins Burns n Third spacing con’t n n the developed capillary permeability allows plasma proteins to go through the barrier. There is decreased osmotic pressure in blood vessels and increased osmotic pressure in interstitial space and fluid accumulates at the burn sites in blister leading to third spacing loss. Fluid shift is from vascular compartment to third space.

Burns n Fluid loss with burns great. Fluid loss by evaporation 20 times greater Burns n Fluid loss with burns great. Fluid loss by evaporation 20 times greater than normal. Loss due to evaporation called white bleeding.

Burns n First 24 -48 hours n n large amounts of Na+ move with Burns n First 24 -48 hours n n large amounts of Na+ move with fluid from intravascular (within vessels) to interstitial fluid (Normally Na+ present approximately in same proportions both in intravascular and interstitial areas) Increase in release of aldosterone and antidiuretic hormone as a result of general stress response (this inc amt of Na+ and H 2 O retained. Pt. Becomes oliguric.

Burns n First 24 -48 hours con’t n n K+ elevated in blood since Burns n First 24 -48 hours con’t n n K+ elevated in blood since tissue destruction and oliguria (hyperkalemia) Patients’ feet cold due to inc. BMR (body’s reaction to try to replace heat lost from evaporation)

Burns n 48 -72 hours n n Na+ shifts back to intravascular space (capillaries Burns n 48 -72 hours n n Na+ shifts back to intravascular space (capillaries begin to regain their integrity) Diuresis leads to low K+ (hypokalemia) RBC loss from a microangiopathic anemia (severeness depends on extent of burn) RBC destruction initially caused by heat of the burn and later by hemolysis of heat damaged cells (result not only anemia but possible

Burns n 48 -72 hours con’t n n n kidney damage. Damaged RBC’s release Burns n 48 -72 hours con’t n n n kidney damage. Damaged RBC’s release Hgb which is filtered by kidneys. Myoglobin is released by damaged muscle tissue. Both are filtered by kidneys and kidney tubules. They may get plugged which leads to acute tubule necrosis. Diuresis phase lasts 3 -5 days after burns. Vascular leakage recovery complete.

Burns n Parkland/Baxter Formula 4 ml RL/kg body wt X % TBSA=ml RL for Burns n Parkland/Baxter Formula 4 ml RL/kg body wt X % TBSA=ml RL for 24 hours n eg. Pt. wt=75 kg and burned 25% 4/75/25=7500 ml/24 hours 50% 1 st 8 hours=3750 ml 25% 2 nd 8 hours=1875 ml 25% 3 rd 8 hours=1875 n

Burns n Parkland/Baxter Formula eg. Pt. Wt 82 kg body wt and burned 58% Burns n Parkland/Baxter Formula eg. Pt. Wt 82 kg body wt and burned 58% 4/82/58=19024 ml/24 hours 50% 1 st 8 hours=9512 ml 25% 2 nd 8 hours=4756 ml 25% 3 rd 8 hours=4756 ml n n Usually D 5 1/2 NS with KCL when pt in diuretic phase

Burns n n Goal: perfuse vital organs as fully as possible without overload Nutrition Burns n n Goal: perfuse vital organs as fully as possible without overload Nutrition n greater protein requirement due to negative nitrogen balance 2 times calories 2 times protein

Burns n n Full thickness burns result in death of skin and subcutaneous tissue Burns n n Full thickness burns result in death of skin and subcutaneous tissue Compartment syndrome n pain, pallor, decreased capillary refill, decreased peripheral pulses, decreased sensation, impaired movement (Poor peripheral tissue perfusion)

Burns n n n IV best route for pain relief (peripheral vasoconstriction limits absorption Burns n n n IV best route for pain relief (peripheral vasoconstriction limits absorption of drug given IM or SQ route) Open wound-use bed cradle Circumferential burns usually involve an extremity n edema may shut off circulation and an escharotomy or fasciotomy may be necessary to

Burns n n relieve the constriction and return normal blood flow Infection remains a Burns n n relieve the constriction and return normal blood flow Infection remains a threat until all second degree burns have healed and third degree burns have been closed by grafting (second degree could become third degree if infection goes deeper)

Burns (Grafts) n n Graft-a piece of tissue separated completely from its normal and Burns (Grafts) n n Graft-a piece of tissue separated completely from its normal and original position and transferred by one or more stages to correct a distant defect Free graft: completely separated from their donor site (blood supply completely interrupted) n survival of graft depends on vascular bed from recipient site

Burns (Grafts) n Free flap graft (free-tissue transfer) n n n cover a variety Burns (Grafts) n Free flap graft (free-tissue transfer) n n n cover a variety of wounds, cover exposed tendons, bones, major blood vessels. Completely severed from the body and transferred to another site Pedicle graft n a segment of tissue that has been left attached at one end (pedicle) while other end has been

Burns (grafts) n Pedicle graft (con’t) n n n moved to recipient area used Burns (grafts) n Pedicle graft (con’t) n n n moved to recipient area used when thick pieces of skin that could not survive an interruption of blood supply are transplanted usually about 3 -4 weeks for sufficient blood supply to be established

Burns (grafts) n Split thickness graft n n varies from thin to nearly full Burns (grafts) n Split thickness graft n n varies from thin to nearly full thickness of skin Full thickness graft n composed of a full depth of skin(epidermis and dermis) n gives best cosmetic appearance so used for face, neck, hands

Burns (grafts) n Pre-op skin grafts n n hgb and clotting time noted since Burns (grafts) n Pre-op skin grafts n n hgb and clotting time noted since their levels can affect healing process tissues need to be free from infection pt in optimum physical condition pt teaching

Burns (grafts) n Necessary for a graft to take n n recipient bed must Burns (grafts) n Necessary for a graft to take n n recipient bed must be adequately vascularized graft must be in complete contact with the bed immobilization must be assured area must be free from infection

Burns (grafts) n Types of grafts n n n allografts (cadaver) temporary xenografts animal Burns (grafts) n Types of grafts n n n allografts (cadaver) temporary xenografts animal (pigskin) autografts (self) n n n split thickness-epidermis 8 -12 thousandth of an inch thick full thickness-full depth of skin sheet grafts are put on joint areas (areas that stress) and secured with staples or sutures

Bone (grafts) n Autografts (con’t) n n n mesh grafts-donor skin expand to cover Bone (grafts) n Autografts (con’t) n n n mesh grafts-donor skin expand to cover large area expands graft 1 1/2 -9 times its original surface culture epithelial growth medium-grows 50 -70 times initial sample (donor site heals in 1 -2 weeks) Debridement n n n Surgical (excise) Mechanical or enzymatic (commercial preparation) natural (body and bacterial enzymes dissolve eschar

“Cultured Skin” n n ref UCSD 2001 Growing cultured skin from samples taken from “Cultured Skin” n n ref UCSD 2001 Growing cultured skin from samples taken from patients Copyrighted materials have been deleted from this slide

Burns (medications) n Silver nitrate 0. 5% (rarely used) n n con’t wet dressing Burns (medications) n Silver nitrate 0. 5% (rarely used) n n con’t wet dressing effectively prevents cross infection >0. 5% injures the tissue and not effective<0. 5% danger of electrolyte imbalance (especially Na and K) since the electrolytes are withdrawn from the body fluids and also from the dressing. Turns black in sunlight and stains clothes and hands black

Burns (medications) n Silvadene n n n wide-spectrum antimicrobial that is nonstaining and relatively Burns (medications) n Silvadene n n n wide-spectrum antimicrobial that is nonstaining and relatively painless no systemic metabolic abnormalities however is contraindicated in pregnant women near term and premature infants does not penetrate the eschar as well as sulfamylon

Burns (medications) n Sulfamyalon acetate n n n interferes with bacterial cellular metabolism diffuses Burns (medications) n Sulfamyalon acetate n n n interferes with bacterial cellular metabolism diffuses rapidly through burned skin and eschar used for gram-negative organism burning sensation after applied topically may cause metabolic acidosis and is a carbonic andryrase inhibitor may cause a rash

Burns (medications) n Furacin-nitrofurazone (gauze or cream) n n n a synthetic broad-spectrum antibacterial Burns (medications) n Furacin-nitrofurazone (gauze or cream) n n n a synthetic broad-spectrum antibacterial inhibits enzymes required for carbohydrate metabolism in bacteria Xeroform-a fine mesh gauze with antimicrobial action

Case Study n A 42 -year old patient is brought to the ED after Case Study n A 42 -year old patient is brought to the ED after being rescued from a house fire, where firefigthers found her unconscious in a bedroom closet. She has sustained burns to her right arm, right chest, and both lower extremities. On admission, she arouses to painful stimuli only. Her VS are BP 140/74, HR 112, RR 30/min and labored. She is afebrile. She has facial edema and visible soot in the oral pharynx and nares. Crackles are heard on auscultation, with decreased resp. excursion. Stridor is audible. The affected skin areas are white and inelastic, surrounded by heperemic, moist-looking tissue. She has pain on pinprick in the hyperemic tissue only.

Case Study cont. n n Lab results reveal a mildly elevated glucose level, elevated Case Study cont. n n Lab results reveal a mildly elevated glucose level, elevated Hg and Hct. Urine specific gravity of 1. 030. Low Pa. O 2 and an elevated carboxyhemoglobin level, at 37%. What is your treatment plan? Nursing Diagnosis?

What to do about the pain during PT n U of W Harborview Burn What to do about the pain during PT n U of W Harborview Burn Center is using VR (virtual reality) n n a non-pharmacological analgesic (distraction) used in addition to traditional levels of opioids during wound care and physical therapy found VR worked much better than Nintendo 64 pilot study showed dramatic drops in pain during treatments

Why VR works for pain n Pain perception is largely psychological pain requires conscious Why VR works for pain n Pain perception is largely psychological pain requires conscious attention VR draws pt into another world (this drains a lot of attentional resources leaving less attention available to process pain signals) n in snow world for example the patient fly through icy canyons etc (pts experience burning sensation during wound care so this game is designed to put out the fire)

NY Hospital-Cornell Medical Center Burn Center (1998 data) n n 5, 000 outpatients seen/yr NY Hospital-Cornell Medical Center Burn Center (1998 data) n n 5, 000 outpatients seen/yr (>1, 000 children) 1, 300 inpatients seen/yr team approach(surgeons, nurses, therapists, nutritionists, social workers) mission n develop an increasing effective teaching and

NY Hospital-Cornell Medical Center Burn Center (1998 data) n NY’s mission con’t n n NY Hospital-Cornell Medical Center Burn Center (1998 data) n NY’s mission con’t n n n public awareness methods having the highest standards of clinical and therapeutic excellence continued expansion of research in all phases of thermal injury n an optimum environment in which patients may recover with the help and expertise of NY’s hospital-wide administrative, medical and paramedical specialists

UW Burn Center n Approach to deep burn wounds n n n remove wound UW Burn Center n Approach to deep burn wounds n n n remove wound surgically within 1 st post burn week immediate grafts after wound removed to provide best functional and cosmetic results Treatment for (TEN) Toxic Epidermal Necrolysis disease resulting from a drug reaction whereby the body’s entire epidermis sloughs

UW Burn Center n treatment of TEN con’ n n n use of pig UW Burn Center n treatment of TEN con’ n n n use of pig skin and immaculate supportive care mortality has been reduced from 70% to 15% hospital stay has been reduced from months to average of 3 weeks

UCSD Burn Center n 450 admits/year n Brave Heart Kids Program n n Activities UCSD Burn Center n 450 admits/year n Brave Heart Kids Program n n Activities Work on promoting self-esteem

Baltimore Regional Burn Center (John Hopkins) n n 1800/year outpatients Michael D. Hendrix Research Baltimore Regional Burn Center (John Hopkins) n n 1800/year outpatients Michael D. Hendrix Research Center n n n Died from burn and ARDS in 1995 Delta plane crash in Georgia Family donated large amount of money to research Research n n n Infection prevention Wound healing New ways to culture skin Treatment of ARDS Immunologic response to burns

Prevention of Burn Injuries n Proper education and supervision n n n childproof items Prevention of Burn Injuries n Proper education and supervision n n n childproof items in electrical sockets keep dangerous items (matches) out of reach Safety measures for the elderly teach small children 911 smoke detectors in house STOP, DROP, AND ROLL