Zone of coagulation - This occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins.
Zone of stasis - The surrounding zone is characterized by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insults—such as prolonged hypotension, infection, or edema—can convert this zone into an area of complete tissue loss.
Zone of hyperemia - In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.
Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury
Severe metabolic acidosis--can develop in minutes
Myoglobinuria--acute renal tubular necrosis- myoglobin released from muscle tissue whenever massive muscle damage occurs--goes to kidneys--and can mechanically block the renal tubules due to the large size!
Electricity can instantaneously destroy tissue. This child has a burn that resulted from biting on an electrical cord. These burns often occur at the corners of the mouth, as seen here.
How did the burn occur? Did the burn occur outside or inside? Did the clothes catch on fire? How long did it take to extinguish the flames? How were the flames extinguished? Was gasoline or another fuel involved? Was there an explosion? Was there a building/house fire? Was the patient found in a smoke-filled room? How did the patient escape? If the patient jumped out a window, from what floor? Were others killed at the scene? Was there a motor vehicle crash? How badly was the vehicle damaged? Was there a motor vehicle fire? Are there other injuries? Are the purported circumstances of the injury consistent with the burn characteristics?
What kind of electricity was involved? What was the duration of contact? Did the patient fall? What was the estimated voltage? Was there loss of consciousness? Was cardiopulmonary resuscitation administered at the scene?
Specific burn –Treatment notes Care for Thermal Burn
For <10% TBSA burn-apply moist cool sterile dressings to small burn
For larger-cover area with dry sterile dressings or sheet
Specific burn –Treatment notes Care for Chemical Burn (1 of 2)
Most common renal complication of burns in the emergent phase is Acute Tubular Necrosis (ATN) (muscle destruction > myoglobulin release > protein leak clogs kidney cells >ischemia) Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.
Massive fluid shifts out of blood vessels as a result of increased capillary permeability. When capillary walls become more permeable, water, sodium, and later plasma protein (esp. albumin) moves into interstitial spaces & other tissues. The colloidal osmotic pressure decreases with loss of protein from the vascular space. This called second spacing.
Potassium- hyperkalemia is note if pt is in renal failure, adrenocortical insufficiency, or massive deep muscle injury with lg. amts. of potassium released from damaged cells. Cardiac arrhythmias and ventricular failure can occur if K+ level greater >7mEq/L. muscle weakness & EKG changes are noted.
Hypokalemia is noted with silver nitrate therapy and long hydrotherapy. Other causes: vomiting, diarrhea, prolonged GI suction, prolonged IV therapy without K+ supplementation. Constant K+ losses occur through the burn wound.
Infection- due to destruction of body’s 1st line of defense. Partial thickness wds can convert to full-thickness wds with infection present. Pt may get sepsis from wound infections. Signs of sepsis are: high temp., increased pulse & resp., decreased BP, and decreased urinary output, mild confusion, chills, malaise, and loss of appetite. WBC bet. 10,000 and 20,000. Infections usually gram neg. bacteria (pseudomonas, proteus)
Nursing management during Rehabilitation Phase
Must be directed to returning patient to society, address emotional concerns, spiritual and cultural needs, self-esteem, teaching of wound care management, nutrition, role of exercises and physical therapy explained. A common emotional response seen is regression.
Critical Stress Defusing/Debriefing sessions should be offered early and often
Staff of burn units are prone to higher rates of burn-out. The care of a burn patient can be a long period that stresses the patient, care giver, and significant others. The road to recovery is full of potential threats to the patient. Support services are necessary for the medical team of any long-term burn patients.