2. OBJECTIVES:
• Review anatomy (elderly)
• Causes of burns
• Burn classification & severity
• Extent of Injury
v TBSA*
v Categories and Zones
Physiological Responses
v Hypovolemic stage
• Relative hypovolemia r/t fluid shifts.
v Diuretic stage
• r/t IVF resuscitation & overhydration.
Treatment
v Emergent
v Acute (hospitalization)
v Rehabilitation
3. EFFECTS OF BURNS:
A severe burn can be a devastating injury (physically & emotionally).
• Affect not only the burn victim, but the entire family.
• Burns can also cause emotional problems such as depression, nightmares, or PTSD.
• Loss of a friend, family member, or possessions may add grief to the emotional
impact of a burn.
SEVERE BURNS: may leave pt with a loss of certain physical abilities, including:
vLoss of limbs, disfigurement, loss of mobility, scarring.
vRECURRENT INFECTIONS: burned skin has ↓ ability to fight infection.
vSevere burns can penetrate deep skin layers, causing muscle or tissue
damage that may affect every system of the body.
5. EFFECTS OF AGING ON SKIN:
• Less resilience to mechanical trauma.
• Atrophy of dermal & subQ tissues
• ↓ microcirculation
• ↓ immunological response
• ↓ physiological reserve
• Co-morbidities
• ↑ morbidity and mortality
v Tissue changes predispose elderly pts to
deeper wounds & slower healing.
v Massive amts of IVF can effect renal and
cardiac fx in pts with CHF or renal disease.
6. SKIN FUNCTIONS:
• Protection
• Temperature regulation
• Regulates fluid loss
• Vitamin D synthesis
• Sensory perception
• Person’s identity
• Body image
• Cosmetic appearance
7. CAUSES OF BURNS:
• Thermal
• Chemical
• Radiation
• Electrical (alternating vs direct current)
• Friction (road rash)
• Cold (frostbite)
• Medications (S.J. syndrome)
8. CLASSIFICATION OF BURNS:
1st: Superficial skin (into epidermis)
2nd: Partial-thickness burn
• Superficial or deep
• Partially into dermis (partial)
• Fully into dermis (deep)
3rd: Full-thickness burn
• Into SUBQ tissue
4th: Muscle & bone involved
12. 1st Degree
• Superficial
• Classic sunburn
• Scald injury
• Localized to epidermis
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13. 2nd Degree (Superficial)
• Extends into upper dermis.
• Blisters, blanching, painful (ex: severe sunburn)
• Weepy “wet” appearance
• Regeneration of hair follicles / sweat glands within 7-14 days
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14. 2nd Degree (Deep)
• Partial-thickness, extends deep into dermis.
• Nerves & blood vessels damaged.
• Pale, mottled, dry skin.
• ↓ sensation
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15.
16.
17.
18. 3rd Degree (Full-Thickness)
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• Destroys epidermis, dermis, & accessory structures
• Extends into SUBQ tissue
• Dry, brown, yellow, or black in color
• Non-pliable à feels leathery
• May need skin graft
• ↓ sensation
19.
20. 3 ZONES OF BURNS:
Zone of coagulation necrosis
• Irreversible tissue damage
• Direct burn site
Zone of stasis
• Immediate surrounding area
• ↓ perfusion
• Tissue may regenerate
• GOAL: inc. perfusion
Zone of hyperemia
• Tissue perfusion is inc.
• Vasodilation & edema
• Inc. risk for sepsis and prolonged hypoperfusion
26. RULE OF PALMS:
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• Used for scattered burns.
• Not measured with nurse’s
palm, but with pt’s palm.
• Entire hand up to the wrist
= 1% TBSA
27. • Lung Injury can occur with…
- Smoke
- Chemical Toxins
- Byproducts of incomplete combustion (treated wood, sutt)
• Exposure to Toxic Gases:
- Carbon monoxide poisoning
- Cyanide poisoning
• Supraglottic Injury:
- Thermal injuries most common cause.
- Injury to pharynx & larynx à airway obstruction
• Subglottic Injury:
- Chemical injury most common cause.
- Damages ciliary function
- Erythema & edema à bronchospasms
- Mucosal ulceration
INHALATION INJURIES:
29. • Exposure to smoke in a confined area.
• Facial burns / singed nasal hair
• Soot around mouth / nose
• Carbonaceous sputum (black)
• Hypoxemia (agitation, tachycardia, restless, dysrhythmias, confusion)
• Abnormal breath sounds
• Respiratory distress (↑ WOB, sternal retractions, dysphagia)
• ↑ carboxyHgb levels
• Abnormal ABGs (↑ RR à alkalosis, ↓ RR à acidosis)
• Inactivation of surfactant results in:
- Alveolar collapse
- Pneumonia
- Pulmonary edema
INHALATION INJURIES:
CLINICAL MANIFESTATIONS
30.
31. TOXIC GASES:
Carbon Monoxide (CO) Poisoning:
• Binds to Hgb more rapidly than oxygen.
• Cells starved of O2 even with supp. oxygen
• Tissue Hypoxia
Cyanide Poisoning:
• Binds to respiratory enzymes in the mitochondria
• Inhibits cell metabolism
• Impaired oxygen utilization
32.
33. Carbon Monoxide Poisoning
• Carboxyhemoglobin Levels (COHgb)
• Pulse ox unable to differentiate between oxyHgb/ COHgb à INACCURATE PULSE OX READING
COHgb <10-15%
• No Symptoms
• Headache or visual acuity
COHgb 15-40%
• CNS dysfunction
• Restless, confused, dizzy
• Impaired dexterity
• N/V
COHgb 40-60%
• Loss of consciousness
• Tachycardia / Tachypnea
• Seizures
• Cherry red or cyanotic skin.
COHgb >60%
• Coma / death
34. • Falsely elevated SpO2 readings
in pt’s with CO poisoning.
• Need to put pts on
supplemental oxygen.
If pt given 100% O2 or placed in
hyperbaric chamber… half-life of
COHgb is cut substantially.
36. • Capillaries leak à Third spacing
• F&E Imbalances: Na+, K+, Ca+, lactate
- Hypovolemia
- pH: acidosis (r/t muscle breakdown)
- Hyperkalemia**
- Hyponatremia
• Hemoconcentration:
- ↑ blood viscosity
- ↓ perfusion
- May show high H+H prior to IVF resuscitation.
- After starting IVF… H+H will ↓ drastically.
- Tissue hypoxia
PATHO. OF BURNS:
37.
38.
39. Multi-Organ Effects of Burns
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Curling’s ulcer
Rhabdomyolysis à AKI
40. Electrolyte Disturbances:
Initial Resuscitation (0-36 hrs after injury):
• Begins at time of injury (not EMS arrival).
• Depends on burn severity.
• Hyperkalemia à cells damaged à release of K+ from cells à dysrhythmias
• Hyponatremia à capillary leakage à edema
• Pts will require serial bloodwork: BMP (q2-4h)
- CENTRAL ACCESS for frequent lab tests.
- IO access may be required.
Post-Resuscitation:
• Hypernatremia
• Hypokalemia
• Hypocalcemia
• Hypomagnesemia
• Hypophosphatemia
41. Electrolyte Disturbances: Post-Resuscitation
• Hypernatremia: Fluid shifts intravascularly
- Change IVF to isotonic or hypotonic (shifts fluid into cells)
- Isotonic: NS, LRs, D5W
- Hypotonic: 0.45% NS, 0.33% NS, 2.5 D5W
• Hypokalemia: K+ shifts back into cells & urinary losses of K+
- Monitor EKG for dysrhythmias
• Hypocalcemia: Ca+ shift back into cells & urinary losses of Ca+
• Hypomagnesemia: Coexistent with hypokalemia & hypocalcemia
• Hypophosphatemia: Mobilization of fluid & nutritional status
- Phosphorus always shows us pt’s NUTRITIONAL STATUS***
- Low phosphorus = poor nutrition
42. vIVF Resuscitation: Based on burn size (TBSA)
vFluid of choice: Lactated Ringer’s
Formula is used for…
• Burns covering >20% TBSA
• 2nd degree burns
• 3rd degree burns
Adult Formula: 4ml x weight (kg) x TBSA burned
• Initial 24-hr fluid requirement:
- Half of the volume to be infused given in the first 8 hrs.
- Remaining half given over next 16 hrs.
- Based on initial time of burn event (NOT arrival to ED).
- Titrate infusion rate to urinary output.
- Want ↑ u/o to prevent AKI (100-150 mL/hr)
PARKLAND FORMULA:
43. Children with burns >20%:
• 2ml x weight (kg) x TBSA burned
• Add calculated maintenance fluid:
0–10 kg à 100cc/kg
11–20 kg à 50 cc/kg (+1000)
>21 kg à 20 cc/kg (+1500)
• Divide total by 24 à hourly maintenance rate (cc/hr)
Lactated Ringer’s (LRs)***
- First half given over 8 hrs.
- Second half given over 16 hrs.
- Titrate infusion rate to urinary output.
- Contains buffers that help with metabolic acidosis & ↑ lactic acid levels.
2
PARKLAND FORMULA:
44.
45. RESUSCITATIVE PHASE: (pre-hospital)
• Extricate the patient safely
• STOP the burning process!!!
ü Cool with tepid water
ü Never apply ice! (vasoconstriction à further tissue damage)
ü Remove all jewelry
ü Clothing adhering to skin is NOT removed.
ü If clothing is not adhering, remove it.
• Electrical Injuries
ü Remove patient from source.
ü Protect rescuer (wood), use PPE
• Chemical Injuries:
ü Brush powdered chemicals off prior to removing clothes & lavaging.
ü Remove all clothing
ü Lavage with clean water prior to & during transport.
ü Remove contact lenses.
ü Irrigate eyes: inner à outer canthus (prevent cross-contamination)
ü Neutralizing agents not recommended
46. vIdentify life-threatening injuries (secondary injuries: internal organs, frx)
vRapid transport to hospital – Minimize time on scene.
PRIMARY SURVERY:
Airway with c-spine precautions:
• Assess for inhalation injuries
• Facial burns
• Stridor
Breathing:
• NRB 100%
• Intubation
Circulation:
• Remove clothing and jewelry
• Two large bore IVs through non-burned skin.
• Administer LRs.
• Monitor for signs of hypovolemia.
• Prevent heat loss à cover with clean sheets & blankets
RESUSCITATIVE PHASE: (pre-hospital)
47. 1. Administer High Flow 100% Oxygen at 15 L/min (NRB or ETT)
2. Assess Breathing: Look for signs and symptoms of inhalation injury & deterioration.
3. Assess for Deep Circumferential Chest Burns
• Burns can restrict chest expansion à altered respirations.
• Burnt skin loses elasticity quickly à tourniquet effect when combined with rapidly accumulating edema.
• Respiratory insufficiency or ischemia of an extremity are a risk.
• Escharotomy may be required.
4. Assess for COHb Poisoning:
• Consider CO poisoning in pts who sustain burns in an enclosed area.
• CO has a 280x greater affinity for Hgb than oxygen does.
• O2 administration is pivotal to help O2 bind to Hgb & unbound CO can be exhaled.
• SpO2 is unreliable indicator of CO poisoning.
• Pulse-ox interprets CO as oxygen à pt can be hypoxic with high SpO2 readings
-Supplemental O2 should be given regardless of SpO2
Assess for symptoms of high COHb levels:
• Hx of altered LOC
• Cherry pink skin
• Anxiety, restlessness
48. • HR
• BP à arterial line
• Urine output:
- Insert a Foley
- Monitor hourly u/o
- Simple way to assess fluid balance
• Distal pulses
• Capillary refill
• Color and turgor of unburned skin
• ABGs
• Serum lactate
ASSESS FLUID STATUS:
49. PREVENT HYPOTHERMIA:
1. Cover the burn ASAP
2. Stop cooling the wound if core temperature <35oC
3. Cover the patient with blankets:
• Warm blankets
• Space blankets
• Forced air warming blanket (Bair Hugger)
4. Warm IV fluids
5. Keep the room warm
6. Check temp. regularly
7. Remove any wet dressings, sheets etc. (evaporative heat loss)
50. q Exposure in confined area
q Facial burns / singed nasal hair
q Soot around mouth / nose
q Carbonaceous sputum (black)
• Massive edema develops rapidly à requires ETT
• Longer they wait, the narrower the airway gets.
• If airway is completely closed off…need to trach pt.
Electrical injuries:
• HIGH RISK of ATN r/t myoglobin release à
rhabdomyolysis à AKI
• Require LARGE VOLUMES of IVF replacement.
51.
52. BURN SHOCK:
• Shock from intravascular volume loss r/t sudden F&E shifts
immediately following a burn injury.
• Combination of distributive & hypovolemic shock.
• ↑ capillary permeability, third-spacing à relative hypovolemia
• ↓ oncotic pressure:
- Leaking of proteins (fluid follows protein)
- Draws intravascular fluid into interstitium (tissues).
- Relative hypovolemia (fluids moves intravascularly à interstitially)
• Edema formation
- Due to ↓ oncotic pressure
- Natural inflammatory response
- Risk of compartment-like syndrome à escharotomy or fasciotomy
62. SPECIAL BURN CONSIDERATIONS:
Facial Burns:
• Potential for inhalation injuries
• Edema à compromised airway à ETT
• Elevate HOB
• Prevent excessive bleeding & damage to new tissue growth.
• Topical antimicrobial agent
Ear Burns:
• Chondritis (r/t poor vascular supply of ear)
• Prevent pressure on area
• Sulfamylon (mafenide acetate): antimicrobial of choice
Eye Burns:
• Remove contact lenses
• Exam by ophthalmologist
• Irrigate / Irrigate / Irrigate
• Protect cornea & conjunctive from exposure / drying out (eyelid retraction)
• Ophthalmic ointments and artificial tears.
All will go to burn centers!
63. Hands, Feet, or Major Joints:
• May cause permanent disability
• GOAL: Preservation of FX!!
• Active ROM
• Splinting & anti-deformity positioning
• Prevent webbing (scar tissue): Wrap digits individually
• Elevation to prevent edema
• Prevent venous stasis / pooling (elastic bandages, thromboguards)
Genitalia & Perineum
• Monitor for urinary tract obstruction.
-Indwelling Foley until wounds healed or grafted.
• High risk of urine or fecal contamination.
• Elevation of scrotum to relieve edema.
SPECIAL BURN CONSIDERATIONS:
64.
65. High voltage (>1000 volts):
• Requires trauma evaluation
• Cardiac dysrhythmias / cardiac arrest
• Hypoxia
• Deep tissue necrosis
• Compartment Syndrome (esp. extremities)
• Long bone or vertebral frx (rigidity), SCI, TBI
• Rhabdomyolysis à AKI
• Acute cataract formation
• Neurological deficits
• Motor or sensory deficits
• Neuropathy
Low voltage:
• Local Injury
• Common in children (cords, outlets)
66. • Voltage takes the shortest path to the ground.
ENTERANCE & EXIT BURNS:
• Extensive tissue damage occurs btwn.
entrance and exit wounds.
• Tissue necrosis
• Upon exiting, the electricity can cause
tissues to explode.
• Exit wounds may be larger.
68. SCARS & CONTRACTURES:
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• Wrap digits individually
• Splints to prevent contractures
• ROM exercises
• Want to maintain joints in the
most functional position.
Webbing occurs r/t scar tissue formation.
69. • Stop burning process!!!
• Protective equipment (PPE)
• Decontamination required:
• Brush off powder substance
• Continuous water irrigation
• ALKALIS: require longer irrigation
• Determine specific chemical agent
• Control pain
• Minimize heat loss à cover with dry blankets
• Monitor for signs of chemical absorption
• Chemicals can be absorbed thru. skin à systemic complications
70. PAIN CONTROL:
MAJOR FOCUS OF BURN MANAGEMENT:
• Background pain
• Procedural pain
• Meds often exceed normal dosing guidelines
• Hypermetabolism à require higher doses of pain meds.
Assess pain levels frequently:
• Pain meds: ALWAYS given IV***
• SUBQ & IM injections ineffective: impaired circulation à altered absorption rates
• Cannot determine rate of absorption if given IM or SUBQ…always given IV.
Tx of anxiety:
• Anxiolytics
• Relaxation, hypnosis, guided imagery, distraction
Pt’s with HX of alcohol or substance abuse:
• Compound pain management
• Opiates: drug of choice
72. Susceptibility to infection in burn pts:
• Loss of skin (first line of defense)
• Extended hospital stays
• Invasive procedures
• IVs, central lines
• Foley catheters
• Immuno-compromised
INFECTION CONTROL MEASURES:
73. INFECTION CONTROL MEASURES:
• Aseptic management of wound & environment
• Topical antibacterial agents
• Care of invasive catheters (central lines, A-line, Foley)
• Aggressive wound management
• Prevention of MDROs: identification of infectious organism
• Use of appropriate ABX
• Monitor lab values / signs of sepsis
• Early wound closure / restore skin barrier
• Adequate nutrition
• Interventions to improve patient outcomes
• Staff education
74. STEVENS-JOHNSON SYNDROME (SJS):
Reaction caused by certain meds: OTC drugs, ABX, sulfa drugs
• Nikolsky sign: epidermis separates from dermis with even slight rubbing.
• Mucosal sloughing: assess oral cavity
• >20% TBSA à Toxic epidermal necrolysis (TENS)
• Stop the drug
• Resuscitate (IVF)
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75.
76. ASSESS FOR CHILD ABUSE:
• Donut pattern on buttocks
• Stocking pattern
• Glove pattern
• Sparing: soles of feet, back of knees
• Line of demarcation
• Waterlines
• Scalds
77.
78. DIFFUSE ROAD-RASH:
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• Very painful
• Bacitracin
• Debridement of dirt & stones
• Topical agents
• Heal fairly quickly
84. ESCHAROTOMY:
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• Longitudinal incision thru eschar itself.
• Only down to SUBQ tissue (not thru!!)
• Relieves stiff eschar that forms (thru epidermis & dermis)
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• Need to debride wound FIRST.
• Viable tissue: bleeds
• Mesh graft placed onto wound bed
• Stapled to skin
• Keep it moist à covered w.
metahoney, xeroform dressing
SKIN GRAFTING:
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SKIN GRAFTING:
92. SKIN GRAFTING:
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• Harvest skin from larger areas
• Typically the thigh
93. NUTRITIONAL
CONSIDERATIONS:
• Stress-induced hypermetabolic / catabolic response
• Post-burn hypermetabolism:
- Skeletal muscle breakdown
- Delayed wound healing / skin graft loss
- Impaired immunological response
• Muscle weakness & atrophy:
- r/t prolonged mechanical ventilation
- Extended rehabilitation time
• Oral Diet
- High-calorie, high-protein diet w. protein supplements
- Protein: 1.5-2 g/kg/day
• Enteral feedings
• Beta-blockers: propranolol (lowers metabolic rate & release of
cytokines / stress hormones)
• Anabolic hormones: oxandrolone
- These meds help ↓ length of stay by ↓ metabolism
