These are wounds coused by thermol , electric, and hot water

1. Burn Management
Principles
Katie Hollowed RN
Bridget Burke MSN ACNP-BC
Maggie Dylewski PhD RD
American Burn Association
Children’s Burn Foundation
August 27, 2009

2. Anatomy & Physiology
Burn Wound Management
Katie Hollowed, RN

3. • Protects against infection
• Maintains body fluids
• Regulates temperature
• Provides cosmetic identity
Skin Function

4. • Epidermis
non-vascular, stratified epithelial cells
• Dermis
vascular layer, collagen strands with
nerve endings, hair follicles, oil & sweat
glands, lymph spaces
• Subcutaneous tissue
adipose tissue & fibrous connective tissue
Skin Structure

5. SKIN STRUCTURE
Epidermis
Dermis
Subcutaneous
tissue

6. Burn Depth
• 1st degree
• 2nd degree
• 3rd degree
• 4th degree
• Epidermis
• Dermis
• Subcutaneous
tissue
• Muscle or bone

7. FULL THICKNESS
• 3rd or 4th degree
burn
• Dry, leathery
• White, brown, tan,
or black
• No potential for
healing
• Insensate
Burn Depth
PARTIAL
THICKNESS
• 1st or 2nd degree
burn
• Blisters, pink, or
red
• Wet, weepy
• Potential for
healing
• Painful

8. Partial Thickness (1st degree)

9. Partial Thickness (2nd degree)

10. Full Thickness (3rd degree)

11. Full Thickness (4th degree)

12. Airway
COMPROMISE
• Upper airway
• Lower airway
• Carbon monoxide poisoning

13. Airway
SIGNS & SYMPTOMS
• Singed nasal hairs, eyebrows, eyelashes,
beards, mustaches
• Soot or carbon in the mouth or nose
• Sore throat
• Hoarseness
• Wheezing/dyspnea
• Erythema, blistering of the mucosa
• Hypoxia

14. Upper Airway

15. Lower Airway

16. Carbon Monoxide

17. Fluid Resuscitation
PATHOPHYSIOLOGY
• Increase in capillary permeability
• Fluid shifts causing hypovolemic state with
massive edema

18. Fluid Resuscitation
BURN SHOCK
• Intravascular to interstitial fluid shifts
• Decrease B/P secondary to hypovolemia
• Decrease oxygen to the organs
• Decrease in cardiac output
• Circulatory collapse

19. Fluid Resuscitation
PARKLAND FORMULA
Day 1
• 4cc x kg x %TBSA Burn
• ½ in the 1st 8 hours
• The other 1/2 over the next 16 hours
RINGERS LACTATE

20. Determination of Percent
• Rule of Nines
• Palmar Method
• Lund-Browder Chart

21. Rule of Nines

22. Lund Browder

23. Fluid Resuscitation
PARKLAND FORMULA
Day 1
EXAMPLE
4cc x 70kg x 70%
4 x 70 x 70 = 19,600cc/24 hours
9,800for the 1st 8 hours or 1,225cc/hr.
9,800 for the next 16 hours or 612cc/hr.

24. Fluid Resuscitation
PARAMETERS
• Urine output 30-50cc/hr
• Pulse less than 120/min.
• Stable B/P

25. Pediatric Resuscitation
PATHOPHYSIOLOGY
Greater surface area/unit body mass
• Require relatively greater amounts of
resuscitation fluid
• Have lesser intravascular volume/unit of
surface area burned
• Are more susceptible to fluid overload &
hemodilution

27. Pediatric Resuscitation
Maintenance PLUS resuscitation fluid
• Maintenance:D5LR
1st 10 kg:100cc/kg/24 hours
2nd 10 kg:50cc/kg/24 hours
Each kg above 20 kg:20 cc/kg/24 hours
• Resuscitation (Ringers Lactate)
• 3-4cc x kg x TBSA Burn

28. Pediatric Resuscitation
EXAMPLE
23 kg child with 20% TBSA burn
• Resuscitation (LR)
3cc x 23kg x 20% TBSA = 1380cc
½ in the 1st 8 hours = 86cc/hr
• Maintenance (D5LR)
1st 10 kg:100cc/kg/24hr = 1000cc/24hr
2nd 10 kg:50cc/kg/24hr = 500cc/24hr
Remaining 3 kg:20cc/kg/24hr = 60cc/24hr
1560cc/24hr = 65cc/hr
TOTAL:86cc/hr LR + 65cc/hr D5LR

29. Wound Care
CLEANING
• Shower, Shower, Shower!!!
• Clean wounds daily with
soap & water

30. Wound Care
SOAP & WATER!!!

31. Wound Care
DEBRIDEMENT
• Mechanical
• Chemical
• Surgical

32. Wound Care
DEBRIDEMENT

33. Wound Care
DEBRIDEMENT

34. INFECTION
• Gram positive
• Gram negative
• Fungal
PATHOGENS

35. Infection

36. Antimicrobial Creams &
Ointments
• Silver sulfadiazine
• Neomycin/Bacitracin ointment
• Silver Nitrate

37. Slurry
SSD & Normal Saline

38. Wound Care
DRESSINGS

39. Wound Care

40. Acetic Acid
• Pseudomonas
• If no other antimicrobial available
• Creates a hostile environment for
pseudomonas but does not kill them
• Alternate with Dakins solution
• Moisten every 12 hours

41. Dakins Solution
If no other antimicrobial
cream/ointment available
70 ml bleach (JIX)/1000 ml H2O =
.25% sodium hypochlorite
Moisten every 12 hours

42. Granulation Tissue

43. Hypertonic Saline
Melts hypergranulation tissue
1 teaspoon salt/ 1 L H2O boiling water
Moisten every 12 hours

44. Wound Closure,
Physiotherapy
and Pain Management
Bridget Burke MSN ACNP-BC

45. Wound Closure
• Surgical Debridement (sloughectomy)
• Excision & autograft

46. Surgery

47. Excision

48. Donor Site

49. Autograft

50. Post Op Dressing

51. Post-Op Wound Care
• Remove outer dressings on day 2
• Shower, soap & water
• Replace dressing with topical antimicrobial
If no antimicrobial available, use hypertonic
saline, dakins, or acetic acid

52. Outcome

53. Outcome

54. Outcome

55. Life after Burn Injury
• Quality of life in the FUTURE is
determined by activity in the PRESENT
• A position of comfort promotes a
position of deformity

56. Restoring function
• Early ambulation
• Out of bed to chair 3-4 times a day
• Limit amount
of time spent
in bed
• Avoid further
preventable
complications

57. Sub-optimal outcomes
Contractures
-Prevents proper
functioning
-Decrease mobility

59. Burn Positioning

60. Purposes of Splinting:
Functional
Corrective
Preventive
Promote function through
-support/positioning
-compensation of lost function
-aids correction of misalignment and
contracture

61. Hand
splints

62. Axillary
splint

63. Knee
Ankle Foot
Splints

64. Pain Management

65. Goals of Pain Management
• Balance between sleep/dressing changes
& participation in therapy
• Patient and family satisfied with pain
management
• Successful transition to less intervention
as appropriate

66. Age Appropriate Assessment Scales
• Young children receive less pain meds
than their adult counterparts
– “They don’t complain of pain”
• Faces scale
• Assess child’s behavior
– Crying
– Irritable
– Lethargy

67. Burn Injury and Pain
• All burns are painful!
• Slight air currents are excruciating
• Once eschar sloughs, granulation tissue
has sharp (new burn) pain

68. Pharmacological Pain
Management
• Mainstay of therapy
• Pain is SUBJECTIVE!
• Analgesics most effective when given on
regular schedule
• Dose and type of med should be
re-evaluated frequently

69. Effective Medications
• Pethedine
• Paracetamol
• Ketamine
• Morphine
• Fentanyl
• midazolam (Versed)
• lorazepam (Ativan)
• diazepam (Valium)

70. Non-pharmacological Therapies
• Anxiety prevalent in burn patients
– Exacerbates acute pain
• A pair of scrubs will elicit anxiety in burned
child (“white coat syndrome”)

71. Non-pharmalogical therapies
• Distraction
– Crayons
– Music
– Singing
• Soothing by parents
• Creating a “safe place”

72. Nutrition & Burns
Maggie L. Dylewski, PhD, RD
Shriners Hospitals for Children
Boston, Massachusetts

73. Outline
Objective: to explain why adequate
nutrition is essential for burn patients
• Basic Nutrition
• The importance of nutrition & burns
• Nutrition Assessment
• Nutrition Therapy

74. Nutrition Defined
• Nutrition:
the study of foods, their nutrients, and
other chemical constituents; their action,
interaction, and balance in relation to
health and disease; and the process by
which the human body ingests, digests,
and absorbs, transports, utilizes and
excretes food substances.

75. What Is a Kilocalorie
(or kilojoule)?
• Measurement of energy
• “The amount of heat it takes to raise
the temperature of 1 gram of water by
1 degree Celsius”

76. Basal Metabolism
• Minimum energy expended to keep a
resting, awake body alive
• Includes energy needed for maintaining
heartbeat, respiration, body temperature
• Amount of energy needed for basal
metabolism varies between individuals

77. Nutrients Come From Food
• Nutrients: Compounds in foods that
sustain your body processes.
• Provide energy
• Provide building blocks
• Needed for growth
• Needed to stay healthy

78. Macronutrients
• Carbohydrates
• Bread, potato, rice, nshima, porridge
• Protein
• Meats, beans, eggs, milk
• Fat
• Oils, butter

79. Micronutrients
• Vitamins
• Minerals

80. Guidelines For Good Nutrition
• Eat a variety of foods
• Limit candy, chips, soda
• Especially among children!
• Drink plenty of water

81. A Healthy Diet Leads To…
• Better health
– Less sickness
– Less disease
• More energy and strength
• Better physical appearance
– Skin, hair, nails

82. Nutrition & Wound Healing
Nutrition plays a key role in wound healing
• Lack of nutrition leads to
• Poor wound healing
• Burn wound
• Donor site
• Compromised immune system
• All burn patients need good nutrition!
– Children and pregnant women are at the
highest risk.

83. Burns = Hypermetabolism
• Physiological state of increased metabolic
activity
• Burn more kilocalories at rest
• Muscle breaks down to release protein

84. Why Does Muscle Break Down?
• Provides amino acids for the synthesis of
proteins needed for wound healing and
immune function
• Collagen
• Immune cells
• Enzymes

85. Strategies to Reduce
Hypermetabolism
• Early excision and grafting of wounds
• Prevention of infection
• Pain management
• Warm environment
• Nutrition

86. Nutrition Assessment
• Nutrition assessment is an on-going
dynamic process that takes into
consideration many factors:
Total burn surface area
Depth of burn
Days post-burn
Weight, Height,
Baseline nutritional status

87. Energy Needs For Burn Patients
0 10 20 30 40 50 60 70 80
Minor Surgery
Major Surgery
Sepsis
Multiple Trauma
Organ Transplant
Burns
%above REE
% above basal metabolism

88. Determining Energy Requirements
• An activity/Injury factor is multiplied by the
Baal Metabolic Rate to determine daily
calorie needs
Daily kilocalorie needs = BMR x 1.5 – 1.75

89. Determining Protein Needs
Goal = promote protein synthesis
• For children 0-6 years = 3 - 4g/kg
• For children > 6 years = 2.5 – 3g/kg
• For adults = 2.5 g/kg

90. Monitoring Nutrition Status
• Weights: Biweekly
• Calorie and Protein Counts: Daily
• Prealbumin: Weekly
• C-reactive protein: Weekly
• Urinary Urea Nitrogen (UUN): Weekly

91. Other Ways to Monitor Nutrition
Status
• Weights
• Ask patient or parent
• Is patient eating the same amount that they
eat at home?
• Is patient producing urine?

92. Diets for Burn Patients
PROTEIN!

93. Burn Patients Need a High Kilocalorie, High
Protein Diet.
• Meat
• Eggs
• Beans
• Nuts
• Cheese
• Milk
GOOD SOURCES OF
PROTEIN
NOT SOURCES OF
PROTEIN
• Nshima
• Rice
• Soda
• Water
• Candy
• Chips

94. Supplements
• Multivitamin
• plumpy nut
• Peanut paste
• High in kilocalories and protein
• F100
• Milk based formula
• High in Calories and protein

95. Protein Energy Malnutrition
• Underconsumption of
calories or protein
• Due to
– Primary Malnutrition
• Not enough food
• Poor quality food
– Secondary Malnutrition
• Intestinal parasites
• Poor food intake due to
injury or disease
Kwashiorkor

96. Malnutrition & Wound Healing

97. Nutrition Support Goals For
Malnourished Burn Patients
• Treat/prevent hypoglycemia and
dehydration
• Prevent refeeding syndrome
• Promote protein synthesis
• High kcal, high protein diet
• F100
• De-worm

98. Thank-you!