Burns and its management for nursing students

1. BURNS AND ITS MANAGEMENT
PROF. Dr.PUVANESWARI. K
NHCON
BANAGALORE

2. Anatomy of skin

3. Functions of Skin
 Skin is the largest organ of the body
 Essential for:
- Thermoregulation
- Prevention of fluid loss by evaporation
- Barrier against infection
- Protection against environment
provided by sensory information

4. Burn and Scalds
 Burn
A burn is a type of injury
results from direct contact or
exposure to thermal , electrical,
chemical or radiation source are
termed Burns.
 Scalds
Injuries results from moist heat
are termed as scalds

5. ETIOLOGY
 Thermal burns
 Chemical burns
 Radiation burns
 Electrical burns
 Inhalational injury

6.  Thermal burns – Flame , hot liquid, semi
liquids , residential fires , explosion
 Chemical burns- Acid, alkali or organic
compounds

7.  Radiation burns – Radiation therapy , radioactive
substances and x-ray, Sun burn ( solar radiation),
 Electrical burns
 Inhalational injury – Asphyxiants ( Residential
Fire)

8. PATHOPHYSIOLOGY- Skin
Direct injury to skin devitalises the cells
( 40 O-44OC)
Cellular system Infarction
Sodium Potassium pump fails
Cellular edema

9. 3 Zones of tissue injury
 Zone of Coagulation – Directly damaged
skin is coagulated and fully destroyed (
Inner)
 Zone of stasis- Surrounding tissue exposed
to heat is edematous and has impaired
blood flow ( Middle zone)
 Zone of Hyperemia- It consists of the tissue
that is inflammed and vasodilated ( Outer)

10. Pathophysiology - Fluid shifts
Following burn injury
Release of vasoactive substances ( histamine, kinins
catacholamines ,serotonin , leukotrins, prostaglandins)
Alters cell permeability( Na enters the cell and K exits the
cell)
Increases intercellualr and interstitial fluid further deplets
intra vascular fluid volume
Hypovolemia

11. Hypovolemia
Vital organs gets lack of blood supply
Decreased Blood supply to mesentric bed →
Intestitial ileus → Curling’s ulcer
Decreased renal blood → Oliguria
flow (Renal failure)
Toxins released from the wound along with sepsis
causes acute tubular necrosis.
Myoglobin released from muscles (in case of electric
injury or often from Eschar) is most injurious to
kidneys.

12. Pulmonary system
Inhalational injury by exposure to asphyxiants
Oxygen molecule are displaced and combined
of Hb to form carboxy haemoglobin ( CO
have 200 times more affinity towards Hb than
O2)
Injury to URT Leads to Erythema, ulceration ,
edema etc
 Altered pulmonary resistance causing
pulmonary edema

13. Myo cardial depression
Liberation of Myocardial depressant factor
Decreased cardiac → Decreased
myocardial
output function

14. Impaired skin integrity
 Disruption of skin nerve endings , sweat glands
and hair follicles
 Barrier function of skin is last
Immuno supression
 Decreased Lymphocyte activity , Decrease in
immunoglobulin production ,suppression of
complement activity and an alteration of neutrophil
and macrophages function
 Increase risk of infection

15. Metabolic
 Hyper metabolic rate (BMR).
 Negative nitrogen balance.
 Electrolyte imbalance.
 Deficiencies of vitamins and essential
elements.
 Metabolic acidosis due to hypoxia and
lactic

17. Psychological response
 Can vary from fear to psychosis
 In addition separation from family
during admission in hospital

19. Infections
 Streptococci (Beta haemolytic—most
common)
 Pseudomonas
 Staphylococci
 Other gram-negative organisms
 Candida albicans

20. Classification of burn injury
 Partial thickness burns
Ist degree
IInd degree
IIIrd degree
 Full thickness burns
 IVth degree

21. Classification According to Depth
 First-degree partial thickness Burns (mild): ( Superficial )
epidermis is involved . Eg . Sun burn
 Pain, erythema & slight swelling, no blisters
 Tissue damage usually minimal, no scarring
 Pain resolves in 48-72 hours
 Second degree partial thickness Burns: It appears wet .
It involves entire epidermis & variable dermis
 Vesicles and blisters characteristic
 Extremely painful due to exposed nerve endings
 Heal in 7-14 days if without infection

22.  3rd degrees Partial thickness burns
 Damage through out the dermis
 Dry and may be brown , black or ivory
 Denaturated skin is called Eschar
 Burn tissue is not painful as a result of damage to the
nerve endings
4th degree full thickness burns
 Involves skin , fat muscles and sometimes bone also
 Appears tarred or may be completely burned away
 Amputation is common with this injury

23. Clinical manifestations and
Assessment
 Blisters over the skin
 Oliguria ( < 0.5 ml/kg/1hour).
 Decreased GI motility
 Absence of bowel sounds , stool,
flatus
Nausea
Vomiting
Abdominal distension )

24.  Alteration in respiration ( Tachypnea,
stridor , dyspnea, cyanosis)
 Decreased cerebral tissue oxygenation
manifestations
 Thermal burns to URT- Edematous ,
erythematous , mucosal blisters
,ulceration , flarring of nostrils, stinged
nasal hairs)
 Carbonaceous sputum

25.  Decreased cardiac output – Hypo
tension , weak peripheral pulse , oliguria
Pain response –
 Background pain- Even during rest ,
Position changes , movement of
abdominal wall ,chest etc
 Procedural pain – Experienced during
Therapeutic procedures

26.  Altered level of consciousness
 Headache , dizziness, memory loss ,
confusion
 Disorientation , visual changes
 Hypernatremia and hyperkalemia
 Elevated Hematocrit in Ist 24 Hours
 Elevated BUN

27. Management
 Emergency care phase
 Acute phase
 Rehabilitation phase

28. Emergency care phase
 Time between the initial injury and 36-48
hours after injury
 Fluid resuscitation
 Airway , Breathing is a major concern
Assessment is important
Burn severity
Burn depth
Burn Size
Burn Location

29. Burn severity (American Burn
Association
 Major burn injury – 20-25% TBSA or
burns involves the face , eyes ,ears
,hands , feet and perineum resulting
functional cosmetic disability
 Moderate Burn injury – 15-20 %TBSA
 Minor Burn injury – 10-15% TBSA

30. Burn depth
 Superficial burns – No much
complication
 Deep Burn- Produces severe injury. It
causes systemic effects , contractures
etc
Size of the Burn – Determined by
Rule of Nine

32. Burn location
 Burns to head and chest- Pulmonary
complication, facial burns, corneal abrasion
circumferential burns ( chest)
 Burns in Ears – Auricular chondritis or
infection
 Burns of hands and joints – Vocational
disability , circumferential burns
 Burns to perineum – Infection

33. Emergency Phase
Goals
 Maintain and protect airway
 Restore the hemodynamic stability
 Minimizes the pain
 Wound care

34. 1.Maintain and protect airway
 Assess the oropharynx for any clinical
manifestations
 Administer 100% oxygen if inhalational
injury ( Tight fitting mask continuous until
CarboxicHb level is reduced to 15%)

35. 2.Restore Haemodynamic
stability
 Start IV line ( Subclavian, Internal and
external Jugular or femoral vein)
 Fluid resuscitation – To restore the
functions of vital organs

36. First 24 hours Second 24 hours
FORMUL
A
Electrolyte Colloid Dextros
e
Electrolyte Colloid Dextrose
Evans NS
1 ml/kg/% of
burn
1
ml/kg/%
of burn
2000ml ½ of the Ist
24 hours
½ of the
Ist 24
hours
2000ml
Brooke RL 1.5ml/kg/%
of burn
.5ml/kg/
% of
burn
2000ml ½ - ¾ of
the
Ist 24
hour
½ - ¾ of
the Ist 24
hours
2000ml
Modified
brooke
RL 2 ml/kg/%
of burn
None None None 0.3-
.0.5ml/kg/
% of burn
Titrate to
maintain
urine
output
Parkland RL 4ml/kg/% of
burn
None None None 0.3-
.0.5ml/kg/
% of burn
Hypertoni
c saline
Fluid
containing
250meq of Na
to maintain
None None

37. 3.Minimising pain
 IV narcotics
 NSAID
 TT
 Clean the wound , Follow aseptic
techniques
 Cover the wound with with sterile towel
4. Wound care

38. Acute phase ( 48-72 hours)
1. Prevention of infection
 Auto contamination should be avoided
 Follow aseptic techniques
 PPE
 Antibiotics

39. 2.Metabolic support
 Aggressive nutritional Support ( energy,
healing ,prevention of harmful effects of
catabolism )
 Oral intake , enteral tube feeding,
peripheral parenteral nutrition (TPN)

40. 3.Minimizes the pain
 Narcotics
 NSAID
 Inhalational analgesics
 Patient controlled analgesics
 Other modalities – Hypnosis, Play
therapy, Bio feed back, Music therapy
etc

41. 4.Wound care
 Daily wound care involves cleansing ,
debridement , ESCHAR -removal of
dead tissue and dressing of the wound
 1% of silver sulphadioxide , Mafenide
acetate are used.
 Grafting (Allograft, Autograft,Xenograft )

42. 5.Psychological care
 Provide psychological support
 Anticipatory guidance and
encouragement
 Coping strategies

43. Management -Rehabilitation
 Minimizes functional loss
 Early wound excision
 Exercise – Ambulation , active exercises
 Splinting and positioning ( all three
phases)-
 Static and dynamic splinting
Control of scar
 Hypertrophic scarring results from
deposition of collagen
 Use Custom fit anti burn support

44. Complications
 Shock
 Pulmonary complications due to
inhalational injury
 ARF
 Infection and sepsis
 Curling’s ulcer
 Extensive scarring and disability
 Psychological trauma
 Cancer ( Marjolins ulcer – 21 years )

45. Nurses role/ Goals in Burns
rehabilitation
 Promoting activity tolerance
 Improving body image and self concept
 Monitoring and managing potential
complications
 Prevent contractures of the shoulders and hips
and also to maintain their ranges.
 Educate care givers on passive stretches.
 Improve functional activities such as walking,
sit to stand, rolling in bed etc.

46. Purposes of medico legal
cases- Burns
 To ensure that the burn patient understand the
nature of treatment including the potential
complications
 To indicate that the burns patients decision
was made without pressure.
 To protect the burn patient against
unauthorised procedures
 To protect the hospital staff / hospital informed
consent to be taken ..

47.  Circumstances requiring a permit –
Get consent to do all procedures
including admission
 Consent issues – Burn patient or the
responsible adult relative of the patient
signs the consent form of the hospital