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BURN INJURIES AND IT’S
MANAGEMENT
PREPARED BY
NEHA KEWAT
TUTOR
LEARNING OBJECTIVES
 Introduction
 Definition of burn
 Types / causes of burn
 Degree of burn
 Extent of body surface area injured
 Pathophysiology
 Management of burn injuries
INTRODUCTION :-
Burn is the type of injury that is caused by
excess heat ,flame ,radiations, chemical or
electricity . Burn injuries occurs when heat
energy transfer to skin and damage the
layers , muscles and tissue of the skin.
Young ,children and older adults continue to
have increased morbidity and mortality
when compared to other age group which
similar injuries and present a challenge for
the burn team.
DEFINITION:-
BURN :-
Tissue injury caused by application of thermal
energy in any form to the body surface is termed as
burn.
Or
Cell destruction of the layers of the skin and the
resultant depletion of fluid and electrolytes.
TYPES /CAUSES
OF BURN:-
• Thermal
• Scaled
• Flame
• Radiation
• Chemical burn
• Electrical burn
CHARACTERISTICS OF BURN
ACCORDING TO DEPTH:-
Burn 4th degree
EXTENT OF BODY SURFACE AREA
INJURED:-
Rule of nine:-
LUND AND BROWDER METHOD:-
 Palmer methods:-
in patients with scattered
burns, the palmer method may be used to
estimate the extent of the burns . the size
of the patients hand , including the fingers
is approximately 1% of the patient TBSA .
PATHOPHYSIOLOGY:-
Heat causes coagulation necrosis of skin
and subcutaneous tissue.
Release of vasoactive peptides
Altered capillary permeability
Loss of fluid severe hypovolemia
Decrease cardiac output decreased myocardial
function
decreased renal blood oliguria
flow (renal failure)
Altered pulmonary resistance causing pulmonary edema
infection
systemic inflammatory response syndrome (SIRS)
Multiorgan dysfunction syndrome (MODS)
PATHOPHYSIOLOGICAL CHANGES
WITH SEVERE BURNS:-
BODY SYSTEM PATHOLOGICAL CHANGES
Cardiovascular Cardiac depression, edema ,
hypovolemia
pulmonary Vasoconstriction, edema
Gastrointestinal Impaired motility and absorption,
vasoconstriction , loss of mucosal
barrier function with bacterial
translocation ,increased pH
kidney vasoconstriction
others Anemia ,immunodepression
MANAGEMENT OF BURN INJURY:-
Burn care is typically categorised into 3
phases of care :-
Emergent /resuscitative phase
• On the scene care
• Medical management
• Nursing management
Acute /intermediate
rehabilitation
PRE HOSPITAL MANAGEMENT:-
• Rescuer to avoid injuring
yourself
• Remove patient from
source of injury
• Stop burn process
• Burning clothing ;jewelary
,watches , belt to be
removed
• Pour ample water on burnt
area
• CHEMICAL BURN:
• Remove saturated clothing
• Brush skin if agent is powder
• Irrigation with water
• ELECTRICAL BURN:
• Turn of the current
• Use non- conductor items to separate from sourcecooling
of injured area within 1 min helps minimize the depth of
injury
• To not break blisters
• Prevent contamination : wrap burn part in clean dry
sheet/cloth
• Assess life threatening injuries
EMERGENT/RESUSCITATIVE
PHASE
ON-THE-SCENE CARE:-The first step in management
is to remove the patient from the source of injury
and stop the burning process while preventing
injury to rescuer. Rescue worker priorities include
establishing an airway, supplying oxygen, inserting
atleast one large bore IV line , and converting the
wound.
An immediate primary survey of the patient is carried
out to assess the ABCDE
A – Airway
B - Breathing
C - Circulatory and cardiac status
D - Disability
E - saintaing warm environment
Cont.……
The secondary survey focuses on –
Obtaining a history
The completion of the total body system
assessment (TBSA)
Initial fluid resuscitation
Provision of psychosocial support of the
conscious patient.
•MEDICAL MANAGEMENT:-
Initial priorities in the emergency department remain
airway , breathing and circulation.
 For mild pulmonary injury , 100% humidified
oxygen is administered and the patient is
encourage to cough so that secretions can be
expectorated or removed by suctioning .
 For more severe situation of cough , administer
bronchodilator and mucolytics agent.
 Once urgent respiratory need are appropriately
addressed , fluid resuscitation is initiated in burns
greater than 20% TBSA .
FLUID RESUSCITATION:-
Parkland formula
• Fluid of choice
• Lactate Ringer’s (RL)
• Normal saline
• 4ml *%of burn * weight(kg) in 24 hours
• first half of total volume given in the first 8 hours
• Remaining half of total volume given over following 16 hours
• Next 24hrs
• Total volume half of first day
• Colloids (0.5ml/kg/%)
• 5%glucose to make up the rest
Brooke formula (modified)
• 2ml *% of burn * weight (Kg) in 24 hrs
• first half of total volume given in the first 8 hrs
• Remaining half of total volume given over following 16
hrs
• Next 24hrs
• Total volume half of first day
• Colloids(0.3 – 0.5ml/kg/%)
Evan’s formula
• Requirement for first 24hrs
• Colloids: 1ml/kg/%burn
• Saline :1ml/kg/%burn
• D5 :- 2000ml
• Requirement for second 24hrs
• Half of first 24hrs
Assessment of adequacy of fluid
resuscitation:-
• Monitor
• Urinary output
• Daily weight
• Vital signs
• Level of conciousness
ACUTE/INTERMEDIATE PHASE
The acute phase of burn care follows the emergent resuscitative
phase and begins 48 to 72hrs after the burn injury.
During this phase, attention is directed towards continued
assessment and maintenance of respiratory and circulatory
status ,fluid and electrolyte balance ,and GI and kidney function.
This phase include:-
• Infection prevention
• Burn wound care
• Pain management
• modulation of hypermetabolism
• Early positioning /mobility are priority
INFECTION PREVENTION
A multiple – strategies approach is crucial in prevention and
control of wound infection. such strategies includes:-
 The use of barrier techniques eg. Gowns ,gloves, eye protection
, and mask.
 Environmental cleaning with periodic cultures of patient care
equipment.
 Application of appropriate topical antimicrobial agents
 Early excision and closure of the burn wound
 Appropriate use of systemic antibiotic and antifungal
agents .
WOUND CLEANING
Proper management of burn wounds is required to prevent
wound deterioration .
Gentle cleaning with mild soap ,water and a wash cloth can
prevent infection by decreasing bacteria and debris on the
wound surface
Goals :-
• The goal of wound care is debridement of nonvisible
tissue.
• Removal of previously applied topical agent and
• Application of new topical agent
TOPICAL ANTIBACTERIAL THERAPY
The goal of topical therapy is to provide a dressing with the following
characteristics :-
• Is effective against gram positive and gram negative
organisms and fungi
• Penetrates the eschar but it not systematically toxic
• Is cost effective , available, and acceptable to the patient .
• Is easy to apply and remove and decrease the frequency of
dressing changes, decrease pain and minimizes nursing
time
Specific agents :- 1.silver salfadiazine 1% water soluble
cream.
2.mafenide acetate 5% to 10 % hydrophilic
based cream.
3.silver nitrate 0.5% aqueous solution
WOUND DRESSING
After the ordered topical agent are applied , the wound is covered
with several layer of dressing are:-
 Lighter dressing is used over joint to allow for mobility .
 Circumferential dressing should always be applied distally to
proximally in order to promote return of excess fluid to the
central circulation.
 Occlusive dressing gauze and a topical antimicrobial agent
may be used over areas with new skin grafts to protect the new
graft and promote an optimal condition for its adherence to the
recipient site.
WOUND DEBRIDEMENT
The goal of debridement (the removal of devitalized tissue)are:
• Removal of devitalized tissue
• Removal of tissue contaminated by bacteria and foreign
bodies , thereby protecting the patient from invasion of
bacteria.
Types of debridement:-
1. Natural
2. Mechanical
3. Chemical
4. Surgical
1. NATURAL DEBRIDEMENT
Natural debridement ,the devitalized tissue
separates from the underline valuable
tissue spontaneously bacteria present at
the inter face of the burned tissue and the
viable tissue gradually liquify of the
collagen that hold the eschar in place.
2. MECHANICAL DEBRIDEMENT
Mechanical debridement involve the use of
surgical tool to separate and remove the
eschar .
Dressing changes and wound cleaning and
the removal of wound debris
Wet to dry dressing are not advocated in
burn care because of the chances
removing viable cell along with necrotic
tissue.
3.CHEMICAL DEBRIDEMENT
Topical enzymatic agents are available to promote
debridement of burn wound because such
agents usually do not have antimicrobial
properties ,they may be used together with
topical antibacterial therapy to protect the
patients from bacterial invasion.
4.SURGICAL DEBRIDEMENT
Surgical debridement is carried out before the natural
separation of eschar is allowed to occur.
The operative procedure involve either excision of the
full thickness of the skin down to the fascia or
shaving of the burned skin layers gradually down to
freely bleeding ,viable tissue.
WOUND GRAFTING
Grafting permits earlier functional ability and reduces wound
contacture (shrinkage of burn scar through collagen maturation
)
If wound are deep or extensive, spontaneous re-epithelization is
not possible.
Types
 Autografts
 Homograft and xenografts
 Biosynthetic and synthetic dressings
Autografts are the ideal means of covering burn
wounds because the grafts are the patients own
skin and therefore are not rejected by the patients
immune system.
Homografts are skin obtained from recently deceased
or living humans other then the patients .
Xenografts consist of skin taken from animals
(usually pig)
Biosynthetic and synthetic dressing , which may
eventually replace biologic dressings as
temporary wound covering . One widely used
synthetic dressing is Biobrane, a dual layer
dressing of nylon and silicon .
Biobrane protect the wound from fluid loss and
bacterial invasion .it can remain it place until
spontaneous re-epithelization and wound healing
occur . it can also be laid on top to close the
interstices.
PAIN MANAGEMENT
A burn injury considered one of the most painful
types of truama that a patient can experience.
To manage the pain follows are:-
 Pharmacological treatment includes:-
• Opioids
• Nonsteroidal anti-inflammatory drugs
• Anxiolytics
• Anesthetic agent
• Benzodiazepines
1. Thermal Burn Medication :-
 Topical Antibiotics :- Topical antibiotics are used to prevent infections
and bacteria growth. Eg. Neosporine, silvadene.
 Analgesics :- Analgesics are used for pain control and to ensure that
the patients is as comfortable as possible. Eg. Morphine sulphate,
vicoding and demerol.
 Nonsteroidal Anti inflammatory agents :- Ibuprofen is usually used
during the initial therapy. Other options such as Naproxen, Ansaid,
and Anaprox may be prescribed.
2. Chemical burn medication :-
 Analgesics:- morphine and acetaminophen are prescribed for pain
management and may be used for sedation. This is usually beneficial
for patients who have sustained injuries to their eyes.
 Nonsteroidal anti inflammatory agents:- advil motrin ansaid,
Naprosyn and Anaprox.
 Non pharmacological treatment includes:-
• Relaxation techniques
• Music therapy
• hypnosis
• Distraction
• Therapeutic touch
• Humors
• Virtual reality technique
• Guided imaginary
MODULATION OF HYPERMETABOLISM
Burn injuries produce profound metabolic abnormalities fueled by
the exaggerated stress response to injury.
Hypermetabolism can affect the morbidity and mortality by
increasing the risk of infection and slowing the healing rate .
In addition to the promotion of burn wound healing, early enteral
nutrition is advocated to ameliorate the hypermetabolic
response and prevent ileus and stress ulcerations.
Nutrition should be provided upon arrival to the burn center and
may require placement of a feeding tube.
Parenteral nutrition is associated with many complications and
should only be provided with intolerance to enteral feeding or
prolonged ileus.
Insulin therapy in patients with burns is needed to treat the
hyperglycemia that occurs from accelarated glucogenesis and
is beneficial in musle protein synthesis.
NURSING MANAGEMENT
 Restoring normal fluid balance
 Preventing infection
 Modulating hypermetabolism
 Promoting skin integrity
 Relieving pain and discomfort
 Promoting physical mobility
 Strengtheing coping strategies
 Supporting patients and family process
 Monitoring and managing complication
Nursing diagnosis
1. Ineffective airway clearance and impaired gas exchange related
to tracheal oedema or interstitial oedema secondary to inhalation
injury and /or circumsfrential torso burn manifested by hypoxemia
and hypercapnia.
2. Deficient fluid volume secondady to fluid shifts into the
interstitium and evaporative loss of fluids from the injured skin.
3. Ineffective tissue perfusion related to compression and impaired
vascular circulation in the extremities with circumferential burns, as
demonstrated by decreased or absent peripheral pulse.
4.Acute pain related to burn trauma.
5. Risk for infection related to loss of skin, impaired immune
response and invasive therapies.
6. Gastrointestinal bleeding related to stress response.
7. Risk for hypothermia related loss of skin and /or external cooling.
REHABILITATION PHASE
Rehabilitation begins immediately after the burn has occurred and
often extend for years after injury.
Burn rehabilitation is comprehensive and complex and requires a
multidisciplinary approach to optimize the patient physical and
psychosocial recovery related to the injury.
Rehabilitation is a cultivation, restoration and conservation of
human resources. (Whitehouse 1956)
Rehabilitation is a dynamic process through which a person is
assisted to achieve optimal physical, emotional, psychological,
social and vocational potential and to maintain dignity, self
respect and quality of life that is self - fulfilling and satisfying
as possible.
Goals :-
 Return patients to the highest level of function possible
within the context of their injuries.
Occupational and physical therapies are essential to optimize
patients goals and outcome.
Rehabilitation team for burns patients
 Anaesthetist's intecsivists
 Nursing practitioners
 Physiotherapist
 Occupational therapist
 Social worker
 Orthotists pristhetics
 Psychologist
 Dietitians
 Oral health speciality
 Reconstructive surgeon
 Pain management
Pain management
Analgesic drug - baseline pain control
• Paracetamol /non- steroid anti inflammatory drugs,
tramadol, slow - release narcotics
Other management for pain controlling
• TENS (transcutan electric nerve stimulation)
• Distraction
• Aromatherapy
• Relaxation techniques
• Reinforcement and coping strategies
• Virtual reality therapy
ADL management
Movement has to be encouraged from the beginning
• Activities of daily living must be practiced
• Splints might necessary
Edema management
Oedema removal : The only body system that can actively remove
excess fluid and debris from the interstitium is the lymphatic system.
The principles of reduction of oedema should be adhered to in totality
and not just in part:
• Compression - such as coban, oedema gloves
• Movement - rhythmic, pumping
• Elevation or positioning of limbs for gravity assisted flow of
oedema from them
• Maximisation of lymphatic function
Immobilisation
Stopping movement, function and ambulation has its place. It
should be enforced only when there is concomintant injury
to tendon or bone or when tissues have been repaired.
If a body part must be immobilised - to allow skin graft
adherence, for example - then the part should be splinted or
positioned in an anti - deformity position for the minimum
time possible.
Skin reconstruction
• Skin reconstruction is tailored to the depth of burn found
at the time of surgery.
• The application and time frames if reconstruction
techniques utilised will be dependent on attending
surgeon's preference.
• Other factors influencing choice of management include
availability and cost of biotechnological products.
Scar management
Scar management relates to the
physical and aesthetic components as
well as the emotional and psychosocial
implications of scarring.
• Hypertrophic scarring results from
the build up of excess collagen
fibres during wound healing and the
reorientation of those fibres in non -
uniform patterns.
• Keloid scarring differs from
hypertrophic scarring in that it
extends beyond the boundary of the
initial injury. It is more common in
people with pigmented skin than in
white people.
• Contractures scar ia a permanent
tightening of skin that may affect the
underlying muscles and tendons that
limits mobility and possible damage
or degeneration of the nerves.
Physical therapy, pressure and
exercise in many cases aid in
controlling contracture burn scars.
A skin graft or a flap procedure may
be performed.
Phases of rehabilitation :-
 First phase:-it is initial evaluation and resuscitation,
occurs on day 1-3 days and requires an accurate fluid
resuscitation and through evaluation for other injuries
and comorbid conditions.
 Second phase:- it is initial wound excision and
biological closure , includes the maneuver that
changes the natural history of the disease . This is
accomplished typically by by a series of staged
operations that are completed during the first few days
after injury.
 Third phase :- it's a wound closure , involves
replacement of temporary wound covers with a
definitive cover, there is also closure and acute
reconstruction of areas with small surface area.
 Final phase:- it is reconstruction and reintegration
Acute rehabilitation for burn patient :-
1. Performing ROM exercise
2. Splinting and antideformity positioning
3. ADL Training
4. Initial scar management
5. Wound care and dressing
BURNS AND ITS MANAGEMENT.pptx PREPARED BY NEHA KEWAT

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BURNS AND ITS MANAGEMENT.pptx PREPARED BY NEHA KEWAT

  • 1. BURN INJURIES AND IT’S MANAGEMENT PREPARED BY NEHA KEWAT TUTOR
  • 2. LEARNING OBJECTIVES  Introduction  Definition of burn  Types / causes of burn  Degree of burn  Extent of body surface area injured  Pathophysiology  Management of burn injuries
  • 3. INTRODUCTION :- Burn is the type of injury that is caused by excess heat ,flame ,radiations, chemical or electricity . Burn injuries occurs when heat energy transfer to skin and damage the layers , muscles and tissue of the skin. Young ,children and older adults continue to have increased morbidity and mortality when compared to other age group which similar injuries and present a challenge for the burn team.
  • 4. DEFINITION:- BURN :- Tissue injury caused by application of thermal energy in any form to the body surface is termed as burn. Or Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.
  • 5. TYPES /CAUSES OF BURN:- • Thermal • Scaled • Flame • Radiation • Chemical burn • Electrical burn
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  • 10. EXTENT OF BODY SURFACE AREA INJURED:- Rule of nine:-
  • 12.  Palmer methods:- in patients with scattered burns, the palmer method may be used to estimate the extent of the burns . the size of the patients hand , including the fingers is approximately 1% of the patient TBSA .
  • 13. PATHOPHYSIOLOGY:- Heat causes coagulation necrosis of skin and subcutaneous tissue. Release of vasoactive peptides Altered capillary permeability Loss of fluid severe hypovolemia
  • 14. Decrease cardiac output decreased myocardial function decreased renal blood oliguria flow (renal failure) Altered pulmonary resistance causing pulmonary edema infection systemic inflammatory response syndrome (SIRS) Multiorgan dysfunction syndrome (MODS)
  • 15. PATHOPHYSIOLOGICAL CHANGES WITH SEVERE BURNS:- BODY SYSTEM PATHOLOGICAL CHANGES Cardiovascular Cardiac depression, edema , hypovolemia pulmonary Vasoconstriction, edema Gastrointestinal Impaired motility and absorption, vasoconstriction , loss of mucosal barrier function with bacterial translocation ,increased pH kidney vasoconstriction others Anemia ,immunodepression
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  • 25. MANAGEMENT OF BURN INJURY:- Burn care is typically categorised into 3 phases of care :- Emergent /resuscitative phase • On the scene care • Medical management • Nursing management Acute /intermediate rehabilitation
  • 26. PRE HOSPITAL MANAGEMENT:- • Rescuer to avoid injuring yourself • Remove patient from source of injury • Stop burn process • Burning clothing ;jewelary ,watches , belt to be removed • Pour ample water on burnt area
  • 27. • CHEMICAL BURN: • Remove saturated clothing • Brush skin if agent is powder • Irrigation with water • ELECTRICAL BURN: • Turn of the current • Use non- conductor items to separate from sourcecooling of injured area within 1 min helps minimize the depth of injury • To not break blisters • Prevent contamination : wrap burn part in clean dry sheet/cloth • Assess life threatening injuries
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  • 29. EMERGENT/RESUSCITATIVE PHASE ON-THE-SCENE CARE:-The first step in management is to remove the patient from the source of injury and stop the burning process while preventing injury to rescuer. Rescue worker priorities include establishing an airway, supplying oxygen, inserting atleast one large bore IV line , and converting the wound. An immediate primary survey of the patient is carried out to assess the ABCDE A – Airway B - Breathing C - Circulatory and cardiac status D - Disability E - saintaing warm environment
  • 30. Cont.…… The secondary survey focuses on – Obtaining a history The completion of the total body system assessment (TBSA) Initial fluid resuscitation Provision of psychosocial support of the conscious patient.
  • 31. •MEDICAL MANAGEMENT:- Initial priorities in the emergency department remain airway , breathing and circulation.  For mild pulmonary injury , 100% humidified oxygen is administered and the patient is encourage to cough so that secretions can be expectorated or removed by suctioning .  For more severe situation of cough , administer bronchodilator and mucolytics agent.  Once urgent respiratory need are appropriately addressed , fluid resuscitation is initiated in burns greater than 20% TBSA .
  • 32. FLUID RESUSCITATION:- Parkland formula • Fluid of choice • Lactate Ringer’s (RL) • Normal saline • 4ml *%of burn * weight(kg) in 24 hours • first half of total volume given in the first 8 hours • Remaining half of total volume given over following 16 hours • Next 24hrs • Total volume half of first day • Colloids (0.5ml/kg/%) • 5%glucose to make up the rest
  • 33. Brooke formula (modified) • 2ml *% of burn * weight (Kg) in 24 hrs • first half of total volume given in the first 8 hrs • Remaining half of total volume given over following 16 hrs • Next 24hrs • Total volume half of first day • Colloids(0.3 – 0.5ml/kg/%)
  • 34. Evan’s formula • Requirement for first 24hrs • Colloids: 1ml/kg/%burn • Saline :1ml/kg/%burn • D5 :- 2000ml • Requirement for second 24hrs • Half of first 24hrs
  • 35. Assessment of adequacy of fluid resuscitation:- • Monitor • Urinary output • Daily weight • Vital signs • Level of conciousness
  • 36. ACUTE/INTERMEDIATE PHASE The acute phase of burn care follows the emergent resuscitative phase and begins 48 to 72hrs after the burn injury. During this phase, attention is directed towards continued assessment and maintenance of respiratory and circulatory status ,fluid and electrolyte balance ,and GI and kidney function. This phase include:- • Infection prevention • Burn wound care • Pain management • modulation of hypermetabolism • Early positioning /mobility are priority
  • 37. INFECTION PREVENTION A multiple – strategies approach is crucial in prevention and control of wound infection. such strategies includes:-  The use of barrier techniques eg. Gowns ,gloves, eye protection , and mask.  Environmental cleaning with periodic cultures of patient care equipment.  Application of appropriate topical antimicrobial agents  Early excision and closure of the burn wound  Appropriate use of systemic antibiotic and antifungal agents .
  • 38. WOUND CLEANING Proper management of burn wounds is required to prevent wound deterioration . Gentle cleaning with mild soap ,water and a wash cloth can prevent infection by decreasing bacteria and debris on the wound surface Goals :- • The goal of wound care is debridement of nonvisible tissue. • Removal of previously applied topical agent and • Application of new topical agent
  • 39. TOPICAL ANTIBACTERIAL THERAPY The goal of topical therapy is to provide a dressing with the following characteristics :- • Is effective against gram positive and gram negative organisms and fungi • Penetrates the eschar but it not systematically toxic • Is cost effective , available, and acceptable to the patient . • Is easy to apply and remove and decrease the frequency of dressing changes, decrease pain and minimizes nursing time Specific agents :- 1.silver salfadiazine 1% water soluble cream. 2.mafenide acetate 5% to 10 % hydrophilic based cream. 3.silver nitrate 0.5% aqueous solution
  • 40. WOUND DRESSING After the ordered topical agent are applied , the wound is covered with several layer of dressing are:-  Lighter dressing is used over joint to allow for mobility .  Circumferential dressing should always be applied distally to proximally in order to promote return of excess fluid to the central circulation.  Occlusive dressing gauze and a topical antimicrobial agent may be used over areas with new skin grafts to protect the new graft and promote an optimal condition for its adherence to the recipient site.
  • 41. WOUND DEBRIDEMENT The goal of debridement (the removal of devitalized tissue)are: • Removal of devitalized tissue • Removal of tissue contaminated by bacteria and foreign bodies , thereby protecting the patient from invasion of bacteria. Types of debridement:- 1. Natural 2. Mechanical 3. Chemical 4. Surgical
  • 42. 1. NATURAL DEBRIDEMENT Natural debridement ,the devitalized tissue separates from the underline valuable tissue spontaneously bacteria present at the inter face of the burned tissue and the viable tissue gradually liquify of the collagen that hold the eschar in place.
  • 43. 2. MECHANICAL DEBRIDEMENT Mechanical debridement involve the use of surgical tool to separate and remove the eschar . Dressing changes and wound cleaning and the removal of wound debris Wet to dry dressing are not advocated in burn care because of the chances removing viable cell along with necrotic tissue.
  • 44. 3.CHEMICAL DEBRIDEMENT Topical enzymatic agents are available to promote debridement of burn wound because such agents usually do not have antimicrobial properties ,they may be used together with topical antibacterial therapy to protect the patients from bacterial invasion.
  • 45. 4.SURGICAL DEBRIDEMENT Surgical debridement is carried out before the natural separation of eschar is allowed to occur. The operative procedure involve either excision of the full thickness of the skin down to the fascia or shaving of the burned skin layers gradually down to freely bleeding ,viable tissue.
  • 46. WOUND GRAFTING Grafting permits earlier functional ability and reduces wound contacture (shrinkage of burn scar through collagen maturation ) If wound are deep or extensive, spontaneous re-epithelization is not possible. Types  Autografts  Homograft and xenografts  Biosynthetic and synthetic dressings
  • 47. Autografts are the ideal means of covering burn wounds because the grafts are the patients own skin and therefore are not rejected by the patients immune system. Homografts are skin obtained from recently deceased or living humans other then the patients . Xenografts consist of skin taken from animals (usually pig)
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  • 49. Biosynthetic and synthetic dressing , which may eventually replace biologic dressings as temporary wound covering . One widely used synthetic dressing is Biobrane, a dual layer dressing of nylon and silicon . Biobrane protect the wound from fluid loss and bacterial invasion .it can remain it place until spontaneous re-epithelization and wound healing occur . it can also be laid on top to close the interstices.
  • 50. PAIN MANAGEMENT A burn injury considered one of the most painful types of truama that a patient can experience. To manage the pain follows are:-  Pharmacological treatment includes:- • Opioids • Nonsteroidal anti-inflammatory drugs • Anxiolytics • Anesthetic agent • Benzodiazepines
  • 51. 1. Thermal Burn Medication :-  Topical Antibiotics :- Topical antibiotics are used to prevent infections and bacteria growth. Eg. Neosporine, silvadene.  Analgesics :- Analgesics are used for pain control and to ensure that the patients is as comfortable as possible. Eg. Morphine sulphate, vicoding and demerol.  Nonsteroidal Anti inflammatory agents :- Ibuprofen is usually used during the initial therapy. Other options such as Naproxen, Ansaid, and Anaprox may be prescribed. 2. Chemical burn medication :-  Analgesics:- morphine and acetaminophen are prescribed for pain management and may be used for sedation. This is usually beneficial for patients who have sustained injuries to their eyes.  Nonsteroidal anti inflammatory agents:- advil motrin ansaid, Naprosyn and Anaprox.
  • 52.  Non pharmacological treatment includes:- • Relaxation techniques • Music therapy • hypnosis • Distraction • Therapeutic touch • Humors • Virtual reality technique • Guided imaginary
  • 53. MODULATION OF HYPERMETABOLISM Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to injury. Hypermetabolism can affect the morbidity and mortality by increasing the risk of infection and slowing the healing rate . In addition to the promotion of burn wound healing, early enteral nutrition is advocated to ameliorate the hypermetabolic response and prevent ileus and stress ulcerations. Nutrition should be provided upon arrival to the burn center and may require placement of a feeding tube. Parenteral nutrition is associated with many complications and should only be provided with intolerance to enteral feeding or prolonged ileus. Insulin therapy in patients with burns is needed to treat the hyperglycemia that occurs from accelarated glucogenesis and is beneficial in musle protein synthesis.
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  • 55. NURSING MANAGEMENT  Restoring normal fluid balance  Preventing infection  Modulating hypermetabolism  Promoting skin integrity  Relieving pain and discomfort  Promoting physical mobility  Strengtheing coping strategies  Supporting patients and family process  Monitoring and managing complication
  • 56. Nursing diagnosis 1. Ineffective airway clearance and impaired gas exchange related to tracheal oedema or interstitial oedema secondary to inhalation injury and /or circumsfrential torso burn manifested by hypoxemia and hypercapnia. 2. Deficient fluid volume secondady to fluid shifts into the interstitium and evaporative loss of fluids from the injured skin. 3. Ineffective tissue perfusion related to compression and impaired vascular circulation in the extremities with circumferential burns, as demonstrated by decreased or absent peripheral pulse. 4.Acute pain related to burn trauma. 5. Risk for infection related to loss of skin, impaired immune response and invasive therapies. 6. Gastrointestinal bleeding related to stress response. 7. Risk for hypothermia related loss of skin and /or external cooling.
  • 57. REHABILITATION PHASE Rehabilitation begins immediately after the burn has occurred and often extend for years after injury. Burn rehabilitation is comprehensive and complex and requires a multidisciplinary approach to optimize the patient physical and psychosocial recovery related to the injury. Rehabilitation is a cultivation, restoration and conservation of human resources. (Whitehouse 1956) Rehabilitation is a dynamic process through which a person is assisted to achieve optimal physical, emotional, psychological, social and vocational potential and to maintain dignity, self respect and quality of life that is self - fulfilling and satisfying as possible.
  • 58. Goals :-  Return patients to the highest level of function possible within the context of their injuries. Occupational and physical therapies are essential to optimize patients goals and outcome. Rehabilitation team for burns patients  Anaesthetist's intecsivists  Nursing practitioners  Physiotherapist  Occupational therapist  Social worker  Orthotists pristhetics  Psychologist  Dietitians  Oral health speciality  Reconstructive surgeon  Pain management
  • 59. Pain management Analgesic drug - baseline pain control • Paracetamol /non- steroid anti inflammatory drugs, tramadol, slow - release narcotics Other management for pain controlling • TENS (transcutan electric nerve stimulation) • Distraction • Aromatherapy • Relaxation techniques • Reinforcement and coping strategies • Virtual reality therapy
  • 60. ADL management Movement has to be encouraged from the beginning • Activities of daily living must be practiced • Splints might necessary Edema management Oedema removal : The only body system that can actively remove excess fluid and debris from the interstitium is the lymphatic system. The principles of reduction of oedema should be adhered to in totality and not just in part: • Compression - such as coban, oedema gloves • Movement - rhythmic, pumping • Elevation or positioning of limbs for gravity assisted flow of oedema from them • Maximisation of lymphatic function
  • 61. Immobilisation Stopping movement, function and ambulation has its place. It should be enforced only when there is concomintant injury to tendon or bone or when tissues have been repaired. If a body part must be immobilised - to allow skin graft adherence, for example - then the part should be splinted or positioned in an anti - deformity position for the minimum time possible. Skin reconstruction • Skin reconstruction is tailored to the depth of burn found at the time of surgery. • The application and time frames if reconstruction techniques utilised will be dependent on attending surgeon's preference. • Other factors influencing choice of management include availability and cost of biotechnological products.
  • 62. Scar management Scar management relates to the physical and aesthetic components as well as the emotional and psychosocial implications of scarring. • Hypertrophic scarring results from the build up of excess collagen fibres during wound healing and the reorientation of those fibres in non - uniform patterns. • Keloid scarring differs from hypertrophic scarring in that it extends beyond the boundary of the initial injury. It is more common in people with pigmented skin than in white people. • Contractures scar ia a permanent tightening of skin that may affect the underlying muscles and tendons that limits mobility and possible damage or degeneration of the nerves. Physical therapy, pressure and exercise in many cases aid in controlling contracture burn scars. A skin graft or a flap procedure may be performed.
  • 63. Phases of rehabilitation :-  First phase:-it is initial evaluation and resuscitation, occurs on day 1-3 days and requires an accurate fluid resuscitation and through evaluation for other injuries and comorbid conditions.  Second phase:- it is initial wound excision and biological closure , includes the maneuver that changes the natural history of the disease . This is accomplished typically by by a series of staged operations that are completed during the first few days after injury.
  • 64.  Third phase :- it's a wound closure , involves replacement of temporary wound covers with a definitive cover, there is also closure and acute reconstruction of areas with small surface area.  Final phase:- it is reconstruction and reintegration Acute rehabilitation for burn patient :- 1. Performing ROM exercise 2. Splinting and antideformity positioning 3. ADL Training 4. Initial scar management 5. Wound care and dressing