Burns Linda Copenhaver
Introduction • Incidence of Burns • 450K in U.S. seek medical care annually • Approximately 45K are hospitalized • Which setting do most burn trauma injuries occur? • How many Burn Trauma centers in U.S.?
Types of Burn Injury • Thermal • Chemical • Electrical-what type considered here? Which state has highest incidence of ____ injuries? • Radiation
Thermal Burns( Most Common) • Caused by flame, flash, scald, or contact burns • STOP & DROP • Roll to shut off O2 supply to fire • Flush or immerse in cold water • DO NOT use ICE on deep burns, just localized, superficial burns
Chemical Burns • Remove person from contact with agent • Flush with water continuously • Remove affected clothing if possible • Alkaline agents worse than acid, process keeps going
Electrical burns • Coagulation necrosis • Severity depends on voltage, amount of resistance, time, and current pathways.
Electrical Burn–Back Fig. 25-2 B
Frequently only entry (yellow-white) and exit (blow out) wounds are visible • Current practice: Now refer to contact points vs entry and exit points. • Extensive tissue damage is masked • How can we evaluate “masked tissue damage”???
Electrical Burns (cont) • Patient at risk for arrhythmias due to _____, metabolic acidosis due to _____, and acute tubular necrosis due to ______. • Current can be so strong to fracture long bones and cause respiratory muscles to contract
Cross Section of Skin Fig. 25-3
Depth of Burns Superficial Partial Thickness Burn (1st degree) Epidermis involved Sunburn, UV light, mild radiation, Pink to red Slight edema Mild pain
Depth of Burns • Deep Partial Thickness (2nd) • Epidermis and some of dermis, is painful, red, blisters
Depth of Burns • Deep Partial Thickness (2nd) • Epidermis and Dermis • Very Painful, edema, pale • Moist or dry, but more commonly wet • Blisters
Depth of Burns (cont) • Full Thickness Burns (3rd) • Epidermis, Dermis, and Subcutaneous tissue burned • Nerve endings destroyed • Little or no pain
Depth of Burns (cont) • Full thickness (4th degree) • Involves past the 3 layers down to the bone and/or organs
Rule of Nines Chart; quick & easy Fig. 25-4 B
Lund-Browder Chart; More accurate Fig. 25-4 A
Burn Unit Referral Criteria • Deep Partial Thickness burns > 10% TBSA • Burns that involve the face, hands, feet, genitalia, perineum, or major joints • Full thickness burns in any age group • Electrical burns, including lighting • Inhalation burns requiring intubation • Chemical burns that involve deep and extensive TBSA burned
Medical/Nursing Management of Burns • I. Emergent Phase • Period of time from onset of burns to the beginning of fluid remobilization • Usually lasts 24-48 hours
Emergent Phase (cont) • Also called FLUID ACCUMULATION PHASE • The greatest initial threat to a major burn victim is hypovolemic shock • Let’s do the Patho on p. 479 Lewis…this is a DING DING!
What are the Priorities in this patient??? • Is this patient a candidate for a major burn center?
Nursing Care During Emergent Phase • Impaired Gas Exchange r/t tissue hypoxia secondary to carbon monoxide poisoning • Note: CO poisoning is the MOST immediate cause of death from fire.
Signs & Symptoms of Carbon Monoxide Poisoning • Edema of Airway • Hoarseness • Dysphagia • Stridor • Copius Secretions usually black tinged • Skin will appear cherry red
Interventions for CO Poisoning: • Assess for S&S CO poisoning (mild to severe) • Humidified O2 100% via face mask • High Fowler’s Position • TCDB q 1 hour • Intubation & Ventilation • Bronchodilators for bronchospasm • One other thing…..does anyone know???
Nursing Care during Emergent Phase (cont) • Impaired Gas Exchange r/t mucosal edema throughout respiratory tract secondary to smoke inhalation, hot air, chemical gases
Interventions: • Early intubation to prevent trach placement • Ventilation • Humidified O2 100% • ABG’s • Bronchodilators
Questions to Ask Burn Victims • Were you in an enclosed space? • Were you standing up? • Was it a flame and chemical fire? • Are you having difficulty breathing?
What are your #1 priorities in this patient? Patient #1 Patient #2
Emergent Phase (cont) • Ineffective Breathing pattern r/t constriction of chest/trachea secondary to the effects of full thickness burns. • Assess for signs of constriction • Escharotomies with circumferential burns of chest
Escharotomy of chest and arm • What is the pathophysiology here?
Emergent Phase (cont) • Fluid Volume Deficit (intravascular) r/t massive fluid shift to interstitial spaces • Assess fluid needs: • Brooke Formula • Evans Formula
Parkland Baxter Formula • Most widely used • Formula • LR 4ml X kg body weight X TBSA % burned • ½ total amount given 1st 8 hours • ¼ total amount given next 8 hours • ¼ total amount given next 8 hours
Okay Nurses Let’s Calculate • What would the fluid replacement be for a patient who weighed 60kg and had 30% TBSA burned??? • 1st 8 hours= _____ or ____ml/hr • 2nd 8 hours= _____ or _____ml/hr • 3rd 8 hours= ______ or _____ml/hr
Crystalloids used such as LR, 0.9NS, D5NS • Colloids (albumin, dextran, FFP) used to expand plasma. • Colloids not given until after capillary permeability decreases and returns to normal…..WHY?
Insert foley catheter to monitor output. What should urine output be in an adult??? • Frequent vital signs • SBP>100 • Pulse<100 • RR 16-20
Emergent Phase (cont) • Monitor Electrolytes and Hematocrit; tells you about fluid shift. • What should Hct be doing as time progresses???
Emergent Phase (cont) • Potential for Infection r/t loss of skin and micro invasion • Meticulous hand washing • Sterile technique during dressing changes & wound care • Hair near burned areas shaved
Potential for Infection r/t loss of skin and micro invasion (cont) • Blisters popped or not??? • Tetanus Toxoid I.M. given to all major burn victims to fight anaerobic contamination of burn wound
Hydrotherapy in cart (water is heated to approximately 104 degrees) • < 30 minutes to prevent _____
Hydrotherapy Cart • What does hydrotherapy accomplish?
Wound Care • Open Method • Apply topical chemotherapy
Topical Meds/Antimicrobials • Silvadene cream • Silver Nitrate or silver impregnated dressings such as Silverlon or Acticoat • Sulfamylon cream
Wound Care (cont) • Closed Method • Apply topical chemo and wrap with gauze, fluffs, kerlix • Assess for constriction; circulation checks
Emergent Phase (cont) • Elevate burned arms on pillows • Give pain meds 30 minutes prior to treatments • Wrap distal to proximal
Emergent Phase (cont) • Alteration in body temp (hypothermia) r/t loss of skin • Set thermostats at warm temp in room (~85 degrees) • Maintain body temp above 37 (98.6) degrees C; patient outcome on POC: • Patient will maintain body temp of 38 • (100.4)
Emergent Phase (cont) • Potential for injury r/t effects of stress response: • Stress diabetes What is the patho here??? • Curling’s ulcer (associated with burn trauma patients) • Gastroduodenal ulcer caused by increased gastric acid secretion
So which meds would nurse anticipate in the POC? Sliding scale and routine insulin sc H2 blockers for GI ulcer prevention: Pepcid, Protonix, Zantac