Initial Care of Burns

1. Initial Care of Burns Connie Handel RN University of Wisconsin Hospital and Clinics

2. Objectives • Discover who’s getting burned? • Discuss Burn pathophysiology. • Understand why some treatments are better than others. • Review treatment options.

3. Skin Structures • Epidermis – outermost layer of keratinized cells • Dermis – contains skin appendages, vascular supply and nerve endings • Subcutaneous Tissue

4. Barrier to infection Protection from external injury Temperature control Control of body fluids Sensory organ Determines identity Functions of the Skin

6. What is a burn? • Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

7. Burn Depth

8. First Degree Burns • Epidermis affected only • Red or pink, dry, painful, blanches to touch • Epidermis is intact • Spontaneous healing within 7 days. Outer injured epithelial cells peel • Seldom clinically significant

9. Superficial Partial Thickness • Entire epidermis & portion of dermis (Papillary dermis) • Homogenous pink • Painful • Blisters • Blanches • Hair usually intact • Does not scar, may pigment differently

10. Sup 2nd degree

11. Deep partial thickness • Reticular dermis • Mottled red and white • Not painful to pinprick or pressure • Does not blanch • Heals > 3 weeks • Usually scars • Need to excise and graft

12. Deep Partial Thickness x

13. Deep dermal

14. Full Thickness: 3rd degree • May go into fat or deeper • Red, white, brown, black • Inelastic and leathery • painless or numb • Heals only from the periphery • Always excise and graft

15. Full-thickness

16. Etiology

17. Types of burns

18. Circumstances of injury

19. Where do burns occur

20. Admissions by age

21. % of admissions vs. burn size

22. Inhalation Injury Exposure to heat and toxic products of combustion • 50% of fire deaths are related to inhalation injuries • Asphyxia/Carbon Monoxide displacement of oxygen

23. Inhalation injury diagnosis • Closed-space fire • Face burns

24. Terminology • Inhalation injury “nonspecific” • Thermal injury • Upper airway • Heat and toxic fumes • Local chemical irritation • Throughout airway • Primarily toxic fumes • Systemic toxicity • CO

25. Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea Signs and symptoms

26. Pathophysiology • The main factor responsible for mortality in thermally injured patients • Carbon monoxide the most common toxin • 200 times greater affinity • Competitive inhibition with cytochrome P-450

28. Poison management = CO • 500 unintentional deaths each year • Persistent Neurologic Sequelae • May improve over time • Delayed Neurologic Sequelae • Relapse later

29. Carbon Monoxide Poisoning • 10% COHb – asymptomatic, seen most often in smokers, truck drivers, traffic police • 20% COHb - headache, nausea, vomiting, loss of dexterity • 30% COHb - confusion & lethargy, possible ECG changes • 40-60% COHb - coma • 60% + - usually fatal

30. Poison management = CO • Treatment • CO level means nothing to predict outcome • Length of hypoxia is the determining factor • Oxygen • HBO • No studies show benefit in treatment

31. Reduction of CO

32. Determine Burn Severity • % BSA involved • Depth of injury • Age • Associated/pre-existing disease or illness • Burns to face, hands, genitalia xx

33. Difficulties with accurate initial assessment of burn size & depth • Soot, blisters, adherent clothing or debris obscure wound • Burns are dynamic…Progression is always a risk

34. Burn Extent Total Body Surface Area (TBSA)? • Rule of nines • Lund and Browder chart • Patients palm = about 1% TBSA

35. Extent of Burn :“Rule of Nines” • Adult anatomical areas = 9% BSA (or multiple) • Not accurate for infants or children due to larger BSA of head & smaller BSA legs. • Burn diagrams illustrate adult – child differences

36. Lund & Browder Chart

37. Extent of Burns Patient’s palmar surface (hand + fingers) = 1% TBSA

38. Burn Depth Factors • Temperature • Duration of contact • Dermal thickness • Blood supply • Special Consideration: Very young and very old have thinner skin

39. Burns begin at 44 degrees C • 6 hours for burns to occur at 111 degrees F (44 C) • 1 second of burns to occur at 140 degrees F (60 C)

40. Time For Full Thickness Burns To Occur In Scalds • 5 seconds in water @ 140 F (60 C) • 30 seconds in water @ 130 F (55 C) • 5 minutes in water @ 120 F (49 C)

41. Pain control

42. Ice Pack-----DO NOT USE EVER • DOES NOT • Reverse temperature • Inhibit destruction • Prevent edema • DOES • Delay edema • Reduce pain

43. Non-medication methods • Cover burns with plastic wrap • Wet dressings will stick and cause more pain • Other burn dressings are expensive and not necessary • Quik Clot is expensive and will not provide any patient benefit

44. Medication • Medications • Opioids • Narcotics • Pain medications • IV Analgesia

45. Resuscitation

46. IV access • < 15% TBSA – oral resuscitation • 15 – 40% TBSA – one large bore IV • > 40% -- two large bore IV’s • IV’s should be in the upper extremities • Suture IV’s started through burns

47. Field resuscitation • Start IV with LR, through burn OK • < 6 years = 125mL/hr • 6-13 years = 250mL/hr • >13 years = 500mL/hr

48. Contact

49. Contact Burn

50. Scald Burn