BURN INJURIES Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.

Burn size 1. Small burns: body s response is localized to the injured area 2. Large or extensive burns: a. consist of 25% or more of the total body surface area (TBSA) b. body s response to injury is systemic c. affect all of the major systems of the body Characteristics 1. Minor Burns a. Partial thickness burns are no greater than 15% of the TBSA in the adult b. Full thickness burns are < 2% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no preexisting medical condition at the time of the burn injury g. No other injury occurred with the burn 2. Moderate Burns a. Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult b. Full thickness burns are 2% to 10% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury g. No other complicated injury occurred with the burn 3. Major Burns a. Partial thickness burns are > 25% of the TBSA in the adult b. Full thickness burns are > 10% of the TBSA c. Burn areas involve the eyes, ears, hands, face, feet, or perineum d. The burn injury was an electrical or inhalation injury e. The client is older than 60 y.o.

The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury g. Burns are accompanied by other injuries Estimating the extent of injury Rule of nine Lund and Browder Method - Modifies percentages for body segments acc. to age - Provides a more accurate estimate of the burn size - Uses a diagram of the body divided into sections, with the representative % of the TBSA for ages throughout the lifespan - Should be reevaluated after initial wound debridement Assessment of Burn Injury TYPES OF BURNS A. Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects B. Chemical Burns: a. Caused by tissue contact with strong alkali, or organic compounds b. Systemic toxicity from cutaneous absorption can occur C. Electrical Burns: a. Caused by heat generated by electrical energy as it passes through the body b. Results in internal tissue damage c. Cutaneous burns cause muscle and soft tissue damage that may be extensive, particularly in high voltage electrical injuries d. Alternating current is more dangerous than direct current because it is associated with CP arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures D. Radiation Burns: caused by exposure to UV light, x-rays, or radioactive source INHALATION INJURIES A. Smoke inhalation injury : results from inhalation of superheated air, steam, toxic fumes, or smoke : Assessment - facial burns - erythema - swelling of oro / nasopharynx - singed nasal hair - stridor, wheezing and dyspnea - flaring nostrils - sooty sputum and cough

f.

- hoarse voice - agitation and anxiety - tachycardia B. Carbon Monoxide Poisoning : CO is colorless, odorless and tasteless gas that has an affinity for Hgb 200 times greater than that of oxygen : O2 molecules are displaced and carbon monoxide reversibly binds to Hgb to form carboxyhemoglobin : can lead to coma and death C. Smoke Poisoning : Caused by inhalation of by-products of combustion : A localized inflammatory reaction occurs, causing a decrease in bronchial ciliary action and a decrease in surfactant : Assessment - mucosal edema in the airways - wheezing on auscultation - after several hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop - ARDS can result D. Direct Thermal Heat Injury : Can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids : Can occur to the upper airways, w/c appear erythematous and edematous, with mucosal blisters and ulcerations : Mucosal edema can lead to upper airway obstruction, esp. during the first 24 to 48 hours : Monitored for airway obstruction, ET intubation if obstruction occurs PATHOPHYSIOLOGY OF BURNS HEMODYNAMIC / SYSTEMIC CHANGES A. Initially hyponatremia and hyperkalemia occur. Followed by hypokalemia as fluid shifts occur and K+ is not replaced. B. The hematocrit level increases as a result of plasma loss; this initial increase falls to below normal at the 3rd to 4th day postburn as a result of the RBC damage and loss at the time of injury. C. Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid, and diuresis of the excess fluid occurs over the next days to weeks.

D. Blood flow to the GIT is diminished, leading to intestinal ileus and GI dysfunction. E. Immune system function is depressed, resulting in immunosuppression and thus increasing the risk of infection and sepsis. F. Pulmonary hypertension can develop, resulting in a decrease in the arterial O2 tension and a decrease in lung compliance. G. Evaporative fluid losses through the burn wound are greater than normal, and the losses continue until complete wound closure occurs H. If the intravascular space is not replenished with IV fluids, hypovolemic shock and ultimately death will occur. I. BURN INTERVENTIONS  Maintain airway  Fluid resuscitation  Relieve pain  Prevent infection  Provide nutrition  Prevent stress ulceration  Provide psychologic support  Prevent contractures MANAGEMENT OF THE BURN INJURY Phases of Management of the Burn Injury FLUID SHIFTING IN BURNS FLUID RESUSCITATION Indications: - Adults with burns involving more than 15% - 20% TBSA - Children with burns involving more than 10-15% TBSA - Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr Successful fluid resuscitation is evidenced by: - Stable vital signs - Palpable peripheral pulse - Adequate urine output - Clear sensorium Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion

If the Hgb and Hct levels decrease or if the urinary output exceeds 50ml/hr, the rate of IV fluid administration may be decreased Generally, a crystalloid (Ringer s lactate) solution is used initially. Colloid is used during the 2nd day (5% albumin, plasmate or hetastarch) PARKLAND FORMULA Example: Patient s weight: 70 kg; % TBSA burn: 80% 1st 24 hours: 4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer s 1st 8 hours = 11,200 ml or 1,400 ml/hour 2nd 16 hours = 11,200 ml or 700 ml/hour 2nd 24 hours: 0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period 0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W = 117 ml colloid/hour + 84 ml D5W/hour PAIN MANAGEMENT y Administer morphine sulfate or meperidine (Demerol), as prescribed, by the IV route y Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring y Avoid administering medication by the oral route, because of the possibility of GI dysfunction y Medicate the client prior to painful procedures NUTRITION y Essential to promote wound healing and prevent infection y Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed y Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition y Provide a diet high in protein, carbohydrates, fats and vitamins ESCHAROTOMY y A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation y Performed for circulatory compromise resulting from circumferential burns y After escharotomy, assess pulses, color, movement, and sensation of affected

y y

extremity and control any bleeding with pressure Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed Apply topical antimicrobial agents as prescribed

FASCIOTOMY y An incision is made, extending through the SQ tissue and fascia y Performed if adequate tissue perfusion does not return after an escharotomy y Performed in OR under GA, after procedure assess same as above WOUND CARE 1. The cleansing, debridement and dressing of the burn wounds 2. Hydrotherapy a. Wounds are cleansed by immersion, showering or spraying b. Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress c. Client should be premedicated prior to the procedure d. Not used for hemodynamically unstable or those with new skin grafts 3. Debridement a. Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing b. May be mechanical, enzymatic or surgical c. Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily TOPICAL ANTIMICROBIAL AGENTS FOR BURNS y Silver sulfadiazine y Most widely used agent and least common incidence of side effects y May cause transient leukopenia that disappears 2-3 days of treatment y Use with either open treatment, light or occlusive dressings y Applied once or twice daily after thorough wound cleansing y Mafenide acetate 10% cream or 5% solution (Sulfamylon) y Painful during and for a while after application

y y y y y y y y y y y

May cause metabolic acidosis, not used if >20% TBSA Cream must be reapplied 12 hours to maintain therapeutic effectiveness Solution concentration is maintained with bulky wet dressings, rewet every 2-4 hours Silver nitrate (0.5% solution) Stains everything including normal skin brown or black Monitor electrolyte balance carefully Other topical dressings Cerium nitrate Povidone iodine Gentamycin Polymixin B Bacitracin ointment

y y y

Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete Biosynthetic and synthetic Visual inspection of wound is possible, as dressings are transparent or translucent Monitor for wound exudate and signs of infection

WOUND CLOSURE y Prevents infection and loss of fluid y Promotes healing y Prevents contractures y Performed on the 5th to 21st day, depending on the extent of the burn AUTOGRAFTING y Permanent wound coverage y Surgical removal of a thin layer of the client s own unburned skin, which is then applied to the excised burn wound y Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence y Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed y Care of the graft site y Care of the donor site TEMPORARY WOUND COVERINGS y Biological y Amnion y Amniotic membranes from human placenta y Dressing is changed every 48 hours y Allograft (Homograft) y Donated human cadaver skin is harvested w/in 24 hrs after death y Monitor for wound exudate and signs of infection y Rejection can occur w/in 24 hours y Xenograft (Heterograft) y Porcine skin is harvested after slaughter and preserved y Rejection can occur w/in 24 72 hours