FAHC Burn Care Manual: Complied By: Peter Igneri, PA-C, Jennifer Gratton, RN

FAHC Burn Care Manual
Complied by: Peter Igneri, PA-C, Jennifer Gratton, RN
BURN CARE MANUAL FAHC
FAHC BURN CARE MANUAL 2008
Table of Contents
INTRODUCTION ................................................................................ 4 INITIAL ASSESMENT........................................................................ 5 INHALATION INJURY ....................................................................... 8 ESTIMATING TOTAL BODY SURFACE AREA OF BURNS.......... 12 TYPES OF BURNS AND TREATMENTS........................................ 15 DRESSING CHANGES.................................................................... 22 DRESSING TYPES FOR BURNS.................................................... 25 TOPICALS FOR BURN DRESSINGS ............................................. 29 EXCISION AND BURN GRAFTING ................................................ 31 MANAGEMENT OF SPECIFIC BURN AREAS ............................... 35
CHEST...................................................................................................................... 35 AXILLA.................................................................................................................... 35 NECK AND BREAST.............................................................................................. 36 LOWER EXTREMITIES ......................................................................................... 36 UPPER EXTREMITIES........................................................................................... 37 HANDS..................................................................................................................... 37 BACK ....................................................................................................................... 38 PHASES OF GRAFT MATURATION........................................................................ 39 LONG TERM COMPLICATIONS.............................................................................. 41
BURN NUTRITION........................................................................... 44 BURN NUTRITION - PEDIATRIC .................................................... 50 BURN REHABILITATION................................................................ 53
HYPOTHERMIA AND FROSTBITE................................................. 58

Frostbite protocol .......................................................................................................... 60
PEDIATRIC BURNS: SPECIAL CONSIDERATIONS ..................... 61 PSYCHOSOCIAL ASPECTS OF BURNS ....................................... 64 BURN CARE REMINDERS ............................................................. 65 WEBSITE REFERENCES................................................................ 67 BURN (Dressing change) CART INFORMATION ......................... 68
INTRODUCTION This burn care document was developed by the burn committee as a resource for Fletcher Allen staff that may have questions in regards to caring for the burn patient. Although there are advances in burn treatments most of the documents in this binder remain the standard of care for the patient. As new treatment develops the manual can easily be updated. Thanks to all of the people that researched information for the manual for all there time and effort. Fletcher Allen Burn Committee Jennifer Gratton, RN Trauma Program Supervisor Peter Igneri, PA Trauma Service Lori Camp, RN Trauma Case Manager Jess Langer, RN Care Coordinator Baird 6 Pam Kupiec, RN Baird 6 Marie Zebertavage, RN Baird 6 Tracey Wagner, RN Baird 5 Carole Richards, RN Baird 5 Gail Tuscany, RN SICU Patrick Delaney, RN SICU Patty Crease, RN SICU Gil Helmken, RN ED Ray Scollins, RN FACT Kristen Brewster Occupational Therapy Barb Blokland Occupational Therapy Karyann Bombardier Physical Therapy Julie Jacob, SW Trauma Social Worker
Burn Care
INITIAL ASSESSMENT
Primary Survey A Airway. Secure the airway first. Get history as much as reasonably possible before intubation Soot or singed nasal hairs? B Breathing; High flow Oxygen for all. Escharotomy? - Monitor chest wall excursion in presence of FT torso burns Listen: verify breath sounds Assess rate & depth C Circulation Monitor BP, pulse rate, skin color Establish IV access, Warm IV fluids Monitor peripheral pulses in circumferential burns. D - Disability; Associated Injuries? CO poisoning? Substance abuse? Hypoxia? Pre-existing medical condition E Exposure; Remove all clothing and jewelry Ensure warm environment Clean DRY blankets It is OK to use water to stop the burning process and clean but not at the expense of reducing body core temperature.
Secondary survey Repeat Primary Complete head to toe evaluation Start after resuscitation fully established BURN CARE MANUAL FAHC 5
Complete the HPI What type of burn (flame, chemical, scald) Duration of exposure What time did burn occur? What treatment already provided.(chemical brushed off, water to cool, etc) Did burn occur in house fire/enclosed space (think inhalation injury) Order labs and x rays CBC, BUN, Cr, Lytes Carboxyhemoglobin CXR Blood gas Insert Foley EKG (especially in electrical injury) Special considerations; Abuse patterns o Children, elderly Concomitant trauma o C-spine precautions o Trauma protocols if trauma is majority of injuries Determine TBSA Use Lund Browder chart. Can start with patients palm = 1% of patients BSA A good online program is sagediagram.com. Need patient weight and height and age for this program. Can print out a graphic with parkland calculations. Initiate resuscitation strategy DO NOT need on <15% TBSA Parkland formula o 2-4 ml RL X kg X % BSA burn o in 1st 8 hrs o in 2nd 8 hrs o in 3rd 8 hrs Pediatric parkland o 2-4 ml RL X kg X % BSA burn o in 1st 8 hrs o in 2nd 8 hrs o in 3rd 8 hrs o add maintenance fluid use D5LR 100cc/kg for 10 kg of weight 50 cc/kg next 10 kg of weight 20cc/kg remaining 10 kg after
Pediatric calculation example 23 Kg child with 20% deep burn Resuscitation (Ringers Lactate) 3 ml X 23 Kg X 20% Burn = 1380 mls in 1st 8 hrs post burn = 86 cc/hr Maintenance (D5LR) 1st 10 Kg: 100 cc/kg/24hr = 1,000 cc/24 hr 2nd 10 Kg: 50 cc/kg/24hr = 500 cc/24 hr Remaining 3 Kg: 20cc/kg/24hr = 60 cc/24 hr 1560 cc/24 hr = 65cc/hr
Cleaning & Debridement Whenever possible, clean using mixture of Hibiclens and sterile water (not saline it stings more when mixed with Hibiclens). If picking patient up at OSH, remove wet dressings and place bacitracin and fluffs or Exu-Dry for transport. If transporting out to MGH or other larger Burn center, contact them and find out what they like for dressings on transferred patients. (i.e. MGH typically wants a dry sterile dressing) Assemble team to view at same time to avoid time consuming dressing removal and reapplication. Take picture(s) if possible print color pictures for chart. Involve resident physicians to teach when possible. First cleaning should take place in the ED if possible. Set a plan for the next cleaning/shower time and let other team members know. Use reverse isolation precautions to clean and dbride when TBSA>15% Associated inhalation injury Immunocompromised patient. Dressings/Supplies: There is a burn care cart in the ED that requires a key from PIXIS system. Keep track of supplies in order to replace on cart ASAP. The SICU does not stock burn dressings. If needed for the SICU order burn cart through distribution/transport tracking. Please ensure IBM card used to deal with cost center issues when getting supplies from another unit. Mepilex Ag dressing is available only in CSR as of May 2008. It may be stocked in the patient floors in the future.
INHALATION INJURY
The three injury processes, resulting from smoke exposure, are presented in the order in which peak symptoms occur. Carbon Monoxide Toxicity- peak symptoms immediate Upper Airway Injury with Potential Obstruction peak symptoms can be delayed for an hour or more Lower Airway Injury with Impaired Gas Exchange- peak symptoms can be delayed for hours Carbon Monoxide Toxicity Pathophysiology: Carbon Monoxide binds to the hemoglobin molecule displacing oxygen thereby decreasing the oxygen delivered to tissue. The affinity of CO to hemoglobin is much higher than O2. Risk Factors Any exposure to smoke Any exposure to fumes Diagnosis Pulse oximeter may be completely normal value as it only measures O2 level. A high index of suspicion in any fire victim with a history of smoke exposure A carboxyhemoglobin level exceeding 10% total (Morbidity is related to peak level at scene not the first value obtained) Unexplained metabolic acidosis Hgb Level Carbon Monoxide Intoxication Normal Value Headache, Confusion Disorientation, fatigue, nausea, visual changes Hallucination, combativeness, coma, shock, shock state Cardiopulmonary arrest, Death
CO High Symptoms 0-5 15-20 20-40 40-60 60 or above
*CO Hgb - carboxyhemoglobin
Table 2: Treatment of Carbon Monoxide and Cyanide Toxicity Carbon Monoxide Awake High flow by mask oxygen (Fi02 100%) until carboxyhemoglobin < 10% Obtunded Intubate 100% oxygen via positive pressure ventilation Hyperbaria used if patient not responding to 100% oxygen (specific indications remain undefined) Upper Airway Injury: Pathophysiology: Direct heat injury caused by the inhalation of air heated to a temperature (150 C or higher) ordinarily results in burns to the face, oropharynx, and upper airway (above the vocal cords). Even superheated air is rapidly cooled before reaching the lower respiratory tract because of the tremendous heat-exchanging efficiency of the oropharynx and nasopharynx. Cyanide Metabolic Acidosis Cardiovascular support Sodium nitrite followed by sodium thiosulfate if there is a high likelihood of toxicity (unexplained metabolic acidosis)
Pathophysiology of Airway Injury: The initial response to smoke is usually that caused by intense airways irritation, and airways edema producing increased airways resistance. The late response, typically seen 2 to 5 days after the insult, is the result of the initial mucosal injury leading to mucosal slough, increased secretions, intense airways inflammation and impaired immune function.
The Lung Injury: Lower airway The degree of initial and late injury will, in large part, be related to the status of the pre-injured lung. A lung with any element of reactive airway disease or chronic changes from smoke, for example, will likely react more severely to a smoke exposure than a healthy lung. In addition, the inflammatory response caused by the injury will lead to much of the subsequent damage. Oxidants in smoke and those released by inflammatory cells play a critical role in the airways
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injury. A decrease in lung anti-oxidants is also seen further increasing the degree of injury. The mechanism of the airway and parenchymal injury is complex. The cell toxic agents, present on the particulates lead to a number of pathologic events. First, there is direct mucosal injury, loss of ciliary activity with subsequent impairment of particulate and mucous clearance and later bacterial clearance. Second, there is a marked, early increase in bronchial blood flow, as well as increased bronchial vessel permeability, leading to submucosal edema and vascularengorgement narrowing of the airway lumen. Third, there is tissue destruction due to the above response, as well as a secondary inflammatory response. The result is a slough of mucosa in both large and small airways, and a marked increase in mucous production. Lower Airway Injury: Closely resembles the same signs and symptoms as upper airway, especially during the acute phase of burns.
Signs and Symptoms

Burns of face, mouth or neck Singed nasal /facial hair Red & dry mucosa Edema of tongue or pharynx Chest tightness Hoarseness, wheezing, stridor Cough or dyspnea Profuse secretions, sooty sputum
Inhalation Burns
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ESTIMATING TOTAL BODY SURFACE AREA OF BURNS

Total Body Surface area, TBSA, for burns is calculated based on the partial and full thickness burns (not superficial, first degree burns) It is important to make an initial calculation early on, and follow up with updated estimates in the following days to see the progression/regression of the burns. All Admitted patients to FAHC should have a Lund Browder or Sage diagram placed in the front of the clinical records of the chart. Lund Browder
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It takes into account the age of the patient as it relates to the TBSA. SAGE diagram Another tool to use is the Sage Diagram. This is available via the internet at: www.sagediagram.com This is a free service which permits the user to draw in the areas burned on a diagram, and based on the patients height and weight will provide an estimated total body surface area of burns. This diagram can be printed for charting.
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Following the RULE OF NINES Adults: Each arm is 9%, each leg is 18%, the front of the torso is 18%, the Back is 18%, the head and neck are 9%, and the perineum is 1% Children: Modified due to larger head proportionately: Each arm is 9%, each leg is 14%, Front and back are 18% each, and the Head is 18%
Estimating the size of the Burn as a % of the Total Body Surface (TBSA)
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TYPES OF BURNS AND TREATMENTS

First Degree Burns- superficial burns A first degree burn is confined exclusively to the outer surface and is not considered a significant burn. No skin barrier functions are altered. The most common form is sunburn which heals by itself in less than a week without a scar. Treatment Topical antimicrobial (Bacitracin) applied several times a day
Second Degree Burns- partial thickness burns Second degree burns cause damage to the epidermis and portions of the dermis. Since it does not extend through both layers, it is termed partial thickness. There are a number of depths of a second degree or partial thickness burn which are used to characterize the burn. Superficial Second Degree Involves the entire epidermis and no more than the upper third of the dermis is heat destroyed. Rapid healing occurs in 1-2 weeks, because of the large amount of remaining skin and good blood supply. Scar is uncommon. Initial pain is the MOST SEVERE of any burn, as the nerve endings of the skin are exposed to the air.
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Appearance The micro vessels perfusing this area are injured resulting in the leakage of large amounts of plasma, which in turn lifts off the heatdestroyed epidermis, causing blisters to form. The blisters often increase in size even after the burn. A light pink, wet appearing very painful wound is seen as the blisters are disrupted. ** Frequently, the epidermis does not lift off the dermis for 12 to 24 hours and what initially appears to be first degree is actually a second degree burn.
Treatment Debridement of affected skin to expose underlying wound. Debride blisters that are limiting joint movement. Clean wound and apply antimicrobial ointment such as bacitracin. Excellent alternative is the use of skin substitute which seals the wound and decrease pain. Below is an example of Biobrane application-usually put on in the Emergency Department setting.
Must dbride blisters prior to placing to allow firm adhesion
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Also can apply closed dressing of gauze for absorbency and wrap. This will need to be changed daily.
Healing This type of burn heals in 10-12 days without scarring. There is a low risk of infection.
Mid-Second degree-Mid partial thickness burn In this type of burn, destruction to about half the dermis occurs. Healing is slower due to the fact that there is less remaining dermis and less of a blood supply. Pain can be severe but is usually less intense than the superficial due in part by nerves that are destroyed.
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Appearance The burn surface may have blisters but is redder and less wet.
Treatment Treatment is typically Silvadene cream and occlusive dressing with a closed dressing technique. A temporary skin substitute is also a treatment of choice. Healing This type of burn usually heals in 2 to 4 weeks. The longer the healing time, the more chance of scarring. Deep Second Degree-Deep partial thickness In this type of burn most of the skin is destroyed except a small amount of remaining dermis. The wound looks white or charred indicating dead tissue. Blood flow is compromised and a layer of dead dermis or eschar adheres to the wound surface. Pain is much less as the nerves are actually destroyed by the heat. Usually, it is difficult to distinguish a deep dermal burn from a full thickness burn by visualization. The presence of sensation to touch usually indicates the burn is a deep partial injury.
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Appearance The wound surface may be dry and red in appearance with white areas in the deeper parts. There is marked decrease in blood flow making the wound very prone to conversion to a deeper injury and to infection. Direct contact with flames is a common cause. The appearance of the deep dermal burn changes dramatically over the next several days after burn as the area of dermal necrosis along with surface coagulated protein turns the wound a white to yellow color. This resembles the third degree burn and differentiation sometimes is difficult. The presence of some pain can assist in diagnosis because the pain is usually absent in full thickness injury.
Treatment Wash with antimicrobial soap and water. Apply silvadene closed dressing. Often grafting is needed to speed healing. Monitor for infection. Often converts to full thickness injury.
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Note how fingers are wrapped separately to maintain motion Healing This type of burn may heal in 2-3 months. If it heals scarring is usually severe.
Full thickness burns Both layers of skin are completely destroyed leaving no cells to heal. Any significant burn will require skin grafting. Small burns will heal with scar. Entire destruction of the epidermis and dermis, leaving no residual epidermal cells to repopulate. Appearance A characteristic initial appearance of the avascular burn tissue is a waxy white color. If the burn produces char or extends into fat as with prolonged contact with a flame source, a leathery brown appearance can be seen along with surface coagulation veins. The burn wound is painless and has a coarse non-pliable texture to touch.
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Treatment Wash with antimicrobial soap and water. Apply Silvadene cream with a closed dressing. Grafting is treatment of choice. High risk for infection.
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DRESSING CHANGES
FULL THICKNESS AND DEEP PARTIAL THICKNESS (PRE-GRAFT)
For the Bedside nurse/provider: 1) Gather necessary supplies (order burn cart via transport tracking) 2) Ensure adequate quantities of burn creams. 3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix, clean white gloves, and other items 4) Have adequate pain medicine available 5) Connect with PT/OT, BST to establish time of burn care PREPARATION: 1) Gather all materials prior to starting burn care 2) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff participating in care 3) Remove dressings, exposing a minimal amount of body surface area to prevent hypothermia 4) In sterile fashion, cleanse area with equal amounts of Hibiclens and sterile saline, using lap sponges 5) Dbride areas of loose skin and eschar with sterile scissors 6) Allow to air dry 7) Apply ordered creams to affected areas, usually Silvadene to torso and limbs, Bacitracin to face, and Sulfamylon to cartilaginous area 8) Cover wounds with Exu-Dry, contain Exu-Dry with Kerlix wraps if needed
SUPERFICIAL (FIRST DEGREE) AND HEALED DONOR SITES
For the Bedside nurse/provider: 1) Gather necessary supplies (order burn cart via transport tracking) 2) Ensure adequate quantities of burn creams 3) Have adequate dressing supplies, including Exu-Dry, gauze, Fluffs, Xeroform, Kerlix, clean white gloves, and other items 4) Have adequate pain medicine available 5) Connect with PT/OT, BST to establish time of burn care
Procedure: 1) Wash and/or have patient help wash all affected areas with anti-bacterial soap and water
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2) Pat dry with clean cloth 3) Apply Eucerin Cream to areas, remembering that with application, Some is good, More is better 4) Cover, if ordered, with loose dressing, or with clean white shirt if on torso, or clean white gloves (turned inside-out) if on hands 5) Reinforce dressings, and reapply creams as ordered and PRN to keep skin well-coated
NEWLY GRAFTED BURNS AND DONOR SITES
For the Bedside nurse/provider: 1) Gather necessary supplies (order burn cart via transport tracking) 2) Ensure adequate quantities of burn creams 3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix, clean white gloves, and other items 4) Have adequate pain medicine available 5) Connect with PT/OT, BST to establish time of burn care PROCEDURE: 1) Have adequate amounts of gowns, hats, masks, and sterile gloves for all staff involved with procedure 2) Maintain integrity of newly grafted burn sites for 5 days, or unless directed otherwise by house staff 3) Minimize areas uncovered during burn care to maintain euthermia 4) Remove dressings from donor sites to Xeroform- remove via sterile scissors only the areas peeling back or loose 5) Cleanse with equal amounts of Hibiclens and Sterile Saline 6) Allow to air dry 7) Apply generous amounts of Bacitracin over Xeroform, remembering that with creams, Some is good, More is better 8) Cover with Telfa and Kerlix, making sure distal circulation is not constricted 9) ** Newly grafted burn dressings must be removed initially by house staff, to assess successful take of grafted skin**
DRESSING CHANGES PARTIAL THICKNESS AND DONOR SITES
For the Bedside nurse/provider: 1) Gather necessary supplies (order cart via transport tracking) 2) Ensure adequate quantities of burn creams 3) Have adequate dressing supplies, including Exu-Dry, gauze, fluffs, Xeroform, Kerlix, clean white gloves, and other items 4) Have adequate pain medicine available
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5) Connect with PT/OT, BST to establish time of burn care PROCEDURE: 1) Have staff wear gown, gloves, and mask for burn isolation 2) Cleanse wounds with sterile Hibiclens and Saline (mixed in equal amounts), washing with lap sponges if available 3) Note: gentle scrubbing will help with light debriding of partial thickness burns, and remove previous creams 4) Clip any loose or pealing Xeroform from donor sites, using sterile scissors 5) Allow to air dry 6) Cover areas affected with Bacitracin, unless otherwise directed. Remember: When applying creams, Some is good, More is better 7) Apply Exu-Dry dressing over partial thickness burns, Telfa pads covered by Kerlix, or dressed as ordered ** Be sure dressings are not constrictive to peripheral/distal circulation
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DRESSING TYPES FOR BURNS
EXU-DRY- non-adherent dressing made up of multiple layers. It is designed to conform readily and comfortably to contoured areas. It is highly absorbent and has an anti shear layer. It is compatible with topical agents. Mainly used with first and second degree burns and after grafting. It comes in gloves and jackets and pants also.
FLUFFS-these are woven gauze dressings used over third degree burns to assist in debriding prior to grafting. These can be used out of package or a Kerlix can be opened all the way up to use as a fluff. It is often used as a padding layer to protect grafts postop and to apply soft but constant pressure onto the grafts to facilitate imbibition.
CONFORM - this is slightly elastic cotton roll gauze dressing. It is good for use on fingers and anywhere that mobility is important as it flexes easily. It comes in 1 inch and up sizes.
KERLEX- this is used to wrap burns and assist in keeping underlying dressings in place. Often used over Exu-Dry to keep in place.
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Coban this is an elastic self adherent dressing that is used to help with reduction in the amount of swelling in an extremity burn. It is used over and in conjunction with other dressings mentioned herein.
ACE - these commonly found elastic wraps are used over dressings to help with swelling and sometimes just used to keep materials in place.
MEPITEL-Mepitel is a porous, semi-transparent, low-adherent wound contact layer, consisting of a flexible polyamide net coated with soft silicone. The silicone coating is slightly tacky, which facilitates the application and retention of the dressing to the peri-wound area. This gentle adhesion also tends to prevent maceration by inhibiting the lateral movement of exudate from the wound on to the surrounding skin. The nature of the bond that forms between Mepitel and the skin surface is such that the dressing can be removed with minimum pain and without damaging delicate new tissue. Mepitel is not absorbent, but contains apertures or pores approximately 1mm in diameter that allows the passage of exudate into a secondary absorbent dressing. Depending on the nature and condition of the wound, Mepitel may be left in place for extended periods, up to 7-10 days in some instances, but the outer absorbent layer should be changed as frequently as required. When Mepitel is used for the
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fixation of skin grafts and protection of blisters, it is recommended that the dressing should not be changed before the fifth day post-application. It can be used under a wound vac. It can be removed and cleaned with mild soap and water and reused. Washing will restore the stickiness to the material.
XEROFORM - Xeroform Petrolatum Gauze is a sterile dressing composed of 3% Bismuth tribromophenate in a petrolatum blend on fine mesh gauze. The Xeroform gauze patch is a medicating and deodorizing, occlusive and nonadhering dressing packaged in sterile convenient peel-open, tamper-proof packages. Xeroform has a bacteriostatic action. Its property is 3% Bismuth Tribromophenate in a special petrolatum blend on fine mesh gauze. It is non-adherent and conforms to body contours. We often use Xeroform to cover an open wound in the days right after a graft is taken down and the staples taken out, and occasionally over a donor site. When used as a donor site covering, do not peel off! Allow neoepitheliazation to push the dressing off. Trim the edges that are not longer adherent. Sometimes bacitracin is used to add another layer of moisture and no stick to the fine mesh gauze dressing.
MEPILEX AG-The new Mepilex Ag is a novel antimicrobial dressing since it combines silver with Safetac soft silicone technology. It targets bacteria and protects the skin. This dressing will release silver for up to 7 days. It may be lifted and adjusted without losing its adherent properties. It also can be cut to size and is easy to apply. . In order for the silver to activate, there must be active serous discharge from the wound. It will not provide antimicrobial protection without being moist.
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Tubigrip stretching cotton dressing used to apply pressure to swollen area or sometimes just used to keep dressing in place. Can make a shirt out of larger sizes.
White cotton Gloves these are simply white cotton gloves used as a dressing. It allows for increased mobility while still protecting the burn. Hands and glove are coated in appropriate topical agent (usually bacitracin). These gloves can be cleaned and dried and used again. Turn gloves inside out so seems are on the outside (more comfortable).
BandNet (Spandage) Tubular mesh netting type dressing that allows contact layers to stay in proximity to the wound. Sometimes used on the OR in order to apply pressure to the dressing and keep graft in place. When used over a graft will be stapled in place.
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TOPICALS FOR BURN DRESSINGS

FOR ALL TOPICALS: Some is good, more is better! Too much can cause reactions. Thin coat of topical directly on burn and then more topical applied to the dressing material prior to placing over burn is best. SILVADENE (Silver Sulfadiazine): Initial cream for suspected partial and fullthickness burns (2nd and 3rd degree). Action: Contains Silver Sulfadiazine in micronized form which has broad microbial activity. It is bactericidal against many gram-negative and gram-positive bacteria as well as being effective against yeast. This is also used to help partial and deep partial-thickness burns to slough off eschar. The patient may have pain, burning and itching at the site of application. Precautions: Use cautiously if patient has a sulfa allergy. Because sulfonamide therapy is known to increase the possibility of kernicterus, Silvadene Cream 1% should not be used on pregnant women approaching or at term, on premature infants, or on newborn infants during the first 2 months of life. SULFAMYLON (mafenide): Used for its anti-infective and antimicrobial agents, primarily over cartilage, such as ears in 2 deep second and third degree burns. Action: Sulfamylon Cream, applied topically, produces a marked reduction in the bacterial population present in the avascular tissues of second- and third-degree burns. Reduction in bacterial growth after application of Sulfamylon Cream has also been reported to permit spontaneous healing of deep partial-thickness burns, and thus prevent conversion of burn wounds from partial-thickness to fullthickness. It should be noted, however, that delayed eschar separation has occurred in some cases. Frequently associated with increased pain at the application site. Precautions: Sulfamylon and its metabolite, inhibit carbonic anhydrase, which may result in metabolic acidosis, usually compensated by hyperventilation. In the presence of impaired renal function, high blood levels of Sulfamylon and its metabolite may exaggerate the carbonic anhydrase inhibition. Therefore, close monitoring of acid-base balance is necessary, particularly in patients with extensive second-degree or partial-thickness burns and in those with pulmonary or renal dysfunction. Some burn patients treated with Sulfamylon Cream have also been reported to manifest an unexplained syndrome of marked hyperventilation with resulting respiratory alkalosis (slightly alkaline blood pH, low arterial pCO2, and decreased total CO2); change in arterial pO2 is variable. The etiology and significance of these findings are unknown. Mafenide acetate cream should be used with caution in burn patients with acute renal failure. Sulfamylon Cream should be administered with caution to patients with history of hypersensitivity to mafenide. It is not known whether there is cross sensitivity to other sulfonamides.
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Fungal colonization in and below eschar may occur concomitantly with reduction of bacterial growth in the burn wound. However, fungal dissemination through the infected burn wound is rare. SILVER NITRATE: Used in liquid form as a wet dressing over partial and full thickness burns, for patients with sulfa allergies. Requires frequent re-application to keep area moist. Action: Silver Nitrate is a topical solution agent with bacteriostatic properties against staph aureus, E. Coli, and Ps. Aeruginosa. It is most effective with the wound is clean and dbrided of all dead tissue. Precautions: May cause hyponatremia, monitor electrolytes closely. Will cause discoloration of skin, clothes and equipment. BACITRACIN: Used with partial thickness burns, with grafted areas initially after dressing removed, with donor sites until nearly healed, and with facial burns. Action: Bacitracin is produced by a strain of the bacterial species Bacillus subtilis. It is widely used for topical therapy such as for skin and eye infections; it is effective against gram-positive bacteria, including strains of staphylococcus. Precautions: May cause burning, redness or a rash at which time the ointment should be stopped. EUCERIN: Used for first degree (superficial) burns and for healing partial thickness burns, grafted burns, and donor sites to keep area moist. Action: Moisturizing lotion
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EXCISION AND BURN GRAFTING A skin graft is surgical procedure in which a piece of skin from one area of the patient's body is transplanted to another. Skin from another person or animal may be used as temporary cover for large burn areas in order to decrease fluid loss. The skin is taken from a donor site, which has healthy skin and implanted at the damaged recipient site. Skin graft and flaps are more serious than other scar revision surgeries such as dermabrasion. They are usually performed in a hospital under general anesthesia. The treated area depending on the size of the area and severity of the injury will determine the amount of time needed for healing. This time may be 6 weeks or a few months. Within 36 hours of the surgery new blood vessels will begin to grow from the recipient area into the transplanted skin. Most grafts are successful, but some may require additional surgery if they do not heal properly. There are several types of skin grafts: pinch, split-thickness, full-thickness, and pedicle grafts. Pinch grafts - Quarter inch pieces of skin are placed on the injured site. These small pieces of skin will then grow to cover injured sites. These will grow even in areas of poor blood supply and resist infection.
Split-thickness grafts - consists of sheets of superficial and some deep layers of skin. The grafts removed from the donor sites may be up to 4 inches wide and 10 to 12 inches long. The grafts are then placed at the recipient site. Once the graft is in place, the area may be covered with a compression dressing or the area maybe left exposed. Split-thickness grafts are used for non-weight-bearing parts of the body. Full-thickness grafts - are used for weight-bearing portions of the body and friction prone areas such as, feet and joints. A full-thickness graft contains all of the layers of the skin including blood vessels. The blood vessels will begin growing from the recipient area into the transplanted skin within 36 hours. Pedicle grafts - with a pedicle graft a portion of the skin used from the donor site will remain attached to the donor area and the remainder is attached to the recipient site. The blood supply remains intact at the donor location and is not cut loose until the new blood supply has completely developed. This procedure is more likely to be used for hands, face or neck areas of the body.
The success of a skin graft can be determined within 72 hours of the surgery. If a graft survives the first 72 hours without an infection or trauma the body, in most cases, will not reject the graft. Before the surgery, the recipient and donor sites must be free of infection and have a stable blood supply. Following the procedure moving and stretching the recipient site must be avoided. Dressings need to be sterile and antibiotics may be prescribed to avoid infection. BURN CARE MANUAL FAHC 31
EXCISION There are two types of excisions when skin grafting, fascial and tangential. Fascial: burn eschar is excised down to muscle fascia. Good graft take, decreased bleeding, fast. Cosmetic and functional results worse than with tangential excision. Perform where burn depth is deep into subcutaneous tissue, person may not tolerate blood loss, or where reduced blood loss and stress outweigh cosmetic and functional advantages of tangential excision Tangential: burn dbrided to briskly bleeding dermis or glistening fat. Bleeding and operative time increased. Improved functional and cosmetic results. Blood loss much higher.
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EXCISION Tangential
PROS
CONS
Fascial
Improved function High blood loss Improved cosmesis Need more skin Takes longer Risk over/under excision End points hard to define Rapid Cosmetic defect Defined endpoints Risk of nerve injury Wide-mesh grafts Risk of joint exposure Good graft take Distal edema Skin substitutes
FASCIAL EXCISION
TANGENTIAL EXCISON
Good, brisk bleeding used at guide to depth of excision
Early excision and grafting (2-5 days post injury) is associated with improved outcomes. After one week there is and increased dermal blood flow and BURN CARE MANUAL FAHC 33
granulation is forming under eschar. This results in an increased blood loss with excision. It is best to only excise up to 18-25%TBSA in the first operation and never more than 18% in a single operation after that. Monitor the patients temperature closely and if unable to maintain normothermia the operation should be stopped. Post operatively patients may experience periods of hypotension and decreased urine output. This is due to vasodilatation, re-warming and loss of the tourniquet effect after the constricting eschar is removed. EXCISION AND GRAFTING IMPORTANT POINTS: -harder than you think -requires planning ahead to figure out what you want to accomplish and how you are going to accomplish it -what are you going to use for back up skin (cadaver, Biobrane, Integra) -what type of excision -what type of graft -what is the best position for the patient -make sure you have enough help before you go the to OR -If burn requires splinting, make sure to coordinate with therapists in advance Surgical Approach Based on Burn Size-Must Prioritize 1. Life 2. Limb 3. Looks
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MANAGEMENT OF SPECIFIC BURN AREAS

CHEST
Management Based on Specific Burned Area-Chest

Chest/abdomen high priority in large and moderate sized burn. If FT burn excise to fascia (spare umbilicus and nipples), 3:1 graft. Skirt axilla, do not excise to fascia.
AXILLA
Management Based on Specific Burned Area-Axilla

Skirt axilla, do not excise to fascia. Need to excise and graft chest or shoulder first. Wait until chest/shoulder healed to tangentially excise axilla; allows anchoring of grafts. Axilla takes high priority in smaller burns and should be grafted after hands.
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NECK AND BREAST
Management Based on Specific Burned Area-Neck & Breast

Neck low priority in massive burns, but a high priority in small burns. Thick sheet grafts (20/1000s in) or 1:1 mesh preferred for neck. Breast burns in younger women tangentially excised. In elderly consider mastectomy.
LOWER EXTREMITIES
Management Based on Specific Burned Area-Lower Extremities

2nd priority after chest in massive burns. Excise to fascia if full thickness. In moderate burns excise FT leg burns to fascia if there are hand, neck, or face burns that require lots of skin. For small burns prefer tangential excision with sheet grafts over joints.
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UPPER EXTREMITIES
Management Based on Specific Burned Area-Upper Extremities

Lower priority to excise to fascia in massive burns (9%TBSA). Cover with 3:1 except 1.5:1 over elbow, wrist, hands. Small burns tangentially excise and use 1.5:1 over arm and sheet grafts over elbow and hands.
HANDS
Management Based on Specific Burned Area- Hands

Lower priority in massive burns. Need a lot of skin . May need to pare down eschar and wait until granulation forms to graft. Small burns hands a priority. Tangentially excise and use 1:1or sheet graft.
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BACK
Management Based on Specific Burned Area- Back

Very thick skin so will often heal. Delay in massive burns unless absolutely sure is FT, then excise to fascia, graft 3:1. Smaller burns: wait to do back until priority areas closed.
GRAFTING IMPORTANT POINTS Sheet grafts or unopened 1:1 meshed graft should be used for functional areas such as hands, neck or elbows Secure grafts with clips, staples, or absorbable sutures. Remember the clips and staples have to come out so use these judiciously Immobilize seams Wound-vacs are often used to keep graft in place Cover grafts with Xeroform or Adaptic and staple in place Use large bulky absorbent dressing to protect grafts Take down occurs post operative day 5 Use Eucerin once grafts healed to keep from drying out DONOR SITES IMPORTANT POINTS Bleed vigorously, use thrombin and epinephrine for immediate hemostasis Cover with Xeroform, will separate from donor site when healed Healing occurs in 10-14 days Deep donor sites (>0.016 inch) should be grated with a thin (0.005 inch) graft to speed healing and minimize scarring Use Eucerin over healed donor sites to keep moist
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PHASES OF GRAFT MATURATION

Three phases: 1. Adherence: fibrin bonds between graft and excised bed form immediately. Fibrovascular ingrowth by 3 days. 2. Imbibition: Cell swelling in first 48 hours, may nourish graft. 3. Revascularization: vascular connections form in 4-7 days, lymphatic connections one week
5 DAYS POST GRAFTING
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LONG TERM COMPLICATIONS
HYPERTROPHIC SCARRING
Hypertrophic scar more common after spontaneous closure of DPT burns or healing of widely meshed grafts. Deep donor sites.
HYPERTROPHIC SCARRING
Compression garments can help control hypertrophic scarring. Restrict capillary blood flow. Garments worn 12-18 months for 23 hours a day, 7 days a week.
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CONTRACTURES
Grafts and spontaneously healing burns may develop contractures. Splinting, aggressive OT/PT, and early grafting may prevent contractures.
HETERTROPHIC OSSIFICATION
Bone deposition outside of bone. X-rays show calcifications in soft tissues. ? Causes Often occurs in joints injured by burns or in grafted or healed burns. May show up months-years after injury. Symptoms pain, limitation of mobility. Treatment PT, analgesics, surgery.
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Marjolins Ucer
Squamous cell carcinoma that can occur in an area of healed or grafted burns. May develop decades after the original injury.
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BURN NUTRITION
Characteristics: Nutrition needs are altered in patients with burns. Energy (calorie) and protein needs are elevated and remain high after a burn and during subsequent treatment. If other injuries accompany the burn, the additional injuries also increases calorie needs. Protein losses and energy expenditure are directly related to the size of the burn. Nutrition support for the burn patient requires meeting energy and protein needs. Periodic re assessment of calorie needs during recovery prevents complications from overfeeding. Providing enough calories and protein can help minimize loss of lean body mass and enable healing. Calorie needs: Energy needs surge 7 to 10 days post burn. Calorie needs may change due to change in patient status. Injuries and infections can also increase calorie requirements. Best practice is to re assess calorie needs weekly, taking into consideration changes in condition including extubation, activity, infection, surgery and frequency of dressing change. Indirect calorimetries, or metabolic carts, provide the most accurate evaluation of calorie needs when compared to predictive equations. Calorie needs will be high before grafting and decrease afterwards. Good nutrition is needed to heal the donor sites along with the grafted burns. The metabolic cart can measure energy expenditure (MEE) over a brief period of time. This information can be extrapolated to twenty four hour caloric requirements. The results of the metabolic carts can be multiplied by 1.1 to 1.3 if the patient is active with physical therapy or dressing changes. The timing of the metabolic cart is key in getting an accurate study. It is helpful for the patient to be tolerating tube feedings at goal as the metabolic cart is performed. Predictive equations are another way of assessing calorie needs. Ireton Jones and Harris-Benedict are two of the predictive equations commonly used in assessing calorie needs of burn patients. In intubated patients periodic metabolic carts will give more accurate and useful information when compared to a predictive equation in determining the calorie needs of burn patients.
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Assessment of energy needs: Key to assessing calorie needs is to get an accurate weight that reflects the patients weight at the time of injury; it may be a stated weight. Ireton Jones in ventilator dependent patients: EEE=1784-11(age) +5(weight in kg) +244(if male) +239(if trauma) +804(burn) Harris Benedict equation (HBE). BEE=Basal Energy Expenditure. The result of this equation is then multiplied by a stress factor. Men: BEE=66.5+13.7(wt in kg) +5 (height in cm)-6.8(age years) Women: BEE=655+9.6(wt in kg) +1.75(height in cm)-4.7(age in years) Stressors Activity factor: Confined to bed Out of bed Injury factor: Minor operation Skeletal trauma Major Surgery Sepsis Burn factor: <20% TBSA 20-25% TBSA 25-30% TBSA 30-35% TBSA 35-40% TBSA 40-100% TBSA Inhalation injury Protein needs: Protein needs are also elevated in patients with burns. Typically patients receive 1.5 grams of protein per kg but may require close to 2.5 grams of protein per kg per day. Although providing high amounts of protein to burn patients will not ameliorate catabolism, it will contribute to anabolism and enable healing. Protein is needed to heal burn and graft sites. Patients with burns have protein loss due to loss of skin from the burn itself. Nutrition support: Enteral nutrition is best practice in all patients including burns. Enteral nutrition is better utilized, supports immune function and improves outcome. If enteral access is safe and available, starting tube feeds early in the patients hospital BURN CARE MANUAL FAHC 45 Stress factors 1.2 1.3 1.2 1.3 1.4 1.6 1.2 1.6 1.7 1.8 1.9 1.9-2 1.5
stay will decrease ventilator days and length of stay. Patients may also eat if getting tube fed. Tube feeds should be initiated in all patients with: Burns >20% of TBSA Burns >10% with other significant injuries Elderly patients Patients who will frequently be NPO for surgery/dressing changes/procedure requiring sedation. Patients with baseline nutrition compromise such as a history of unintentional weight loss. In patients lacking in safe enteral access Total Parenteral Nutrition (TPN) can be used as a nutrition source until the patient can be fed enterally. TPN solutions are customized to the patient individual needs. The TPN is monitored to maintain its safely and usefulness. Enteral nutrition: The tube feed of choice for the burn patient on formulary at FAHC now is Crucial. Crucial is a high protein, high calorie enteral formula. It contains hydrolyzed casein as a protein source which has been shown to be better absorbed in critically ill patients. The primary fat source is marine oil. The omega 3 fats in marine oil act as immunomodulators. It does contain arginine, another nutrient associated with wound healing. It is supplemented with elevated levels of key nutrients associated with wound healing. It can be fed into the stomach or small bowel. Details of the nutrient content of this product are posted on the nutrition services web site. http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_ Guide.pdf Typically when tube feedings are started they are run continuously, they can be run over shorter periods of time to allow time off for meals or therapy. Tube feedings can act as a sole source of nutrition or as a supplement to a regular diet. Crucial is contraindicated in: Patients who are septic Patients who are pregnant Patients with elevated potassium and renal failure or insufficiency Patients with liver failure Patients who are HIV positive
Other tube feed options are available for these populations.
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Diet by mouth: If the patient is able to eat, a regular, high calorie high protein diet is best choice. In addition to the patients meals, snacks and supplements can provide addition calories. The supplements available at FAHC are posted on the nutrition services web site. The best choice supplement is the one the patient will take on a regular basis. Low sugar supplements are available for patients with diabetes. Lactose free supplements are also available. The diet tech can assist patient with meal selection and indicate high protein options on the menu. They will also offer snacks and supplements. A complete list of high calorie supplements is available at: http://intranet.fahc.org/Depts/Nutrition/Nutrition_Contrib/Documents/Diet_Order_ Guide.pdf The dietitian will also meet with the patient and their family and discussed the reason for high protein high calorie diet and suggest options from the menu and supplement on the formulary. At least 3 meals and 2 snacks per day are encouraged. Nutrition services will accommodate patients special requests as able. Typically patients receive a supplement at every meal. The aim of providing high calorie supplements to burn patients is to provide addition calories and protein for healing. The supplements are intended to be consumed in addition to meals; typically they are not a meal substitute. For patients who cant tolerate solid food or are only drinking ensure plus, four to five cans of ensure plus are needed per day to prove close to adequate calories. Supplements such as ensure or mighty shakes can be consumed between meals and in the evenings to avoid interfering with meal time appetite. This is a good strategy for patients who have a poor appetite or feel full quickly. Patients often fatigue if consuming the same supplement for a long time, varying the type of supplement can help patients continue to drink supplements. The best choice of supplement is the one the patient is willing to consume on a regular basis. Although ensure plus is the highest in calories, some patients may prefer mighty shakes or CIB (a fruit juice based supplement). High protein foods include chicken, turkey, beef, fish, eggs, milk and other dairy products, and nuts. Good snack choices are sandwiches, yogurt, cottage cheese, milk, peanut butter or cheese and crackers, egg, tuna or chicken salad. All are available as between meal snacks. Other high calorie, high protein foods are available on the patient menu. The patient will be encouraged to choose these. Also burn patients will be offered between meal snacks. The overall goal is to allow the patient to maximize calorie
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and protein intake for healing. FAHC nutrition services will try to accommodate special requests. Supplemental vitamin and nutrients: Supplemental vitamins are required when healing burns to provide specific nutrients for healing and to compensate for losses via the burns. Vitamin C is a component of collagen formation. Zinc is lost when skin or gastrointestinal fluids are removed/lost. Glutamine is a nutrient that acts as an immunomodulator. Arginine has been shown to enable wound healing in some studies. Arginine is contraindicated in septic patients. In patients taking a regular diet with small burns, likely there is no benefit in giving supplemental vitamins except a multivitamin and mineral and vitamin D. Listed below are commonly given supplements, dose and who will most benefit. Nutrient Tube fed only Tube feed combined with diet 500 mg per 1000 mg per day day 220 mg per 220 mg per day day for 14 days One chewable One chewable tablet daily tablet daily None None if tube fed > 1 liter per day None None 10 grams 3 times per day 400 IU per day None 10 grams 3 times per day Diet only, large burn 1000 mg per day 220 mg per day for 14 days One chewable tablet daily 10,00 iu po Monday, Wednesday and Friday 400 IU bid Diet only, small burn None None
Vitamin C Zinc (ZNSO4)
Multivitamin and mineral Vitamin A
One chewable tablet daily none
Vitamin D Arginine supplement Glutamine
400 IU daily
Two packets None daily 10 grams 3 None times a day as tolerated
Monitor: Monitoring the patients response to nutrition support allows for changes to best provided nutrition for healing. Nutrition services will review the bedside flow sheet to see the amount of TPN or tube feed the patient receives. Also, patients eating by mouth are closely monitored using the flow sheets. Calorie counts can be implemented in patients who are eating poorly and are candidates for
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supplemental tube feeds. Weekly weights are needed to evaluate if the patient is consuming enough calories.
Labs: Prealbumin is affected by acute stress and will be low early in the hospital course. It is not a good indicator of response to nutrition therapy early in the hospital stay. It can be helpful when the patient is no longer acutely stressed. Actual nutrient intake is the best way to evaluate nutrition status. Patients, who are eating poorly, or not at all, either have a nutrition problem or will soon develop one. Electrolytes, magnesium and phosphorus should be followed daily in patients receiving nutrition support. Close monitor of blood sugars, at least initially, even in non diabetic patients is needed.
Prepared by Karen Tufano RD CD Bonnie Beynnon RD CD CNSD
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BURN NUTRITION - PEDIATRIC

Burned children pose a special challenge to meet their growth needs. A burned child has more limited endogenous reserves and greater calorie and protein needs/kg than an adult so they can more quickly reach negative nitrogen balance with a smaller burn area than an adult. Also the immaturity of an infants system makes them more susceptible to diarrhea, dehydration and malnutrition. Children follow the same Ebb and Flow phase as adults after a burn with the Ebb phase lasting about 3-5 days which is characterized by hypometabolism, and the flow phase which occurs during the 6-10th days is characterized by hypermetabolism. Caloric Needs The degree of hypermetabolism is directly related to the size of the burn. Studies in burned children at Shriners Hospitals for Children show that energy needs approximate the RDA for children, as the increased energy needs for the burns are offset by decreased activity. This is the calculation generally used here at FAHC. RDA Infants Birth to 6 months 6-12 months Children 1-3 years 4-6 years 7-10 years Male 11-14 years 15-18 years Female 11-14 years 15-18 years
108 kcal/kg 98 kcal/kg
102 kcal/kg 90 kcal/kg 70 kcal/kg
Another formula which is also for children with burns is the Curreri formula. This formula is generally not used at this facility. Monitoring the burned pediatric patient A nutrition assessment protocol depending on the severity of the patients burn and alertness would include the following: - A diet history
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Meeting with the patient/family to obtain food preferences, initiate high calorie, high protein snacks, and possibly supplemental age appropriate shakes, and/or the addition of modular ingredients to food foods to boost calorie and protein intake. Monitoring of calorie and protein intake whether on PO feeds, tube feeds parenteral nutrition or combination of the above. Glucose levels may need to be monitored. Monitoring of Prealbumin. Vitamin and mineral supplementation may need to be provided. Bi-weekly weights or more often as deemed necessary. Nitrogen balance studies if thought that nutrition intake may be inadequate.
Protein Needs: Protein needs are elevated in burned pediatric patients, and it is recommended that 20-23% of the calories be provided as protein with >10% BSA burns which translates to about 2.5-4.0 grams protein/kg. Micronutrient Needs: Micronutrient needs increase based on the severity of the burn, and stores of micronutrients are lower in a young child. The following are recommendations for vitamins and mineral supplementation in the burned child: (3) Children and adolescents (3 years and older) 1. Major burn - one multivitamin daily - 500 mg ascorbic acid twice daily - 10,000 IU vitamin A daily - 220 mg zinc sulfate daily 2. Minor burn (<20%) or reconstructive patient - one multivitamin daily Children (<3 years of age) 1. Major burn - one childrens multivitamin daily - 250 mg ascorbic acid twice daily - 5000 IU vitamin A daily - 100 mg zinc sulfate daily 2. Minor burn - one multivitamin daily Children with burns <20% of body surface area usually can meet their energy and protein needs with a high calorie, high protein oral diet. Snacks should be offered along with a multivitamin. High calorie shakes may be offered. If the patient has a larger burn, energy needs may not be met by oral feeds alone, and supplemental tube feeds may be needed. Feeding enterally is always
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the preferred method, but if the patient is unable to tolerate enteral feeds, parenteral nutrition may be needed.
References: 1. Young VR, Motil KJ, Burke JF. Energy and protein metabolism in relation to requirements of the burned pediatric patient. Textbook of Pediatric Nutrition. New York, Raven Press; 1981: 309-340. 2. Curreri PW, Richmond D, Marvin J, et al. Dietary Requirements of patients with major burns. J Am Diet Assoc. 1974; 65: 415-417. 3. Samour PQ, Helm KK, Lang CE, Handbook of Pediatric Nutrition (2nd edition). Aspen Publishers, Inc. Gaithersburg, Maryland 1999: pg 502.
Prepared by Patty McKibben MS, RD, CD Edited by Carlie Geer MS, RD, CD and Linda LaShure RD, CD
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BURN REHABILITATION
Burn rehabilitation is a 24 hour a day process!!!! The ultimate goal of burn rehabilitation is to return the patient back to society in as near to their normal functional capacity as what existed prior to the burn injury, through prevention and treatment of burn scar contracture deformity and hypertrophy scarring. This goal is achieved through functional activities, exercise programs, splinting, positioning, and scar management. Functional Activities Outcomes: Prevent loss of function during hospitalization or prevent secondary complications. Reinforce carry over of ROM and strengthening exercise programs. Exercise Programs Outcomes: Maximize functional ROM and strength through exercise programs to be carried out by the patient and or caregivers. Splinting Outcomes: Protect joints and tendons, provide optimal positioning for wound and graft healing, maximize and maintain ROM (see photos on following pages).
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S:\Groups\Rehab Therapies\ACUTE\Burn Rehabilitation.doc
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Positioning The position of comfort is the position of contracture Outcomes: Edema control; prevent tissue destruction. Maintain burned tissue in and elongated state (see diagram) *These positions are not indicated for all patients, please review therapist recommendations closely.
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Timelines for development of tissue restrictions Burn scar contracture 1 - 4 days Tendons and sheaths 5 - 21 days Adaptive muscle shortening 2 - 3 weeks Ligament and joint capsule 1 - 3 months Effects of Compression Therapy Flattens the scar Increases pliability Decreases blood flow Accelerates scar maturation Realigns collagen bundles Decreases edema Decreases the rate of collagen synthesis Compression is mandatory on all burn wounds that require >21 days or skin grafting to heal Compression is required until the scar is mature Compression should begin within 2 weeks of wound closure Frequency of Wear All the time except bathing and cream application Not off for more than 30 minutes to 1 hour at a time Duration of Use Until scar maturation Minimum of 6-8 months; usually 9-12 months; longer in children As long as a scar is red, it is vascular. It can contract and hypertrophy Amount of Compression Reported clinical improvement with 5 - 15 mm Hg Elastic bandage: (coban) Extremity: 10-15 mmHg (may need 2 layers) Trunk: 3-4 mmHg Tubular support bandage: 10-20 mmHg Use 2 layers Pressure Garment: 25 mm Hg Elastic Tubular Support Bandages Advantages Used on healed burns that can not tolerate shearing forces Interim pressure device Comfortable Can be placed over dressing Controls edema Disadvantages Limited to cylindrical body parts
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Improper application or bunching can cause skin breakdown or edema Some patients are allergic to elastic Same diameter through out a tapered extremity
Custom Made Elastic Compression Garments Advantages Can be fit for every part of the body Customized closures, materials, styles Multiple options Variety of colors Multiple companies Disadvantages Expensive Not all insurances reimburse Fit - dependent on accurate measurements Difficult to don/doff May cause skin breakdown May retard/alter bone growth Weight gain/loss should be stable Proper Fit of Custom Garments Extend garment 2-3 beyond scar Avoid stopping garment over muscle belly or joint Anchor garment so it does not slip Avoid zippers when possible If zippers are needed, avoid placing them over scar and bony prominences Initial fitting should not be done by patient at home Should be tight enough that its difficult to pull away from skin, but does not compromise neurovascular status Avoid wrinkles
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HYPOTHERMIA AND FROSTBITE

Hypothermia Hypothermia, or exposure, exists when the body core temperature falls below 98oF. The heart rate, cardiac output, respiratory rate, and blood pressure fall. As the muscles cool, shivering begins, become violent, and then gradually ceases below 86oF as the muscles become stiff. Central nervous system cooling leads to a decrease in cerebral blood flow, dilation of the pupils, stupor, and then coma. Hypothermia may be classified by duration into acute (several minutes to a few hours), sub-acute (several hours to a day), and chronic (one to many days). Acutely, there is a large difference between body core and outside temperatures. In sub-acute and chronic hypothermia, the differences between body core and shell temperatures are smaller. In general, hypothermia occurs in one of the following four (4) clinical settings: Immersion Hypothermia is usually acute or sub-acute and results from immersion in cold water. A similar hypothermia can be due to exposure to cold rain and high winds. Field Hypothermia occurs in previously healthy individuals such as skiers, climbers, hunters, and hikers and may accompany injuries occurring outdoors in cold weather. Urban Hypothermia occurs in individuals with a physical predisposition, disability, or illness. Predisposing conditions include those which increase heat loss (premature infants and newborns with relatively large surface areas), or interference with heat production, i.e., the elderly with impaired circulation. Hypothermia occurs when the body core is accidentally cooled to below 98oF. It can be caused by exposure to cold, snow or ice. Hypothermia requires medical attention as soon as possible. First aid should be applied to prevent further heat loss and re-warm the body core and extremities. Patients with hypothermia should be treated gently to avoid heart problems. Frostbite: The term "frostbite" refers to actual localized of body parts to variable depth depending on the temperature, length of exposure, amount of insulation and other factors. Frostbite requires temperatures of freezing or below. The most commonly involved body parts are on an exposed position (face, ears, hands, and feet). In addition, the body's tendency to protect itself from cold by restricting peripheral circulation predisposes to frostbite of the extremities. Localized cold injury results from local freezing and interference with circulation. Intra-cellular and extra-cellular ice crystals appear and as they grow in size cause cellular damage. Superficial frostbite involves only the outer layers of the skin and causes burning or tingling followed by numbness. Inspection shows a grayish-white patch of skin,
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usually on the face or extremities. The deeper tissues remain soft and pliable. After thawing, the area becomes red and sensitive, and slight edema with a few small blebs may appear. A few days later, the skin may peel. Deep frostbite, a much more serious injury, usually occurs in the hands and feet. Inspection shows a cold, waxy, pale, or cyanotic member, solid and unyielding, which resembles a piece of chicken just out of the freezer. After thawing, blisters of various sizes usually develop. A relatively favorable sign is the occurrence of huge blisters filled with pinkish fluid, extending close to the tips of the affected digits. In more severe frostbite, the blisters tend to be smaller and filled with a darker fluid, the part remains numb and cool, and the joints remain stiff. In the most severe cases, the frozen area is completely numb, cold, and bloodless, without blisters or edema, and gangrene develops rapidly. The amount of damage tends to be overestimated in the early stages, and amputation should be delayed if possible until clear demarcation occurs. Signs & Symptoms of Frostbite Tingling and burns are early symptoms and a warning to get out of the cold immediately. If this isn't possible, vigorously move the affected part to increase circulation. The next stage is numbness. By this time, you probably have frostbite. In the third stage, skin may appear pale or white and cold to the touch. In the final stages, there is a swelling and blisters may form after the skin thaws. A physician should examine all frostbite as soon as possible. Prompt treatment will increase the chance for complete recovery. Initial Management Superficial frostbite can be thawed by direct body heat, such as a warm hand on a frozen cheek, or by general body warming indoors. The preferred initial treatment for deep frostbite is rapid re-warming on a water bath at a temperature of 104 - 108oF. Rapid re-warming should not be performed in the field if there is a danger that the extremity might be frozen. The re-warming flushing process is quite painful, and narcotics may be required for relief of pain. Vasodilatation in the affected member is encouraged by raising the body core temperature with direct heat to other parts of the body and hot drinks. After thawing, the once frozen part is wrapped in clean, soft material. Toes and fingers are separated with cotton pledgets, and the limb is elevated to minimize swelling. Patients should not be allowed to walk on a thawed foot. Smoking is prohibited. Tissue loss will be less with rapid re-warming even if the part has been frozen for several days.
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Frostbite protocol
Admission/ED: Rewarm affected areas rapidly in warm water (40-42C) for 15 to 30 minutes or until thawing is complete. On completion of re-warming: treat the affected parts as follows: 1. Dbride white blisters and institute topical treatment with aloe Vera every 6 hours. 2. Leave hemorrhagic blisters intact and institute topical aloe Vera every 6 hours. 3. Elevate affected parts with splinting as indicated. 4. Administer anti-tetanus prophylaxis (toxoid or Ig). 5. Provide analgesia: opiate IV/PO PRN. 6. Administer ibuprofen 4-600 mg orally Q 12 hours. 7. Administer penicillin 500 mg PO Q 6 hours for 48 to 72 hours. 8. Begin ASAP QD hydrotherapy (PT consult) for 30 to 45 min. @40C. Until devitalized tissue sloughs. Less benefit if delayed >48 hr. 9. Documentation: obtain photographic records at a. Admission b. 24 hours c. Every 2 to 3 days until discharge. 10. Smoking: Prohibit the patient from smoking/nicotine. 11. After hydrotherapy has reached maximal benefit, switch to bacitracin/Sulfamylon/silvadene as indicated. 12. Debridement is carried out PRN in the office setting or in the OR over the next 1-2 months. 13. Consider contacting interventional radiology or vascular for possible tPA, reserpine, or other angiographic revascularization of cold, insensate but not necrotic extremities (i.e. early intervention). There is some literature showing benefit. Consult Drs. Morris, Najerian, Bhave or Sartorelli for guidance if unsure if patient is candidate for angiographic intervention. Adapted from Murphy JV, Banwell PE, Roberts AH, et al. Frostbite: pathogenesis and treatment. J Trauma 2000;48(1):171-8; Gentilello LM, Rifley W. Continuous arteriovenous rewarming: report of a new technique for treating hypothermia. J Trauma 1991;31:1151-4; Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy. Bruen, K. J., MD, et al. Arch Surg. 2007;142:546-553.
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PEDIATRIC BURNS: SPECIAL CONSIDERATIONS
Highlights of ABA Burn Admission Criteria related to children Age < 10 with greater than 10% TBSA burns- second and third degree Age > 10 with 20% TBSA burns Third degree burns > 5% Burns to face , hands, feet, genitalia, or overlying major joint Suspected Abuse: Mechanism of injury is consistent with developmental status and must match clinical picture
It bears repeating: < 10% Burns- start on maintenance with fluid bolus as needed Pediatric Parkland formula for 2nd and 3rd degree o 2-4 ml RL X kg X % BSA burn o in 1st 8 hrs o in 2nd 8 hrs o in 3rd 8 hrs o In children, must add dextrose containing maintenance IV fluids in addition to resuscitation: use D5LR100cc/kg for 10 kg of weight 50 cc/kg next 10 kg of weight 20cc/kg remaining weight Goals: Urine output of 0.5 cc/hr (1-2 cc/kg/hour for children) Reverse base deficit Restore blood pressure
Caring for Children Childrens needs and understanding of the injury will differ based upon their stage of development.
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Key developmental considerations include: Infants: Learn through sensory stimulation and movement, including touch, may experience separation anxiety Early Childhood: At risk for developing low self-esteem as they may view the injury as punishment for being bad, coordinate procedures around daily routines School-Age: Decrease anxiety by educating child and involving in care as much as possible Adolescence: Concern with body image, at increased risk of depression however, may not share feelings with others. Consider psychological counseling
Support for the child and family is critical. When children are frightened and uncomfortable, they may regress to the developmental level that allows them to deal with the stress of the injury. They may be confused by the intensity of concern given to their physical needs and care. All children need reassurance that they are all right and that they will get better. General Care Guidelines include: Tell child first before doing anything Allow for choices whenever possible Give descriptions of sensations that may be felt as well as what child can do to cope with them Do not use words such as done or finished until burn care is completed Avoid emotional words such as pain, scream or hurt Utilize treatment rooms or spaces other than childs bedroom for dressing changes and interventions -in order to maintain a safety zone Establish ground rules before procedure. For example, agree on an allotted time for dressing change or to identify who may perform what piece of dressing change If child refuses to focus on dressing change or refuses to actively participate- continue to encourage cooperation. Reinforce with praise and gradually increase expectations for childs participation in care If child cannot help- encourage child to count 1-10 or 20 as fast as possible, rest for agreed upon time ( another 1-10 or 20), then continue burn care work , repeating pattern as indicated
Child Life Specialists are available throughout FAHC to provide procedural support and medical play opportunities for children and families, including siblings.
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Managing Pain Children can enter a shock like state after an injury that can mask their expressive ability. It is critical to remember that the childs initial experience with pain sets the stage for the rest of the hospitalization. Barriers: Younger children have difficulty conceptualizing or quantifying pain. Older children have difficulty in describing pain due to lack of experience Often non-pharmacologic techniques are under -used. Developmentally Appropriate Interventions Ages 0-2 Distraction Ages 2-6 Deep Breathing, Distraction Ages 6 and older Deep Breathing, Distraction, Imagery, Progressive Muscle Relaxation It is sometimes difficult to predict the most effective pain management for children with new burns, but providing a dose that gives the maximum coverage for pain and anxiety is optimal.
Pharmacological Support: Give IV doses immediately before interventions Give PO doses 45 minutes to 1 hour before Frequently used medications and dosages: Morphine IV 0.1 mg/kg/dose Fentanyl IV 1-5 mcg/kg/dose Versed IV 0.05 mg/kg/dose Oxycodone PO 0.15-0.4 mg/kg/dose Versed PO 0.5-1 mg/kg/dose Tylenol 10-15mg/kg/dose Ibuprofen 10mg/kg/dose Assess the need for anesthesia support for Propofol or additional medications Consider PACT team consult for complex pain management
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PSYCHOSOCIAL ASPECTS OF BURNS

Psychosocial aspects of the burn survivor Patients with burn injuries are a very unique population not only in terms of the physical treatment and recovery but also the psychosocial aspects of recovery. The first challenge that a patient with a burn injury faces is survival. Their focus changes to the psychosocial aspects of recovery as the rate of survival increases. Burn patients go through various stages of emotional recovery as their physical recovery continues to progress. Each patient is an individual and their emotional journey through recovery will be unique. Many factors determine how someone will respond and cope with the traumatic injury including the events surrounding the trauma, fatalities involved, and preexisting psychosocial issues. The emotional responses that one has to such events will span the spectrum and vary with each individual. There is no right, wrong or appropriate way for individuals to react it is their process. Some emotional responses you might observe are anxiety, depression, sleep disturbances and grief, all of which are very normal. The best way we can support individuals is to honor and respect where they are & try to meet their emotional and physical needs. There are very valuable resources within our hospital including social work, medical psychology and child life specialists, all of whom have knowledge, skills and expertise in supporting individuals and their families through this process.
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BURN CARE REMINDERS

Burn clinic number 802-847-3790 WOUND CARE 1. Shower daily with a mild soap. 2. Pat all areas dry. 3. Apply prescribed topicals and/or lotions per discharge summary. Cover all areas so that you cannot see any burn or healed areas through it. Dont forget to reapply! 4. Once topicals and/or lotions have been applied, bandage burns if directed. 5. **Remember new skin is fragile and may tear, bruise, or blister if bumped. Apply bacitracin to these areas & watch this area closely. ** ITCHING 1. Itching is a common problem in the wound healing process. 2. Tips to relieve itching include: a. Applying Eucerin or other non-perfume moisturizing cream more frequently, especially before bed time. b. Cool compresses c. Benadryl may help to decrease discomfort. Apply more ointment as a first step. **If using must read label & follow directions. d. Loose fitting clothing. AVOID EXPOSURE TO HOT AND COLD, DIRECT SUNLIGHT 1. Hot Weather: Your new skin is less able to tolerate extreme temperature: a. Deep burn tissue has a decreased ability to sweat so you may experience more heat discomfort. Stay indoors in a cool room if this occurs. b. Go outside in the evening when it is cooler out. c. Stay in the shade if outdoors during warm weather. d. Keep burned skin covered while outdoors (long sleeves, pants, hat, gloves, etc.) e. New skin will burn and blister if exposed to direct sunlight. Must use a sunscreen with the highest SPF you can find. f. The risk of scarring increases with exposure to extremes of hot, cold and direct sunlight. This risk lasts up to one year on burned skin and on skin grafts. 2. Cold Weather: Your burned skin is very sensitive to cold and is at high risk for frostbite. Dress warmly! a. If you experience numbness, tingling or change in the color of your skin, get out of the cold. b. Wear gloves or mittens. If your face is burned, cover it with a scarf.
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SCARRING 1. Initially it is very difficult to tell how much scarring will be permanent. It is difficult to predict how much scarring any one person will have since the amount of scarring is determined on an individual basis and by the depth of your burn. When you return to clinic you will be evaluated for the possible need for pressure garments. If you have been grafted (split thickness skin graft) you will almost always require pressure garments, all others will be evaluated on an individual basis. EXERCISE 1. Per physical and occupational therapy instructions. DIET 1. A healthy, high protein diet is preferable and will promote wound healing. You may need to supplement your diet with Ensure, Carnation Instant Breakfast, or other protein shakes. a. High Protein Food- Dairy (milk, cheese, yogurt, eggs), Poultry, Beef, Fish (tuna, etc), certain nuts, or Peanut butter. EMOTIONAL READJUSTMENT 1. If you are having anxiety, sadness, or sleep issues related to this injury please do not hesitate to call the burn clinic (847-3790) or discuss this at your next appointment. FOLLOW-UP 1. Keep all appointments. Burn clinic is located on the 5th Floor of the ACC building. 847-3790
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WEBSITE REFERENCES
www.ameriburn.org www.burnprevention.org www.burntalk.com www.nfpa.org www.burntherapist.com www.firefightersburninstitute.com www.cdc.gov www.traumaf.org www.shrinershq.org/Hospitals www.burnsurgery.org www.sagediagram.com www.wounds1.com www.phoenix-society.org American Burn Association Burn Prevention Foundation Burn Talk National Fire Protection Association Burn Therapist Firefighters Burn Institute Centers for Disease Control The Trauma Foundation Shriners Hospitals for Children Burn Surgery Sage Diagram Wounds1-burn dressings Phoenix Society for Burn Survivors
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BURN (Dressing change) CART INFORMATION

The burn cart was developed as a need for patient care units to get burn supplies they normally do not stock on their units. The cart is located in distribution and will be re-stocked by distribution when returned.
To request the cart;

The unit enters the request in transport tracking and distribution is notified to bring the cart to that particular unit. Please give plenty of notice before you wish to have the cart ready. It can be obtained through this mechanism 24 hours a day. The cart should be kept outside the room.
To return the cart:

The cart is returned through transport tracking as soon as burn care is completed. Record items used on PAR sheet in top drawer of cart. Restocking of the cart only occurs during regular business hours. If you need additional items contact distribution through your normal channels Currently the Mepilex, Mepitel and large Telfa are kept in CSR. Unit staff will need to go to CSR to get these products. The large burn jacket is a patient charge and should be charged accordingly. See attached sheet for contents
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Burn Cart Charge Master Form

Floor Name: CC#
Approver Name:
M#:
Time Cart Delivered to Dept.

Exp. Date Item # New Item # Product
Time Cart Returned:

PAR ON CART Unit of Measure Write Down Qty used
01/01/2010
009291 001988 55408 001777 001763 001764 001765 001766 001839 55418
Hibiclens 16 oz Sterile Bowls Telfa 3 X 8 Telfa 3 X 2 Ace Bandage 2" non sterile Ace Bandage 3" non sterile Ace Bandage 4" non sterile Ace Bandage 6" non sterile Kerlix Lap Sponges Exu-dry dressing 24x36 Exu-dry dressing 15x24 Exu-dry Dressing 9x15 Exu-dry Jacket Large Exu-dry gloves Small Exudry Buttock Dressing Adult Exu-dry Jacket Small Exu-dry gloves Medium 59036 59037 59038 59039 Bandnet Size # 3 Bandnet Size # 6 Bandnet Size # 8 Bandnet Size # 10 Exu-dry gloves Large Burn Fluff Dressing/large Conform - kling 2" Conform - kling 3" Conform - kling 4" Dermal Gloves Small Dermal Gloves Medium Dermal Gloves Large Dermal Gloves X-Large
4 2 2 2 2 4 4 4 20 6 2 6 15 2 2 2 1 2 1 1 1 1 4 12 1 1 4 2 2 2 2
bottles each boxes boxes rolls rolls rolls rolls rolls packs each each each each each each each each box box box box each packs box box rolls pair pair pair pair
01/01/2001 05/01/2010 08/01/2010
001872 001873 001874 001875 001878 001880 001881
08/01/2010
001882 001903 001905 001906 001907 002044
12/01/2010
020217 001771 001772 55407 012247 012248 012249 012250
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FAHC Burn Care Manual: Complied By: Peter Igneri, PA-C, Jennifer Gratton, RN

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FAHC Burn Care Manual

Complied by: Peter Igneri, PA-C, Jennifer Gratton, RN

BURN CARE MANUAL FAHC

FAHC BURN CARE MANUAL 2008

BURN NUTRITION........................................................................... 44 BURN NUTRITION - PEDIATRIC .................................................... 50 BURN REHABILITATION................................................................ 53

BURN CARE MANUAL FAHC

HYPOTHERMIA AND FROSTBITE................................................. 58

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

CO High Symptoms 0-5 15-20 20-40 40-60 60 or above

*CO Hgb - carboxyhemoglobin

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

Signs and Symptoms

BURN CARE MANUAL FAHC

ESTIMATING TOTAL BODY SURFACE AREA OF BURNS

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

TYPES OF BURNS AND TREATMENTS

BURN CARE MANUAL FAHC

Must dbride blisters prior to placing to allow firm adhesion

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

SUPERFICIAL (FIRST DEGREE) AND HEALED DONOR SITES

BURN CARE MANUAL FAHC

NEWLY GRAFTED BURNS AND DONOR SITES

DRESSING CHANGES PARTIAL THICKNESS AND DONOR SITES

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

DRESSING TYPES FOR BURNS

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

TOPICALS FOR BURN DRESSINGS

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

BURN CARE MANUAL FAHC

Good, brisk bleeding used at guide to depth of excision

BURN CARE MANUAL FAHC

MANAGEMENT OF SPECIFIC BURN AREAS

Management Based on Specific Burned Area-Chest

Management Based on Specific Burned Area-Axilla

BURN CARE MANUAL FAHC

NECK AND BREAST

Management Based on Specific Burned Area-Neck & Breast

Management Based on Specific Burned Area-Lower Extremities

BURN CARE MANUAL FAHC

Management Based on Specific Burned Area-Upper Extremities

Management Based on Specific Burned Area- Hands

BURN CARE MANUAL FAHC

Management Based on Specific Burned Area- Back

BURN CARE MANUAL FAHC

PHASES OF GRAFT MATURATION

5 DAYS POST GRAFTING