BURN

Textbook of Medical Surgical -Nursing Brunner and Suddarth Chapter 57

Critical Care Nursing Linda D.Urden p.1032
Trauma Nursing Core Course Emergency Nurses Association p.211
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Learning Outcome
• Discuss the etiologies and pathologies mechanism of disease that leads to
life threatening conditions
• Analyze the application of concepts of medical surgical nursing to
provide safe , quality evidenced based patient centered care to diverse
clients with life threatening conditions.
• Formulate Nursing Care Plan to address life threatening conditions ,needs
,problems and issues based on priorities
II.Acute /Critically Ill patients and multiple organ
system Failure
• BURNS
• METABOLIC SYNDROME
• SEPSIS
• Different types of SHOCK
• CARDIO-PULMONARY ARREST
BURNS

• Upon the completion of the discussion: The the students will be able to;
• Describe the local and systemic effects of a major burn injury
• Describe the mechanism of injury associated with surface injury and burn
trauma
• Describe the etiologies and pathologies of burn
• Describe potential fluid and electrolytes alteration of emergent and
resuscitative and acute phases of burn management
Learning outcome :continue
• Describe goals and of BURN Wound Care and Nurses’ role :
• Wound cleaning topical and antibacterial therapy wound dressing , dressing
changes wound debridement excision, skin grafting
• Utilize nursing process for care of burn patient
Keywords :
• ALLODERM
• AUTOGRAFT
• BIOBRANE
• CARBOXYHEMOGLOBIN
• COLLAGEN
• CONTRUCTURE
• CULTURED EPITHELIAL AUTOGRAFTS(CEA)
• DEBRIDEMENT
KEYWORDS
• DONOR SITE HYPERTOPHIC SCAR
• ESCHAR INTEGRA
• ESCHAROTOMY RULE OF NINE
• EXCISION AUTOGRAFT
• FACIOTOMY HOMOGRAFT
• HETEROGRAFT HETEROGRAFTS(XENOGRAFT)
• HEMOGRAFT
• HYDROTHERAPY
INTEGUMENTARY SYSTEM
Functions of Skin
• Epidermis .07-012mm thick dead cornified cells,tough protective barrier
against the environment
• From surface inwards >5 layers
• stratum corneum.
• Stratum lucidum
• Stratum granulosum
• Stratum spinosum
• Stratum germinativum
• Deepest layer of epidermis contain fibronectin
DERMIS -1-2mm thick
Composed of 2 layers
The more superficial >papillary layer next to stratum germinativum
Deeper layer >reticular layer(blood vessels glands ,hair follicles , lymphatics
nerves fat cells a net like structure of elastin fibers and collagen fibers
surrounds the reticular dermis)
This function to strengthen the skin , providing structure and elasticity ,
supports the components of the skin , such as hair follicles
Sweat glands and sebaceous glands , nerves to the skin and capillaries that
nourish the avascular epidermis.
Sensory fibers for pain, touch , and temperature
MAST CELLS in the connective tissue
• Performs the function of phagocytosis,
• Production fibroblast
• Beneath the dermis is ;
• Hypodermis acts as heat insulator ,shock absorber and nutritional depot
• Main function of skin: Protection against environment through sensations of
touch pressure , and pain
• Maintenance of body temperature
• Barrier to evaporate water loss;
• Metabolic activity :Vitamin D production
• mmunologic protection prevents the microbes from entering the body
PATHOPYSIOLOGY/ ETIOLOGY OF BURN
• Injury resulting in tissue loss or damage
• Causes: Thermal ,electrical , chemical or radiation sources
• Temperature of causticity of burn agent
• Duration of tissue contact with source determine the extent of tissue injury
• Tissue damage : Temperature 40degrees C-44 degrees C
• Burn wound itself is responsible for systemic effects seen in burn patient
Classification of Burns
Cont.

Tissue damage is caused by enzyme malfunction and denaturation of

proteins.
Prolonged exposure or higher temperatures can lead to tissue necrosis
(protein coagulation; the change in the structure of CHON from liquid to
solid or thicker liquid )brought by heat ,mechanical action or acids.
The areas extending outward from central area of injury sustain various
degrees of damage and identified as ZONES of INJURY
ZONES OF
INJURY
Classification of BURN INJURY
• BURNS are classified primarily according to size and depth of the injury
• Type and location of burn and patient’s age and medical history are
significant considerations.
• Recognition of magnitude of burn injury based on depth and size and
the prior health of the patient(crucial to plan of care) are CARDINAL
DETERMINANTS OF SURVIVAL
Quick easy methods can be used to estimate the size burn area
RULE OF NINE (initial triage )surface area are divided into 9%.
Characteristics of Burn According to Depths
Rule of Nine
Extent of Surface Area
Injured
Rule of Nine modified for infants and very small
children
Lund and Browder Method the most accurate &
accepted method in determining % of burn
PALM METHOD
• The patient with scattered burns , the palm method maybe used to estimate
the extent of the burns .The size of the is approximately patient’s palm 1%
of the total body surface area (TBSA)

• The BERKOW Method can be used to estimate burn size for infants and
children , requires special chart provided by National Burn Institute , which
is not always be available in local hospitals
Depth of BURN INJURY(slide 17p.1019CCN)
• The depth of the burn is defined by how much the skin’s two layers are destroyed
by the heat source
• Superficial(first degree burn, involves only the first two or three of 5 layers of
epidermis)
• Partial-thickness involves upper third of dermis (various stages of second-degree
burn,superficial,mid-dermal or deep- dermal partial thickness burns) erythema
mild discomfort ,light to bright red ,mottled ,may appear wet, and
weeping ,bullae , extremely painful,
• Microvessels perfuse , resulting in leaking large amount of plasma into
interstitium,this lifts off the thin damaged epidermis 7-21 days healing
Deep-dermal partial-thickness
• Involve entire epidermal layer and part of dermis, deep dermal burn are not
characterized by blister formation , only modest plasma surface leakage
occurs because of severe impairment in blood supply
• Wound surface is patchy , red , white areas
• Dermal necrosis and surface coagulated protein turn the wound from white
to yellow (prolonged healing time)
• HEALING>epidermal elements , germinate, and migrate ,until epidermal
surface is restored , epithelialization(6 weeks)
• Untreated >unstable epithelium , late hypertrophic scaring, marked
contracture
FULL THICKNESS BURN(3rd Degree)
• Destruction of layers of skin down to and including subcutaneous
tissue(appears pale white or charred ,red , brown , and leathery
• Surface of the burn maybe dry and skin is broken,FAT maybe exposed
• Painless and insensitive to palpation(epithelial elements are
destroyed ,wound will not heal by epithelialization.
• Wound closure of small-full thickness burns can be achieved by
contraction(<4cm area) requires skin grafting
• >Untreated, extremely susceptible to infection FE inbalances, altered
thermoregulation , metabolic disturbances
Mechanism of Injury and Biomechanics
• Burns are injuries to tissues caused by heat ,friction , electricity radiation or
chemicals
• In order of prevalence the most common mechanism of burn injury for
persons ages 5 and older
• Flames /Fire
• Scald injuries
• Contact with hot objects
TYPES OF INJURY
Burns are intentional and unintentional
Radiation - associated with radiation exposure ,localized , indicate high
radiation doses to the affected area
• Thermal- scalds , contact with heat and fire injuries ,contact with flame
tend to be deep-dermal or full-thickness injuries
• Chemical acids alkalis ,concentration of chemical agent ,industrial
substances such as liquid concrete
• Electrical Occupational exposure and accidents involving household current
• Lightning
Location of injury
• Burns involving functional areas of the body often require specialized
intervention
• Injuries canto these areas can result in significant long-term morbidity from
impaired function and altered appearance
• AGE and HISTORY determines survival
• High risk younger than 2 years and those older than 60 years old
• History >cardiac pulmonary kidney dysfunction;diabetes CNS disorders
Burns :Radiation
Radiation
• Common Causes include sun,sunburn or radiation beams used to treat
cancer patients
Thermal Burn
Chemical Burn
Electrical Burn
Zones of Injury in Burns
Goal : save life , minimize disability , prepare for definitive care: may
involve multiple organ system

• Major Trauma : first hour of injury is crucial > first 24 to 36 hours

important in burn management
• Obtain History regarding the nature of injury is important
• Mechanism of injury ,age , location and size of burn , type of fluid already
administered , significant medical history
AIRWAY MANAGEMENT
• Possibility of cervical instability
• Carbon monoxide (CO)poisoning
• Carboxyhemoglobin levels
• Oxygen therapy >100% O2 major burns
• Tachypnea , upper airway obstruction( hoarseness , stridor, wheezing)
• Early intubation may save life who have inhalation injury
• Edema may obstruct the larynx ;frequent blood sampling BP monitoring may
necessitate placement of arterial monitoring
• (Agitation , anxiety )
Inhalation Injury (pp1025)
• Can occur in the presence or absence of cutaneous injury .
• Strongly associated with burns sustained in a closed space
• Carbon monoxide (CO) poisoning , upper airway injury ,lower airway
injury
• Facial burn , singed eyebrows, nasal hair, carbon deposits in the oropharynx
, carbonaceous sputum, acute inhalation injury,
• Prevent the necessity of tracheostomy or cricothyrotomy
• Use of early intubation and respiratory support must be considered
before tracheal edema occur
RESPIRATORY MANAGEMENT
• Circumferential full thickness burn to the chest wall can lead to restrictions
of chest wall expansion and decreased lung compliance
• Decreased lung compliance requires higher ventilatory pressures to provide
patient adequate tidal volume
• Patients who have not undergone intubation , chest wall restriction include
rapid ,shallow respirations poor chest wall excursions ; severe agitation
• ABG reveals <inO2 tension and > par
CARBON MONOXIDE POISONING
• At the scene of fire with few cutaneous thermal injury but died of CO
poisoning
• CO odorless colorless and tasteless by product of incomplete combustion ,
results in bonding to available hemoglobin, (HbCO)
• CARBOXYHEMOGLOBIN binds poorly with oxygen , reducing the
oxygen-capacity of blood causing HYPOXIA
• The pulse oximeter can not distinguish OXYHGB and HbCO
• CNS and Heart
• S/S headache ,dizziness,nausea,dyspnea and confusion
• CO poisoning leading to MYOCARDIAL SCHEMIA CNS complication
caused by lowered oxygen delivery and already compromised circulatory
system
• S/S tachycardia , tachypnea, confusion and lightheadedness
• As the CO level rises , patient exhibit a level of responsiveness , which may
progress
• Treatment of choice is HIGH FLOW O2at 100% through tight fitting
• Rebreathing mask
UPPER AIRWAY INJURY p1026
• Pharynx, larynx, glottis, trachea and larger bronchi
• Injuries can be caused by direct heat by chemical inflammation and necrosis
• Heat exchange capability is so efficient that most heat absorption and
damage occur in pharynx and larynx above true vocal cords
• Heat damage may be severe to cause upper airway through resuscitation
period.
• Caution: HYPOVOLEMIA, Supraglottic edema maybe delayed until fluid
resuscitation is underway
• Monitor : hoarseness , stridor audible airflow turbulence production of
carbonaceous sputum.
Continue:

• Intubation is recommended whenever airway patency is questionable

(secure)
• Maintain pulmonary toilet ,treating bronchospasm
• Therapeutic deep breathing early mobility , suctioning and bronchodilator
assist in mobilizing and removing secretions
• Precaution: ventilator-associated pneumonia
LOWER AIRWAY INJURY
• Typically caused by chemical damage to mucosal surfaces
• Tracheobronchitis with severe spasm may occur first minutes to few hours
of injury (test :XENON VENTILATION/Perfusion lung scan
• Secondary effects:
• 1.Thermal damage
• 2.massive fluid resuscitation and high volume-high pressure can precipitate
ACUTE LUNG INJURY(ALI)
• 3.ACUTE RESPIRATORY DISTRESS
Management:
• Lung protective ventilation with low tidal volumes,
• Higher level of end expiratory pressure (PEEP)
• Plateau pressures maintained below 30 mmHg
CIRCULATORY MANAGEMENT
• Assess extent depth of burns ,TBSA calculated for estimation of
resuscitation requirements
• Parkland formula:
• Burn shock caused by loss of fluid from vascular compartment into area of
injury resulting in hypovolemia
• The larger the percentage of burn the greater the potential of shock
• Lactated Ringers(>16 gauge) in a peripheral vein
• Restore cardiac output to normal in most patients
Lactated Ringers closely matches extracellular fluid
• Isotonic salt solution generate no difference in osmotic pressure between
plasma and interstitial space
• The entire extracellular space must be expanded to replace intravascular
losses
• Diuretics must not be given during the resuscitative phase of burn care
• Meticulous attention to intake and output ,heart rate,BP,level of consciousness
• Under resuscitation may result to inadequate organ perfusion and potential
for wound conversion from partial to-full thickness injury
• Over resuscitation may lead to moderate to severe pulmonary edema ,
excessive wound edema , causing decrease in perfusion of unburned tissue
in distal portions of extremities or to edema inhibiting perfusion of zone of
stasis , resulting in wound conversion (the process by which superficial
partial thickness burns convert into deeper burn necessitating surgical
intervention) from partial to full thickness injury
• Fluid requirements maybe much higher than estimated ,using Parkland
Formula
• ECGs used for thermal burns –injured patients in the presence of electrical
burns , inhalation injury or associated traumatic injury
• ECG leads placements may present a challenge with intensive burns
CHEMICAL BURNS
• Causes :Alkalis ,acids and inorganic compounds
• Injury :pH of the product or by concentration of product
• EXOTHERMIC EFFECT(produce heat )
• LARGE AMOUNT OF WATER should be used to flush the area
• Eye burns: continuous irrigation for many hours after injury,remove contact
lenses before irrigation
• Phenol burns
• Hydrofluoric acid ( Tx:2.5 %calcium gluconate gel)
ELECTRICAL BURNS
• Alteration in acid-base balance
• *RHABDOMYOLYSIS resulting in MYOGLOBINURIA:
• *MYOGLOBIN is normal in constituent in muscle. Extensive destruction, it is released
into the circulatory system and filtered by the kidneys ,it can be highly toxic can lead to
acute renal failure
• FLUID RESUSCITATION does not correlate with Parkland formula
• *+HEMOGLOBINURIA =myoglobinuria and acidosis (TX Sodium bicarbonate may be
administered to bring pH level =normal
• Diuretics may be administered IV until myoglobinuria is resolved (forced alkaline
diuresis)

• Baseline ECG and myocardial biomarker levels are obtained

Check for Cardiac Status
• Hx of loss of consciousness/cardiac arrest
• Cardiac Dysrhythmia at the scene of accident
Abnormal ECG
more than 20% TBSA
Very young age /advanced age
Prior Hx of heart disease