BURNS

Definition
-Cell destruction of the layers of the skin and theresultant depletion of fluid and electrolytes. -Is an injury caused by an exogenous agent that produces a characteristic reaction to local tissues that may vary from mild erythema to full thickness destruction of the skin and inner tissues.

Causes of Burns
1. Thermal o o o Dry heat Moist heat Flash Burn

2. Electrical could be high or low voltage 3. Chemicals could be alkaline or acidic in nature 4. Radiation Ionizing or non-ionizing

Pathophysiology

Skin Loss

Burns

Airway and Lung injuries

Inflammatory and Circulatory Changes

Skin Loss
-Loss of protective barrier enabling microorganism to enter the body resulting in septicemia -Hypovolemia -Loss of skin resulting in altered thermoregulation resulting in hypothermia

Airway and lung injury

-Caused by Fire blast or fumes -inhalation injury -Carbon monoxide inhalation -Mechanical block on rib movement due to chest burns

Inflammatory Changes
Burns Pain and alteration of proteins by heat Release of Neuropeptides and activation of complements

Degranulation of mast cells

Neutrophils attraction and granulation

Release of free radicals and protease

Further damage to tissues

Circulatory Changes
Loss of Skin Increase Capillary Permeability

Direct Fluid Loss

Third Space Fluid Collection

Non Burn Tissue Edema

Circulatory Failure

Classifications of Burns Nomenclature Superficial Burns Partial Thickness Burns Full Thickness Burns Traditional Nomenclature 1 degree burn 2nd degree burn 3rd degree burn
st

Estimating Extent of Burn

Lund and Browder Method y y y Modifies percentages for body segments acc. to age Provides a more accurate estimate of the burn size Uses a diagram of the body divided into sections, with the representative % of the TBSA for ages throughout the lifespan Should be reevaluated after initial wound debridement

Assessment of Burn Injury Degree Assessment of Extent st 1 degree Pink to red: slight edema,
which subsides quickly. Pain may last up to 48 hours. Relieved by cooling. Sunburn is a typical example

Reparative Process
In about 5 days, epidermis peels, heals spontaneously. Itching and pink skin persist for about a week. No scarring. Heals spont. If it does not become infected w/in 10 days - 2 weeks.

2nd degree

Pink or red; blisters form (vesicles); weeping, edematous, elastic. Superficial layers of skin are destroyed; wound moist and painful. Deep dermal: Mottled white and red: edematous reddened areas blanch on pressure. May be yellowish but soft and elastic may or may not be sensitive to touch; sensitive to cold air. Hair does not pull out easily

Takes several weeks to heal. Scarring may occur.

Takes several weeks to heal. Scarring may occur.

3rd degree

Destruction of epithelial cells epidermis and dermis destroyed Reddened areas do not blanch with pressure. Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar. Destruction of epithelium, fat, muscles, and bone.

Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft. For areas larger than 3-5 cm, grafting is required. Expect scarring and loss of skin function. Area requires debridement, formation of granulation tissue, and grafting.

Burn Interventions
 MAINTAIN AIRWAY  FLUID RESUSCITATION  RELIEVE PAIN  PREVENT INFECTION  PROVIDE NUTRITION  PREVENT STRESS ULCERATION  PROVIDE PSYCHOLOGIC SUPPORT  PREVENT CONTRACTURES

Management of Burn Injury

Emergent phase - begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury - the 1 goal is to prevent hypovolemic shock and preserve vital organ functioning - includes prehospital care and emergency room care Resuscitative phase - begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased - the amount of fluid administered is based on the client s weight and extent of injury - most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital - the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion

Acute phase - begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun - usually begins 48 - 72 hours after the time of injury - emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved - the focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy

Rehabilitative phase - final phase of burn care - overlaps the acute care phase and goes well beyond hospitalization - goals of this phase are designed so that the client can gain independence and achieve maximal function

Fluid Shifting in Burns OLIGURIC PHASE Intravascular to Interstitial Hct increased, renal output decreased, hyper K, hypo Na, hypo CHON, metabolic acidosis DIURETIC PHASE Interstitial to Intravascular Hct decreased, renal output increased, hypo K, hypo Na, hypo CHON, metabolic acidosis

MANAGEMENT OF BURNS
A B C D E F Airway Breathing Circulation Disability Exposure with environment control Fluid Resuscitation

FLUID RESUSCITATION
 Indications: - Adults with burns involving more than 15% - 20% TBSA - Children with burns involving more than 10-15% TBSA - Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury  The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr  Successful fluid resuscitation is evidenced by: - Stable vital signs - Palpable peripheral pulse - Adequate urine output - Clear sensorium  Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion  If the Hgb and Hct levels decrease or if the urinary output exceeds 50ml/hr, the rate of IV fluid administration may be decreased

 Generally, a crystalloid (Ringer s lactate) solution is used initially. Colloid is used during the 2nd day (5% albumin, plasmate or hetastarch)

Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st 24hrs after a Burn Injury Formula BROOKE 2ml/kg/% BSA + 2000ml/24hr (maintenance) PARKLAND (Baxter) 4ml/kg/% BSA for 24hr period Solution crystalloid, colloid D5W maintenance Infusion Rate in 1st 8 hours in next 16 hours

crystalloid only (lactated Ringer s)

in 1st 8 hours in next 16 hours

Parkland formula
Example: Patient s weight: 70 kg; % TBSA burn: 80%

1st 24 hours: 4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringer s  1st 8 hours = 11,200 ml or 1,400 ml/hour  2nd 16 hours = 11,200 ml or 700 ml/hour 2nd 24 hours: 0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period 0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W = 117 ml colloid/hour + 84 ml D5W/hour PAIN MANAGEMENT  Administer morphine sulfate or meperidine (Demerol), as prescribed, by the IV route  Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring  Avoid administering medication by the oral route, because of the possibility of GI dysfunction  Medicate the client prior to painful procedures

NUTRITION  Essential to promote wound healing and prevent infection  Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed  Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition Provide a diet high in protein, carbohydrates, fats and vitamins

ESCHAROTOMY  A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation  Performed for circulatory compromise resulting from circumferential burns  After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure  Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed  Apply topical antimicrobial agents as prescribed FASCIOTOMY  An incision is made, extending through the SQ tissue and fascia  Performed if adequate tissue perfusion does not return after an escharotomy  Performed in OR under GA, after procedure assess same as above WOUND CARE 1. The cleansing, debridement and dressing of the burn wounds 2. Hydrotherapy a. Wounds are cleansed by immersion, showering or spraying b. Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress c. Client should be premedicated prior to the procedure d. Not used for hemodynamically unstable or those with new skin grafts

3. Debridement a. Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing b. May be mechanical, enzymatic or surgical c. Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily

Method OPEN


Open Method Versus Closed Method of Wound Care Advantages Disadvantage

   Visualization of the wound Easier mobility and joint ROM Simplicity in wound care  Increase chance of hypothermia from exposure

Antimicrobial cream applied, and wound is left open to the air w/o a dressing Antimicrobial cream is applied every 12 hrs

CLOSED
 Gauze dressings are carefully wrapped from the distal to the proximal area of the extremity to ensure circulation is not compromised No 2 burn surfaces should be allowed to touch; can promote webbing of digits, contractures, and poor cosmetic outcome Dressings are changed every 8 12 hours

 

Decreases evaporative fluid and heat loss Aids in debridement

  

Mobility limitations Prevents effective ROM exercises Wound assessment is limited

WOUND CLOSURE     Prevents infection and loss of fluid Promotes healing Prevents contractures Performed on the 5th to 21st day, depending on the extent of the burn

AUTOGRAFTING  Permanent wound coverage  Surgical removal of a thin layer of the client s own unburned skin, which is then applied to the excised burn wound  Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence  Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed  Care of the graft site  Care of the donor site

TEMPORARY WOUND COVERINGS Biological Amnion  Amniotic membranes from human placenta  Dressing is changed every 48 hours Allograft (Homograft)  Donated human cadaver skin is harvested w/in 24 hrs after death  Monitor for wound exudate and signs of infection  Rejection can occur w/in 24 hours Xenograft (Heterograft)  Porcine skin is harvested after slaughter and preserved  Rejection can occur w/in 24 72 hours  Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete

Sources: http://www.slideworld.org/slideshow.aspx/BURNS%27-Etiology,-PathophysiologyManagement-ppt-2843023#1a

http://www.surgical-tutor.org.uk/default-home.htm?core/trauma/burns.htm~right

http://www.medicinenet.com/burns/article.htm

http://www.scribd.com/doc/2199673/5-2-BURN1