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M6 13-005

Exam 16: Burns

Thermal flames, scalding and thermal energy (heat), most common type of burn.
Non-thermal electricity, chemicals and radiation
Effects of the burn depend on what two factors? Extent of body surface burned, total body surface area (TBSA). Depth of burn injury.
Stages of Burns 1. Emergent. 2. Intermediate (Acute or diuretic). 3. Long-term rehabilitation. 4. Possible respiratory distress.
Emergent Phase 1st stage. 24-48 hours. Capillaries dilate and become hyperpermeable. Intravascular fluid into interstitial spaces. Blistering. Blood pressure drops. Acute renal failure (kideny blood flow ↓). Burn shock.
Burn shock characteristics 1) Hypotension, ↓ urine output, ↑ pulse, rapid and shallow respirations, and restlessness. 2) Most deaths from burns result from burn shock.
Intermediate (acute or diruetic) phase. 2nd Stage. 48-72 Hours. Potential for circulatory overload from shift of fluid from interstitial space back into capillaries. Kidneys begin to excrete large volumes of fluid. Circulatory overload can occur and ↑ workload of heart.
How much amperage can cause heave ventricular fibrillation? A current of only 0.1Amp.
Long-term Rehabilitation phase 3rd phase. Begins when the burn wound treatment begins.
Suspect some respiratory distress with any patient who has been burned where? around the upper chest, neck or face. Breathing difficulties may take several hours to occur. The cilia and mucosa may be damaged and atelectasis can occur.
Respiratory symptoms to look for in burn patients 1) Hoarse voice, productive cough, sooty sputum. 2) Singed nasal hairs. 3) Agitation, tachypnea, flaring nostrils, intercostal retractions. 4) Erythema or edema of the oropharynx or nasopharynx.
Superficial (1st Degree burn). The epidermis is injured, but the dermis is unaffected. It heals in less than 5 days, usually spontaneously with symptomatic treatment.
Superficial (1st Degree burn): Type sunburn, low intensity flash flame, brief scald.
Superficial (1st Degree burn): Appearance dry surface without vesicles; minimal or no edema red; blanches on pressure and refills when pressure is removed; increased erythema (redness).
Superficial (1st Degree burn): Sensation Painful
Partial thickness (second degree) Affects both the epidermis and the dermis. A superficial partial thickness burn can heal within 2 weeks with only some pigmentation changes but no scarring. A deep partial thickness burn may need debridement and skin grafts. Healing may take up to 3 wks
Partial thickness (second degree): Type scalds, flash flame to clothes or skin, chemicals, ultraviolet light (sunburn).
Partial thickness (second degree): Appearance blistered, moist, mottled pink or reddened, blanches on pressure and refills.
Partial thickness (second degree): Sensation Very painful
Full thickness (third degree). All the layers of the skin are destroyed and thus there is no pain. If not debrided, this type of burn leads to sepsis, extensive scarring and contractures. Skin grafts are necessary because the skin cells are no longer alive to regenerate.
Full thickness (third degree): May reach muscle and bone
Full thickness (third degree): Type fire, contact with hot objects or liquids, flame, chemicals, electrical contact.
Full thickness (third degree): Appearance tough with leathery eschar; white, charred, dark, brown, tan or red; does not blanch on pressure; dull and dry.
Full thickness (third degree): Sensation Little pain.
Other Complications of Acute phase Heart Failure. Renal Failure. Contractures. Paralytic Ileus. Curling’s Ulcer (vomiting blood 8-14 days after a severe burn).
rule of nines used to determine the total body surface area (BSA) burned
Rule of nines breakdown Head: 9%. Each upper Extremity: 9%. Front torso: 18%. Posterior Torso: 18%. Each lower extremity: 18%. Perineum: 1%.
Rule of nines: Infants & children Upper extremity is 9%. Head and neck is 18%. Anterior trunk is 18%. Posterior trunk is 18%. Lower extremity is 14%.
In the case of chemical burns, it is important to rinse the skin with water to remove the chemicals.
Electrical burns often result in cardiac arrest
the first concern after the burn source has been eliminated Immediate assessment of the patient’s airway
Signs and symptoms of inhalation injury include singed facial hair, black-tinged sputum, soot in the throat, hoarseness and burns around the face.
a life-threatening respiratory sign. Stridor
The goal of IV therapy with a burn patient is to maintain a urine output 50 Ml/hr
Brooke (modified) formula: Lactated Ringers 2 ml x kg body wt x % burn
Brooke (modified) formula: Colloid (plasma, albumin, or DEXTRAN) 0.3 – 0.5 ml x kg body wt x % burn.
Brooke (modified) formula: 5% Glucose/water Approximate evaporative losses (average of 2000 ml for a 220 pound person with a 50% burn).
Parkland-Baxter formula: Lactated Ringers 4 ml x kg body wt x % burn
With burn Patient, Monitor fluid intake and output every hour. This will require insertion of an indwelling foley catheter
A thorough physical assessment is completed every _____ to _____ in the emergent phase 30 minutes to 1 hour.
Patients with severe burns often develop a _____ ______ as a result of trauma. paralytic ileus
Care of burns Open method. Closed method.
The open method (also called the exposed method) exposes the burned areas to air. This method is not used as much since the advent of effective topical antimicrobials.
With partial thickness burns, a hard crust forms in 2 to 3 days
Advantages of the open method. Area can be observed more easily. Movement is less restrictive. Circulation is less restricted. Exercises to prevent contractures can be done more easily.
Disadvantages of the open method. Painful. Body can chill more easily. Potential for contamination. Appearance is unattractive and may cause emotional distress. (e) Protective isolation is required.
The closed (occlusive) method is the preferred method of wound management.
With closed method, The burn area is covered with a non-adherent dressing that consists of gauze impregnated with petroleum jelly or ointment based antimicrobials
Advantages of the closed method. It protects the burn area from further injury. It prevents contamination of the burn area.
Disadvantages of the closed method Its painful
Autograft patient’s own skin, which is transplanted from one part of the body to another.
Allograft or homograft is human skin obtained from a cadaver. This is a temporary graft, which is used to cover a large area. It will slough away after approximately 1 week. It is used until the patient’s own skin can be used for skin grafting.
Heterograft obtained from animals, principally pigs. Like allografts, heterografts are temporary.
Skin Substitutes Alternative materials used to cover the wound and promote healing. Advantage that they can be applied immediately after the skin is cleaned and debrided. You do not have to wait until enough skin is available for grafting purposes.
TransCyte a temporary skin substitute made from neonatal human fibroblast cells.
Biobrane nylon-silicone membrane coated with a protein derived from pig tissue.
The purposes of skin grafting are: Lessen the potential for infection. Minimize fluid loss by evaporation. Hasten recovery. Reduce scarring. Prevent loss of function.
The nutritional challenge with a burn patient is providing enough nutrients to meet the increased metabolic requirement of the burn patient. Adequate nutrition is required for healing and for skin grafting.
Because large quantities of protein are lost through burn wound seepage in fluids, protein intake should be increased up to four times the normal recommended dietary allowance. Calorie needs may be increased to 4000 - 5000/day. In addition, protein, calories and vitamins are required to repair the damaged tissue.
Burn Meds Silver Sulfadiazine (Silvadene). Mafenide (Sulfamylon). Silver Nitrate.
Silver Sulfadiazine (Silvadene) has broad antimicrobial activity against gram-negative, gram-positive and Candida organisms. Beware that repeated applications may develop a slimy, grayish look similar to that of an infection.
Mafenide (Sulfamylon) bacteriostatic against gram-negative and gram-positive organisms. Can penetrate thick eschar but causes some pain with application.
Silver Nitrate bacteriostatic. Apply with wet dressing. Beware that it is hypotonic and will draw fluids and electrolytes from the wound, therefore electrolytes must be monitored. Application also causes pain.
common drug of choice with burn patients for pain Morphine
Created by: jtzuetrong