Burns Initial Care

							              Burns:
           Initial Care

             A Learning Program
                  provided by the
              Rural Health Office
                      of the
Mel and Enid Zuckerman College of Public Health
                      at the
         University of Arizona, Tucson




                  Written by
        Daniel G Judkins, RN, MS, MPH
                 August 2005
                 Pre-Test
Open the separate file on this CD, and print
 out the pre-test and pre-test answer sheet.
 Take the test. Next, open the file
 containing the pre-test answers, and
 grade your test.

If you have not already completed the pre-
   test, exit this file now, take the pre-test,
   then return here.
       Learning Objectives

1)   Define 1st, 2nd, and 3rd degree burn.

2)   List three signs of burned airway.

3)   State most important emergency action for a burned airway.

4)   State most important emergency action for a chemical burn.

5)   Discuss the external appearance of an electrical burn entrance
     or exit wound with respect to the internal damage.
     Learning Objectives, continued

6)    Describe why a burned airway requires endotracheal intubation.

7)    Given the extent of a burn (in percent), define the fluid
      re-hydration treatment plan.

8)    Define myoglobinuria in the context of burn injury, and describe
      its treatment.

9)    Choose the type of wound covering that should be used for the
      initial treatment of a burn. What type of topical medications
      should be applied to a burn early in the emergency care
      process?
      Learning Objectives, continued

10)    Discuss pain control for early care of burn patients.

11)    Discuss priorities when the patient has serious burns plus
       serious multiple trauma.

12)    Given a description of the extent of a burn, calculate the
       percent using the “rule of 9’s”.

13)    Describe the process of transferring a burn patient to a burn
       center.
Outline of Learning Program

     •   1st degree
     •   2nd degree
     •   3rd degree
     •   Airway burns
     •   Chemical burns
     •   Electrical burns
Outline of Learning Program,
                continued
     • Safety
        – Gasoline
        – Explosions
        – Stop the burning
     • Airway/breathing
        – Assessment
        – Treatment
     • Circulation
        –   Fluid resuscitation
        –   Parkland formula
        –   Pediatric fluid management
        –   Urine output
        –   Special fluid management
Outline of Learning Program,
               continued

     • Emergency wound care
         – Covering the wound
         – “Do not…”
     •   Pain management
     •   Burns combined with serious trauma
     •   Burn extent: the rule of 9’s
     •   Transfer to a burn center
     •   References
          First Degree Burns
Superficial:
• red
• dry
• painful without blisters
• blanches with pressure
• do not include in BSA% estimate
• sunburn
• epithelium injured but intact
   Second Degree Burns




 Partial Thickness:
• red
• blisters
• weepy
• shiny
• blanches with pressure
• painful
• scald
• epithelium and varying layers of dermis are destroyed
      Third Degree Burns


Full thickness:
• red
• dry
• white
• charred
• leathery
• hair follicle removes easily
• less pain
• extends to subcutaneous layer, muscle, bones
• epidermis and dermis are destroyed
Depth of burn
       Airway burns
     Burned while sniffing gasoline




On arrival               One hour later
            Airway burns
• Assessment
  – Mechanism of injury: closed space
  – Face burns, singed facial hair, carbonaceous
    sputum, soot on face, hoarse cough, voice
    change, respiratory distress, can’t swallow,
    lab: carboxyhemoglobin > 10%
• Treatment
  – 100% oxygen (humidified)
  – Early endotracheal intubation
  – Aggressive suctioning
  – Monitor chest wall excursion for deep torso
    burns
  – Refer to Burn Center
             Chemical burns
•   Use full personal protective equipment
•   Remove clothing and jewelry
•   Bush away any dry powder before irrigating
•   Flush with lots of warm water on scene and
    during transport
•   Identify agent after emergency treatment
•   Eye: remove contacts, continuous irrigation with
    saline
•   Certain chemicals require special considerations
    (such as hydrofluoric acid)
•   Refer to burn center
 Electrical burns
• Safety: turn off power
• CPR, if indicated
• Remove clothing and
  jewelry
• Assess for hidden
  injuries
• Monitor for
  arrhythmias
• Assess neuro status
• Assess pulses in
  affected extremities
• IV fluid resuscitation,
  to physiological
  response

                            foot was later amputated due to extensive damage
    Safety
• Assess scene for
  safety
  – Spilled gasoline               Spilled fuel
  – Downed electrical lines
  – Possibility of
    explosions
• Stop the burning
  – Remove smoldering
    clothing




                              Note downed power pole
         Airway / breathing
• Assessment
  – Hypoxia, dyspnea
  – Indictors of airway burn
  – Pulse oximeter may not be
    accurate due to
    carboxyhemoglobin


• Treatment
  – Oxygen at 10% (humidified)      What’s wrong with this picture?
  – Endotracheal intubation early
         Circulation

• Circulation
   – Fluid resuscitation
      • Two large-bore IV’s in non-burned extremities (or through
        burn if necessary)
      • Use Lactated Ringer’s
      • Estimate body surface area burned (2nd & 3rd degree)
   – Parkland formula
      • Adults: 2-4 mL x kg x %burn. Give 1st half over 1st 8 hours
        and remainder over next 16 hours.
      • Peds > 10 years old: same formula as for adults
      • Peds < 10 yeas old: Start with 3-4mL x kg x %burn, then
        consult with Burn Center. Use both LR and D5LR in young
        children.
             Urine Output
• Urine output
  – Move to fluid maintenance by titrating to
    urine output
    • Adult, adolescent: 30-50 mL/hr (0.5 mL/kg/hr)
    • Peds under 30 kg: 1 mL/kg/hr
    • High voltage electrical injury: 75 – 100 mL/hr
      (1-2 mL/kg/hr)
  – Place Foley and do hourly urine outputs
          Myoglobinuria
• Due to muscle damage
• High risk in electrical injury
• May add 12.5 to 25 grams of mannitol plus 1
  amp sodium bicarbonate to each liter of LR
   Emergency wound care
• Cover patient with clean or sterile dry sheet.

• Do not use wet dressings.

• Do not apply topical medications or substances
  such as antibiotic ointments.

• Keep the patient warm; prevent hypothermia.
  Use blankets, cover head, use thermal blanket.
      Special fluid management
              situations
•   Electrical injury
•   Inhalation injury
•   Patients where early resuscitation was delayed
•   Intoxication
•   Dehydrated patient
•   Patient also in hemorrhagic shock
•   Elderly
•   Pre-existing cardiac or renal disease
•   Consult with Burn Center early
         Pain management

• Morphine IV if BP normal.

• No IM pain meds.

• Consider anxiolytic meds.

• Do not use ice or iced normal saline as a comfort
  measure.
     Burns combined with
       serious trauma

• Handle as a major trauma patient.
• Trauma concerns take priority over
  burn concerns, except for airway
  burn.
• Take to trauma center.
  Burn extent: “The rule of 9’s”


Head: 9%
Arm: 9%
Leg front: 9%
Leg back: 9%
Chest: 9%
Abdomen: 9%
Upper back: 9%
Buttocks: 9%
Perineum: 1%
(Area of palm): 1%
          Pediatric
Body Surface Area Calculation
             Criteria for
      transfer to a burn center
• > 5% BSA (2nd degree)     • Burns + trauma (may
• Burns to face, hands,       go to trauma center,
  feet, genitalia,            then transfer to burn
  perineum, or major          center)
  joints                    • Burns with pre-
• Any 3rd degree burn         existing medical
                              problems
• Electrical or lightning
  burn                      • Burns in patients
                              needing special
• Chemical burn               social, emotional, or
• Inhalation burn             rehabilitation
        References

• American Burn Association
  – www.ameriburn.org
• Arizona Burn Center
  – www. azburncenter.com
  – 602-344-5726
  – 1-866-PHX-BURN (749-2876)
             Post Test
• Exit this slide show, and go to the
  post-test included on this CD.
• Take the test, using the answer sheet
  provided.
• Grade the post-test using the
  answers provided in a separate file.
• Compare the scores on your pre- and
  post-tests.