Burns Initial Care
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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.