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					IN THE NAME OF GOD
#BURNS
        BURNS INCIDENCE
   Approx. 140 Burn Centers in U. S.
   Approx. 1.25 million people suffer a burn
    injury in the U.S. each year.
   About 5,500 people die from burns and
    related inhalation injuries annually
   Young people and elderly are high risks
   Most injuries occur at home
   75% of patients are victims of their own
    actions
Burns
   Devastating         Nurse’s role:
   Heals slowly            Be knowledgeable of
                             the pathophysiology
   Disfiguring              of burns
   Long months of          Help meet
    rehabilitation           biopsychosocial
   Occupational             needs
    therapy                 Carry out measures
                             to meet physical
                             needs
Phases of Burn Care
   Emergent/Resuscitative Phase (onset of injury
    to completion of fluid resuscitation)
      On the scene care (ABC, initial wound care, injury)

      Management of fluid loss & shock

   Acute/intermediate Phase (beg. of diuresis to
    near completion of wound closure)
      Maintenance of resp. & circulatory status, fluid &
       electrolyte balance, GI function
      Infection prevention, wound care, pain
       management, nutritional support
   Rehabilitation Phase (wound closure to optimal
    level)
      Wound healing, restoring maximal functional
       activity, alterations in self-image & lifestyle
                        Burns
   Emergency management
       cold wet towels, cool water, no direct ice, cover
        with sterile dressing
       don’t break blisters
       lotion only after a burn is completely cooled
       wrap loosely to avoid putting pressure on burned
        skin
       ABC
       Prevent shock
       Fluid replacement
       Flush area thoroughly with water or saline
        (chemical burns)
                      Burns
   Short term effects of burns
       fl volume deficit
       hypovolemic shock
       infection
   Long term effects of burns
       scarring (full thickness burns)
       contraction
                     Burns
   Minor burns
       <15% TBSA with <2% full thickness


   Moderate burns
       partial thickness burns 15-25% TBSA with
        2-10% full thickness
                     Burns
   Major Burns
       >25% TBSA or >10% full thickness
        involvement of hands, feet, face or
        genitalia


   Survival due to refinement of fluid
    resuscitation management and early
    transfer to burn unit.
                  Burns
   Facial burns have the possibility of
    airway impairment
   Important to know the circumstance of
    burn:greater risk of airway involvement
    if burn occurred in closed space
   Always suspect a head injury if a
    patient had an electrical burn which
    resulted from a fall
         Mechanism of Burn
             Injuries
   flame (thermal) 55%
       contact with fire etc.
       (smoke inhalation can be as damaging as
        thermal)
       get pt. Supine to decrease facial burn
        (STOP, DROP, ROLL)
       prolonged exposure to cold considered
        thermal burn
          Mechanism of Burn
              Injuries
   Scald 33%
       most common for children
   chemical 10%
       severity depends on duration of contact, conc.
        Strength of chemical, amt. Of tissue exposed
       alkaline more serious than acid
       irrigate area immediately (most chem labs have
        high pressure showers)
       powder-brush off; do not inhale
             Mechanism of Burn
                 Injuries
   chemical con’t
       chemical burns destroy tissue through
        protein coagulation rather than heat
       some acids (sulfuric and muriatic) also
        destroy tissue through heat production in
        chemical reaction with tissue
       first aid
            take of clothes (chemical on clothes)
         Mechanisms of Burn
              Injuries
       First aid of Chemical con’t
            if powder, dust off before irrigate
            so not attempt to neutralize agent (takes valuable time)
            running water will dilute the chemical
   Electrical <10%
       voltage running through body can do a lot of
        damage (leaves an exit wound as well as entrance
        wound); evaluate internal damage along the path
        of the current
         Mechanisms of Burn
              Injuries
   Electrical con’t
       as electrical current goes through tissue, it
        produces heat causing thermal coagulation
        necrosis
       immediate extent of injury unknown
        (electrical current pathway)
       deep muscle burn-burgundy color urine
Classification of Burns
   Burn injuries are           Depth
    described according             Superficial Partial-
                                     thickness
    to:                             Deep partial-thickness
       Depth of injury             Full-thickness
       Extent of body          BSA
        surface area (BSA)          Rule of nines
        injured                     Lund & Bowder method
                                    Palm method
        Classification of Burns
   First degree (superficial partial-
    thickness)
       eg. Sunburn
       involvement: usually epidermis only
       symptoms: tingling, hypersthesia (inc.
        sensitivity to pain), skin reddened,blanched
        with pressure, minimal or no edema
       how it heals: some peeling over a week,
                  no scar
             Types of Burns
   Second degree burn (partial-thickness)
       eg. Scalding burns
       involvement:epidermis and part of dermis
       symptoms: hyperesthesia, sensitivity to
        cold, blistered mottled red base, broken
        epidermis , weeping surface
       how it heals: new epidermis grows in
                  1-3 weeks
               Types of Burns
   Third degree (full thickness)
       eg. Fire burn, prolonged exposure to hot liquid
       involvement: epidermis, entire dermis, and
        sometimes subcutaneous tissue, muscle, and bone
       symptoms: painless, s/s shock, hematuria,
        hemolysis of blood likely,skin and fat exposed
        edema, skin (dry, pale white, or charred)
       how it heals: needs skin grafting unless very small
                        Burns
   Rules of nine (total equals 100%)
            arms 9 each (4 1/2 front, 4 1/2 back)
            legs 18 each (9 front, 9 back)
            trunk 36 (front 18 and back 18)
            head and neck 9 (41/2 front, 4 1/2 back)
            perineum 1

   A superficial burn can bring on a severe
    systemic reaction when it covers a large
    body surface area
                    Burns
   Suspect inhalation injury if victim has
    burns on head, neck, or anterior chest
   s/s inhalation injury
       dyspnea, carbonaceous sputum, wheezing.
        Hoarseness (caused by laryngeal edema),
        altered mentation
                     Burns
   Pain
        continuous problem with second-degree
        burns but not third degree because nerves
        have not completely been destroyed as
        with third degree
       when eschar removed from third degree,
        other pain mechanisms become operative
                      Burns
   Assessing a patient with burns
     ABCs

        history and physical, rules of
        nine,pulmonary status,check peripheral
        pulses on burned extremities,vital signs,
        urine output, labs fluid replacement,
        prevention of infection, psychological
        needs
   temp usually hypothermic
Physiologic Changes con’t
   Pulmonary
       carbon monoxide most common cause of
        inhalation injury because it is a byproduct
        of the combustion of organic materials
        and therefore present in smoke (need
        100% O2 due to cell hypoxia
       upper airway injury, pulmonary edema, etc
     Physiologic Changes in
          Burn Injury
   Cardiovascular
       outpouring of catecholamines from SNS
        (sympathetic nervous system) with injury
        which leads to peripheral blood vessel
        constriction and increase pulse rate
       vessels become more permeable due to
        injury and allow fluid and colloids to leak
        into surrounding tissues (third spacing)
Physiologic Changes con’t
   Cardiovascular
       peripheral vascular vasoconstriction further
        decreases cardiac output
       with third spacing less intravascular fluid
        which leads to low blood volume and low
        cardiac output which contributes to
        inadequate tissue perfusion
Physiologic Changes con’t
   Renal
       decreased renal blood flow which leads to
        glomerular damage
   GI
       hypovolemia leads to gastric dilatation and
        paralytic ileus
       Curling’s ulcer-stress ulcer
Physiologic Changes con’t
   Fluid and Electrolytes
       hyponatremia (first week of acute phase)
        as water shifts from interstitial to the
        vascular space
       hyperkalemia (immediate after burn)
        results from massive cell destruction
       hypokalemia may occur later with fluid
        shifts and inadequate potassium intake
                        Burns
   Pyschosocial
       self-concept
       body image
   There is a rapid fluid and electrolyte change
    taking place
       fluid loss leads to decreased blood volume which
        leads to thicker blood and decreased efficiency of
        circulation. There is a inc cellular elements of
        blood which leads to inc Hct
                        Burns
   What happens in third spacing
       burns produce a dilatation of capillaries and the
        small vessels in the area of the burn leading to
        increase capillary permeability. The plasma seeps
        out into the surrounding tissues which produce
        blisters and edema..
       The capillary walls that are damaged permit
        plasma proteins to move into interstitial
        (extracellular) spaces
                      Burns
   Third spacing con’t
        the developed capillary permeability allows
        plasma proteins to go through the barrier.
       There is decreased osmotic pressure in
        blood vessels and increased osmotic
        pressure in interstitial space and fluid
        accumulates at the burn sites in blister
        leading to third spacing loss. Fluid shift is
        from vascular compartment to third space.
                  Burns
   Fluid loss with burns great. Fluid loss
    by evaporation 20 times greater than
    normal. Loss due to evaporation called
    white bleeding.
                        Burns
   First 24-48 hours
       large amounts of Na+ move with fluid from
        intravascular (within vessels) to interstitial fluid
        (Normally Na+ present approximately in same
        proportions both in intravascular and interstitial
        areas)
       Increase in release of aldosterone and antidiuretic
        hormone as a result of general stress response
        (this inc amt of Na+ and H2O retained. Pt.
        Becomes oliguric.
                        Burns
   First 24-48 hours con’t
       K+ elevated in blood since tissue destruction and
        oliguria (hyperkalemia)
       Patients’ feet cold due to inc. BMR (body’s
        reaction to try to replace heat lost from
        evaporation)
                        Burns
   48-72 hours
       Na+ shifts back to intravascular space (capillaries
        begin to regain their integrity)
       Diuresis leads to low K+ (hypokalemia)
       RBC loss from a microangiopathic anemia
        (severeness depends on extent of burn)
       RBC destruction initially caused by heat of the
        burn and later by hemolysis of heat damaged cells
        (result not only anemia but possible
                       Burns
   48-72 hours con’t
       kidney damage. Damaged RBC’s release Hgb
        which is filtered by kidneys.
       Myoglobin is released by damaged muscle tissue.
        Both are filtered by kidneys and kidney tubules.
        They may get plugged which leads to acute tubule
        necrosis.
   Diuresis phase lasts 3-5 days after burns.
    Vascular leakage recovery complete.
                 Burns
   Parkland/Baxter Formula
     4 ml RL/kg body wt X % TBSA=ml RL for
      24 hours
     eg. Pt. wt=75 kg and burned 25%

    4/75/25=7500 ml/24 hours
    50% 1st 8 hours=3750ml
    25% 2nd 8 hours=1875 ml
    25% 3rd 8 hours=1875
                  Burns
   Parkland/Baxter Formula
     eg. Pt. Wt 82kg body wt and burned 58%
    4/82/58=19024 ml/24 hours
    50% 1st 8 hours=9512 ml
    25% 2nd 8 hours=4756 ml
    25% 3rd 8 hours=4756 ml
   Usually D5 1/2 NS with KCL when pt in
    diuretic phase
                     Burns
   Goal: perfuse vital organs as fully as
    possible without overload
   Nutrition
       greater protein requirement due to
        negative nitrogen balance
       2 times calories
       2 times protein
                      Burns
   Full thickness burns result in death of
    skin and subcutaneous tissue
   Compartment syndrome
       pain, pallor, decreased capillary refill,
        decreased peripheral pulses, decreased
        sensation, impaired movement (Poor
        peripheral tissue perfusion)
                       Burns
   IV best route for pain relief (peripheral
    vasoconstriction limits absorption of drug
    given IM or SQ route)
   Open wound-use bed cradle
   Circumferential burns usually involve an
    extremity
       edema may shut off circulation and an
        escharotomy or fasciotomy may be necessary to
                      Burns
       relieve the constriction and return normal
        blood flow
   Infection remains a threat until all
    second degree burns have healed and
    third degree burns have been closed by
    grafting (second degree could become
    third degree if infection goes deeper)
              Burns (Grafts)
   Graft-a piece of tissue separated
    completely from its normal and original
    position and transferred by one or more
    stages to correct a distant defect
   Free graft: completely separated from
    their donor site (blood supply
    completely interrupted)
       survival of graft depends on vascular bed
        from recipient site
              Burns (Grafts)
   Free flap graft (free-tissue transfer)
       cover a variety of wounds, cover exposed
        tendons, bones, major blood vessels.
       Completely severed from the body and
        transferred to another site
   Pedicle graft
       a segment of tissue that has been left
        attached at one end (pedicle) while other
        end has been
              Burns (grafts)
   Pedicle graft (con’t)
       moved to recipient area
       used when thick pieces of skin that could
        not survive an interruption of blood supply
        are transplanted
       usually about 3-4 weeks for sufficient blood
        supply to be established
                 Burns (grafts)
   Split thickness graft
       varies from thin to nearly full thickness of
        skin
   Full thickness graft
       composed of a full depth of skin(epidermis
        and dermis)
               gives best cosmetic appearance so used for face,
                neck, hands
                Burns (grafts)
   Pre-op skin grafts
       hgb and clotting time noted since their
        levels can affect healing process
       tissues need to be free from infection
       pt in optimum physical condition
       pt teaching
              Burns (grafts)
   Necessary for a graft to take
       recipient bed must be adequately
        vascularized
       graft must be in complete contact with the
        bed
       immobilization must be assured
        area must be free from infection
                 Burns (grafts)
   Types of grafts
       allografts (cadaver) temporary
       xenografts animal (pigskin)
       autografts (self)
            split thickness-epidermis 8-12 thousandth of an
             inch thick
            full thickness-full depth of skin
            sheet grafts are put on joint areas (areas that
             stress) and secured with staples or sutures
                   Bone (grafts)
       Autografts (con’t)
            mesh grafts-donor skin expand to cover large area
             expands graft 1 1/2 -9 times its original surface
            culture epithelial growth medium-grows 50-70 times
             initial sample (donor site heals in 1-2 weeks)
   Debridement
       Surgical (excise)
       Mechanical or enzymatic (commercial preparation)
       natural (body and bacterial enzymes dissolve
        eschar
“Cultured Skin” ref UCSD 2001
   Growing cultured skin from samples
    taken from patients

   Copyrighted materials have been deleted from this slide
         Burns (medications)
   Silver nitrate 0.5% (rarely used)
       con’t wet dressing effectively prevents cross
        infection
       >0.5% injures the tissue and not effective<0.5%
       danger of electrolyte imbalance (especially Na and
        K) since the electrolytes are withdrawn from the
        body fluids and also from the dressing.
       Turns black in sunlight and stains clothes and
        hands black
         Burns (medications)
   Silvadene
       wide-spectrum antimicrobial that is
        nonstaining and relatively painless
       no systemic metabolic abnormalities
        however is contraindicated in pregnant
        women near term and premature infants
       does not penetrate the eschar as well as
        sulfamylon
         Burns (medications)
   Sulfamyalon acetate
       interferes with bacterial cellular metabolism
       diffuses rapidly through burned skin and eschar
       used for gram-negative organism
       burning sensation after applied topically
       may cause metabolic acidosis and is a carbonic
        andryrase inhibitor
       may cause a rash
         Burns (medications)
   Furacin-nitrofurazone (gauze or cream)
       a synthetic broad-spectrum antibacterial
       inhibits enzymes required for carbohydrate
        metabolism in bacteria


   Xeroform-a fine mesh gauze with
    antimicrobial action
Case Study
   A 42-year old patient is brought to the ED
    after being rescued from a house fire, where
    firefigthers found her unconscious in a
    bedroom closet. She has sustained burns to
    her right arm, right chest, and both lower
    extremities. On admission, she arouses to
    painful stimuli only. Her VS are BP 140/74,
    HR 112, RR 30/min and labored. She is
    afebrile. She has facial edema and visible
    soot in the oral pharynx and nares. Crackles
    are heard on auscultation, with decreased
    resp. excursion. Stridor is audible. The
    affected skin areas are white and inelastic,
    surrounded by heperemic, moist-looking
    tissue. She has pain on pinprick in the
Case Study cont.
   Lab results reveal a mildly elevated
    glucose level, elevated Hg and Hct.
    Urine specific gravity of 1.030. Low
    PaO2 and an elevated
    carboxyhemoglobin level, at 37%.

   What is your treatment plan? Nursing
    Diagnosis?
           What to do about the
             pain during PT
   U of W Harborview Burn Center is using VR
    (virtual reality)
       a non-pharmacological analgesic (distraction)
       used in addition to traditional levels of opioids
        during wound care and physical therapy
       found VR worked much better than Nintendo64
       pilot study showed dramatic drops in pain during
        treatments
         Why VR works for pain
   Pain perception is largely psychological
   pain requires conscious attention
    VR draws pt into another world (this drains a
    lot of attentional resources leaving less
    attention available to process pain signals)
       in snow world for example the patient fly through
        icy canyons etc (pts experience burning sensation
        during wound care so this game is designed to put
        out the fire)
    NY Hospital-Cornell Medical Center
        Burn Center (1998 data)
   5,000 outpatients seen/yr (>1,000
    children)
   1,300 inpatients seen/yr
   team approach(surgeons,nurses,
    therapists, nutritionists, social workers)
   mission
        develop an increasing effective teaching
         and
    NY Hospital-Cornell Medical Center
        Burn Center (1998 data)
   NY’s mission con’t
        public awareness methods
        having the highest standards of clinical and
         therapeutic excellence
   continued expansion of research in all phases
    of thermal injury
        an optimum environment in which patients may
         recover with the help and expertise of NY’s
         hospital-wide administrative, medical and
         paramedical specialists
             UW Burn Center
   Approach to deep burn wounds
          remove wound surgically within 1st post burn
           week
          immediate grafts after wound removed to
           provide best functional and cosmetic results
   Treatment for (TEN) Toxic Epidermal
    Necrolysis disease resulting from a
    drug reaction whereby the body’s entire
    epidermis sloughs
            UW Burn Center
   treatment of TEN con’
       use of pig skin and immaculate supportive
        care
       mortality has been reduced from 70% to
        15%
       hospital stay has been reduced from
        months to average of 3 weeks
             UCSD Burn Center
   450 admits/year
       Brave Heart Kids Program
            Activities
            Work on promoting self-esteem
Baltimore Regional Burn Center
        (John Hopkins)
   1800/year outpatients
   Michael D. Hendrix Research Center
       Died from burn and ARDS in 1995 Delta plane crash in
        Georgia
       Family donated large amount of money to research
   Research
       Infection prevention
       Wound healing
       New ways to culture skin
       Treatment of ARDS
       Immunologic response to burns
          Prevention of Burn
               Injuries
   Proper education and supervision
       childproof items in electrical sockets
       keep dangerous items (matches) out of
        reach
   Safety measures for the elderly
   teach small children 911
   smoke detectors in house
   STOP, DROP, AND ROLL

				
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