Why do people die from burns?
Shock, dehydration, sepsis |
If pt survives first 72 hours infection |
Universal Trauma Model
American Burn Association (ABA)
- Develops strategies, prevention, research |
PRIMARY GOAL IS PREVENTION! |
Burn: alteration in skin integrity resulting in tissue loss/damage |
4 Major Types/Causes of Burns
Thermal |
Chemical |
Electrical |
Radiation |
Thermal Burns
MOST COMMON |
Due to exposure to dry heat (flames) or moist heat (steam, hot liquids) |
Direct exposure to heat = cell destruction |
Includes inhalation injuries r/t gases (CO) & particles
Chemical Burns
Direct skin contact w/ acidic or basic agents
- Treating acidic easier than basic (caustic) |
May cause local tissue damage, system tox. |
Damage can continue until traces disappear |
Includes powders & gases |
Treat quick to flush pH & lessen damage |
Electrical Burns
Higher mortality than thermal burns
- Can generate a lot of damage, subdermal - high resistance off of tissues |
Destructive process of electrical burns persists for weeks beyond the insult |
Has an "exit wound" |
Affects...
- Muscles & bones
- Heart (dysrhythmias)
- Rhabdo AKI, acute tubular necrosis |
Electrical Burns - Electrical Current
Radiation Burns
Caused by solar or radioactive agents
- UV burns, thermal radiation, ionizing radiation (x-rays) |
Also may include friction burns r/t trauma |
Inhalation Injuries
Result of resp. tract exposure to direct heat, chemicals, or carbon monoxide poisoning
CO poisoning: CO takes over RBC's AMS, HA, dizzy 100% NRB
Cross Section of the Skin
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Burn Severity Affected By...
Length of exposure |
Mechanism of injury |
Depth of burn |
Location on body |
TBSA % |
Age - children, older |
PMH - DM, CHF |
Entire leg risk of compartment syndrome
Perineum risk of infection
Functions of the Skin
Protective barrier |
Assists w/ fluid & elect. balance |
Thermoregulation |
Excretion |
Sensory organ |
Epidermis: basic protection
Dermis: blood vessels, nerves, sweat glands
SQ: fatty tissue; can have veins, arteries, & nerves
Burn Injuries
1st degree |
(Superficial wounds) |
2nd degree |
(Partial thickness) |
3rd degree |
(Full thickness) |
4th degree? |
(Bone?) |
First Degree Burn
Painful r/t damaged nerves
Warm, blanching effect
Superficial Partial Thickness Burn (Second Degree)
May be shiny, pink, red - blanching?
Scar formation
Deep Partial Thickness Burn (Second Degree)
MORE SEVERE, skin grafts may be necessary
Third Degree Burn
May be black, some redness, yellow
Skin grafts (doesn't heal on own)
Eschar needs to be removed
Breathing issues if front &/or back of chest
Cartilaginous areas may not heal as well (r/t dec. blood supply)
May have some disability
3 Zones of Injury
Zone of coag.: injury site, tissue necrosis
Zone of stasis: inflammatory response = vasoconstriction = tissue may be salvaged
Zone of hyperemia: inc. inflammation = vasodilation = inc. blood flow
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Systemic Response to Burns
All systems are affected |
Extent of dysfunction depends on the TBSA involved |
Early: hypofunction hyperfunction
- Occurs rapidly
- Inc. permeability plasma leaks to interstitial spaces dec. CO r/t dec. fluid volume (dec. BP) hyperfunction (compensatory mechanisms) |
Maximal edema occurs in 8-48 hours |
Major Burn Event
R/t systemic inflammation |
Concerns:
Shock:
- Fluid & electrolyte imbalance
- Temp. regulation
- Pain control (IV)
Infection:
- Reverse isolation (no plants, fresh fruits/veggies, current immunizations)
- Temp. regulation (room ~80oF) |
Lund & Browder Classification
* More accurate than the Rule of 9's
Burn Survival & Burn Size
Suvival rate decreases = TBSA increases
Burn Shock
Leading cause of mortality |
Leads to...
- Hypotension
- Tissue hypoxia
- Acute renal failure |
It's critical to accurately estimate fluid losses in order to determine replacement!
- Replace using Parkland Formula |
Parkland Formula of Fluid Rescuscitation
Lactated Ringer's - corrects Na deficits
Should be started ASAP!
2 PIV's if no central line
Give albumin for edema
Monitor urine output
Priorities w/ Burn Patients
1. Stop the burning process |
2. Airway - ensure patent |
3. C-spine stabilization |
4. Breathing - give 100% O2 or ventilate |
5. Circulation - assess pulses or CPR |
Stages of Burn Assessment/Care
1. Emergent/Resuscitative Phase |
2. Acute Phase |
3. Rehabilitative Phase |
1. Emergent/Resuscitative Phase
24-48 hours |
Point of injury |
Fluid resuscitation |
Big risk of...
- Hypovolemic shock
- Resp. problems
- Compartment syndrome |
Acute Phase
48-72 hours/wound starts to heal |
Starts w/ diuresis - Ends w/ closure of burn wound |
Interventions:
- Reassess ABC's
- Fluid resuscitation
- Urine output (myoglobinuria)
- Circulation (escharotomy)
- Pain control
- Nutritional support
- Focus on wound care
- Prevent infection |
Assessment (Immediate Resuscitative Phase)
A |
Airway intubated prophylactically |
B |
Breathing & ventilation |
C |
Circulation |
D |
Deficits (neuro)
Deformities
Disability |
E |
Exposure |
Rehabilitative Phase
May be years |
Begins w/ wound closure - Ends w/ pt at highest level of functioning |
Finger injury may not heal correctly webbing
Psychosocial therapy
Multidisciplinary care - respiratory therapy, PT/OT, speech therapy, plastic surgery
Wound Care
Debridement
- Surgical, enzymatic
- May be painful ALWAYS pre-medicate
- Prepare for graft |
Dressings
- Gauze
- Biologic (skin, membrane)
- Synthetic
- Biosynthetic |
Skin grafts
- Skin won't heal on its own (full thickness)
- Concerns: circulation, mobilization/ROM, pressure on injury |
Pressure garments |
Hydrotherapy (cleaning) |
Homo-/allografts = humans
Hetero-/xenografts = animals
Protective Barriers
Minor |
Solosite (gel)
Opsite (clear Tegaderm) |
Superficial |
Allevyn
Acticoat (antimicrobial)
Mepillex
Silvadene/Bacitracin (part/full thickness) |
Mid to Deep |
Acticoat |
Scar Management |
Cica Care (silicone gel sheeting)
Jobskin |
Jobskin: worn to prevent contractures, hypotrophic scar formation
- Worn 23 hours/day
- Inhibits pooling, venous stasis
Nursing Diagnoses
Risk for infection |
Fluid volume deficit |
Alteration in...
- Skin integrity
- Tissue perfusion
- Resp. status |
Imbalanced nutrition (weight loss r/t inc. metabolic rate) |
Impaired mobility |
Decreased self-esteem |
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Really informative!
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