Burn Flashcards
Injury by Age and High Risk
<3 Years-Scalds
- Children 6-18 months
- Male
- Youngest in family
- Single parent
3-14 Years -> Flames from ignited clothing
15-60 Years -> Industrial accidents
> 60 Years -> Smoking, house fires, and accidents related to momentary loss of consciousness (low functional ability to get out of fires)
- Low support
- Cognitive Deficits
- History of substance abuse (can’t get out of harms way)
Individuals at Risk
Poor work history
Low social support
History of behavioral problems
Occupational:
- Firefighters
- Welders
- Electrician
- Oil or chemical workers
INTEGUMENTARY SYSTEM
Largest organ
Functions:
- Barrier/protector-Container (tbird spacing – skin keeps in place, without skin, can loose body weight)
- Regulator/Homeostatic mechanism
- Synthesizer (melatonin/vitamin D) (endocrine function)
- Sensor
Acid mantle
- 4.5-6 pH
- Lipids and organic salts (combat bacteria)
- Antibacterial and antifungal properties
Anatomy: Epidermis
Thin outer layer
Great capacity for regeneration (highest)
Resistance to corrosive chemicals/mechanical stimuli
- Washing hands a lot in the winter
anatomy: dermis
Thicker, inner layer
Less capacity for regeneration (takes longer to heal)
Contains receptors, vascular network, hair follicles, sebaceous and sweat glands
anatomy: subcutaneous tissue
Thickness varies
No capacity for regeneration
Mostly fat
- heavier, more adipose tissue
tip:
Epi- not as sensitive as dermal layers
Dermis- keeps skin supple
SubQ- grafting required as regeneration is severly limited
Causative Agents
Majority in the home
- Cooking
- Bathing (water heater)
- Smoking (huge, smoke detectors important)
Agents
- Flame
- Chemicals
- Electricity
- Radiation
Depth of Injury: severity depends on
Duration of contact (longer = worse the burn can be)
Temperature of the agent
Amount of tissue exposed
Ability of the agent and tissue of dissipate the thermal energy (how viscous a liquid substance is)
tip:
Duration- How long was the agent on the skin? Ie. Molten metal vs water. (stays hotter longer)
Temp-
Water dissapates energy quickly. Oil does not.
Level of Severity
Causative agent, time and circumstances surrounding the burn injury
- Percentage of BSA burned
- Depth of burn
- Anatomical location of the burn
- Person’s age
- Person’s medical history
- Presence of concomitant injury
- Presence of inhalation injury
Superficial (1st degree)
Epidermis only, painful, red, dry, blanches with pressure (stage 1 pressure ulcer also), no edema
Heal with minimal intervention within 3-5 days
Topical analgesisc
Superficial partial-thickness (2nd degree)
epidermis and superficial dermal layers and heal with minimal intervention in 10-14 days (1-2 weeks)
dermis, moist, pink or mottled red, painful, blisters (color change based on patient normal sin tone)
Deep partial-thickness
- Entire epidermal layer and deep dermal layers
- Need surgical intervention if significant in size, and heal 3-4WEEKS
Full thickness (3rd degree)
Destruction of epidermis, dermis, sweat glands and hair follicles (doesn’t regenerate)
White, red, brown or black. Reddened areas do not blanche
Require tissue grafting
Possible to have no pain in the acute phase (destroyed nerve endings, but surrounding areas can feel as it radiates)
Minor burn
partial thickness <15% BSA in adults and <10% in children
full thickness <2% BSA in adults
Moderate, Uncomplicated Burn Injury
partial thickness 15% to 25% BSA in adults and 10-20% in children
full thickness burns <10% BSA.
Major burns
Partial thickness Second-degree burns of more than>25% BSA in adults or > 20% in children,
All third degree (full thickness burns) >10% BSA – major burn
Burns of hands, face, eyes, ears, feet, perineum, & joints
All inhalation burns, electrical burns – major burn
Burns complicated by fracture or major trauma.
Extremes in age, intercurrent diseases.
tip: major burns are referred to a burn center
rule of 9
face - 4.5%
anterior arms each: 4.5%
posterior arms each: 4.5%
chest: 9%
abdomen: 9%
anterior leg: 9%
posterior leg: 9%
genital: 1%
rule of 9 peds
suspicious burns: cigarette burns, not so much palmar burns
- KNOW: peds use scale for burns
Pathophysiology of burns
All body systems are affected
a) Local response (primary)
b) Systemic response (Secondary) -inflammation
- May result in SIRS
- Greater than 20% of the TBSA will develop a form of hypovolemic shock or burn shock
Another common cause of death in the burn population is related to multiple organ failure resulting from a systemic inflammation (SIRS) and infection (Septic shock)
Local Response
1) Occurs immediately
2) Cellular injury due to heat (apoptosis)
3) Release of cellular enzymes – prostaglandin
4) Release of vasoactive substances – Histamines, Catecholamines, Platelet activating factor, cortisol (stress hormones, increase cardiac output)
5) Activation of compliment (Via Platelet Activating Factor) (hypercoagulable space)
6) Altered vascular permeability (via Histamine)
- Shift of protein molecules, fluid and electrolytes (lots of fluid)
tip: leads to sirs and more locally -> hypovolemic shock
Thermal Injury Systemic Effects: Pulmonary
Increased respiratory rate
- Increased Basal Metabolic Rate
- Increased oxygen demand
- Decreased Red Blood Cell volume
- Decreased Hemoglobin (esp. with hemolysis with burn injury)
Possible inhalation injury
- Closed space injury (fire with enclosed areas)
- Assess for:
Singed nasal hairs
Carbon deposits in sputum (black soot in sputum)
Facial burns
Hoarseness
Wheezing
Possible carbon monoxide poisoning
Complications
- Airway obstruction/edema-24 hrs
- Pulmonary edema-24-48 hrs
- Pneumonia s/d adjunct with intubation along with burn, inhalation of smoke, etc. -48 hrs and beyond
tip: upper airway wheezing may indicate an injured trachea
Thermal Injury Systemic Effects: pulmonary assessment
Work of breathing
ABG, pulse OX (Carbon monoxide poisoning?) – pulse ox stays same bc can’t differentiate between oxygen and carbon monoxide
Intubation early (based off presentation)
tip:
- obstruction -> local injury/inhalation
- pul. edema -> loss of vascular permeability
- pneumonia -> blunted immune system
Thermal Injury Systemic Effects: cardiovascular + assessment
Catecholamine release-vasoconstriction
Massive systemic edema secondary to increased vascular permeability
Acid base disequilibrium
Anemia secondary to RBC destruction
Cardiac output
- ½ normal initially then normal within 24 hours (unless patient isn’t treated)
- Responds to fluid therapy (opposed to sepsis)
assessment:
- VS
- U/O
- weight
- CO
Thermal Injury Systemic Effects: renal system (pre renal failure) + assessment
1) Loss of fluid, increase K+ s/d rbc destruction, Blood Urea Nitrogen s/d protein released from destruction of RBC and metabolized into BUN -> (Increases in blood and urine)
2) Sluggish glomerular filtration rate
3) Myoglobinuria
- From Muscle destruction, see elevations in Creatinine Kinase
- Results in ATN, treated with fluid resuscitation to flush out the glomerulus to get rid of CK out of body) -> similar disease process to rhabdomyolysis
assessment:
- U/O
- BUN/Cr
- CK
Thermal Injury Systemic Effects: GI system (reduced BF to stomach)
Hyper metabolic activity
- Increased glucose secondary to increased cortisol levels
- Impaired CHO metabolism d/t shunting of blood away from gut and slowed peristalsis
- Curling’s Stress Ulcer –> specific to burns, resulting from reduced plasma volume, ischemia to GI tract, sloughing of mucosa
assessment:
- bowel sounds
- abdominal distention
- blood glucose
tip: decompress the bowel, add PPI/H2 blocker
Causes of Burns: Thermal (most common)
Severity is related to heat intensity and duration of contact
- Flame
- Molten metals, tar, or melted synthetics (plastics)
- Liquid (boiling water – children)
Causes of Burns: Electrical
Similar to crush injuries; muscle necrosis, rhabdomyolosis, and myoglobinuria (causes contraction of skeletal muscle)
- Watch for arrhythmia
- Cervical collar- > long bone fractures secondary to muscle contraction
- Can cause thrombosis of any vessel in the body. Injury not always visible
- Follow CBC, lytes, ECG, urine myoglobin, CPK, cardiac enzymes
Causes of Burns: Chemical agents – Caustic burns
1) Severity is related to the type, volume, and concentration and duration
2) Strong acids (found in bathroom cleaners, rust removers) are quickly neutralized or absorbed - found in industrial setting
- Rinse off skin and call poison control
3) Alkalis (found in cleaning supplies) cause liquefaction necrosis (sliminess on skin when washing off substance), may lead to progressive necrosis – found in home setting
4) Organic (petroleum based solvent products, paint thinner) cause coagulation necrosis, CNS depression, hypothermia, hypotension, pulmonary edema (maybe leukemia, important to ventilate area working in)
Causes of Burns: Radiation burns (s/d to cancer treatment, delayed onset)
Initially appear hyperemic then resemble third degree-Occur days, weeks after exposure
If due to medical induced, will occur at entry point of radiation
(Will scar and have patterns of skin tone changes)
Criteria for Referral to a Burn Center
Partial-thickness burns more than 10% of TBSA
Inhalation injury
how do we treat radiation burns
stop raditation
Management of Burns
Treatment starts immediately after the burn insult has occurred.
Goals (ABCs):
- Manage fluids
- Manage airway
- Nutritional needs (last)
Treatment in the ED (initial):
- High-flow oxygen (carbon monoxide binds to Hgb, so give as much oxygen so when un-binded, oxygen can replace readily)
- Rule out arrhythmia (telemetry monitor, 12 lead EKG)
- Stabilize in ED, whether patient stays or is transferred
Burn Care: Primary Survey: Starts at first contact
Airway maintenance with cervical spine protection
Breathing and ventilation
Circulation with hemorrhage control
Disability (assess neurological deficit)
Exposure (completely undress the patient, but maintain temperature)
- Strip them down
- Use shower head to wash char if can
- Will lose heat so make sure to maintain core temp
tip:
EXPOSURE- IS ACID STILL ON THE PATIENT? Patients lose heat quickly following burns and can become hypothermic
Burn Care: airway mgmt
First priority: protect airway
Cervical precautions if spinal injury suspected
Facial burns: suspect inhalation injury
Enclosed space: suspect carbon monoxide poisoning
Administer 100% oxygen
Observe continuously
Special Management Considerations
1) Inhalation injury (leading cause of fire-related death)
2) Clinical signs and symptoms related to central nervous system and heart
3) Carbon monoxide (CO) poisoning:
- Normal HbCO is less than 2%
- 10% No symptoms
- 20% Headache, nausea/vomiting, dyspnea on exertion
- 30% confusion, lethargy, tachypnea
- 40% to 60% Seizure, coma, changes on electrocardiogram
- >60% Death
Tx: includes methylene blue dye (changes all body secretions to bright blue color), prevents neuronal death related to CO poisoning
tip:
CM - can’t smell, mild headache
propofol can cause liver insurfficiency
Burn Care: Thermal Parkland formula
Fluid resuscitation 1st 24 hours
Adults – 4ml LR x kg wt x % burn
Children - 3ml LR x kg wt x % burn
1st-8 hours after burn administer ½ of total fluids
2nd-8 hours -administer ¼ of total
3rd-8 hours-administer ¼ of total
Indications of Adequate Fluid Replacement
Urinary output 30-70 ml/hr (0.5 ml/kg/hr)
Pulse rate 100-120 bpm
CVP <12 cm H2O (0-10 normal)
PAOP <18 mmHg
Lungs Clear
Sensorium Clear (not always clear if intubated/sedated)
GI absence of nausea and dynamic ileus
Arterial base deficit and lactate normal values (normal for hospital ranges)
Burn Care: Temperature control
Warm air bed
Heat lamp or panels
Used to maintain core temperature
Loss of epidermal barrier leads to loss of temperature
-Warming beds may turn patients as well “High airloss beds”
-Use of heat lamps may be seen
Acute phase: Diuresis to wound healing goals
Early wound closure (GOAL)
- Greater risk for scar tissue and contractures
Maintenance of functionality
Prevention of infection
Adequate nutrition
tip:
Prevention of infection- burns are treated as sterile tech during dressing changes.
Burns: pain mgmt
Burns are very painful
Give intravenous opiates (exclusively) - morphine sulfate and fentanyl (procedural)
Administer benzodiazepines (Ativan, versed, Xanax) for anxiolysis
Do not give intramuscular or subcutaneous pain medications because absorption is unpredictable (insulin gtt)
Administer opioids IV
Burns: Extremity pulse assessment
Edema formation may cause neurovascular compromise
Doppler flow probe best way to check arterial pulses (second check), can determine presence of blood flow
Escharotomy may be indicated for circumferential burns of the extremities (constricts vascular supply, want to debride, similar to fasciotomy)
Will present like compartment syndrome
tip: similar to compartment syndrome
Burns: Laboratory assessment
Complete blood count, electrolytes, blood urea nitrogen, creatinine, urinalysis, and blood screening
Special circumstances may warrant arterial blood gases (only reliable way to get carboxyhemoglobin levels), carboxyhemoglobin, alcohol and drug screens
Electrocardiography for electrical burns or preexisting cardiac problems
Burns: wound care
Cover with clean, dry dressings or sheets (petroleum gauze)
Keep patient warm
Tetanus prophylaxis for burns greater than 10% TBSA
Burns: Burn center referral
Partial-thickness burns more than 10% TBSA
Inhalation injury
Treatment: Wound care
1) Topical antimicrobials (non-biological agents, broad spectrum)
- Silvadene
- Silver nitrate
- Honey
2) Cleaning
- Hydrotherapy (bath to clean)
- Showers
3) Gauze
- Xeroform gauze (most common, petroleum gauze)
4) Debridement
- Surgical (designated by surgeon)
- Mechanical (intrinsically when taking off dressing)
- Enzymatic (requires enzyme (santel), breaks down collagen, doesn’t hurt patient, takes a long time to work before seeing benefits)
5) Debridement of the eschar and skin graft closure before eschar becomes infected-Wet to dry dressing, Enzymatic (Santyl) or Surgical
a) Monitor:
- Signs of infection
- Granulation
6) Dressings
a) Several times per day
b) Functions
- Decrease pain
- Maintain position
- Keeps wound clean and moist
https://www.youtube.com/watch?v=x96JWGt8q48 dressing changes
tip: Minuca-honey, silver, poly-sporin
Petroleum based, bismuth impregnated guaze
Santyl- enzymatix debrider
Granulation tissue (viable, if bleed – good tto bleeding because it beans it’s healing properly)
Contractures occur in the hands usually
Treatment: Excision
Done early for deep partial and full thickness
Lessen pressure
Escharectomy
- Removal of eschar
Treatment: Grafting
Autograft-own tissue
Allograft – cadaver
Xenograft – Tissue from a different organism
Treatment: Maintenance of function
Position of comfort-position of contractures
ROM (Range of Motion
CPM (Continuous Passive Motion)
Splinting
Pressure garments
Treatment: Prevention of infection
Leading cause of death
Sterile technique
Isolation (protective)
Treatment: Nutrition-Start within 24 hours (as soon as possible)
1) Tube feedings start early prevent translocation of bacteria
2) High protein/caloric diet
3) Caloric need maybe 7,000-8,000Kcal/day or less depending on how quickly wounds are surgically closed.
4) Imbalanced nutrition: less than body requirements
- Up to twice resting caloric requirements
- Goal is to provide adequate calories to prevent starvation and enhance wound healing
- Enteral and oral routes preferred. Risk vs. Benefit.
5) map >65
Rehabilitative phase
Up to 5 years
Continue follow up
Psychological needs
- Support
- Survival anxiety
- Pain tolerance
- Personal meaning
- Acceptance of loss
Types of Skin Disorders that Act Like Burns: Toxic epidermal necrolysis (TENS) – necrosis of epidermal layer (Stevens-Johnson’s Syndrome)
Most common cause drug reaction
Skin sloughs its epidermal layer
High mortality rate 25-50% (fairly fatal)
Treated like burns
If catch early, can have good outcomes
Types of Skin Disorders that Act Like Burns: Staphylococcal scalded skin (SSS) – sunburn with peeling of skin (Ritter’s disease)
More frequent in children
Reaction to staph infection
Low mortality rate 5%
Sloughing of skin
Treated with antibiotics
