Burn and Thermal injury Flashcards
Criteria for transferring a burn to a burn center
- Partial thickness burns greater than 10%
- burns that involve the face, hands, feet, genitalia, perineum or major joints
- full thickness (third degree) burns
- electrical burns including lightening injury
- chemical burns
- inhalation injury
- burn injury in pts with preexisting medical disorders that could complicate managment
priorities for managing burn pt
- consult burn services
- do not apply ice
- cover affected area with saran wrap or blue side of chux
- edema management- ELEVATE
- fluids and IV acesss- no fluid boluses; PIV access
- pain management: Oral when possibe, IV if needed
- maintain normothermia
physiological affects from burns
- inflammation, hypermetabolism, muscle wasting and insulin resistance are all hallmarks of the pathophysiological response to severe burns
organ systems affected by burns?
- respiratory
- metabolic
- immunological
- cardiovascular
estimate % TBSA burned
Adult
* Head and neck- 9%
* arms- 9%
* trunk and back: 18% each
* groin- 1%
* palms-1%
* legs- 18% each leg
Baby
- only difference is legs are 14 percent each
- estimate burn depth?
burns are dynamic. Evolution/progression is always a risk
Factors
- temperature
- duration of contact
- dermal thickness
- special consideration to very old and very young
Jackson’s thermal wound theory
Three zones of injury
Zone of hyperemia
- increase blood flow due to normal inflammatory response
Zone of stasis
- potentially viable cells are ischemic due to clotting and vasoconstriction
Zone of coagulation
- coagulation and necrosis has occurred tissue is non-viable
- stasis and hyperemia are still viable
- epidermis only
- pain & redness
- heals in a few days
- outer injured epithelial cells peel
- seldom clinically significant
Superficial 1st degree
- entire epidermis and portion of dermis
- pain, blisters, moist, cap refill
- heals within 2-3 weeks
- deeper partial thickness- skin graft may improve function/functionality
Partial thickness: 2nd degree
- all skin layers are affected
- area will appear white, hemorrhagic, brown, black or charred
- inelastic and leathery
- painless or numb
- typically, requires skin graftin for definitive closure
Full thickness: 3rd degree
nutritional needs for burn patients?
- nutritional requirement increase in conjunction to the burn size
- hypermetabolic state begins 36-48 hours after injury and may persist for 6 weeks-3months follwing injury
- all patients with burns greater than 20% TBSA should have a feeding tube placed
- getting behind on nutritional needs is a huge detriment to healing
dx and tx of inhalation injury?
inhalation injury may not be apparent on admission- consider hx of injury as it may continue to worsen over the next 5 days
Definitive diagnosis is done in three ways
- Xenon scan is the most accurate
- bronchoscopy may show inflamed mucosa with carbonaceous material present
- clinically if the P/F ration (Pao2/Fio2) Is less than 300 it is indicative of inhalation injury
Treatment
- supportive only
- no steroids, no antibiotics, some can recieve supplemental O2
- never neutralize
- water, water, water
- exceptions: carbonic acid or pheno-use rubbing alcohol then water
- sulfic acid- soapy water
- metal compounds- mneral oil
- hydrofluoric acid- water an calcium gluconate
Chemical burns
three types of electrical burns?
True
- where current flows thorugh body (the patient will tell you whether or not this happened
Flash
- no current actually passes, but the electric discharge heats up the air enough to cause flash burn
Flame
- when patients close catch fire
Flash and flame burns are similar to thermal burns and are treated the same way
electrical burns affect which systems?
skin
cardiovascular
neurological
musculoskeletal
kidney failure
respiratory failure
110-220V work up
- deep tissue injury less likely, may have temporary nerve injury
- if no persistent symptoms + normal ekg+ normal rhthym strip may d/c home
- if abnormal EKG/rhythm strip admit for 24 hrs
1000+ V workup
- two types of severe tissue damage and those with very little/none
- no tissue damage? on cardiac monitoring at least 24 hours while patient admitted
- tissue damage admit
- myoglobin (dark cola colored urine)
- formal neurology consult and slitlamp exam
- deep burns (full thickness even partial thickness burns) that are circumferential will limit expansion of the undelrying tissue as edema forms
- this process will eventually lead to ischemia and concern for compartment syndrome, this procedure may be necessary to allow expansion
- can be performed at bed side
escharatomy
other considerations for burns care?
- Tetanus prophylaxis if no booster in the last 5 years
- no prophylactic antibiotics
- encourage use of burned extremities, may require OT/PT involement
- encourage good nutrition to help facilitate wound healing
- constipation management
TX of partial thickness or indeterminant depth burns
daily bacitracin
- give prn medications 1 hours before dressing changes
- wash burns daily with soap and water
- apply bacitracin to all open areas
- apply non-adherent gauze to all open areas except face
- secure non-adherent gauze with roll gauze
- apply compression layer
tx of full thickness burns
BID silvadene
- give prn pain medication 1 hour before dressing changes
- wash burn daily with soap and water
- apply silvadene BID to all open areas with eschar
- apply roll gauze to all areas that had silvadene applied
- apply compression layer- edema glove, ace wrap, dermafit, compression stocking
- repeat steps 3-6 in the evening
- amazing for pediatrics and pts who may have concern about pain management
- giver prn medication 1 hour prior to wound care
- wash burn well, removing any denuded skin/blisters
- apply mepilex AG to affected area, kerlix, and compression
- this can be left in place for 3-7 days
Mepilex AG
