burn injuries Flashcards
who has increased morbidity and mortality with burns?
Children and the elderly
what indicates the severity of a burn?
Age
Burn depth
Extent of total body surface area injured
Presence of inhalation injury
Presence of other injuries
Location of the injury in special care areas
Presence of chronic illness
what the burn special care areas
face, perineum, hands, and feet
what percentage of TBSA burned are at high risk for mortality?
40%
how is a first degree burn described?
superficial
what categorizes a burn as first degree?
epidermis is intact or partially intact
what are examples of a first degree burn?
sunburn or superficial scald
what are symptoms of a first degree burn?
Red, tender, peeling, itching, minimal or no edema, possible blisters (a positive Nikolsky’s sign)
when is there complete recovery of a first degree burn?
within a week, no scarring
how is a second degree burn described
partial thickness
what are examples of a second degree burn?
scalds or flash flame contact
what are symptoms of a second degree burn
blistered, mottled red base, weeping surface, edema
when is there recovery from a second degree burn
2-3 weeks, some scarring and depigmentation possibly
may require grafting
how is a third degree burn described
full thickness
what categorizes a third degree burn
total destruction of epidermis and dermis
in some cases, destruction of connective tissue and muscle
what causes a third degree burn
flame, prolonged exposure to hot liquids, electrical current, chemical contact
when would a third degree burn be painless
lacks sensation, nerve fibers destroyed
shock
what are the symptoms of both third and fourth degree burns
myoglobinuria and hemolysis
when would a burn have contact points
entrance or exit wounds in electrical burns
what are the symptoms of a third degree burn
dry, pale white, red brown, leatherly, charred
coagulated vessels may be visible
how is fourth degree burn described
deep burn necrosis
what categorizes a fourth degree burn
deep tissue, muscle, and bone affected
what causes a fourth degree burn
Prolonged exposure or high voltage electrical injury
What are the symptoms of a fourth degree burn?
Shock and charred
What is the treatment for a fourth degree burn?
Amputations likely
Grafting of no benefit, given depth and severity of wounds
what is the rule of nines?
used to assess TBSA of a burn
11 parts of the body are 9%
perineum is the final 1%
at what precentage of TBSA produces both a local and a systemic response considered major burn injuries
30%
what are the cardiac effects of burn shock
Hypovolemia
Increased capillary permeability
Decreased CO and BP, increased tachycardia
- Third spacing due to major
inflammatory response
what is included in the initial fluid shift after a major burn
Elevated Hct and Hgb
Hyponatremia
Hyperkalemia
what is included in the later fluid shift after a major burn
Decreased Hct and Hgb
Varied sodium
Hypokalemia
Hyperglycemia
Low total protein and albumin (High metabolic state)
what is compartment syndrome?
edema develops: monitor for circulation
the taut, burned tissue can act like a tourniquet, especially if the burn is circumferential
what is the treatment for edema
elevating the affected limb
escharotomy or fasciotomy to restore tissue perfusion
what is an escharotomy
cutting through the eschar
what is a fasciotomy
incision through fascia to relieve muscle constriction
what are the symptoms of thermal inhalation injury
singed hair, eyebrows, and eyelashes
Sooty appearance of sputum
Hoarseness
Wheezing
what is the priority management for thermal inhalation injury
airway management
what is a concern for thermal inhalation injury and why
ARDS and pneumonia, increased secretions and inflammation
what is the treatment for a thermal inhalation injury
Oxygenation, encourage patient to cough
when is carbon monoxide poisoning suspected
if the injury took place in an enclosed area
what are the symptoms of carbon monoxide poisoning
erythma, upper airway edema, and sloughing of respiratory tract mucosa
What is the treatment for carbon monoxide poisoning
100% oxygen, pulse oximetry is not reliable
What is the burn unit referral criteria?
Partial thickness burns greater than 10%
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age groups
Electrical burns
Chemical burns
Inhalation injury
With pre existing medical disorders
Concomitant trauma
What should be done at the burn scene?
Use cool water (can use cool clean towels or sheets)
Never apply ice directly to the burn
Never wrap the person in ice
Never use cold soaks or dressings for longer than several minutes
Remove restrictive objects immediately (jewelry and all piercings)
Cover the wound with clean cloth to prevent contamination and hypothermia
Irrigate chemical burns with large amount of water
Educate family to monitor for evidence of infection
Educate the family to avoid using grease lotions or butter on burn
Check immunization status for tetanus and determine need for immunization
What are urgent respiratory needs after a burn?
Oxygenation, removal of secretions, bronchodilation
what is given to burn patients who need fluid resuscitation
lactated ringers
what is the most reliable criteria for adequate resuscitation of burn shock?
urine output
0.5-1 ml/kg/hr: for thermal and chemical burn
75-100 ml/hr for electrical injuries
What is the acute/intermediate phase of burn shock?
From beginning of diuresis to near completion of wound closure
What are the priorities of the acute/intermediate phase of burn shock?
Wound care and closure
Prevention or treatment of complications
Nutritional support → don’t eat up their muscles
What is a common symptom of the acute/intermediate phase of burn shock?
Hyperthermia
What form of pain management would we avoid for a burn patient?
Avoid IM or subcutaneous injections → worried about skin integrity
When would pain management be done for a burn patient?
½ hour prior to wound care or cleaning
What is the top priority for burn patients?
infection, pain
What are the precautions we take to prevent infection in burn patients?
Restrict plants and flowers due to risk of contact with Pseudomonas aeruginosa (gram-negative rod)
Restrict consumption of fresh fruits and vegetables
Limit visitors
Administer tetanus shot if indicated
A major source of bacterial infection is the patient’s intestinal tract
After burn: intestinal mucosal becomes permeable: microbial flora and endotoxins can pass freely into the systemic circulation and causing infection
Bacterial translocation and endotoxemia: septic shock
Early enteral feeding is important
Why is nutritional support important for burn patients?
The client who has a large area of burn injury will be in a hypermetabolic and hypercatabolic state → need 8,000 calories per day, prevent hypoglycemia
How do we maintain mobility for a burn patient?
Maintain correct body alignment, splint extremities, and facilitate position changes to prevent contractures
Maintain active and passive range of motion
Assist with ambulation as soon as the client is stable
Apply pressure dressings to prevent contractures and scarring
Monitor areas at high risk for pressure sores
how do we do hydrotherapy
Ambulatory: cleansed in shower
Nonambulatory: shower carts
Intact blisters should be left alone
Remove non viable loose skin
Warm running water (watch for hypothermia)
Use mild soap or detergent to gently wash burns and then rinse with room-temperature water
Encourage the client to exercise joints during the hydrotherapy treatment
What are key things to know about silver sulfadiazine 1% (Silvadene)?
Most bacterial agent
Minimal penetration of eschar
Used with occlusive dressings
Contraindicated with allergies to sulfa
What are key things to know about silver nitrate 1%?
Bacteriostatic (stop the bacteria from reproducing) and fungicidal
Inexpensive
Does not penetrate eschar
Stains clothing and linen
Discolors wound, making assessment difficult
Painful on application
What are key things to know about mafenide acetate 5-10% (Sulfamylon)?
Effective against gram-negative and gram-positive bacteria
Diffuses rapidly through eschar
10% drug of choice for electrical burns
Used on wounds exposed to air
Used as a solution for occlusive dressings to keep the dressing moist
What are key things to know about bacitracin?
Used on wounds exposed to air or with modified dressings
Maintains joint mobility
Bacteriostatic against gram-positive organisms
Limited effectiveness o gram-negative organisms
Painless and easy to apply
How do you complete wound dressing?
Patted dry (removed all previous ointments)
Applied topical agent
A light dressing should be used over joint areas (if it is needed)
Dressings that adhere to the wound can be removed by moistening the wound with tap water
Sterile scissors and forceps may be used to trim loose eschar and encourage separation of devitalized skin (you might see some bleeding, which is ok)
What are the types of wound debridement?
Mechanical, chemical, and surgical
What is mechanical debridement
Use of surgical scissors, scalpels, and forceps to separate and remove the eschar
what is chemical debridement
enzymatic
What is surgical debridement?
Early surgical excision to remove devitalized tissue along with early burn wound closure → most important factors contributing to survival in burn patients
What are the types of wound grafting?
Autograft: a graft of the patient’s own skin
Homograft: skin obtained from living or recently decreased humans
Heterografts: skin taken from animals (usually pigs)
Amnion: obtained from human placenta; required frequent changes
Biobrane: synthetic dressing
As the Biobrane gradually separates, it is trimmed, leaving a healed wound
How do we monitor for infection before and after skin coverings or grafts are applied?
Discoloration of unburned skin surrounding burn wound
Green color to subcutaneous fat
Degeneration of granulation tissue
Development of subeschar hemorrhage
Hyperventilation indicating systemic involvement of infection
Unstable body temperature
What is the rehabilitation phase after a burn?
From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment
What are priorities in the rehabilitation phase after a burn?
Prevention and treatment of scars and contractures
Physical, occupational, and vocational rehabilitation
Functional and cosmetic reconstruction
Psychosocial counseling
