Burn Management - Prehospital and Emergent Flashcards
Phases of Burn Management (4)
- pre-hospital care
- emergent (resuscitative)
- acute (wound healing)
- rehabilitative (restorative)
Pre-hospital/Early Emergent Care: ABC (7)
- Stabilize the C-Spine! - if they have fallen, are unconscious, or were jolted
- provide oxygen and anticipate intubation especially with significant inhalation injury
- Stop the burning with cool sterile water
- Remove nonadherent clothing and wrap in dry dressings to prevent infection and heat loss
- Establish IV access x2 large bore if burn is greater than 15% to start
- Insert urinary catheter to monitor end organ perfusion and AKI if burn is greater than 15%
- Elevate burned limb above heart level to decreased edema
Emergent Phase
How long does it last?
Primary Concerns? (2)
the period of time required to resolve immediate, life-threatening problems resulting from the burn injury
lasts up to 72 hours from time of injury
1. onset of hypovolemic shock
2. formation of edema
Hypovolemic (burn) shock
At the moment of injury, capillary permeability is increased. all fluid components move into the interstitial spaces causing edema and decreased blood volume. water, sodium and protein leakage into the interstitial spaces. Hematocrit increases, viscosity increases, causes increased peripheral resistance. Inadequate tissue perfusion.
- second spacing - fluid accumulating in the interstitium
- third spacing - exudate blister formation. edema in non burned areas
Emergent Phase: Fluid and electrolyte shifts
- colloidal osmotic pressure decreases, resulting in more fluid shifting out of vascular space into the interstitial spaces
- second spacing
Signs of shock (3)
- low BP
- increased Resps
- increased HR
The net result of the fluid shift:
- intravascular volume depletion
- edema
- decreased BP
- increased HR
Alteration in Na, hematocrit, RBC, and Potassium
- RBC are hemolyzed and thrombosis in the apilaries cause an additional loss of RBCs. elecation of the hematocrit occurs due to intravascular fluid loss
Na+ will shift into intersitial spaces
Injured cells and hemolyzed RBC release potassium into circulation
Emergent Phase: Immune response is suppressed following burns causing widespread impairment of the immune system. Why? (5)
- because the skin barrier is destroyed
- bone marrow suppression occurs
- circulating levels of immune globulins decreased
- function of WBC becomes defective
- the inflammatory cascade triggered by tissue damage impairs the function of lymphocyes, monocytes, and neutrophils
SIGNIFICANT RISK OF INFECTION AND SEPSIS WITH EXTENSIVE BURNS
Emergent Phase: Clinical Manifestations (5)
- shock from pain and hypovolemia
- blisters
- adynamic ileus
- shivering
- altered mental status
Emergent Phase: focuses on complications of which three major organ systems?
- cardiovascular
- respiratory
- genitourinary
A TBSA of what percent affects all body systems?
> 25% TBSA burns
Cardiovascular
- dysrhythmias and hypovolemic shock which may progress to irreversible shock
- impaired circulation to extremities
- tissue ischemia
- necrosis
- impaired microcirculation and increased viscosity -> sludging
Respiratory - Upper Airway Injury
- Causes upper airway obstruction related to edema
- Burn eschar on neck and chest can become tight and constricting due to edema also making it difficult to breathe
- swelling can be massive and sudden in onset
- EARLY INTUBATION
Respiratory: Lower Airway Injury
- injury to trachea, brochioles, and alveoli caused by inhalation of toxic chemicals or smoke
- pneumonia and pulmonary edema are common in clients with pre-existing respiratory problems
Genitourinary
- Acute Kidney tubular necrosis due to hypovolemia
- Release of myoglobin and hemoglobin can occlude tubules
- Treatment is fluid replacement
Emergent Phase Nursing/Collaborative Care: from onset of burn event until the patient is stabilized there are three primary goals of therapy:
- Airway management
- Fluid therapy
- Wound care - early prevention of infection
Airway Management (4)
- early endotracheal intubation (within 1-2 hours after injury)
- escharotomies of the chest wall (so intercostal muscles can expand)
- fibreoptic bronchosopy (look for inhalation injury)
- humidified air and 100% oxygen (high fowlers. DB&C)
Fluid Therapy (5)
- At least two large-bore IV lines for > 15% TBSA.
- electrical burn pts have higher fluid requirements
- For burns > 30% CVA line should be considered and ART line
- type of fluid replacement based on size/depth of burn, age and individual considerations - usually start with ringers.
- Parkland (Baxter) formula for fluid replacement
- Colloidal solutions (albumin). started after first 24 hours when permeability returns to normal so it can pull fluid into the vascular space.
How do we know fluid replacement is adequate? (2)
- Urine output 0.5-1 ml/kg/hr. Increases to 75-100ml/hr in pts with electrical burns and evidence of hemoglobinuria and myoglobinemia
- Cardiac Factors: MAP >65, systolic BP > 90, HR< 120
Emergent Phase: Nursing/Collaborative Management: Wound Care
Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been established
- cleansing can be done in a cart shower, shower or bed
- Debridement may need to be done in the OR
Wound care: shower
tap water not exceeding 40 degrees is acceptable
once daily shower
dressing change in morning and evening
What is the most serious threat to further tissue injury?
Infection
- source of infection is the client’s own flora
- predominantly from skin, respiratory tract and GI tract
Open and Closed Methods of Wound Care using multiple dressings
Open - patients burn is covered with a topical antimicrobial and has no dressing over the wound - very controlled setting
Closed - sterile gauze dressings are impregnated with or laid over topical antimicrobial
- Sterile gloves are used when applying ointments and sterile dressings
- when open wound are exposed nurses must wear PPE
- keep room warm b/c pt is at risk for hypothermia
Emergent Phase: Other Care Measures: Hypothermia
Hypothermia - warm environment, warm blankets. Shivering increases O2 consumption and caloric demand - delays wound healing
Burned hands and arms should be extended and elevated to reduce edema
Ears should be kept free of pressure
Pain Management: Types of Pain (4)
Background pain – client partakes in non procedural movement. Shifting in bed, coughing. Continuous in nature and low in intensity. Treating with long-acting
Procedural pain – acute pain at dressing change. High in intensity. Breakthrough medications given
Hyperalgesia – sunburn pain. Sensitivity of the skin related to someone touching them. Don’t have anything touching skin
Itchiness – comes when burn is healing. Can be medication managed
Medications
- Analgesia should be given via IV opioids (morphine) initially. No injected or oral meds.
- are not absorbed. onset is faster with IV meds and GI function is slow d/t shock and paralytic ileus so no ORAL meds
- sedatives, antidepressants, tetanus immunizations, topical antimicrobials
- systemic antibiotics arent often used because there is little to no blood supply to the burn
Emergent Phase: Nutritional Therapy
- fluid replacement takes priority over nutritional needs
- early aggressive nutritional support within hours of burn injury decreases mortality and complications, optimizes wound healing, and minimizes negative effects.
- NG or G-tube
- hypermetabolic state proportional to size of wound.
- may increase 50-100% in some patients
- early and aggressive nutritional support within several hours of a burn injury can decrease mortality, risks and complications and optimize healing
- Early enteral feeding preserves GI function and prevents complications like curlings ulcer
