Burn Unit Flashcards
integumentary system fxn
- protect from infection
- prevent loss of body fluid
- thermoregulation
- produce vit D
- excretion
- identify / appearance
- sensation reception
burn injury patho
-increase infection risk
-massive fluid loss
-unable to regulate temp
-decrease vit D
-decrease ability to sweat
-change in self image
-nerve damage
these burns have more intense pain….
partial thickness burns r/t exposed nerve endings
these burns still have pain but not as much…
full thickness since nerve endings are destroyed, will still have tingling
elderly are more susceptible to burns…
skin thins –> deeper burns, poor healing
-decreased sensation
-reduced reaction time
thermal injury
skin damaged by heat
1. flame
2. scalding liquids
3. heat source
severity of thermal burn…
determined by…
1. duration of contact
2. temperature of agent
3. amount of tissue exposed
4. age of pt
children are more at risk for burns…
unaware of risk
unable to protect themselves
chemical injury types
- contact - skin
- fume inhalation - chlorine
- ingestion / injection
chemical injury
must be COMPLETELY removed / neutralized
-MSDS on units
-list every chemical on units
alkalis chemical injury
deeper tissue damage , liquefy proteins on skin allowing deeper spread
ex : oven cleaners / drain cleaners
acid chemical injury
coagulate the skin and proteins, LIMITING depth of damage
ex: bathroom cleaner, swimming pool cleaner
organic chemical injury
fat soluble and absorbed causing damage to kidney / liver
ex: chemical disinfectants and gasoline
chemical injury management
FLUSH with copious amounts of water
consideration for dry chemical burn…
BRUSH IT OFF, flushing with water will activate the chemical burn process
electrical injury
direct contact with electric source, WILL be an entry and exit point!!!
-has internal damage, extensive muscle damage, organs ischemic and necrotic
cardiac electrical injury
EKG changes and heart damage common, related to release of potassium!!!
musculoskeletal electrical inury
tetany and spasms –> fractures or compartment syndrome
renal electrical injury
myoglobin release (damaged muscle tissue), circulated to kidneys
-rhabdomyosis
**cola colored urine
important thermal questions…
WHEN was pt pulled from fire (heat source)
enclosed space??
pre-existing medical hx
PRIORITY assessment for thermal injury
AIRWAY, could have soot in airway, hoarse voice, wheezing
radiation injury
- ionizing radiation in industry
- nuclear accidents
- therapeutic radiation : chemo
**most frequent = SUNBURN
radiation injury presents with…
redness, edema, blistering, pain
burn injury severity
- type
- depth , extent , body part burned
- additional injury
- pt age
- pre-existing health
-major
-moderate
-minor
major burns
- adult w/ >25 % total body surface area partial thickness burn
- > 10% TBSA full thickness burn
- burns of hands, feet, face, ears, perineum
- inhalation
- electrical
- burn w/ fracture or trauma
- high risk pt
moderate burns
adult w/ 15-25% TBSA partial thickness
< 10% TBSA full thickness
burn center pt criteria
deep partial thickness 15-25% TBSA
full thickness > 2% TBSA
burn to face, hands, feet, genitalia, joint, perineum
chemical / electrical
inhalation
co-morbidities
associated trauma
superficial burn (1st degree)
3 P’s : pink , puffy , painful
cause : flame , SUNBURN , flash from explosion
partial thickness (2nd degree)
superficial partial thickness
deep partial thickness
superficial partial thickness
epidermis and limited portion of dermis
-blisters, bullae, serous fluid
-painful w/ sensation intact and edematous
superficial partial thickness cause
flame , scald , flash , contact
**heals 10-21 days
deep partial thickness
epidermis and most of dermis
-blisters, bullae, serous fluid
-pale ivory, waxy, moist appearance!!!
-painful w/ sensation intact and edematous
deep partial thickness causes
flame , scald, flash , contact
**heal 3-6 weeks
full thickness burns (3-4th degree)
destruction of entire epidermis and dermis , skin does NOT regrow
-down past fat, fascia, muscle, bone
full thickness burn pain
possibly w/ 3rd degree
MINOR in 4th degree, around edges
full thickness burn appearance
dried leathery eschar
white / yellow / brown with thrombosed vessels
loss of elasticity
marked edema
**needs grafting
full thickness treatments
amputation
fasciotomy
escharotomy
full thickness burn causes
flame
chemicals
high voltage
why is there less pain with full thickness burns….
nerve endings are damaged / destroyed
**will be pain around edges where it is only partial thickness
resuscitative phase
first 48 hrs until diuresis… starts pre-hospital
resuscitative phase goals
- AIRWAY secure
- circulation –> fluids!!!
- prevent infection
- body temp
- emotional support
resuscitative phase pre-hospital
- REMOVE source of thermal damage
- ABCs / cervical spine
- O2 100% , maybe intubate
- circulation assessment
- remove clothing / jewelry
- trauma assessment
pre-hospital interventions
- cover to prevent hypothermia –> use CLEAN DRY SHEET with > 20% TBSA
- large bore IV and FLUID
- pain management
- vitals , baseline assessment
ED resuscitative interventions
- AIRWAY , c-spine evaluation
- circulation –> escharotomy or fasciotomy
- calculate fluid requirement : pre-burn wt.
- pain management
- tetanus administration
why is it important to start an IV immediately….
once fluid shift begins it may be impossible to locate a vein
why should we use IV narcotics….
altered absorption via muscle and stomach
-IM / sub-q they will remain in tissue space and will be absorbed rapidly once fluid shift is resolved
what is the preferred pain med for burns…
MORPHINE!!!
**dilaudid if allergic to morphine
factors determining airway obstruction…
- pts injured in closed space
- pts with extensive burns or burns of face
- intra-oral charcoal esp on teeth / gums
- pts unconscious at time of injury
- singed hair, nails, eyelids, eyelashes
- coughing up carbonaceous sputum
- voice hoarseness / brassy cough
- accessory muscle use / stridor
- edema, erythema, ulceration of mucosa
- wheezing , bronchospasm
inhalation injuries are more likely to have….
rapid obstruction within a short time, wheezing sounds will DISAPPEAR , this demands immediate intubation
inhalation injury resuscitative phase
- carbon monoxide is the leading cause of death from a fire
- injuries above glottis
- injuries below glottis
carbon monoxide poisoning
“cherry red” color from vasodilating, confusion, dizziness, headache, n/v
carbon monoxide poisoning tx
100% oxygen for at least 2 hrs or hyperbaric chamber
injuries above glottis
upper airway obstruction, common in head / neck burns and smoke inhalation
-edema will worsen with fluid resuscitation , tissues rehydrate then swell from capillary leak
injuries above glottis intervention…
early intubation since edema can occur within minutes to hours
injuries below glottis
the lungs!!!
-pts may be asymptomatic for 48 hrs
-have normal CXR and ABGs
-occurs with dry heat injury as well
inhalation injury 3 major points…
- pulmonary edema = elevate HOB, humidified O2, call rapid
- early intubation
- CONSTANT monitoring
cardiac resuscitative phase
-cardiac rhythm = electrical has heart damage
-hypovolemic shock
fluid / electrolyte complications
- dehydration
- reduced blood volume
- decreased UO
- hyperkalemia
- metabolic acidosis
elevated hematocrit….
blood is very viscous, could be sign of dehydration
third spacing
fluid shifts into extravascular space
-burns >20% TBSA have edema on burned area and unburned areas
when does maximum edema occur after burns…
24-48 hours post burn
kidney resuscitative phase
decreased kidney bloodflow –> acute kidney injury
-myoglobin is released from damaged muscles circulating to kidney
-will have decreased UO
urine output goal for burn pts…
30-50 mL / hr , pts will get foley for strict i/o every hour
GI resuscitative phase
ischemia r/t redistribution of blood to brain and heart
-PARALYTIC ILEUS, check bowel sounds
-H-2 blockers and PPI to reduce ulcers
-NEED BM or gas to check that GI system is working
metabolic resuscitative phase
increased metabolic state for up to 9-12 months post burn, increased body temp = increased metabolism
nonsurgical resuscitative mgmt
- FLUIDS
- pain management w/ narcotics
fluid management
based on % TBSA
-used for pts with > 20% TBSA burns
fluid administration times
- half of fluid first 8 hrs from time of injury
- second half over next 16 hours from time of injury
**all fluids need to be given within first 24 hours
**fluid overload risk, especially if they have CHF
fluid administration formula
4mL x kg x TBSA
what to hold 8-12 hours post burn on fluid management…
colloids
-blood
-albumin
-hetastarch
-plasma protein fraction
-dextran
albumin
pulls fluid back into the vascular space
electrical burn fluid mgmt
HIGHER fluid volume
-urine output needs to be 75-100 mL/hr
**myoglobin is released –> AKI
escharotomy
used in full thickness and circumferential burns
-loss of circulation
-loss of movement
-relieves pressure
-monitor distal pulses!!!!
fasciotomy
seen w/ electrical burns
-used to relieve compartment syndrome
acute phase
begins 48-72 hrs post burn
acute phase respiratory
- CXR
- fever
- WBC count
acute phase cardiac
monitor weight
monitor i/o
-urine output is the best indiacor of intravascular fluid status
acute phase GI
can start tube feeds if there is bowel function
-monitor for ulcers
-will need high calories, high protein
acute phase skin
INFECTION IS #1 killer in this phase
-maintain joint fxn and mobility
acute phase wound care
- HANDWASHING to reduce infection risk
- isolation r/t infection risk
- pain meds BEFORE beginning
- change gloves when moving to different burn areas –> infection
acute phase debridment
mechanical
enzymatic
autolysis
surgical
mechanical debridement
hydrotherapy - special showers / bedside washing
**uses coarse gauze to remove dead tissue
enzymatic debridement
collagenase - uses enzymes
autolysis
moist wound healing
silver sulfadiazine (silvadene)
-broad spectrum / candida
-wet topical dressing
-partial and full thickness burns
-cooling effect , painless application
-may cause leukopenia!!!
-DO NOT USE W/ SULFA ALLERGY
bacitracin
-no gram negative / fungal coverage
-partial thickness burn wounds and grafts
-not as effective on full thickness
-BEST for use on face leave open to air
-can use ophthalmic ointment near / around eyes
sulfamylon cream (slurry)
-broad spectrum, effective against pseudomonas, little fungal coverage
-cream used on full thickness burns to EARS ONLY
-partial thickness burns and grafts
-wet dressing, do NOT use on large wound burns = hypothermia
-STINGING on application
acticoat, silverlon, mepilex
-broad spectrum, effective on MRSA and fungus
-partial thickness, donor sites
-only changed 4-7 days
-do NOT use on initial large wounds = hypothermia
-used in pts with SJS/TEN
-DO NOT use with normal saline–> will deactivate silver
-stinging on application
enzymatic cream (collagenase)
-no antimicrobial effects, normally mixed w/ other ointment
-full thickness, digests necrotic tissue w/o damaging good tissue
-painless application
-full thickness burns who are not surgical candidates r/t age or medical hx
autograft
taken from unburned area of pts own skin (DONOR SITE)
-ideal coverage for all burn pts
-permanent coverage
allograft
human skin from cadaver
-used as temporary covering once eschar is removed to close wound
-will start to eventually reject
xenograft (heterograft)
skin from other species - normally pig
-temporary coverage
-will eventually reject
cultured skin
pts own skin is sent to lab and grown in larger patches
-permanent coverage
-used with burns of 70% or more TBSA = do not have enough donor skin
-EXPENSIVE, very fragile, susceptible to infection
artificial skin
silicone membrane used to replicate dermis
-permanent coverage
-provides functional dermis
-high infection risk
important pt care to remember after grafts…
DO NOT SLIDE pts in bed , graft will shear off
infection / sepsis s/s
- disorientation
- decrease UO
- metabolic acidosis
- tachypnea
- tachycardia
- hyperglycemia
- hyper / hypothermia
- paralytic ileus
rehabilitative phase
begins at wound CLOSURE and ends with return to highest level of fxn
wound healing mobility…
as wounds heal they contract decreasing mobility
**contractures
splinting
during immobilization after grafting to prevent deformity
pressure garments
flatten hypertrophic areas and provide vascular support to healed wounds
**WEAR 23 HRS / DAY
**use 12-24 months until scar matures
positioning
affected extremities should be elevated at all times to prevent contractures
occipital pressure ulcers
reposition / turn to redistribute pressure
ears chondritis
caused by pressure necrosis , NO PILLOW = keeps ears free of pressure
neck flexion deformity
NO PILLOW
shoulder adduction contracture
position at 90 degree of abduction / flexion
wrists contracture
support in neutral position with splint / pillow
hand edema, claw hand, web space
elevate , resting hand splint, dynamic flexion, thumb splint
hip contracture
position flat, trochanter rolls at hips to prevent external rotation
knees contractures
elevate, avoid tight dressing, ace wraps for ambukation
SJS / TEN
commonly associate with…
1. medication reaction adverse
2. viral infection
3. staph toxin
SJS / TEN s/s
sloughing of epidermis from dermis
extremely painful lesions
SJS = < 30% TBSA
TEN = > 30% TBSA
SJS / TEN mgmt
- AIRWAY is priority , sloughing of oral mucosa / bleeding
-fluid replacement
-nutrition
-wound care = need wound care nurse
-possibly burn center transfer
compartment syndrome s/s
1st sign is pain out of proportion to expected
-paresthesia
-pallor
-paralysis
-pulselessness!!! LATE SIGN
-pressure
rhabdomyolysis
damaged muscle tissues r/t myoglobin
**COLA COLORED URINE
**elevated CK but normal BUN
**75-100 mL/hr UO
AKI
will have elevated BUN and Creatinine
