Burns Flashcards
Management of Patients with Burn Injuries
Most burns occur in _____
the home.
Prevention is key!
Functions of the skin
Protection from infection and injury
Prevents loss of body fluids
Regulates body temp
Provides tactile sense
The strongest predictors for mortality
Increased % TBSA
Presence of inhalation injury
Increased age
Types of burns
Thermal
Chemical
Electrical
Radiation
Inhalation
Thermal burns:
: exposure to heat- flame, flash, scald, or contact with hot objects
Chemical burns
acids, alkaline agents, or organic compounds
Electrical burns:
severity based on voltage and length of exposure. Risk for potential cervical spine injury
Radiation exposure:
thermal effect; damage to the cellular DNA
Inhalation injuries:
inhalation of thermal and/or chemical irritants (upper vs lower airway injury)
_____ is the most common type of burn.
Especially:
Thermal
85% of all burns are thermal.
scalding in children (very curious) and elderly.
Chemical – tissue continues to burn until:
-\_\_\_\_\_\_ must begin immediately \_\_\_\_\_\_\_ ***outcome improved for victim
chemical is completely removed. Dust off dry chemical. Remove clothing articles touching the skin.
Continuous irrigation
at the scene
Electrical- make sure:
Severity difficult to assess, may have:
scene is safe and victim no longer in contact with source.
exit and entrance wound, organ damage.
Zones of burn injury
At the center is the zone of ______, zone of most damage, tissue is ______
Zone of _____, injured cells, potentially salvageable, but with ______, necrosis can occur
Zone of _____: minimal injury, full recovery
Zone of coagulation
not viable
Zone of stasis
persistent ischemia
Zone of hyperemia
burn can evolve and worsen over time
At the center is the zone of coagulation, zone of most damage, tissue is _____
not viable
Zone of stasis, injured cells, potentially salvageable, but with persistent ________________
ischemia, necrosis can occur
Severity of Burn Injury
Depth of burn
Extent of burn
Location of burn
Age
Risk factors
Burn Depth Classifications
Superficial thickness (1st degree)
Partial thickness (2nd degree)
Full thickness (3rd & 4th degree)
Layers of skin affected :
1st- 4th
1st- epidermis
2nd- dermis
3rd- subcutaneous
4th- muscle
First Degree - Superficial
Involves only _____
Causes:
S&S:
Treatment:
epidermis.
Causes: radiation burn or brief exposure to heat source.
S&S: Redness, pain, moderate to severe tenderness; minimal edema, peeling, itching
Treatment: Mild analgesics, cool compresses, skin lubricants; heals within a few days
Second Degree - Partial Thickness
Involves:
Causes:
S&S:
Treatment:
epidermis & dermis; may extend into hair follicles.
scalds, flash flame, contact
Moist blebs, blisters, edema, mottled white, pink to cherry-red, moderate to severe pain
Usually heal 2-3 weeks, depending on depth and area; may require grafting
Third Degree -
Includes:
Causes:
S&S:
Treatment:
Full Thickness
epidermis, dermis, and sometimes subcutaneous tissue; may involve connective tissue and muscle
Causes: flame, prolonged exposure, electrical, chemical, contact
S&S: Dry, leathery, eschar, waxy white, dark brown, or charred appearance, strong burn odor
No pain at burn sites due to loss of nerve endings; severe pain in surrounding areas.
Surgical intervention required.
Fourth Degree –
Includes:
______ appearance
Causes:
Treatment:
Full Thickness
deep tissue, muscle, and bone
Charred
Causes: prolonged exposure or high voltage, electrical injury
Amputations likely; grafting of no benefit
Inhalation injury
Caused by inhalation of _____ and/or _____ irritants
Upper vs lower airway injury:
History of injury important
Hx of injury: suspect inhalation with _________ and burns of ____, ____, and ____
Burns of the face, mouth, anterior neck
Clinical signs:
_______ for definitive diagnosis
thermal and/or chemical
Upper vs lower airway injury: Upper airway above the glottis, lower airway below the glottis
enclosed spaces
face, mouth, anterior neck
singed facial hair, carbonaceous sputum, hoarse voice, stridor
Bronchoscopy
Extent of Burn – Rule of Nines
Expressed as a percent of total body surface area (TBSA). Divide body surfaces into multiples of nine.
Head- 9%
Left arm- 9%
Right arm- 9%
Anterior chest 18%
Posterior chest 18%
Left leg- 18%
Right leg- 18%
Genital region- 1%
Note:
anterior and posterior of head 9%.
Anterior chest 9 + abd 9 =18%
If approximately half of arm were burned, the TBSA burned = 4.5%;
anterior thigh + anterior lower leg = 4.5 % (total 9%)
_______ is another method and is more accurate for children
With all methods, estimate at initial evaluation and again _________
Lund-Browder chart
72 hours later.
Children and burns
Prevention!
Splash and spill burns from hot food off stove is common
Hallmark signs of child abuse:
Definite line of demarcation
Frequent or repetitive hospital visits
Symmetrical burn wounds
Cigarette burns
Other vulnerable populations
The elderly patient
Clients with reduced mental capacity
People with reduced mobility and/or sensory impairments
Electrical- make sure scene is safe and victim no longer in contact with source.
Severity difficult to assess, may have exit and entrance wound, organ damage.
Monitor:
ECG- arrhythmias possible
_____ of burn determines treatment- surgical grafting?
Depth
Do not put anything on a burn!!!!!
Any burn that is circumferential- all around the arm- worried about:
compartment syndrome- check pulses, cap. Refill.
Burn Centers
Most minor burn injuries can be managed in community hospitals
Statewide:
Jaycee Burn Center - Chapel Hill, NC
Wake Forest Baptist Medical Center Burn Center - Winston Salem, NC
Burn Center Referral Criteria -
Partial thickness burns greater than 10% total body surface area (TBSA).
On the Scene Care
Prevent injury to rescuer
Stop injury: extinguish flames or remove from the source
Cool the burn
Remove restrictive objects
Cover the wound
Irrigate chemical burns
Primary survey: ABCDE
On the Scene Care
Treat patient with falls and electrical injuries as for potential ______ injury.
Don’t touch person if still in contact with the _______
Do:
cervical spine
electrical current
assessment surveying all body systems and obtain a history of the incident and pertinent patient history
Airway management
Administer _______ if carbon monoxide poisoning suspected
Consider_____ & ______ (esp. burns to the face & neck)
Place in ______ position (unless spinal cord injury)
_______ if needed to relieve resp. distress
Turn, cough, deep, breath
Provide suctioning & chest physiotherapy
Bronchoscopy
_______ to treat severe bronchospasm
100% humidified O2
early intubation and ventilator support
high Fowlers
Escharotomy
Bronchodilators
Why consider early intubation and ventilator support for burns to face and neck? Edema?
What is escharotomy? – Dead tissue- cutting in to dead tissue to allow for expansion
Signs and symptoms of carbon monoxide poisoning?
Dull headache
Weakness
Dizziness
Nausea or vomiting
Shortness of breath
Confusion
Blurred vision
Loss of consciousness
carbon monoxide
Odorless, tasteless, colorless, gas, binds to O2 molecule..?
Phases of Burn Injury
I. Emergent: onset of injury to completion of fluid resuscitation
II. Acute: from beginning of diuresis to near completion of wound closure
III. Rehabilitative: from wound closure to return to optimal physical and psychosocial adjustment
Emergent Phase:
(____ days)
Onset of ______ and _____
0-3 days
Onset of hypovolemic shock and edema
Emergent Phase
Fluid & Electrolyte Shifts
Increased ____________
loss of intravascular proteins & fluids into the _______
_____ and _____
Increased insensible water loss by ______
Hemolysis of RBCs (elevated Hct from ______)
Major electrolyte shifts:
CAPILLARY PERMEABILITY
interstitial compartment
edema and decreased blood volume
evaporation
HEMOCONCENTRATION
HYPERkalemia, HYPOnatremia
What does Increased capillary permeability mean?
Fluid loss from burn skin 5-10 times greater from undamaged skin
Peak fluid leak at ___, but continues up to ___
Water, electrolytes, proteins leak out of vasculature=EDEMA
6-8 hr
36 hr
Massive fluid shift
***Electrolyte shift– sodium and potassium switch leading to hyperkalemia and hyponatremia
Low sodium- <135
Hyperkalemia- >5
Burn Shock
Fluid shifts + fluid losses =
What do you think vital signs will look like in burn shock?
Intravascular volume depletion
Low bp, high hr
Emergent Phase Pathophysiology continued
Inflammation & healing
______ occurs-repair begins within ______
Immunologic changes
____ immune response
Burns < ___ TBSA produce primarily a local response; burns > ___ = local and systemic response (includes release of cytokines and other mediators)
Burns cause the proteins inside the cells to denature and coagulate, resulting in a form of cell death known as ________
Coagulation necrosis - 6-12 hrs after injury
Reduced
25%
coagulative necrosis.
CV:
Pulmonary:
Kidney:
Thermoregulatory:
GI:
CV: decreased cardiac output, decreased BP, increased HR, edema
Pulmonary: inhalation injury, upper and lower airway injury
Kidney: function may be affected with hypovolemia
Thermoregulatory: inability to regulate body temp (low at first, then elevated)
GI: organ ischemia and dysfunction
Management of Emergent Phase
Fluid resuscitation (next slide)
Pain management
Foley catheter
NPO or NGT to low intermittent suction
Continuously monitored
ECG with electrical burns
Emotional support
NGT with burns > 25% TBSA
Therapeutic Management:Fluid resuscitation
___ of injury
_____ or ____ preferred for major burns
___ during first 24 hours
Fluid calculation based on BSA ex. ABA
Indicator of adequate fluid resuscitation:
Baseline ____
Time
Large bore IV or central line
LR
urine output: 0.5-1 mL/kg/hr*
*more for electrical burns
Rely on urine output instead of BP (bc BP is not an accurate estimate)
Want at least 30 ml/hr
weight
Fluid resuscitation formula
Don’t have to memorize. Just know a massive amount of fluids are given
~1400 ml in 24 hrs
Acute phase
(_______)
Begins with:
Concludes when:
Acute phase- 48-72 hrs to weeks to months
Begins with mobilization of extracellular fluid and diuresis
Concludes when partial thickness wounds are healed, or full thickness burns are covered by skin grafts
lymphatics reabsorb fluid=diuresis
Acute Phase
Fluid and Electrolyte Shifts
Fluid reenters the vascular space from the interstitial space (______)
Increased _____
Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia, varies
Potassium shifts from extracellular fluid into cells: potential _____
Metabolic ____
HEMODILUTION
urinary output
HYPOkalemia
acidosis
Acute Phase
Fluid and Electrolyte Shifts
Fluid reenters the vascular space from the interstitial space (______)
Increased _____
Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia, varies
Potassium shifts from extracellular fluid into cells: potential _____
Metabolic ____
HEMODILUTION
urinary output
HYPOkalemia
acidosis
What happens if you were overaggressive with fluid resuscitation during emergent phase?
SOB, crackles, …listen to lungs
Acute Phase Healing
Partial thickness wounds: healing begins, after:
Full thickness wounds: require _______________ to heal
Early excision (surgical removal) reduces effects of _______
eschar is removed, re-epithelization begins, heals within 10-21 days
surgical debridement and skin grafting
inflammatory mediators
Rehabilitation Phase
Begins once:
May happen within 2 weeks or even months later.
Depends on ____ of burns
Rehab goals:
Common Complications:
the client’s wounds have healed and client is prepared to engage in self care
extent
Resume functional role in society
Rehabilitate from reconstructive surgery (cosmetic or functional)
contractures and scarring
Therapeutic Management:Pain management:
Poor _______, IV in small repeated doses
May give _____ prior to dressing changes
Opioids
NSAIDs
Anxiolytics
Sedatives
Anesthetic agents
Antidepressants
tissue perfusion
PO meds
What’s the difference between background pain, procedural pain, and breakthrough pain?
Therapeutic Management:Wound care
Wound cleaning
Topical antibacterial therapy
Wound dressing
Wound debridement (4 types)
Therapeutic Management:Wound care
Wound cleaning
Topical antibacterial therapy
Wound dressing
Wound debridement (4 types)
Wound debridement (4 types)
Natural- from dressing removal
Mechanical- done in bath (keep room warm)
Chemical- topical
Surgical- go to OR
Therapeutic Management:Wound grafting
Types (autograft, homograft, xenograft)
Care of donor site
Care of graft site
Therapeutic Management:Prevention of infection
____ is the #1 issue.
Infection controlled environment
Monitor temperature (hyperthermia common after BI)
Tetanus vaccination
Antibiotic or antifungal per wound culture results
Controlling hypergylcemia. A lot of patients will develop insulin resistance
Sepsis
Therapeutic Management:Restoration of function
Proper positioning
Specialty beds
Passive and active ROM
Splints of functional devices
Compression garments
OT and PT
Functional and cosmetic reconstruction
Compression garments: wear __________, to minimize __________
most of the day, up to a year
contractures and scarring
Complications
Resp.:
Cardio:
GI:
Kidney :
Sepsis
Respiratory: acute resp failure, ARDS
Cardiovascular: heart failure, pulmonary edema
GI: paralytic ileus, Curling’s ulcer, translocation of bacteria, abdominal compartment syndrome
Kidney: myoglobinuria-> ATN (ATN- acute tubular necrosis
)
Nutrition
________ state – feed as soon as able to eat
When oral route used:
Intubated patients –
Three-fold increase in basal metabolic rate
Hypermetabolic
high-protein, high calorie meals and supplements
enteral feedings
Emotional/psychological needs
Remember, a burn injury can be a crisis for a family.
Elicit patient wishes as early as possible.
Start enteral nutrition therapy early:
blunts the metabolic response, maintain gut viability, decrease bacterial translocation
Burn patients with >20% TBSA injury suffer long and severe response to injury:
hyperdynamic and hypermetabolic response (catabolic state, muscle wasting)
Inflammatory response can remain elevated for ____ after injury
months
Electrical injuries require:
baseline ECG and heart monitoring,
larger fluid volume resuscitation (4ml/kg/TBSA) and want greater urine output,
potential for cervical spine injury
Skin reproducing cells are located along shafts of hair follicles and sweat glands. Burn depth determines if spontaneous re-epithelization will occur
Smoke inhalation is major predictor of mortality: inhalation injury disrupts the supply of oxygen to the body by immense swelling of the upper respiratory tract, chemical irritation of the lower respiratory tract, and injuries resulting from noxious gases, such as carbon monoxide and cyanide
_________ is best indicator of adequate fluid resuscitation
Urine output
Early _____ reduces effects of inflammatory mediators
excision
Need ________ pain assessment and management
around the clock
Goal of ______ with insulin resistance
normoglycemic
