Burns Flashcards
Burns
-occur when cells in the skin or deeper tissues are damaged due to heat, cold, electricity, radiation, caustic chemicals
Types of Burns (6)
- thermal/heat
- cold/frostbite
- electrical
- chemical
- inhalation
- radiation
Lund-Browder Chart
- most accurate for determining TBSA
- accounts for body variation and shape with age
- most accurate for kids
Rule of Nines
- quick and easy way to estimate TBSA
- not always the most accurate
- only include 2nd and 3rd degree burns
Palm Method
- the palm of the patient’s hand (excluding fingers) is approx .5-.8% of TBSA
- palmar surface with fingers 1%
- can be used to estimate small burns < 15% TBSA or large burns > 8% TBSA
- not as accurate for medium sized burns
What 4 things determine the depth of tissue damage from a burn?
- temperature of burning object
- duration of contact
- thickness of the dermis
- blood supply
-young and old have much thinner skin –> burn deeper
How are burns classified?
- First degree: superficial
- Second degree: partial thickness (superficial or deep)
- Third degree: full thickness (down to SQ tissue)
- Fourth degree: goes to tendon, bone, muscle
Superficial (1st degree) Burn Characteristics
- epidermis only
- painful, erythematous skin
- dry, no oozing or weeping
- blanch with pressure
- heal quickly: over 2-3 days, pain and redness subside
- epithelial cells peel away at day 4
- healed in about 6 days
Partial Thickness (2nd degree) Superficial Burn Characteristics
- entire epidermis and a variable portion of dermis
- forms blister w/in 24 hours
- painful, red, weeping
- heal in 7-21 days
- scarring unusual
- pigment changes may occur
Partial Thickness (2nd degree) Deep Burn Characteristics
- extend deeper into dermis; damage hair follicles and glandular tissue
- painful only to pressure (nerves affected)
- blistered (usually unroofed)
- mottled color from white to red
- do not blanch (blood vessels have coagulated)
- heal 3-9 weeks
- hypertrophic scarring
Full Thickness (3rd degree) Burn Characteristics
- entire thickness of epidermis and dermis, into subQ tissue
- whitish to black in color (charred)
- little or no pain (nerves damaged)
- no blisters
- coagulated vessels, no capillary refill
- these burns heal with contractures and severe scars
- surgery needed
Full Thickness (4th degree) Burn Characteristics
- involves fat, fascia, muscle or bone
- these are potentially life threatening
Minor Burns - Characteristics
- partial thickness burn 50 y.o
- full thickness burns <2% w/o other injury
-AND isolated injury; may not involve the hands, face, perineum or feet; may not cross major joints; may not be circumferential
Minor Burns - Cooling Treatment
- remove any hot or burned clothing, jewelry, debris
- burned areas soaked immediately with saline or cool water
- do not use ice (hypothermia)
- monitor core temp to prevent hypothermia esp when burns >10% TBSA
- keep body temp above 95F (35C)
Minor Burns - Cleaning/Debridement
- clean with gentle soap and water
- debride loose epidermis and blisters > 2 cm
- use saline and gauze
- use surgical scrub brushes
- enzymatic debriding agents (Collagenase)
Minor Burns - Blisters??
- if ruptured, debride the tissue
- if intact, there is controversy regarding management
Minor Burns - Topical Treatments
- topical antimicrobials and dressings are best choice
- silver sulfadiazine: thick white topical agent; can’t be used in pregnant or BF moms or infants; antibacterial activity
- bacitracin and polymyxin: easier to apply and remove w/ dressing changes; may be used on perineum and face
- fine mesh gauze
- hydrocolloid dressings
- silver containing dressings: silver = antimicrobial
- biosynthetic dressings: fewer dressing changes; semi-biologic skin substitute
Scarring from Burns
- excessive scarring in form of keloid scars and contractures
- both types may be uncomfortable and can interfere with ROM
Major Burns - Characteristics
- 25% TBSA in 10-40 y.o
- 20%+ TBSA in kids 40
- 10% TBSA full thicknes burns
- all burns involving eyes, ears, face, hands, feet, perineum
- burns across a major joint
- all high voltage electrical burns, chemical or inhalation
- all burns complicated by major trauma (eg broken bone)
- all patients w/ burns and serious co-morbidity (DM, renal failure)
- your facility is not equipped to care for peds
Major Burns - Airway Assessment
- important to assess airway early; large % of smoke inhalation patients develop airway obstruction
- common signs of smoke inhalation: persistent cough, stridor or wheezing; hoarse; deep facial burns; nares with inflammation or singed hair; blistering/edema of oropharynx; depressed mental status; respiratory distress; hypoxia or hypercapnia
Major Burns - Circulation Assessment
- normal heart rates for burn patients 100-120 bpm
- tachycardia is expected: pain, anxiety, hypovolemia, inadequate oxygenation
Fluid Resuscitation
- burn shock during initial 24-48 hours = large fluid shifts and depletion of intravascular volumes
- rapid, aggressive fluids needed
- protect end organ damage
- any patient w/ > 15% TBSA should receive fluids
- lactated ringers preferred
Parkland Formula
- fluids given during the initial 24 hours: 4 mL/kg for each % TBSA/24 hours
- 1/2 of fluids given over first 8 hours; other half given over 16 hours
- in infants and kids, 3 mL/kg for each %TBSA/24 hours (add dextrose)
A 25 y.o male with TBSA of 30% weighs 70 kg.
How much fluid is needed in the first 24 hours?
How much should be given per hour in the first 8 hours?
In the next 16 hours?
- 4 x 70 x 30 = 8400 mL for 24 hours
- 4200 mL over 8 hours = 525/hour
- 4200 mL over 16 hours = 262.5/hour
ABLS Guidelines for Fluid Resuscitation
- adults: 2 mL LR x kg x TBSA
- kids: 3 mL LR x kg x TBSA
- electrical: 4 mL x kg x TBSA
Subsequent Fluid Resuscitation
- urinary output is most reliable guide (foley cath, depends on normal renal function)
- expected urine output for adults (0.5 mL/kg/hr) and for kids (1 mL/kg/hr)
What happens in the case of excessive or inadequate volume during fluid resuscitation?
- excessive: exaggerates edema, compromises blood flow, exacerbates laryngeal swelling
- inadequate: may cause shock and organ failure
Pediatric Fluid Resuscitation
- greater surface area per unit body mass
- require relatively greater amounts of resuscitation fluid
- BUT are more susceptible to fluid overload
Skin Grafting
- skin grafts are a biologic dressing
- consist of skin taken from a donor site and grafted onto a wound
- autograft: from same patient
- allograft: from non-self source
Full Thickness Skin Graft
- contain epidermis and dermis
- retain more of the characteristics of the normal skin
- skin is taken from groin, lateral thigh, lower abdomen or lateral chest
Split Thickness Skin Graft
- contains epidermis and small amount of dermiss
- tolerate a less than ideal wound bed and have broader range of applications
- can be meshed to provide greater surface area coverage
- tend to be abnormally pigmented (pale/white or hyperpigmented)
Escharotomy
- eschar: stiff and unyielding tissue associated with a full thickness burn
- will compress the underlying tissue and cause compression and ischemia
- if circumferential around the chest, it will not allow chest expansion for respiration
Infection Control for Burns
- wounds should be cleaned with a mild soap and water
- topical antibiotics applied to all burns covered by a clean dry dressing
- systemic antibiotics generally not needed
- debridement
- tetanus vaccine given for any burns greater than superficial
- tetanus immune globulin should be given if patient has not completed primary immunization series
What are the most common pathogens for a localized burn infection?
- pseudomonas aeruginosa
- staph aureus
- MRSA
- enterococcus
- localized infections can become a generalized cellulitis or sepsis
Pain Management of Burns
- partial thickness can be especially painful
- IV morphine is common for pain management, other opioids also acceptable
- reasonable to give benzodiazepines to help with anxiety
Mortality Risk Factors for Burns
- age greater than 60
- non-superficial burns over 40% TBSA
- inhalation injury
-risk increases with each risk factor a patient has
Burns in the Pregnant Female
- outcome of pregnancy determined largely by outcome of woman
- consider pregnancy loss in woman with >60% TBSA
- pregnancy itself does not seem to alter maternal outcome
- evaluate and treat the same as non-pregnant female
- prevention of hypoxia and hypotension especially important to not limit blood flow to fetus
- fluid resuscitation needs may be higher
- fetal monitoring: OB consult
Burns and Child Abuse
- common burns of abuse are contact (cigarettes, iron) and scald burns
- history of injury should mesh with physical exam findings
- symmetrical burns are suggestive of abuse (eg lower legs from being lowered into hot water)
- index of suspicion may be higher with other physical exam findings of injury (bruises, etc)
