Burns/Frostbite Flashcards
Functions of the Skin
- Protection
- Barrier
- Thermal regulator (36.5-37.5)
- Sensation
- Excretion & absorption
- Vitamin D synthesis (D2 > D3 – active form)
Definition and 6 Types of Burns
- Loss/disruption of tissue integrity: any layer(s)
- Impedes normal skin function
- Due to excessive exposure to: thermal, chemical, electrical, radiation, friction, or cold source.
4 Factors Affecting Burn Survival Rates
- Age
> older adults have impaired sensation and reaction times
> decreased risk assessment
> thinner, more fragile skin with decreased circulation
> impaired healing times - Severity of burn = percentage of body service area (BSA) burned
3 Depths of Burns - Underlying Disease Processes
What 4 things determine burn severity?
o Depth of burn
o Extent of burn (TBSA)
o Location of burn
o Other patient risk factors
Causes of thermal burns
o Flame
o Scald
o Steam
o Smoke (Inhalation)
Causes of friction burn
Rug burn
Causes of radiation burn
o Sunburn
o Radiation therapy
Causes of electrical burn
o Lightning
o AC/DC current
Causes of chemical burn
o Acid
o Alkali
Electrical burns result from ______ transmission of ____, _____, or arcing
- Result from direct transmission of current, flash or arcing
Explain why the outward appearance of electrical burns can be misleading
- creates a burn where the current enters, and where it exits (entry and exit wounds)
- created path entire way through body, most damage is internal
- Only burn that TBSA not calculated because not accurately reflect damage
Where is most of the damage done in electrical burns, and what is key to monitor?
- Most of the damage is done upon exit of the energy and within the tissues it passes
- Current can impact major organs
> Especially heart; electrical current can effect electrical current of heart; arrhythmias
Examples of acidic burn causative agents
bathroom cleaners, pool chemicals, car batteries, etc.
How does acid cause burns and what are the effects
o Tissue integrity damaged by coagulating cells & skin proteins; can limit depth of tissue damage
o Mild edema
o Charring, hard eschar
o Less dangerous
Examples of alkaline burn causative agents
oven cleaners, fertilizers, industrial cleaners, cement, firework sparklers, etc.
How do alkaline substances cause burns, what are the symptoms, and how does treatment differ?
Causes skin & its proteins to liquify = deeper injury. More severe.
++edema
No charring
Treatment and Number 1 Priority: decontamination; will continue to burn until neutralization with material described in WHMIS. If unknown, use water and soap.
> Neutralization before ABC’s – materials can harm healthcare workers if come into contact
What kind of treatment do radiation burns require?
- Sun
- Xray, MRI
- Therapeutic radiation treatments
- Superficial, requires typical first aid treatment
Sources of thermal burns and the type of burn they precipitate
- Flames > dry heat burns
* Open flame, explosion - Liquids > moist heat (scald) burns
* Hot liquids, steam - Hot object/substance > contact burn
* Hot metal, tar, grease often result in full-thickness injury
When should you suspect smoke inhalation burns?
- If someone was trapped in burning space
- Singed nasal/facial hair
- Close proximity to explosions
- Facial/neck burn = upper/lower airway injury
- Cough = black/gray/bloody sputum
- Hoarse voice
Treatment of Smoke Inhalation Injuries
- Stabilize C-spine
- 100% humidified oxygen; alveolar damage is suspected
- Early intubation; rapid airway closure
> Majority of mortality of burns is due to smoke inhalation, not damage to rest of body
Concern with Carbon Monoxide with smoke inhalation, clinical S+S and treatment
- Colorless, odorless, tasteless gas
- Inability to detect
- Released into air with fire
- 200x higher affinity for hemoglobin; Hgb will bind to CO before O2
- SpO2 monitor doesn’t differentiate between CO and O2 saturation – reads HEMOGLOBIN bound, not what it is bound to
- Clinical S+S: cherry red in face (CO causes vasodilation), classic signs of low oxygen
- Treatment: 100% oxygen 15L to flush CO out for hours
Concern with cyanide poisoning with smoke inhalation
- Product of incomplete synthetic combustion (furniture)
- Consider when in house fire
- Difficult to detect, when it enters into cells they can not produce ATP and enter into anaerobic metabolism even with oxygen present
- If suspected; antidote given.
4 Grades of Frostbite:
1: hyperemia and edema
- clear milky fluid filled blisters with partial thickness necrosis
3: dark fluid filled blisters, non-blanching, cool and bumb, full thickness and SC necrosis > requires debridement
4: blisters beyond digit, bloodless, full thickness into muscle and bone - gangrene
When does grade of frostbite become apparent?
When body part is thawed
Superficial frostbite care
rewarm with body heat
* Analgesia > rewarming is painful (Tylenol, Advil, Dilaudid)
Severe (3-4) frostbite care
- slowly rewarmed with bath water (do not touch basin)
- elevate extremity above heart to reduce edema
- tetanus shot
- loose sterile dressing
- antibiotics
- iloprost (vasodilator + inhibits platelets)
Zones of Injury: Jackson Model
- Zone of coagulation: centre of injury; most deep and damaged part
* Point of maximum damage
* Irreversible tissue loss
* Coagulative necrosis - Zone of stasis:
* Decreased perfusion; can progress if not reversed
* Potentially salvageable
* Goal of treatment: treat and reverse zone of stasis
* Increase circulation and perfusion - Zone of hyperemia:
* Tissue perfusion increased (from inflammatory process - vasodilation)
* Damage is reversible
Pathophysiology of Burns (Capillary Leak Syndrome)
Normal Blood Capillary: Water is the smallest molecule that can pass through the capillary
Postburn Blood Capillary: Permeability is drastically increased due to mass vasodilation and inflammation response, which allows large molecules such as protein to pass through capillaries pores easily.
>Commonly results in hypovolemic shock – fluid lost to interstitial spaces and evaporates off
> Some distributive shock properties
3 Factors Contributing to Shock in Burns and end result
1.Injury causing cell death (hyperkalemia and coagulopathy)
- Massive fluid shifts out of vessels due to increased permeability
- hypovolemic shock due to sodium shift with fluid evaporation - Collioid osmotic pressure decreases (edema and high HcT)
= intravascular volume
low BP
high HR
4 Determinants of Burn Depth
- temperature of heat
- contact time
- medium of heat (water vs steam)
- thickness of skin
Describe superficial burn
- only epidermis
- dry
- pink/red
- intact
- blanches
- no edema
- no blisters
- some pain
Describe deep partial thickness burn
- epidermis and dermis
- wet
- waxy
- red-white
- minimal blanching
- ++ edema
- less blistering
- +pain
Describe partial thickness burn
- epidermis + papillary dermis
- moist
- weeping
- pink-red
- blanches
- edema
- blisters
- ++ pain
Describe full thickness burn
- epidermis, dermis, and fat
- dry
- leathery
- white
- charred skin with eschar
- absent hair
- no blanching
- no pain
- no blisters
- +++ edema
Can also progress into muscle and bone
Rule of 9’s
Used to calculate TBSA
Total (front and back)
Head: 9%
Arms: 9% each
Torso: 36%
Legs: 18% each
Groin 1%
Primary Survey for Burns
STOP the burning process!
> By flushing all areas in contact with chemicals
1. Airway
* Burned airways swell rapidly
* Early intubation
2. Breathing
* Possible gas exposure (CO, cyanide)
* Circumferential burns around torso
3. Circulation/C-spine
* Cardiac status; shock treatment (>20% TBSA)
4. Disability
* Neurological status
5. Exposure & Evaluate
* Remove all rings, watches, jewelry r/t edema
* Remove all clothing from the area
* Cool the burn wound
6. Fluid resuscitation
* Calculate TBSA
What does fluid resuscitation prevent in burn patients and when does it begin?
TBSA >20%
prevents the development of shock & maintains adequate perfusion/increase perfusion to zone of stasis
Best indicator of adequate fluid replacement
Kidney Perfusion (urine output)
Calculation of fluid resuscitation for burn victims
Parkland Formula
Weight in kg x 4ml x %TBSA= total amount of fluid infused in 24hrs from time of injury
Explain timing of delivery and which fluid is used for resuscitation of burn victims
- Give half during first 8hrs
- Remaining half over the next 16hrs
- Use Ringers Lactate
How do you know fluid resuscitation has been achieved in burn victims and how does this differ for electrical burns
- Maintain urinary output at 0.5ml/kg/hr (30-50 ml/hr).
- For electrical burns (TBSA not calculated) with myoglobinuria, maintain urinary output at 1-1.5ml/kg/hr (~75-100 ml/hr) until urine is clear
- Fluids can be increases if urine output is not meeting target
Why do electrical burn victims require higher urine output?
Muscle damage (i.e. electrical burns traveling through body > entry/exit wounds) myoglobin released into the bloodstream
Kidneys remove myoglobin from the body into the urine
In large amounts, myoglobin can damage the kidneys
Higher urine output/hr is required to help clear the myoglobin
Cardiac complications emergent phase of burns
- Increased capillary permeability fluid leaks into interstitial space (edema) hypovolemia SHOCK
- Tissue ischemia anaerobic metabolism and necrosis acidosis
- Dysrhythmias (electrical burns, hyperkalemia, etc)
- Electrolyte shifts Na; hyper (or hypo) K+
- Impaired circulation to extremities/organs
- Impaired microcirculation and increased viscosity
Urinary complications emergent phase of burns
- Decreased blood flow to kidneys causes renal ischemia (AKI)
- Myoglobin Acute tubular necrosis (ATN)
Respiratory complications emergent phase of burns
Upper resp tract injury
* Edema formation
* Mechanical airway obstruction & asphyxia
* Injury r/t length of exposure to smoke or toxic fumes
Lower airway (inhalation) injury
* Direct insult at the alveolar level
* Risk for ARDS
Immunity complications emergent phase of burns
- Loss of skin barrier & presence of eschar favor bacterial growth
- Hypoxia, acidosis, thrombosis of vessels impair resistance to bacteria
- Risk for SIRS, sepsis, MODS
- Blisters: sequestering of fluid & proteins
GI changes that occur in emergent phase of burns
- Shunting of blood to vital organs decreased blood flow to gut paralytic ileus (gastric distention, N/V)
- Ischemia of gastric mucosa duodenal/gastric ulcer; bleeding
Hypermetabolic response in emergent phase of burns
- Mediated by catecholamine release (epi, norepi)
- Increased metabolic demand increases body temp
- “Burn fever”= temp
- Shivering: further increases metabolic requirements
Hematologic changes in emergent phase of burns
- Release of thromboxane A2 by damaged cells thrombocytopenia, abnormal platelet function, fibrinogen levels, inhibition of fibrinolysis
- Net deficit in plasma clotting factors (DIC)
- Anemia destruction of RBCs d/t burn injury
- Blood loss
Cognitive changes in emergent phases of burns
- Hypoxia d/t smoke inhalation
- Concomitant trauma, substance use/abuse, sedation or pain meds
What is Eschar?
- A scab or dry crust that results from trauma, such as a burn, infection, or excoriating skin disease
- DEAD skin
- Potentially dangerous:
- risk for compartment syndrome
- chest restriction (can be hard; if burns circumferential)
- sub-eschar edema
- Extensive circumferential full-thickness burn of a limb or chest eschar may cause problems it is unyielding/rigid
- Escharotomy may be necessary
What do we do about the burn after initial stabilization?
- pain management
- promote wound healing
- PT/OT
- Nutritional therapy
- psychological
Healing/Treatment of Superficial Burns
Superficial/uncomplicated burns heal by regeneration (cell division and replenishing the epidermis) within a few weeks
o Topical abx (i.e. Polysporin) and gauze
Healing/Treatment of Complicated Burns
Full-thickness requires surgery
Debridement and grafting or permanent injury and scarring can occur; will not heal by themselves
Advanced dressing in partial thickness & deep partial thickness burns
“advanced dressing”= something with antimicrobial ex) silver
4 Purposes of Burn Dressings
- Absorb & contain the drainage
- Provide protection for the wound from the environment
o Pts with burns are at increased risk for infection
o Infected wounds take longer to heal & will increase scar tissue formation - Decrease wound pain
o Initially, superficial burns are very sensitive to air currents
o Deeper burns become more sensitive to air as the heal and nerves are re-enervated
o Wound coverings eliminate air currents from the wound surface - Permit high humidity at the wound site
o A moist environment is critical for epithelial cells to migrate and spread
o Re-epithelialization can occur on a dry surface; however, it is slowed down
o moist wound healing is NOT usually used for infected burns or burns with eschar
Purpose of cleansing/debridement
- All dressings are done as a sterile procedure
- Always soak the inner dressing with sterile NS or water prior to removing the old dressing
- You do not want old dressing to adhere to wound because healthy tissue may be removed inadvertently
- Cleanse wound with warm sterile cleansing solution. Wipe burn from center toward outer edges
- Remove excess exudate, topical ointments and loose eschar using a light scrub
- If necessary, lift loose skin/eschar with sterile forceps and trim with sterile scissors, this process should not cause pain or bleeding
Pro Removing Blisters
- Fluid inside the blisters depresses immune function, affects neutrophils job of killing foreign cells, and enhances inflammation
Pro Leaving Blisters Intact
- Blister is a protective cover for the burn
- The blistered skin will gradually wrinkle and collapse onto the healing wound: this skin is a protective layer
- If the blister is removed, the wound can become very painful
- Spontaneous re-absorption of the fluid will take place in ~ 1 week
Grafting
- Surgical procedure: skin or skin substitute is placed over a burn or non-healing wound to permanently replace damaged or missing skin or provide a temporary wound covering
- Use of patient’s own skin to close the wound (autologous)
- Cadaver skin, pigskin, or type of biobrane (expensive) to close the wound
- Surgical debridement of full-thickness burns is necessary to prepare the wound for grafting
Contractures
- An area of skin that has undergone excessive scarring from a deep burn
- Caused from thick bands of hypertrophic scaring that restrict joint movement loss of joint mobility permanently impair function
- Some are unavoidable… but many can be prevented:
- Early excision and grafting for full-thickness burns
- Stretching, minimum of 5-6 times a day; painful, patients may not adhere
- Casting or splinting to position potential contracture area in a stretched position
- Having patient do as much for themselves as possible (ie. Self-grooming, eating etc.)
