Burns Lecture Flashcards
Function of skin
Protection from external trauma
Resists temperature variation (insulation/cooling)
Blocks entry of microorganisms
Prevents moisture loss from underlying tissues
Immune surveillance function
Decreases penetration of some types of radiation
Aids metabolism
Produces lubes and mositurizes
Touch!
Three zones of injury
Hyperemia
Stasis
Coagulation
Zone of Hyperemia
Outermost or most peripheral area to the site of wound or injury
Tissue is characterized by inflammatory changes and minimal damage
Zone of Stasis
Extends towards the central site of injury
Tissue is ischemic
Vessel endothelial damage –> thrombosis
Drying and infection –> deepen injury
24-48 hours post injury, progressive degeneration can be seen
Zone of Coagulation
Central-most area, where most energy causing the burn was absorbed
Thrombotic vessels and necrotic tissue
Minor burns lack this
Body Surface Area
Severity is proportional to the percent of BSA damage + depth
First degree burn
Injury to the superficial cells of the skin
Mild sunburn
Blisters are NOT seen
Some erythema and mild pain
Partial thickness burn that heals within 3-4 days with no scarring
Second Degree Burn: Superficial
** If damage to dermis is minimal
Involves tissue damage to both epidermis and dermis
Erythematous, blistered, weeping and painful
Blanch with pressure
Spared glands
Within 3 weeks, little or no scarring
Second Degree Burn: Deep
** Deeper damage of dermis
Difficult to distinguish from 3rd degree burns
Burn surface is pale and may be hardened or boggy
Less painful than more superficial burns
Slowly heals over 4-6 weeks
Permanent loss of hair follicles and glands
Third Degree Burns
Destruction of full thickness of skin
Pearly white, gray or brown and is dry and inelastic
Deep pressure = pain
Small: months to heal
Scarring and contracture formation
Excision and grafting to prevent contractures
Fourth Degree Burn
Well belwo the dermis and into subq tissue, fascia, bone
Blackened and charred
Dry and painless (nerve ending destruction)
Great risk of infection and other complications
Fluid loss bc of burns
Capillary damage is widespread and vasoactive mediators are released
Fluid, plasma, and electrolytes move to extravascular compartments
Fall in blood volume, cardiac output and tissue/organ perfusion
Critical in first 24 hours
Infections bc of burns
Threat in patients with stable BP/HR/RESP
- Sepsis and pnemonia
- Loss of mechanical protection of skin permits entry of microorganisms
G+: colonize immediately
G-: Day 5
Treatment of infections
Systemic antibiotics: Not with poor circulation; high bacteria per gram
Topical antibiotics: local wound care and strict infection control
Inhalation Injury bc of Burn
High mortality rate
Bronchospasm, ulceration of membranes, edema and impairment of ciliary clearance of bacteria
24-48 hours before symptoms show: hoarseness, dyspnea, tachypnea, and wheezing
– Needs proper recognition and diagnosis
Diagnosis and therapy of inhalation injury
Diagnosis
Management: endotracheal intubation and mechanical ventilation
Maintenance of fluid status is critical
Corticosteroids DO NOT influence survival rates– NOT RECOMMENDED (increase risk of infection and morbidity/mortality
Major burn injury
Second-degree burns with >25% BSA in adults, >20% in children
All third degree burns with at least 10% BSA
All burns of hands, face, eyes, ears, feet and perineum
High-voltage electrical injury
Burns complicated by inhalation injury, major trauma, or poor-risk patients
Moderate, uncomplicated burns
Second degree burns with 15-25% BSA in adults and 10-20% in children
Third degree burns 2-10% BSA
Burn must not have risk to key areas of specialized function
Minor burn injury
Second degree burns with <3 BSA
Burn must not involve risks to specialized functional or cosmetic areas of the body
When is outpatients therapy appropriated?
Minor burns if: no other trauma, no circumferential burns, able to comply
- Many require initial evaluation by a health care provider
Hospital admission?
Major burns or moderate, uncomplicated burns
- Surgical referral: second or third-degree burns covers 3% BSA
- Possible transfer to burn patients
Age-related recommendations
Less than 2 years old
Frail and eldery
More than two burn sites
Varying stages of healing
Candidates to be alert for?
Diabetes mellitus Cardiovascular disease Immune deficiency disorders Immuno suppressants Renal disease, alcoholism, obesity
Electrical burns
Appear superficial
Extensive damage to underlying tissues and organs without obvious outer damage
REFER
Goals of treatment
Relieve pain Prevent desiccation and deepening Prevent infection Provide a protective environment for healing Need for more extensive measures?
Skin substitutes
Human cadaver skin Epidermal substitutes (grown on a culture sheet; lack mechanical stability) Animal substitutes (adheres well, lower cost, covers nerve endings) Dermal substitutes (cadaver or bovine collagen fibers)
Biobrane
Sheet of silicone bonded to a nylon mesh, with collagen peptides protruding downward from the nylon underlayer to promote adherence
Tissue -engineered biological dressings
Repeated application to the injury site of a special mesh/preparation of skin cells
Silver sulfadiazine (silvadene)
Broad spectrum
Lack good water solubility
Some penetration of eschar tissue
Painless
Effective when applied immediately after injury
Adverse effects: neutropenia and rare hypersensitivity
Avoid skin near eyes and mouth, patients with known hypersensitivity or pregnancy/nursing
Mafenide Acetate (Sulfamylon)
Water soluble, diffuses easy, penetrates eschar areas
Best with contaminated burn would, delayed treatment, or dense bacterial growth
Adverse effects: Hypersensitivity, pain upon application, inhibition of carbonic anhydrase
How are topical agents applied?
1/8 inch layer applied to the entire burn witha sterile gloved hand immediately after initial debridement and emergency care
May be covered with gauze and wrapped
Another application 12 hours later
Cleanse and inspect daily and meds reapplied
Wet dressings
Multi layered occlusive gauze dressing are moistened with agent every 2 hours and changed 2-4 times a day
- Silver nitrate, aluminum acetate (burow’s solution), potassium permanganate and acetic acid
Silver nitrate
Good germicidal and astringent activity
Immediately after injury
Precipitates upon contact with proteins - do not penetrate into eschar
Stains clothes and sometimes painful
Aluminum acetate (Burrow’s Solution)
Mild germicidal and astringent activity
Easy dilution of tablet or packet in water to prepare
Potassium Permanganate
Moderate germicidal activity
NOT astringent
Stains skin and clothes
Acetic acid
Good germicidal and astringent activity
Unpleasant, strong odor and irritating
Topical antibiotics
Topical or systemic
Depends on the nature of the organism, presence of blood circulation to the burn, whether the infection has spread
Analgesics
Oral OTC products
Less pain
Severe pain: upgrade to opiates depending on the patient and status
Topical protectants
Palliative preparation (allantoin, calamine, white petrolatum, or zinc oxide) are safe and effective for first and minor second degree burns Sooth and prevent excessive drying and protect from mechanical friction and rubbing
Post wound and follow up
Ensure adequate would healing as well as psychological support with regard to cosmetics and presence of scaring
Moisturize regularly
Pruritis: antihistamines and moisturizers
Protect from sun
Aware of surface changes
