Burns- part 2 Flashcards
burns less than 20% TBSA
- produce localized tissue response
burns greater than 20% TBSA
- considered major injuries and we are worried about all body systems because they are all affected by the release of cytokines
- admitted to burn unit
how to evaluate burn size “TBSA”
- rule of nines
rule of nines
- hand: 1%
- head: 9%
- one arm: 9%
- one side of arm: 4.5%
- chest front: 18% (each half- top and bottom is 9%)
- chest back: 18%
- peri area: 1%
- whole leg: 18%
- whole one side of leg: 9%
Primary survey assessment involves
- ABCDE
- A: airway and c spine
- B: breathing
- C: circulation
- D: disability
- Ex: exposure and examine
- F: fluid resuscitation
primary survey- airway and c spine
- maintain patent airway (may need intubation- assess for inhalation injury since 50% of burn patients will have it)
- check if possible for advanced directive/ code status prior to ETT
- cervical spine immobilization if warranted
Primary survey- Breathing
- high flow 100% oxygen mask
- assess burns and the impact they have on work of breathing
primary assessment- circulation
- elevate extremities
- no pillow under the head
- remove tight jewelry or clothing
- pulse checks with circumferential burns or electrical burns
primary assessment- disability
- neuro exam
primary assessment- exposure and examine
- extent and depth of burn wounds and possible associated trauma
- trauma care tumps burn care
primary assessment- fluid resuscitation
- insert at least 2 large bore (> 18 G) IV and start LR
- 18 or lower number
secondary assessment includes
- circumstances
- medical history
- head to toe
- extent of burn
- covering wounds
- maintain core body temp, pain meds, iv narcotic preferred
- tetanus statues and lab tests
- ABG
- 12 lead EKG and CK-MB/ troponin levels
- Fluid resuscitation
secondary assessment- circumstances
- cause?
- time of injury
- enclosed space?
- associated trauma (electrical)
- length of time before rescue
- chemicals involved
- use of accelerant
secondary assessment- medical history
- current meds
- allergies
- vaccinations
- last flood and fluid intake
secondary assessment- what do you cover the wounds with
- clean dry sheet
secondary assessment- lab tests
- CBC
- CMP
- PT/aPTT
- urinalysis
- surveillance cultures
secondary assessment- what do you do an ABG and carboxyhemoglobin for
- suspected inhalation injury
secondary assessment- what do you do 12 lead EKG and CK-MB/ troponin levels for
- suspected electrical injury
Phase of interventions
- Emergent: first 48 hours
- Acute: weeks to months (day to day care)
- Rehab: > 2 years: once the wound is closed- pt skin is fragile and may get scraps and cuts
Burn Shock
- right after the burn
- hypovolemic and distributive shock: your not bleeding and you only have edema but the fluid is in the wrong place
- Massive fluid loss externally: heavy protein loss
- significant interstitial fluids: wound edema, thrid spaci
inside cell
- normally: k+
- with burns: K+ leaves the cell
outside the cell
- normally: Na+
- with burns: Na+ moves into the cell
with burns what moves outside of capillary
- H20
- Na
- Albumin (more edema)
first 48 hours after a burn
add stuff
longer than 48 hours after a burn
add stuff
circulation
- need large fluid amounts to maintain tissue perfusion
- want early and adequate resuscitation
- begins with the parkland formula and the rule of nines
under resuscitation
- leads to overwhelming acidosis (lactic acidosis)
over resuscitation
- leads to increased complications
- lung injury
- ARDS
- Compartment syndrome
ABLS recommendation for fluids for EMS when > 30% TBSA
- determined by age
- <5: 125 ml/hr
- 6-13: 250 ml/hr
- > 14: 500 ml/hr
*once in ED: fluids calculated via formula, foley catheter inserted, temperature control
parkland fluid formula
- 4 ml LR x TBSA x kg
- give 1/2 of volume within first 8 hours then the rest over the next 16 hours
- adjust fluid rate to maintain UO of 30-50 ml/hr
Fluids when UO is 75 cc for 2 consecutive hours
-decrease
Fluids when UO is 20 or 15 cc for 2 consecutive hours
-increase
electrical injury fluid resuscitation
- 4 ml LR x kg x TBSA
- maintain UO of 75-150 ml/hr or whatever is deemed necessary to clear the urine and protect the kidneys (dont want red bloody urine)
- may need to increase UO 10 1-1.5 per kg/hr to clear urine
goals of burn care
- prevent secondary injury by performing adequate resuscitation
- extent of burn cant be calculated until 24 hours after and poor tissue perfusion in these first 24 hours = extend the depth of the burn
Airway- breathing- assess
- facial burns, inhalation injury or burn (>25% TBSA)= inhalation injury and early intubation is important
airway-breathing- bronchoscopy
- into the airway to see
airway- breathing
- humidified o2 to keep airway clear
- 100% o2 to help remove CO and monitor carboxyhemoglobin
- Assess sputum: thick? dry? soot?- may need aggressive pulmonary interventions to prevent mucous plug (keep moist)
- monitor: pulmonary edema, atelectasis, PNA, ARDS
- elevate HOB
circulation
- want adequate tissue perfusion
- assess for compartment syndrome and check pulses
circulation: cardiac concerns- hypovolemic shock
- massive metabolic acidosis (tissue lactate)
circulation: cardiac concerns- k+
- released in massive amounts
- monitor K+
- treat dysrhythmias
circulation: CARDIAC concerns
- hypovolemic shock
- K+ released in massive amounts
- decreased CO which increases complications
circulation: hemodynamic markers
- CVP: > 10 (not really used too much)
- SV 70% or SVV < 13-15
- UO: >30-50 ML/HR
- ABG: acidosis- want lactate < 2
emergent phase
- pain management (small frequent doses or infusion)
- sedation-anxiolytic
- gi symptom management
emergent phase: gi symptom management
- NG to prevent and manage ileus
- small bore feeding tube- placed early: feed within 24 hours; hypermetabolic injury
- curlings ulcer: stress ulcer- H2 blocker, cytoprotective, PPI
why does ileus form in burn
- blood is sent to vital organs since in truama state
- which means GI tract is not getting blood = frozen and not working = ileus
emergent phase- thermal control
- they cant maintain temp so we need to
- warming blankets
- high room temp (84-86)
- warming lamps
emergent phase- infection control
- gown and gloves for contact when > 20%
- topicals
- high risk for sepsis
compartment syndrome is usually found in…
- full thickness circumferential burns or electrical burns
- pt. with large resuscitation
compartment syndrome assessments
- constant neuro
- sensation/paresthesias
- pupils checks= Q 15 - 60 min
- cap refill
- general feeling of the limb
treatment for compartment syndrome
- escharotomy or fasciotomy
when do escharotomy or fasciotomy
- compartment pressures of greater than 30 (we want them less than 25)
- loss/decrease of sensation in extremity
- loss of dopplerable pulse
escharotomy or fasciotomy
- cuts through the inelastic eschar or into the fascia
- non compliant and doesn’t stretch or expand so can affect breathing and even cause ARDS
- End result of tx: return of blood flow through/to the body part (return of pulses, perfusion, and sensation)
when to get fasciotomy instead of escharotomy
- when its deeper
- electrical or thermal burns
- deep burns
emergent phase summary
- first 48 hours
- up to 72 hours of resuscitation- could last longer
- pt and family is emotional and have information overload
acute phase
- 72 hours to closure
- fluid balance
- edema management
- promote wound closure with wound care
acute phase goals
- infection prevention
- pain control
- nutrition
- prevent complications
when does wound care happen
once pt is stable
wound care
- topicals
- antimicrobials
- enzymatic collagenase
- medical grade honey
- anti-fungal
- NON STICK DRESSINGS ALWASY
antimicrobials used for wound care
- bacitracin
- silver sulfadiazine
- sulfamylon: cream/soaks
enzymatic collagenase for wound care
- chemical debridement
- places (like cheeks) that you wouldn’t want to scrub but you want to break down the dead skin to get it off
anti-fungal used for wound care
nystatin
hydrotherapy
- every day
- uses water to loosen dead tissue and assist with removal of tissue and agents
- prevent hypothermia
- give: high does medications for pain and anxiety (fentanyl, Ativan, ketamine, presedex)
debridement
- chemical
- mechanical
- surgical
- this is where you wash off the topicals and bandages and then take off any dead skin that can fall off
types of grafts
- autograft
- allograft- temporary
- xenograft: pig - temporary
- CEA
CEA
-Cultured epithelial cells “grown” from small portion of skin (skin grown from pt own skin) • Expensive • Used when tissue can’t be taken from patient (if already took skin from somewhere and cant take more because hasn't grown back yet) • TBSA > 85%
autograft types
- sheet or mesh
mesh graft
-Holes or “interstices” are placed in harvested skin to increase the surface coverage area (stretch it out) -Covers larger areas of the body
sheet graft
•One continuous piece of skin •better cosmetic outcome •Used for faces, hands, feet, and joints (highly exposed areas)
downside to autograft
- now have two sites to take care of (graft and donor)
care for graft site
- No pressure on site
- Roll out bubbles of air and fluid
- Keep edges moist
- Observe for “take”…usually 5-6 days
care for donor site
• Pain Management New increased pain area because now have another wound site so the total wound area is bigger • Moist to dry wound healing (think of a scab) • Thin dressing • Heals 7-14 days
pain management
•Hypermetabolism= Patient: rapid metabolizing meds. •Higher dosing •more frequent dosing needed •Not addiction…
other meds for burn pt
- anxiety: benzo and antidepressants
- B blockers to reduce heart rate: propranolol of metoprolol if have breathing issues
- anabolic steroid to increase muscle protein metabolism: oxandrolone
- growth hormone
nutritional concerns with burns
-Hypermetabolic state
- TBSA > 40%= 2X resting
metabolic rate
• Consumes nutrients
• Metabolizes drugs more quickly
• >20% need additional kcal
-Malnutrition primary concern
-High dose Vitamin C
• Decrease fluid needs and increase
healing
-Protein & calorie rich diet
• 2-3g/per kg q 24 hr
-Enteral nutrition preferred
Versus TPN
• Low fat High Carb
• Post pyloric
• Tube feeds: 24 hour goal
and hourly goals used
burn wound infection
- don’t do prohylaxtic abx just give if s/s of infection
-Cellulitis
• Assess for erythema,
edema, increased pain
• Will need debridement
and possible IV
antibiotics
• Will prevent the wound
from healing
rehabilitation phase
•Wound closed •80% tissue strength •Itching •Temperature regulation • Longest stage--years
mobility
- IMPORTANT
- Starts with first day in hospital
•ROM (open and close hans)
•Positioning: splinting position of greatest
function
•Prevent contractures by keeping area under the joints stretched out
Scars constrict & decrease mobility
•concern over joint spaces= contractures
form - no pillow with neck burns
skin care later on for years
-Scar compression – Elastic wraps – Pressure garments – Tight fitting – Skin stretch • Cosmetic concerns for patients • Compliance concerns
laser therapy
Transformation of light
into heat - Vaporizing old scar
creating new wound with new
healing
ablation therapy
- removal of target tissue
downsides of laser therapy and ablation
- Dry, peeling, itching ,delayed
hypopigmentation, infection
•Cost
•Covered by insurance
psychosocial
- Body Image Distress/disorder • Visible cosmetic alteration • Scars/melanin does not come back • Grafting leaves marks • Pressure garments in public • Make-up products -Depression -Shame
new therapies
- Spray on skin
• clinical studies in progress in USA and Europe
Fish skin graft
• used in areas where access to Allograft and
Xeonograft is limited
• not likely to be used in US on People at this time
• We have enough access to allograft
• See next slides how it is used in animals
