Ch. 25 Burns Flashcards
What determines the extent of the burn?
temperature of agent, duration of contact, type of tissue, depth of burn, surface area, risk factors
Who is at highest risk for burns?
children under 4 and adults over 65; and those with low socioeconomic status
What is the focus of burn prevention programs?
making legislative changes and collecting global burn data
What are thermal burns?
burns caused by flame, flash, scald, or contact with hot objects; most common type of burn
What are chemical burns?
burns caused by contact with acids, alkalis, or organic compounds
Where are alkalis found?
oven and drain cleaners, fertilizers, and industrial cleansers
Where are organic compounds found?
chemical disinfectants (phenols) and petroleum products
What type of chemical burn is hardest to treat and why?
alkali burns because they cause protein hydrolysis and liquefaction by adhering to tissues; cause damage even after neutralized
What is a major predictor of mortality in burn patients?
smoke inhalation
What is metabolic aspiration?
causes majority of fire deaths, inhalation of CO or hydrogen cyanide, hypoxia when carboxyhemoglobin serum is greater than 20%; can occur without burns to skin
What is an upper airway injury (burns ch.)?
injury to mouth, oropharynx, or larynx; may be caused by thermal burns or smoke inhalation
What are the manifestations of mucosal burns of oropharynx and larynx?
redness, blistering, and edema
How do you assess for upper airway injury?
facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral or nasal mucosa, carbonaceous sputum, history of burns in enclosed spaces, burns to clothing around chest or neck
What are the manifestations of upper airway burns?
blisters, edema, hoarseness, difficulty swallowing, copious secretions, stridor, retractions, airway obstruction
What is a lower airway injury (burns ch.)?
inhalation injury to trachea, bronchioles, and alveoli by breathing in toxic chemicals or smoke; can cause pulmonary edema that does’t appear until 12-24 hours after, then manifesting as ARDS
What is an electrical burn?
burn caused by intense heat from an electric current; severity depends on voltage, tissue resistance, current pathways, surface area in contact with current, length of time; indication for transfer to burn unit
What are the manifestations of lower airway injuries?
trapped in enclosed space during fire, facial burns or singed hair, dyspnea, carbonaceous sputum, wheezing, hoarseness, altered mental status
What tissues are resistant to electric current?
bones and fat are most resistant while nerves and vessels are least resistant
What is the iceberg effect?
more damage is done under the surface of an electrical burn than to the surface
Why are electric burn patients at risk for broken bones?
muscle contractions caused by electric currents and fall resulting from electric shock; pts spine should be immobilized immediately
What are patients with electric burns at risk for?
dysrhythmias(may occur within 24 hours), cardiac arrest, severe metabolic acidosis, and myoglobinuria (can block renal tubules, red urine)
What is an example of a cold thermal injury?
frostbite
What are the indications for transfer to a burn center?
more than 10% partial thickness, burns on face, hands, feet, genitals, perineum, or major joints, third degree burns, electrical or chemical burns, inhalation injury, heart kidney or resp. disease, concurrent trauma, and in children
What is a superficial partial thickness burn?
burn to the epidermis; 1st degree burn; arrhythmia, blanching, pain with mild swelling, no blisters or vesicles
What is a deep partial thickness burn?
burn to the dermis; 2nd degree burn; fluid-filled vesicles that are red shiny and wet(moist blebs); every pain caused by injury to nerve, mild-moderate edema; blanching; sensitivity
What is a full thickness burn?
burn to fat, muscle and bone; 3rd or 4th degree burn; dry, waxy white, leathery hard skin; no pain due to nerve damage; strong burn odor; impaired sensation when healed; nonblanchable
What is the rule of nines?
method used to initially assess a burn; the patients hand (including fingers) is 1%
What is the Lund-Browder Chart?
method of estimating size of burn; more accurate than rule of nines because it takes into account body area and age
What types of burns would affect the respiratory system?
burns to face and neck; circumferential burns to chest or back that interfere by obstruction caused by edema or eschar
What types of burns would impact self-care deficit?
hands, feet, joints, and eyes; hands and feet cause problems because of the superficial vascular and nerve systems that are damaged healing time is slowed
What types of burns are most susceptible to infection?
ears and nose due to poor vascularity; buttocks or perineum due to urine or feces
Why are circumferential burns on extremities a problem?
compartment syndrome
What are patient risk factors for mortality with burns?
cardiovascular, respiratory, or renal disease have poor prognosis due to bodies demands; DM or PVD are at risk for poor healing; complications such as fractures also impede healing
What causes a superficial partial thickness burn?
sunburn, quick heat flash
What causes deep partial thickness burn?
flames, flash, scald, contact burns, chemical, tar, or electric current
What causes a full thickness burn?
flame, scald, chemical, tar, and electric current
What initial interventions are conducted for thermal burn patients?
ABCs, stabilize spine, assess for inhalation injury, give O2, be prepared for intubation, monitor vitals and rhythm and LOC, remove clothing and jewelry, cover burns with dry dressings, establish 2 large bore IVs, fluid replacement, foley if greater than 15%, elevated burned extremities, give pain meds, treat other injuries
What is the priority intervention during the prehospital phase?
removing patient from the source of the burn; then remember there could be other injuries that take priority over the burn
What should be done with thermal burns less than 10%?
clean, cool, tap water damp towel to minimize depth of burn; do not leave on longer than ten minutes for risk of hypothermia
When should you use ice on a burn?
NEVER- this can cause hypothermia and vasoconstriction reducing blood flow to the area
What should be done if the burn is greater than 10% of the body surface area?
ABCs; also done for electrical or inhalation burns
What are the interventions during prehospital phase for chemical burns?
remove any chemical particles with water for 20m-2h; destruction can occur for up to 72 hours
What is the emergent phase?
up to 72 hours after the burn, primary concern is hypovolemic shock and edema formation; ends when fluid mobilization and diuresis occurs
What happens to F&E when a burn occurs?
risk for hypovolemic shock; massive shift due to increased cap permeability; water moves into second and third spacing (blisters), insensible loss is increased, hemolysis of RBCs, increased hematocrit
What is intravascular volume depletion?
net fluid shifts and losses in a burn patient
Why is hematocrit increased in burn patients?
simply because water is lost increasing the hematocrit ratio
What changes are made to the immune system?
loss of skin, bone marrow depression, and decreased immunoglobulins
What interventions are made for inhalation injuries?
ABCs, stabilize spine, assess for thermal burn, provide 100% humidified O2, prepare for intubation, monitor vitals, remove clothing, insert IVs, replace fluids, insert foley, elevate limbs, obtain ABGs, carboxyhemoglobin levels and chest x-ray, admin pain meds, ID and treat other injuries, cover burned areas with dry dressing
What interventions are done for electrical burns?
remove pt from source, assess ABCs, stabilize spine, provide O2, monitor vital signs, check pulses distal to burns, remove clothes, cover burns with dry dressings, insert IV, replace fluids, ABGs for acid-base, foley, elevate burned limbs, administer IV pain meds, treat associated injuries
What interventions are done for chemical burns?
ABCs before decontamination, stabilize spine, O2 PRN, dry chemical site before irrigation, remove clothes, flush wounds with saline or water (eyes use LR or H2O from inner corner to outer), dry dressing, IV access, fluid replacement, foley, elevate burned limbs, IV pain meds, poison control
What are the clinical manifestations of a burn?
hypovolemia; pain depends on if nerves were effected; decrease BS and paralytic ilius; shivering from heat loss, anxiety, or pain; altered mental status is usually from hypoxia from smoke inhalation
What is sludging?
increased blood viscosity and decreased microvascular function; corrected with fluid replacement
How do burns complicate the CV system?
dysrhythmias and hypovolemic shock; impaired circulation leading to ischemia, paresthesia, and necrosis; increased blood viscosity and decreased microcirculation
What is an escharotomy?
uses a scalpel or electrocautery to open a full-thickness eschar to restore circulation to compromised extremities
How do burns complicate the respiratory system?
upper or lower injuries; upper can occur with or without smoke inhalation; increased agitation, anxiety, restlessness, change in breathing
What tests are done for suspected inhalation injury?
fiberoptic bronchoscopy, carboxyhemoglobin blood levels, sputum for carbon
What does an X-ray look like for burn patients?
can be normal on admission, but changes as time passes
What do ABGs look like for a burn patient?
can be normal on admission, but change over time
What complications occur when a burn patient has preexisting cardiopulmonary problems?
PE or HF if fluid replacement is too vigorous; resp problems increase risk for rep infection; increased risk for dvts
What is the most common cause of death in inhalation injuries?
pneumonia
What urinary complications occur in burn patients?
acute tubular necrosis; hypovolemic shock causes decreased blood flow to kidneys causing renal ischemia; myoglobin and hemoglobin are released to blood stream an docked renal tubules - fluid replacement can counteract the obstruction
How do you manage airway in a burn patient?
intubation within 1-2 hours, vent support based on ABGs, extubatne in 3-6 days, escharotomy of chest wall; bronchoscopy within 6-12h, 100% humidified O2 if no intubation, high fowlers unless spinal injury; chest physiotherapy q1-2h, PEEP, bronchodilators
How do you treat carbon monoxide poisoning?
100% O2 until carboxyhemoglobin levels are normal
What do you do for fluid therapy in a burn patient?
IV access or central line, art line for ABGs and BPs, crystalloid solutions (LR), parkland formula or hourly urine output and vital signs for titration, colloidal solutions can be given after cap permeability is returned to normal
What are the cardiac parameters for fluid resuscitation?
urine output: .5-1 mL/kg/hr; MAP greater than 65, HR less than 120 and systolic BP greater than 90
What type of burn requires greatest fluid replacement?
electrical burns; also require osmotic diuretics (mannitol) to increase urine output and overcome high levels of hemoglobin and myoglobin in urine
What is mannitol?
osmotic diuretic; monitor fluid & electrolytes along with daily weight
What is the most likely source of infection in a burn patient?
the patient’s own normal flora from skin, respiratory or GI
What is the open method of burn wound dressing?
topical antimicrobial with no wound dressing
What is the closed method of burn wound dressing?
sterile gauze dressings cover topical antimicrobials; also called multiple dressing change
What technique is used for dressing changes?
clean method for taking off bandages, sterile method for replacing bandages
What is allograft/homograft skin?
skin graft from a human cadaver; temporary
What is xenograft/heterograft skin?
porcine skin graft; temporary
What is autograft skin?
skin from the patient; permanent
What is cultured epithelial autograft (CEA)?
patient’s own skin and cell cultures; permanent
What is biobrane?
skin graft of porcine collagen bonded to silicone membrane; temporary
What is integra?
skin graft of bovine collagen and glycosaminoglycan bonded to silicone membrane; permanent
What is alloderm?
skin graft of acellular dermal matrix derived from donated human skin; permanent
What is the drug of choice for controlling pain in burn patients?
IV morphine; IM injections won’t be absorbed until healing causing an overdose
What immunization is given to burn patients?
tetanus as long as they have not received it within 10 years
What types of antimicrobial agents are used in burn patients?
topical silver dressings, monitor for allergies to sulfa; systemic antibiotics aren’t used because of decreased vascularization to burn and development of multi drug resistant organisms
What is oxandrolone used for in burn patients?
promote weight gain
What is ranitidine used for in burn patients?
decreased stomach acids and risk of Curling’s ulcer
What type of nutritional therapy is needed for burn patients?
aggressive enteral feeding with small bore tubes to preserve GI function increasing intestinal blood flow and promoting wound healing; assess bowel sounds and for residual q8h; supplement protein powder and high calorie shakes
When does the acute phase of a burn occur?
it begins when fluids mobilize and ends when woulds are healed or covered with skin grafts
When does hyponatremia occur in a burn patient?
develops from excessive GI suction, diarrhea, and water intake (dilution hyponatremia or water intoxication) the signs are weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, and confusion
When does hypernatremia occur in a burn patient?
tube feedings or inappropriate fluid administration; signs include thirst, dried furry tongue, lethargy, confusion, and seizures; limit sodium
When does hyperkalemia occur in burn patients?
renal failure, adrenocortical insufficiency, or massive deep muscle injury (electric); causes cardiac dysrhythmias and arrest; signs are muscle weakness, cramping, and paralysis
What are normal sodium levels?
135-145
When does hypokalemia occur in burn patients?
vomiting, diarrhea, GI suction, IV therapy without K+; signs are fatigue, muscle weakness, cramping, dysrhythmias, paresthesias, and decreased reflexes
What are the symptoms of infection in a burn patient?
hypo/hyperthermia, increased HR and RR, decreased BP and UO, confusion, chills, malaise, loss of appetite, and WBC count of 10k-20k; pt. may be compromised for months after injury
What causes sepsis in burn patients?
gram negative bacteria
What neurological interventions are done in the acute burn phase?
decrease delirium especially at night; usually transient lasting only a few days
What musculoskeletal interventions are done in the acute burn phase?
PT and OT; flexed position is most comfortable; OT should be consulted to prevent contracture formation
What happens to the GI system during the acute burn phase?
paralytic ileus from sepsis; constipation from meds, bed rest, low-fiber diet; diarrhea from enteral feeding or antibiotics; curling’s ulcer
Why do burn patients receive antacids, H2-histamine blockers, and proton pump inhibitors?
prophylaxis to reduce stomach acid and prevent curling ulcer
What happens to the endocrine system during the acute phase of burn?
increased glucose level due to catecholamine release in response to stress, increased feedings, and decreased sensitivity to insulin; treatment is insulin drip NOT reducing the feeing
When is a paraffin or petroleum gauze dressing used?
when partial-thickness burns are fully debrided to protect re-epithelializing keratinocytes
How are skin grafts taken care of in the acute phase?
paraffin or petroleum dressing on wound, saline-moist middle dressing, and dry gauze outer dressing
What is a bleb and how does it effect a burn?
serosanguineous exudate; they prevent the graft from permanently attaching to the wound bed; to treat aspirate with tuberculin syringe by a specialist
What is done to decrease blood loss during excision and grafting?
topical epinephrine or thrombin; injection or saline and epinephrine; tourniquets; Artiss
What are complications of cultured epithelial autograft?
poor graft take because of thin epidermal skin, graft loss in healing, infection, contracture
What are the two types of pain burn patients experience?
continuous background pain and treatment induced pain
How is continuous background pain managed?
IV diluadid or morphine PO twice a day; use lorazepam, midazolam, gabapentin, or pregabalin for breakthrough pain
How is treatment indued pain managed?
premeditated before PT and OT, use relaxation techniques
When is the best time for PT and OT
during and after would cleanings when the skin is softest
What interventions are used for splinting in burn patients?
ensure no undue pressure that can lead to breakdown, keep brace in position for optimal functional positioning
What is the goal of nutritional therapy in burn patients?
adequate calories and protein to promote healing during hyper metabolic and hypercatabolic states; promote antioxidants (selenium, acetycystein, ascorbic acid, vitamin E, zinc, and multivitamin); appetites is diminished so encourage family to bring favorite foods
What is the most common complication in the rehabilitation phase?
contracture when adequate ROM isn’t done, tissues shorten and are fixed in flexed position
What are the characteristics of scarring?
discoloration which fades over time and contour that can be treated with pressure garments after healing
What can be done about itching?
water based moisturizers and antihitamines
