Lesson 4: Burns Flashcards
Etiology of Burn Injuries
Thermal
Chemical
Electrical
What do thermal burns result from?
Result from direct/indirect contact with flame, hot liquid, or steam
Severity of thermal burns influenced by:
Contact time
Temperature
Type of insult
Chemical Burn Injuries
Acids, bases, industrial accidents, assaults
More likely to cause full-thickness damage
Severity of Chemical burns influenced by:
Alkaline burns are more severe than acidic
Contact time (burning continues until removed/diluted, therefore thoroughly irrigate
for 20–30 min)
Chemical concentration
Amount of chemical
Electrical Burn Injuries
Low- and high-voltage currents
Entrance wound – depressed or charred
Exit wound – larger, explosive
Skin may not be severely damaged despite deep tissue injury due to differences in resistance
Concomitant injuries with electrical burns:
Fractures, muscle necrosis, neurological injuries
Cardiac, pulmonary, other organ failure
Severity of electrical burns influenced by:
High-voltage current causes more damage
AC burn injuries are more severe
Contact time
How long do chemical burns take to develop?
24–72 hours
Superficial Burns
First-degree burns”/Integumentary Pattern B
Dry, bright red, or pink skin that blanches upon pressure
No dermal vessel damage
Epidermis damaged
Types of superficial burns:
Sunburn, minor flash burn
Erythema, significant pain, lack of blisters, sunburn
Superficial Partial-Thickness Burns
Superficial second-degree burns”/Integumentary Pattern C
Painful, moist, weeping, blistered skin with local erythema and edema
Blanches to pressure with immediate capillary refill
Epidermis and part of dermis damaged
Examples of Superficial Partial-Thickness Burns
Brief contact burns, flash burns, brief contact with dilute chemicals
Deep Partial-Thickness Burns
Deep second-degree burns”/Integumentary Pattern C
Mottled areas of red with white eschar, blistering possible, may have areas of insensitivity/reduced sensation
Blanches to pressure with slow capillary refill
Scarring, pigment changes, contractures possible
Examples of Deep Partial-Thickness Burns
Severe sunburn, scald, flash burn, brief contact with dilute chemicals
Time to heal for Deep Partial-Thickness Burns:
May take 3 or more weeks to heal
Time to heal for Superficial Partial-Thickness Burns
Heal within 10–14 days with minimal or no scarring
Time to heal for Superficial Burns
Resolves within 3–5 days without scarring
Full-Thickness Burns
Third-degree burns”/Integumentary Pattern D
Initially look red then become mottled white/black, dry, leathery eschar, very painful
Burned areas insensate to light touch
Scarring and contractures likely
Most require surgical debridement and grafting
Examples of Full-Thickness Burns
Prolonged contact with flame, immersion scald injury
What layers affected with full-thickness burn:
Epidermis, Dermis, and complete destruction to subcutaneous fat
Subdermal Burns
“Fourth-degree burns”/Integumentary Pattern E
Charred, mummified appearance
Exposed deep tissues
Burned areas insensate to light touch
May have permanent nerve damage
Require surgery (fasciotomy, escharotomy, grafting) and possible amputation
Examples of subdermal burn:
Electrical burn, strong chemical burn
Rule of Nines:
Divides the integument into areas roughly equivalent to 9% of TBSA
9% of TBSA:
Head, front and back of each UE, front of each LE, back of each LE
Perineum is:
1% of TBSA
Lund-Browder Classification
Takes into account variation of body proportion from child to adult
Appropriate for children under age 16
Preferred by pediatric burn units
Palmar Method
Uses the area of palmar surface of the hand to determine burn size
Highly unreliable, inaccurate
What is burn severity determined by:
Burn size
Burn depth
Age (child vs. adult)
Minor burn:
generally treat as out-patient
Moderate burn:
generally treat as in-patient
Major burn:
generally treat in specialized burn unit
Pathophysiology of Burn Injuries
Zone of coagulation
Zone of stasis
Zone of hyperemia
Zone of coagulation
Central portion, irreparable damage
Characterized by coagulation, ischemia, necrosis
Zone of stasis
Area of cellular injury and compromised perfusion
Conversion: widening and deepening of necrosis
Zone of hyperemia
Outer edges, minimal cellular injury
Be aware of
Bandages that are too tight
Undue pressure from splints
Improper patient positioning
Burn shock
massive fluid shift causing hypovolemia and edema
Results in decreased blood volume
Tissue necrosis, organ failure, and death are possible
Who is at high risk for burn shock?
Patients with >15% TBSA burns at high risk for burn shock
Cardiovascular system:
Fluid resuscitation is of primary importance
Blood pressure generally decreases as a result of hypovolemia
Resting heart rate 100–120 bpm for adults
Monitor peripheral pulses
Must monitor and manage edema
Pulmonary System
Suspect lung involvement if singed facial hair, carbonaceous sputum, closed space injury, burns to face/neck/torso
Monitor for signs of breathing difficulties
Monitor oxygen saturation
Encourage aggressive pulmonary hygiene
Metabolism
Basal metabolic rate doubles or triples Increase in core temperature Sustained hyperglycemia Increased fat catabolism Decrease in body mass
When does metabolism peak after a burn injury?
7–17 days post major burn injury
What percentage of burn patient death are due to infection?
75%
Why is sepsis and infection common?
Endogenous and exogenous bacteria
Decreased tissue perfusion reduces immune system effectiveness
Neutrophils less effective
Eschar, blister fluid, residual topical agents excellent medium for bacterial growth
Open wound for extensive periods of time
Clinical should be aware of what consequences to immune system?
Aggressive debridement and rapid skin coverage necessary to reduce risk of infection
Follow infection-control guidelines
Prophylactic topical antimicrobials
Complications to other systems possible
Multi-organ system dysfunction
CNS dysfunction
Acute kidney failure
GI dysfunction/peristalsis/ileus/ulcers
Psychological Dysfunction
Posttraumatic stress disorder
Anxiety/depression/disturbed sleep
Extremely common
Coordination, Communication, and Documentation
Reinforce goals set by other disciplines
Participate in patient rounds
Patient education
Give patients control over their rehabilitation
Patient/Client-Related Instruction
Instruct patients in ways to control pain
Tell patients what to expect prior to procedures
Instruct how to care for wounds including positioning techniques
Educate patients on the importance of
skin care/scar management
Precautions
Screen for domestic violence Anticipate/prevent complications when possible Contractures Infections Deconditioning Pulmonary dysfunction Pressure ulcers Ensure adequate pain control
Keys to Local Wound Care:
Debridement
Infection Control
Dressings
Scar Management
Debridement
Debride
Foreign debris, residual topical agents, exudate, hair, necrotic tissue
Remove blisters (open and closed)
Consider enzymatic debridement if appropriate
Infection Control:
Use sterile technique for large TBSA burns
Topical antimicrobials are standard
Signs of infection
Topical antimicrobials are standard
Silver sulfadiazine
Mafenide acetate
Bacitracin
Signs of infection
Increasing erythema/pain, foul odor, purulence
Increase in necrosis, fever, increased tachycardia
Dressings
Topical antimicrobial covered with nonadherent impregnated gauze, bulky gauze dressing
Limit bulk to allow/encourage movement, splint use
Short-stretch compression wrap to decrease edema and scarring
Scar Management
Moisturize
Protect from friction and shear
Scar mobilization
Compression – mandatory if wound takes 3+ weeks to close
Consider silicone gel sheets/pads, ultrasound, paraffin
Darker-skinned individuals > incidence of hypertrophic scarring and keloids
Vancouver Scar Scale
Rates 4 scar qualities Vascularity Pliability Pigmentation Height Scores range from 0–14, lower scores indicate less severe scar tissue
Procedural Interventions
Range of motion
Mobility training – assistive device as needed
Breathing exercise
Aerobic exercise – target HR 50–70% of maximum predicted HR
Physical Agents and Modalities
Whirlpool Remove necrotic tissue/topical agents, soften eschar Easier ROM Pulsed lavage with suction – smaller wounds Ultrasound Paraffin
Medical Interventions
Pharmacological management
Ensure adequate control of pain and anxiety
Time procedures with medications
Surgical Interventions
Debridement
Early debridement often performed on patients with medium and large full-thickness burns
Graft failure may be due to:
Infection
Eschar
Insufficient immobilization
Fluid collection under graft
Skin substitutes
Bilayered dressings with epidermal and dermal analog
Used on donor sites and wounds
Examples: AlloDerm, Biobrane, Integra
Cultured epithelial autografts
Cultures patients’ own cells
Grown in lab and stapled/sutured in place
Intervention Goals
Superficial wounds heal spontaneously within the first 2 weeks with pain management and topical dressings to prevent infection
Deeper wounds take longer than 2 weeks to heal and may require surgical intervention.
Need to prevent infection- topical antibiotic creams, Vaseline gauze to prevent trauma to tissue
After initial injury, cooling of burn site important
Escharotomy
Incision through eschar and subcutaneous tissue to release tissue constricting circulation
Fasciotomy
Incision through fascia to release pressure/improve distal circulation
