BURN

- Injury to body tissue caused by excessive heat

- It is most severe form of trauma to the integumentary

Types of burn
1. Thermal most common type caused by flame, flash , scalding and contact hot metal or grease, radiation 2. Chemical caused by tissue contact, ingestion or inhalation of acid, alkalies or vesicant 3. Electrical injury caused by direct damage to nerve and vessels when an electrical current passes through the body. Most serious type of burn. Cardiac arrhythmias may occur. Toxins are created postburn that injure kidneys. Voltage & ampere information is important. 4. Radiation burn ionizing radiation e.g., nuclear energy, radiation therapy 5. Smoke inhalation occurs when smoke (particular products of fire, gases and superheated air) causes respiratory tissue change.

1. EXTENT usually express in percentage of total body surface are (TBSA) burned. Head & neck - 9% Right arm & hand - 9% each arm total of 18% Left arm & hand - 9% each arm total of 18% Right foot & leg - 18% each leg total of 36% Left foot & leg - 18% each leg total of 36% Anterior trunk - 18% Posterior trunk - 18% Genitalia - 1%

THREE DIMENSIONAL OF BURN WOUNDS

LUND & BROWDER METHOD

For children, a more accurate estimate of percentage of TBSA is the Lund & Browder Method. It uses body surface chart, it takes into accounts the changing body proportion of growing children.

B-1

1-4

5-9

10-14

15

ADULTS

Head Neck Lower Extremities Upper Extremities Anterior Trunk Posterior Trunk Buttocks Genitalia

19 2 21 28 13 13 5 1

17 2 19 30 13 13 5 1

13 2 15 34 13 13 5 1

11 2 13 36 13 13 5 1

9 2 11 38 11 13 5 1

7 2 9 40 13 13 5 1

 Burn that does not exceed 25% TBSA produced a primarily local response. Burn that exceed of 25% TBSA may produce both local and systemic responses.
2. Depth traditionally classified as: First Degree superficial involves only the epidermis, tender, slightly swollen, redness, edema formation, painful, 3-4 days healing time, no scaring Ex. sunburn

Second Degree Partial thickness burn - Involves the epidermis, dermis, and hair - Characterized by blister formation or reddened discolored region, most weeping surface, very edematous - Extremely painful because nerve endings for pain are exposed. - 21- 28 days healing time

Third Degree Full thickness burn - Involves the entire dermis plus portion of subcutaneous tissue. - Brown leather appearance, little surface moisture, with marked edema, scar formation (grafting is needed) - Painless to touch because nerve endings for pain have been burn. Fourth Degree Burn - Involves subcutaneous tissue, fascia, muscles & perhaps bones

3. Volume amount of fluids found in the interstitial spaces that lead to edema due to abnormal capillary permeability which allows protein to escape into tissue spaces. Increase capillary hydrostatic pressure which causes water and electrolyte shift. Classification of burn according to the percentage of body: 1. Major burn 25% or more of the body has sustained 2nd degree burn, & 10% has sustained 3rd degree burn; further complicated by fractures, respiratory involvement, & smoke inhalation. Burns of feet, hands, face, and genitalia. 2. Moderate burn less than 10% of the body has sustained 3rd degree burn, & 15 to 25% has sustained 2nd degree burn.

3. Minor burns less than 15% of the body has sustained 2nd degree burn, & less than 2% has sustained 3rd degree burn. Severity of burn depends in a number of factors 1. Type of agent (flame, chemical, thermal or radiation) 2. Length of exposure which directly affect the depth of the injury 3. The specific area of exposure, the size of the area & any organs in close proximity

4. Any concurrent trauma sustained in the burn 5, The age of the victim age is factor in a mortality & morbidity associated in burn, the younger the children the severe burns have, the higher mortality than older children. (below 18 months, above 65 years. Lower temperature & shorter exposure to hear & chemicals can cause more severe burn in children because their skin is much thinner than adult The larger body surface area of children compare to adult put children in a higher risk for fluid loss, heat loss, & dehydration. 6. Any previous medical condition

Pathophysiology
Body responses to burn: Integumentary Alterations - Destroy the evaporative water barrier, thus increasing insensible water loss from 4-15 times the normal. In children, the ratio of the body surface area to body weight is greatly increased & 70% of the body is made up of water making insensible water loss more severe. - Destruction of skin causes loss of the first line of defense against infection & produces an excellent culture medium for bacteria, specifically pseudomonas. For this reason, tetanus immunization is given.

- Loss of skin also results in an inability results in inability to regulate body temperature. Patient with burn injuries exhibit low body temperature (hypothermia) in the early hours after injury. Then, hypermetabolism resets core temperatures, the patient becomes hyperthermic for much of the post burn period even in the absence of infection. - Disruption of the skin can lead to scarring, changes in function, appearance and body image.

Cardiovascular Alterations - Vascular volume decreases, cardiac output decreases & this is the onset of burn shock. - Burn shock involves the massive leaking of circulatory capillary fluid seal this causing fluid to leak from intravascular compartments into interstitial tissue. This leakage continues for 24-48 hours until capillary seal is restored. Peak of fluid loss is 6-8 hours. - Peripheral vasoconstriction maintain the blood pressure in the low-normal range & improves cardiac output. Despite adequate resuscitation, cardiac fillings with pressures (central venous, pulmonary artery & pulmonary artery wedge pressure remain low during the burn shock period.

_ At the time of burn injury, some RBC may be destroyed & others damaged resulting in anemia. Despite this, the hematocrit may be elevated. Signs and symptoms: thirst, pale clammy skin & decreased BP - Effects: Decrease in cardiac output Decrease vascular permeability results in free loss of plasma protein from the blood vessel into intracellular spaces edema Hematocrit is higher because of the release of plasma into the tissue at the burn site Elevated leukocytes

Fluids and Electrolytes Alterations - Edema defined as the presence of excessive fluid in the tissue spaces. In burn involving less than 25% TBSA, the loss of capillary integrity & shift of fluid are localized to burn itself, resulting in blister formation & edema only in the area of injury. - Patient with severe burn develop massive systemic edema. Edema is usually maximal after 24 hours. It begins to resolved within 7 to 10 days. - As edema increases, pressure on small blood flow & consequent ischemia. - Circulating blood volume decreases during shock burn. Evaporative fluid loss through the burn wound may reach 3 to 5 L for 24 hours.

- Immediately after burn injury, hyponatremia (Na depletion) is present, hyperkalemia (excessive potassium) result from massive cell destruction . Hypokalemia (potassium depletion) occur later with fluid shift & inadequate potassium replacement. Pulmonary Alterations Three types of respiratory injuries: 1. Upper respiratory injury 2. Pulmonary injury 3. Carbon monoxide inhalation

- Lower respiratory injury involves damage to the alveolar beds causing impaired gas exchanged - Upper respiratory problem because of edema and obstruction of the upper airway or bronchospasm, chemical irritation from toxic product of combustion. - Pneumonia, atelectasis - Inhalation injury Implication: In children whose upper haft of the body has been burned, a tracheostomy set should always be at the bedside for emergency purposes.

 Because of loss of bicarbonate ions metabolic acidosis occur. In an effort of the body to get rid of the excess carbonic acid, respiration become deep and rapid Kussmaul breathing Renal Alterations - The response of the renal system to burn is renal insufficiency due to hypovolemic shock. Because of diminished cardiac output, renal blood flow is reduced causing impaired renal and decreased effectiveness of the kidney. - Destruction of RBC at the injury site results in free hemoglobin in urine. If muscle damage occurs, myoglobin is release from the muscles & excreted by the kidney, If there is inadequate blood flow through kidney, hemoglobin & myoglobin occlude the renal tubules resulting in acute tubular necrosis & renal failure.

Gastrointestinal Alterations Gastrointestinal complication decreased circulation to the GI system resulting to: 1. Paralytic ileus (absence of intestinal peristalsis) Decrease peristalsis & bowel sound are manifestation of paralytic ileus resulting from burn trauma. Paralytic ileus is the main reason why burn victims are put on NPO with an NGT inserted to remove gastric content & to prevent vomiting & aspiration. Acute gastric dilatation is the first sign of invasive sepsis.

2. Curlings ulcer acute alterations of stomach or duodenum, the most frequent life threatening situation. - Gastric bleeding secondary to massive physiologic stress may be signaled by occult blood in the stool, regurgitation of coffee ground materials from the stomach or bloody vomitus. These signs suggest gastric or duodenal erosion. - Patients with large burn wounds are at risk for abdominal compartment syndrome. Fluid shift into abdominal cavity caused increased abdominal distention, decreasing urine output and resulting in hypotension and difficulty ventilation.

- Three components of the GIT tract are altered after the mucosal barrier become permeable. The permeability allows for overgrowth of gastrointestinal bacteria and the bacteria translocate to other organs causing infection. The body is unable to defend against their own bacteria due to immunosuppression in burn injury.

Metabolic Responses 1. Hyper metabolism markedly increase (metabolic rate) energy requirement expenditure 2. Elevation in catecholamine which increase core temperature & metabolism increase BMR. Amines are secreted in the body serve as neurotransmitter. Ex. Epinephrine, norepinephrine & dopamine 3. Hyperglycemia caused by increase release of glucose to meet the increase metabolic needs thus depleting glucose stores. 4. Negative Nitrogen Balance due to hypermetablic stress, tissue injury & markedly increase energy expenditure 5. Growth delay caused by growth hormone depression due to bodys focus on restoration and healing of damage tissue.

Neuromuscular changes - Are due to infection, immobilization and metabolic changes. These are: Contractures Tendon dislocation Joint dislocation Limb amputation Weakness due to neuropathy disease of the nervous system, degenerative, non inflammatory disease of the nerve

Stages of burn
1. Emergent / Hypovolemic or Shock/ Oliguric Phase - It occurs during the first 48 hours post-burn a. Remove person from source of burn Thermal smoother burn beginning with the head Smoke inhalation ensure patent airway Chemical remove clothing that contains chemical lavage area with copious amount of water. b. Wrap in dry, clean sheet or blanket to prevent further contamination c. Assess how & when burn occurred d. Provide IV route if possible e. Transport immediately

 Intravascular compartment, plasma to interstitial fluid shifting causing hypovolemia, fluid also moves to area normally have little or no fluid (third spacing). This lead to generalized dehydration. Hypovolemia occurs due to plasma loss. This causes decreased cardiac output & fall BP Hemoconcentration, increased hematocrit. Plasma is lost into the interstitial compartment (ISC) Oliguria. This is due to decreased renal tissue perfusion, decrease release of ADH & aldosterone. These are bodys responses to hypovolemia

 Hyperkalemia & hyponatremia. This results from release of potassium from damaged cells; sodium is trapped in the edema fluids Metabolic acidosis. This results from accumulation of metabolites, hyponatremia and hyperkalemia. Primarily, it is due to hyponatremia. Since Na is unavailable because it is trapped in the edema fluids, bicarbonate produced by the kidneys will be excreted.

Assessment Findings: 1.Dehydration, decrease BP, elevated pulse, decrease urine output, , thirst 2. Diagnostic test: hyperkalemia, hyponatremia, elevated hematocrit and metabolic acidosis

Stage I Acute/ Emergent/ Hypovolemic or Shock/ Oliguric Phase Thermal Injury Damage to tissue cells Blood and blood vessels Destruction of cells & tissues Increase capillary permeability Loss of K, Mg, PO4 Gain in K, Mg, PO4 Gain in Na, Colloids & H2O Loss of Na, Colloids & H2O Edema formation Hypoglycemia & Sluggish blood flow hemoconcentration Tissue hypoxia Anemia further hypoxia Thrombus increase RBC hemolysis (at site of injury & if liver & spleen are involved)

2. Fluid remobilization or Diuretic Phase This occur after 48 hours after burn. Fluid shifts from interstitial compartment to intravascular compartment (ISC TO IVC) Hypervolemia, hemodilution & decreased hematocrit. This is due to fluid shift from ISC to IVC Diuresis. This is due to increased renal tissue perfusion, decreased ADH & aldosterone secretion. Hypokalemia, hyponatremia. Potassium moves back into the cells; sodium is still trapped in the edema fluids.

 Metabolic acidosis. Decreased sodium levels cause excretion of bicarbonate by the kidneys. Assessment Findings; 1. Elevated BP, increase urine output 2. Diagnostic test: hypokalemia, hyponatremia, metabolic acidosis

Stage 2 Recovery/ Remobilization/ Diuretic Phase Tissue hypoxia Blood & vessels vasoconstriction Increase aldosterone & ADH Shift of Na, H2O to IVF Increase Na, H2O, K, Cl Increase BP & blood volume Increase glomerular filtration Hypervolemia rate Diuresis, loss of K

3. Convalescent/ Rehabilitation/ Healing Phase This occurs on the 5th day, onwards. Start when diuresis is completed & wound healing, recovery begins The following problems occur during this time: Hypocalcemia. This results from loss of calcium in the exudates. It is also due to utilization of calcium in the granulation tissue (scar) formation in the areas of burn Negative nitrogen balance. There is increased protein catabolism.

Protein demands are increased for healing & protein intake may be inadequate. Hypokalemia. Potassium has shifted back into the cells, serum levels are decreased. Assessment findings: - Dry waxy-white appearance of full thickness burn - Changing to dark brown, wet shiny & serous exudates in partial thickness Diagnostic test: hyponatremia

Stage 3 Rehabilitation/ Healing/ Convalescent phase Increased flow of glucose Increase gluconeogenesis to wound for wound healing Increase insulin, FBS glucagon

Management
1. Promote respiratory Function Establish an open airway. Administer oxygen therapy 2. Promote fluid-electrolyte and acid-base balance First aid treatment In the home: Apply cool water. Avoid use of ice water it interfere with capillary perforation & viability of injured area & further increases depth of burned area. May precipitate cardiac arrhythmia.

In the hospital: Replace of fluids most important goal of initial therapy solution Ringers lactate is the solution of choice because it most closely resemble the composition of the intracellular fluid compartment Assess the following parameters: - Vital signs - Weight - Urine output - Percentage of burn - Central Venous Pressure (CVP) - Level of consciousness

 The vital changes in dehydration are as follows: - Weight loss - decreased CVP - decreased level of consciousness - decreased urine output (30 ml/hour desired) Changes in vital signs are as follow: - elevated body temperature - rapid respiratory rate - increased pulse rate - low blood pressure

3. Fluid replacement. Types of fluid replacement a. Colloids: blood , plasma expanders b. Electrolytes: Lactated Ringers (LR) c. Non-electrolytes: Dextrose 5% in water (D5W)

Parkland (Baxter Formula) Dosage: 3-4 ml/KBW/TBSA Schedule: total quantity to be given in 24 hours One haft fusing for the first 8 hours 50% The other haft during the next 16 hours 25% 2nd 8 hours - 25% 3rd 8 hours

Plain Crystalloids: Plain LR 4ml/KBW/1% TBSA Lactated Ringers only in the 1st 24 hours, day 2 colloid is added Ex. Child weight 20 kg & percentage of body burns is 22% 4 ml x 20 x 22% = 1760 ml 1st 8 hours: 50% = 1760ml x0.50 (880) 2nd 8 hours: 25% = 440 ml 3rd 8 hours: 25% = 440 ml

2. Brooke Formula: 2-3 ml of Crystalloids/KBW/1% TBSA Ex. 50% TBSA, 20 kg body weight 20x1.5x50= 1500 cc Plain LR 2000 cc D5W = 3500 cc total fluids Colloids, electrolytes & glucose in first 24 hours

3. Monafo Hypertonic Na = 250 mEq?L Lactate = 150 mEq/L Chlorine = 100 mEq/L 4. Evans Formula: 1.5 ml/KBW/1% TBSA 0.5 ml/KBW/1% TBSA (colloids) Monitor alteration in fluid & 30 ml/ hour is the desired amount. Weigh daily

4. Prevent infection - Remove foreign adherent material by gentle washing the with iodine-base solution or hexachlorophene & water, then thoroughly rinsing with NSS - Shave hair from burned areas & area immediately surrounding it - Excision of fragments of dead & devitalized tissues - Application of topical agents: (antimicrobials) a. Furacin (Nitrofurazone) Apply 1/6 inch film directly to the burn area Side effects: rash, contact dermatitis

b. Sulfamylon/ Mafylon (the cream butter) Apply evenly 1/16 inch in thickness directly to the burn area Effect: Reduces buffering capacities of blood because it increases bicarbonate excretion when bicarbonate are broken down, they provide heavy acid load. Remember: Monitor pH level of blood Causes burning sensation for 20 minutes after application Administer analgesic prior to application of the medication. It causes pain. Side effects: rash, bone marrow depression & hemolytic anemia

c. Silvadene (Silver sulfadiazine) Apply 1/16 inch film It does not cause acidosis Side effects: rash, leukopenia, nephritis Monitor CBC especially WBC d. Silver Nitrate Apply silver nitrate to the dressing; do not apply directly to the wounds, cuts or broken skin It stains anything which it comes in contact. Discoloration is not permanent.

 Practice asepsis. Handwashing is the most important practice to prevent spread of microorganism. Implement reverse or protective isolation Administer tetanus immunization. If client had not received booster dose for the last five years, administer Immune Globulin Irrigate affected area with normal saline (NS) solution. 5. Maintain adequate nutrition Do not give fluids for the first 48 hours. To prevent paralytic, gastric dilatation & water intoxication. SNS stimulation causes decreased gastric motility that results to gastric dilatation; causes decrease peristalsis that results to paralytic ileus. Increased ADH secretion causes water retention.

 Provide high-calorie, high-carbohydrate, highprotein diet. Provides adequate source of energy. High protein diet promotes healing & tissue repair. Provide diet rich in vitamins A,B and C Vitamin A maintains skin integrity. Vitamins B enhances metabolism Vitamin C increases resistance to stress and infection.

6. Relieve pain Administer Morphine Sulfate per IV as prescribed. Monitor the client for respiratory depression. Have Narcan (Naloxone) readily available (this is the antidote of narcotics, if respiratory depression occurs. Use Branford frame for each of turning & maintenance of good body alignment. Position flat on bed with legs extended especially during the first 24-48 hours in order to: a. avoid postural shock because of fluid loss, circulation to the head may become inadequate.

b. Support healing of burn wounds c. Prevent hip contracture Use bed cradle to relieve pressure from the top sheet and to prevent sticking of exudates to the top sheet. Avoid exposure of affected areas to draft. Sudden gush of wind causes hypersensitivity of exposed nerve endings. Close the door of the clients room. Instructs on proper splinting Encourage on active and passive range of motion exercises

7. Provide wound care A. Hydrotherapy It is done to remove debris, improve circulation, relieve pain, promote healing, improve muscle tone, & prevent contractures Administer analgesic: 15 to 30 minutes before hydrotherapy to promote comfort B. Debridement To remove necrotic tissues from the area of burns. It may be surgical or mechanical debridement. Mechanical debridement is done by wet-to-dry dressings.

 Wound debridement is done with each dressing change to prevent eschar (a tough coagulum of necrotic tissue) formation. Necrotic tissues are not only good medium for bacteria but also promote granulation tissue growth. Daily removal of dried cream by soaking in a whirlpool bath prior to debridement. C. Skin grafting. To improve appearance of affected area. To minimize growth of granulation tissue which result in contractures & ugly scars. 1. Isograft or syngeneic graft The donor site comes from an identical twin 2. Autograft the donor site comes from the self

Types of dressing: 1. Exposed method no dressing is used so that hard eschar forms, protecting wound form of infection. This method is excellent for areas difficult to bandage effectively. Requires isolation and is difficult for a child. 2. Closed method sterile occlusive dressing is applied frequently, usually with topical medications. Debridement occurs every time the dressing is changed, preventing a large loss of blood at one time, as when eschar is removed.

3. Homograft or allograft the donor site comes from another human being. Performed early 2-3 days post burn. Rejection maybe expected 2-3 weeks after grat 4. Heterograft or xenograft the donor site comes from an animal e.g. pigskin . This is temporary. Care of the graft site Elevate and immobilize the graft site. To prevent edema (Donor site heals 7 to 10 days). Ice bag for comfort & bleeding pressure to prevent edema. Use of heat lamps to facilitate healing from donor site. Use scarlet red bacteriostatic agent used for covering donor site, dries and trimmed daily.

 Protect from: M-otion, T-rauma, & I-nfection Avoid weight bearing. Cleanse the graft from exudates to prevent infection & prevent graft adherence. Monitor the graft site for signs & symptoms of infection like foul smelling drainage, fever, elevated WBC, hematoma, or edema in the area Instruct on the following: - Lubricate healing skin with cocoa butter lotion - Protect affected area from sunlight - Use splints & support garments as prescribed.

8. Promote GI support. To prevent stress ulcer (Curlings ulcer) - Insert NGT - Administer antacids, histamine receptor blockers as prescibed. 9. Rehabilitation - The priority goal of rehabilitation among burns clients is to prevent or minimize scarring. The client may wear anti-scar garment for 6 months. - The other goals are to prevent contractures, promote activity tolerance, & improve body image & self-concept.