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Describe burn injury classification Describe the pathophysiology, clinical manifestations and management of burn phases Discuss infection

prevention, nutritional therapy, potential complications and emotional issues of burn patients

Thermal: most common and are caused by contact with hot objects, flame , scald Chemical: necrotizing substances Smoke inhalation and injury: hot air/noxious chemicals Electrical burns: coagulation necrosis from intense heat generated from an electrical current

Most commonly caused by acids Can cause respiratory problems as well as other systemic manisfestations Lavage the area of contamination copiously with water since the burning process will continue until the chemical is removed. Tissue destruction may continue for up to 72 hours

Carbon monoxide poisoning accounts for the majority of deaths at a fire scene CO displaces O2 on the hemoglobin molecule Skin is described as cherry red Treatment: 100% O2.

Injury above the glottis is thermally produced (hot air or steam) Mechanical obstruction occurs quickly Facial burns, singed nasal hair, hoarseness, dark mucous membranes are a clue to inhalation injury Airway management may be emergent

Injury below the glottis is determined by the length of time of exposure to smoke or toxic fumes. Pulmonary edema may not appear for 12-24 hours and will manifest as ARDS

Coagulation necrosis caused by intense heat generated by current Severity depends on amount of voltage, tissue resistance, current pathway, length of time applied and surface area involved Underlying damage may not be apparent Muscle contractions may cause fractures Arrhythmias, myoglobinuria,acidosis

Severity of burn is determined by: Depth of burn Extent of burn Location of burn Patient risk factors Pg 475 table 25-3 burn center referral criteria

2 Classifications of Burn Depth


Partial-thickness
Superficial: 1st degree erythema/blanching/no vesicles/increased pain e.g. Sunburn, quick heat flash Deep: 2nd degree/fluid-filled vesicles/severe pain e.g. Flame, flash, scald, contact burns, chemical tar

Full-thickness
3rd & 4th degree/eschar leather-like/no blisters/no bleeding/little or no pain/all layers hardened, dry, waxy. e.g. Flame, scald, chemical, tar, electric current

2 most common guides for determining total body surface area are: Lund-Browder chart: more accurate because patient age in proportion to body surface is considered.
Rule of nines: easier to remember and considered adequate for resuscitation of an adult burn patient

Related to the severity of the burn injury Face/neck/chest may inhibit respiration secondary to edema/eschar Burns of hands/feet make self care difficult Areas with poor blood flow (ears/nose) difficult to heal Circumferential burns of the extremities can lead to compartment syndrome Buttocks and genitalia susceptible to infection

Older adults Preexisting cardiovascular disease Preexisting renal or respiratory disease Diabetes Peripheral vascular disease Malnutrition, alcoholism, drug abuse Concurrent fractures/injuries

Stop the burning process: ABCs Electrical: Move the patient to safety without becoming a victim? Chemical burns: remove victims clothes/flush with water Thermal burns: cover with clean, cool tap water towel for protection May have sustained other injuries

Phases of Burn Injury


Emergency (Emergent phase) Usually first 48-72 hours Maintain an open airway, ensure adequate breathing/circulation Greatest threat is hypovolemic shock from capillary permeability that may occur as soon as 20 minutes post injury and also from insensible loss from large burns Limit extent of injury/maintain function of vital organs RBCs are hemolyzed by a circulating factor at the time of burn and by direct injury Injured cells release potassium Adequate fluid replacement will restore capillary membrane permeability and prevent tissue destruction Urine output should be at least 30-50 ml/hr.

IV access should include two large bore IVs or if >30% burn, a central line and art line would be preferred

Fluid Resuscitation: Fluid replacement with a major burn patient is based on urine output. Goal To maintain adult urine output at 30-50 ml/hr (or 0.5 ml/kg/hr). Higher urine output ( 1ml/kg/hr or75100ml/hr) for electrical burns. Fluids include crystalloids, colloids or a combination preferred by the burn center Parkland Formula:
Lacted Ringers(4 ml) (body wt in kg) (% burn) = the 24 hr fluid volume to be infused. So, 1st 8 hours post injury = patient should receive of the calculated volume fluid replacement. Then, the 2nd 8 hours
the 3rd 8 hours.

Burns - Clinical Manifestations


Respiratory
Direct airway injury Edematous lips Carbon monoxide poisoning (clinical manifestations?) Thermal (heat) injury Smoke poisoning (common inhalation injury) Pulmonary fluid overload (fld. shifts) External factors (tight eschar on chest)

Cardiovascular: arrhythmias, circulation to extremities may be impaired, sludging (can be corrected by fluids)

From the first 72 hours to complete wound closure Begins with the mobilization of ECF and resulting diuresis Maintenance of cardiovascular/respiratory systems Bowel sounds return . Nutritional status needs to be addressed Burn wound care continues: could include excision and grafting Pain control (Morphine via IV route) Psychosocial interventions Physical and occupational therapy

Interventions for Burn Wound Management


Nonsurgical
Debridement
1. Mechanical 2. Enzymatic

Dressings
1. Standard wound dressings (pt. with large burns requires a room temp of 85 degrees F. to avoid hypothermia) 2. Biologic dressings 3. Synthetic dressing/artificial skin 4. Pressure dressings/garments

Surgical
Surgical excision Wound coverings Artifical implants

In debridement, dead tissue is removed so that the remaining living tissue can adequately heal. Can be mechanical, surgical autolytic, chemical. http://www.medicaledu.com/debridhp.htm

Replaces all the functions of skin Integra artificial skin: http://www.nigms.nih.gov/Education/Factshe et_ArtificialSkin.htm

Infection: sepsis
Renal/urinary: myoglobin damage/hypoperfusion/hypotension

Integumentary: debridement, excision and grafting


Musculoskeletal: contractures Gastrointestinal: illeus, ulcer, diarrhea

Endocrine: increased glucose

Impairment of the immune system Illeus from response to massive trauma and potassium shifts Shivering may occur from heat loss Hypoxia from smoke inhalation Circulation to extremities may be impaired by edema. Escharotomy may be performed Pychosocial

Just a few Nursing Diagnosis


Decreased cardiac output Deficient fluid volume Ineffective tissue perfusion (multiple) Impaired gas exchange Ineffective breathing pattern Pain Excess fluid volume (what about pt. with history of MI ?) Risk for ineffective thermoregulation Disturbed sensory perception Risk for Infection : a big risk Disturbed body image

http://www.silverlon.com/index.htm

Pressure garments are specialized clothing items that apply constant pressure to the skin. The pressure helps prevent formation of hard, irregular scar tissue that might cause deformities and impair joint movement. If the pressure garments are worn as prescribed by burn injury specialists, they can be very effective in avoiding scar thickening and nodular formations. In addition, compression garments help reduce inflammation and the itching sensation in the burned areas. While they cannot stop scar formation, compression garments help ensure that the scars will be as soft and light as possible.

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