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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
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
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.
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
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
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
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.