Burn

complete description about burn injury in details.

1. BURN Prepared by- Deepak Patel M.Sc. Nursing

2. CONTENT Review of anatomy and physiology of skin Introduction Incidence Definition Aetiology Classification Jackson’s thermal wound injury Continue…..

3. CONTENT Pathophysiology Clinical manifestations Diagnostic evaluation Management Complications Prevention summary conclusion

4. 1. REVIEW OF ANATOMY AND physiology of skin

5. INTRODUCTION TO BURN Burns are one of the most devastating conditions encountered in the medicine. The injury represents an assault on all aspects of the patients from the physical to the psychological. The visible physical and invisible psychological scars are long lasting.

6. DEFINITION OF BURN Burn can be defined as any injury that results from the direct contact or exposure to any thermal, chemical, electrical or radiation source.

7. INCIDENCE OF BURN India records 70 l acs burn injury annually of which 1.4 lacs people die and 2.4 suffers from disability. 70% of cases are in 15-35 years age group. Continue…..

8. INCIDENCE OF BURN 4 out of 5 cases are either women or children. 80% cases with women are related to kitchen related accidents. 11 th leading cause of death/injury of children age 1-9 years. Continue…..

9. INCIDENCE OF BURN 250 to 300 acid attacks are reported in India every year. 80% to 90% burns occur at home

10. ETIOLOGY OF BURN Thermal burns Chemical burns Electrical burns Radiation burns Inhalation burns

11. CLASSIFICATION OF BURN INJURY According to burn depth According to extent of burn

12. ACCORDING TO BURN DEPTH Based on skin layers involvement Based on degree of burn

13. Based on skin layers involvement

14. Based on degree of burn

15. ACCORDING TO EXTENT OF BURN Rule of nine Lund and Browder chart Palmer method

16. Rule of nine (adult)

17. Rule of nine (child)

18. Lund and Browder Chart

19. Palmer method

20. JACKSON’S THERMAL WOUND THEORY The inner zone The middle zone The outer zone Continue…..

21. PATHOPHYSIOLOGY OF BURN Cardiovascular alterations Fluid and electrolyte alterations Pulmonary alterations Renal alterations Immunologic alterations Thermoregulatory alterations Gastrointestinal alterations Metabolic alterations

22. DIAGNOSTIC EVALUATION OF BURN History taking Physical examination (See table) Diagnostic tests- Complete blood count ABG analysis Human chorionic gonadotropin testing Serum urea, electrolytes Chest X-ray CT scan Laser Doppler imaging

23. 1. History Taking Time of injury Place of injury (open/closed) unconsciousness during incidence Mechanism of burn injury/agent Duration of exposure to agent Intentional burn injury Last Tetanus shot Any known Allergies

24. 2. Physical Examination Complete head to toe assessment Systematic assessment Burn estimation / severity assessment

25. Burn severity assessment MINOR MODERATE MAJOR Adult <10% TBSA Young or old <5% TBSA <2% Full thickness Burn Adult 10-20% TBSA Young or old 5-10% TBSA 2-5% Full thickness burn High voltage injury Possible inhalation injury Circumferential burn Other health problems Adult >20% TBSA Young or old >10% TBSA >5% Full thickness burn Known inhalation injury Significant burn to face, joints, hands or feet Associated injuries

26. 3. Diagnostic Tests Complete blood count ABG analysis Human chorionic gonadotropin testing Serum biochemistry Chest X-ray CT scan Laser Doppler imaging

27. MANEGEMENT OF BURN Burn care is typically categorized into three phases of care; Emergent / resuscitative phase Acute / intermediate phase Rehabilitative phase

28. PHASES OF BURN CARE PHASE DURATION PRIORITIES Emergent / resuscitative phase From onset of injury to completion of fluid resuscitation. First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Acute / intermediate phase From beginning of diuresis to near completion of wound closure. Wound assessment and care Wound closure Prevention and treatment of complications, including infection Nutritional support Rehabilitation support From major wound closure to return to individual’s optimal level of functioning Prevention of scars and contractures Physical, occupational and vocational rehabilitation Cosmetic reconstruction Psychosocial counselling

29. 1. Emergent / resuscitative phase Medical management Assess burn severity Burn depth Burn size Burn location Age General health Mechanism of injury

30. 1. Emergent / resuscitative phase Medical management 2. Treat minor burns 3. Major burns Monitor airway and breathing Prevent burn (hypovolemic) shock (see formula) Prevent aspiration Minimizing pain and anxiety Wound care Prevent tetanus Prevent tissue ischemia Transport to burn facility

31. Emergent / resuscitative phase Calculation of fluids: Consensus formula: 2. Parkland formula: Ringer’s lactate solution= 2-4 ml X kg body weight X TBSA ½ solution in first 8 hours and rest half in next 16 hours Volume of Ringer’s lactate= 4 ml X % BSA x weight (kg) ½ solution in first 8 hours and rest half in next 16 hours

32. Nursing management of patient in Emergent / resuscitative phase Maintaining proper oxygenation and tissues perfusion Maintaining fluid and electrolyte balance Relieving pain Preventing hypothermia Providing initial wound care Preventing infection Promoting comfort Relieving anxiety and proving psychological support

33. 2. ACUTE / INTERMEDIATE PHASE Medical management Prevent infection Asepsis Prophylactic antibiotics Immunization Environmental control

34. 2. ACUTE / INTERMEDIATE PHASE Medical management 2. Provide metabolic support Formula/ Author name Formula for daily calorie expenditure estimate Curreri (25Kcal / Kg body weight ) + (40Kcal X %TBSA burn ) Modified Harris- Benict RMR X Activity factor X injury factor (RMR- Resting metabolic rate) U.S. Army Institurte Of Surgical Research (Age and gender specific BMR) X (0.89142 + 0.01335 X % TBSA Burn) X (M2 X 24 X Activity factor)

35. 2. ACUTE / INTERMEDIATE PHASE Medical management 3. Minimizing pain Patient controlled analgesia devices Inhalation analgesic (nitrous oxide) Oral analgesics; opioid analgesics, NSAID’s Hypnosis, art and play therapy Guided imaginary, relaxation techniques Distraction therapy, biofeedback Music therapy

36. 2. ACUTE / INTERMEDIATE PHASE Medical management Provide wound care Wound cleansing Wound debridement Natural debridement Mechanical debridement Chemical debridement Surgical debridement

37. 2. ACUTE / INTERMEDIATE PHASE Medical management c) Topical antimicrobial treatment Silver sulfadiazine 1% Mafenide acetate 5% Silver nitrate 0.5% acticoat

38. 2. ACUTE / INTERMEDIATE PHASE Medical management d) Wound dressing Moist dressing Occlusive dressing for new grafts Non-adhesive dressings covers

39. 2. ACUTE / INTERMEDIATE PHASE Medical management Maximize function Splinting Positioning Exercise Ambulation performance of ADI Pressure therapy

40. 2. ACUTE / INTERMEDIATE PHASE Medical management 6. Provide psychological support Meeting the psychological needs Involvement in physical therapy Encouragement in wound care Ventilation of feeling, emotions, fear Promoting self image

41. 2. ACUTE / INTERMEDIATE PHASE Surgical management Escharotomy

42. 2. ACUTE / INTERMEDIATE PHASE Surgical management 2. Faciotomy or faciectomy

43. 2. ACUTE / INTERMEDIATE PHASE Surgical management 2. Wound grafting # Biologic dressing / graft # biosynthetic and synthetic grafts

44. 2. ACUTE / INTERMEDIATE PHASE Surgical management 2. Wound grafting # Biologic dressing / graft types Autograft Isograft Allograft Xenograft

45. 2. ACUTE / INTERMEDIATE PHASE Surgical management 2. Wound grafting # Biosynthetic and synthetic graft types Biobrane Integra Calcium alginate Non-adhering fine mesh gauze

46. INTEGRA

47. CALCIUM AGINATE

48. NON-ADHERING FINE MESH GAUZE

49. Nursing management of patient in acute / intermediate phase Maintaining proper oxygenation and tissues perfusion Maintaining fluid and electrolyte balance Relieving pain Preventing hypothermia Providing wound care Preventing infection

50. Nursing management of patient in acute / intermediate phase Relieving anxiety and proving psychological support Graft care Nutritional support Improving mobility Promoting comfort

51. 3 . REHABILIATION PHASE Medical management Minimizing functional loss Exercise Splinting positioning

52. 3 . REHABILIATION PHASE Medical management 2. Provide psychological support Self image issues Physical limitations Reintegration into society Fear of rejection Good communication Encourage independence

53. 3 . REHABILIATION PHASE Medical management 3. Abnormal wound healing Hypertrophic Keloid scars

54. 3 . REHABILIATION PHASE Medical management 4. Prevention and treatment of scars Pressure use of topical silicon Scar massage Steroid injections Application of elastic pressure garments Cosmetic interventions

55. Nursing management of patient in Rehabilitation phase Improving mobility Improving self esteem Promoting independence Cosmetic counselling Vocational training Improving body image

56. COMPLICATIONS OF BURN Burn shock Pulmonary complications due to inhalation burn Acute renal failure Infections and sepsis

57. COMPLICATIONS OF BURN Curling’s ulcers Extensive and disabling scarring Psychological trauma Marjolin’s ulcer Multiple organ failure