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1. Prepared by: James Amadu Kamara BURNS AND ITS MANAGEMENT

2. Anatomy of skin

3. Functions of Skin Skin is the largest organ of the body Essential for: Thermoregulation Prevention of fluid loss by evaporation Barrier against infection Protection against environment provided by sensory information

4. Burn and Scalds Burn A burn is a type of injury results from direct contact or exposure to thermal , electrical, chemical or radiation source are termed Burns. Scalds Injuries results from moist heat are termed as scalds

5. ETIOLOGY Thermal burns Chemical burns Radiation burns Electrical burns Inhalational injury

6. Thermal burns – Flame , hot liquid, semi liquids , residential fires , explosion Chemical burns- Acid, alkali or organic compounds

7. Radiation burns – Radiation therapy , radioactive substances and x- ray, Sun burn ( solar radiation), Electrical burns Inhalational injury – Asphyxiants ( Residential Fire)

8. PATHOPHYSIOLOGY- Skin Direct injury to skin devitalises the cells ( 40 O - 44 O C) Cellular system Infarction Sodium Potassium pump fails Cellular edema

9. 3 Zones of tissue injury Zone of Coagulation – Directly damaged skin is coagulated and fully destroyed ( Inner) Zone of stasis- Surrounding tissue exposed to heat is edematous and has impaired blood flow ( Middle zone) Zone of Hyperemia- It consists of the tissue that is inflammed and vasodilated ( Outer)

10. Pathophysiology - Fluid shifts Following burn injury Release of vasoactive substances ( histamine, kinins catacholamines ,serotonin , leukotrins, prostaglandins) Alters cell permeability( Na enters the cell and K exits the cell) Increases intercellualr and interstitial fluid further deplets intra vascular fluid volume Hypovolemia

11. Hypovolemia Vital organs gets lack of blood supply Decreased Blood supply to mesentric bed → Intestitial ileus → Curling’s ulcer Decreased renal blood → Oliguria flow ( Renal failure ) Toxins released from the wound along with sepsis causes acute tubular necrosis. Myoglobin released from muscles (in case of electric injury or often from Eschar ) is most injurious to kidneys.

12. Pulmonary system Inhalational injury by exposure to asphyxiants Oxygen molecule are displaced and combined of Hb to form carboxy haemoglobin ( CO have 200 times more affinity towards Hb than O 2) Injury to URT Leads to Erythema, ulceration , edema etc Altered pulmonary resistance causing pulmonary edema Systemic inflammatory response syndrome

13. Myo cardial depression Liberation of Myocardial depressant factor Decreased cardiac → Decreased myocardial output function

14. Impaired skin integrity Disruption of skin nerve endings , sweat glands and hair follicles Barrier function of skin is last Immuno supression Decreased Lymphocyte activity , Decrease in immunoglobulin production ,suppression of complement activity and an alteration of neutrophil and macrophages function Increase risk of infection

15. Metabolic Hyper metabolic rate (BMR). Negative nitrogen balance. Electrolyte imbalance. Deficiencies of vitamins and essential elements. Metabolic acidosis due to hypoxia and lactic

16. Psychological response Can vary from fear to psychosis In addition separation from family during admission in hospital

17. Infections Streptococci (Beta haemolytic— most common) Pseudomonas Staphylococci Other gram- negative organisms Candida albicans

18. Classification of burn injury s Partial thickness burns Ist degree IInd degree IIIrd degree Full thickness burn s IVth degree

19. Classification According to Depth First- degree partial thickness Burns (mild) : ( Superficial ) epidermis is involved . Eg . Sun burn Pain, erythema & slight swelling, no blisters Tissue damage usually minimal, no scarring Pain resolves in 48- 72 hours Second degree partial thickness Burns : It appears wet . It involves entire epidermis & variable dermis Vesicles and blisters characteristic Extremely painful due to exposed nerve endings Heal in 7- 14 days if without infection

20. 3 rd degrees Partial thickness burns Damage through out the dermis Dry and may be brown , black or ivory Denaturated skin is called Eschar Burn tissue is not painful as a result of damage to the nerve endings 4 th degree full thickness burns Involves skin , fat muscles and sometimes bone also Appears tarred or may be completely burned away Amputation is common with this injury

21. Clinical manifestations and Assessment Blisters over the skin Oliguria ( < 0.5 ml/kg/1hour). Decreased GI motility Absence of bowel sounds , stool, flatus Nausea Vomiting Abdominal distension )

22. Alteration in respiration ( Tachypnea, stridor , dyspnea, cyanosis) Decreased cerebral tissue oxygenation manifestations Thermal burns to URT - Edematous , erythematous , mucosal blisters ,ulceration , flarring of nostrils, stinged nasal hairs) Carbonaceous sputum

23. Decreased cardiac output – Hypo tension , weak peripheral pulse , oliguria Pain response – Background pain- Even during rest , Position changes , movement of abdominal wall ,chest etc Procedural pain – Experienced during Therapeutic procedures

24. Altered level of consciousness Headache , dizziness, memory loss , confusion Disorientation , visual changes Hypernatremia and hyperkalemia Elevated Hematocrit in Ist 24 Hours Elevated BUN

25. Management Emergency care phase Acute phase Rehabilitation phas e

26. Emergency care phase Time between the initial injury and 36- 48 hours after injury Fluid resuscitation Airway , Breathing is a major concern Assessment is important Burn severity Burn depth Burn Size Burn Location

27. Burn severity (American Burn Association Major burn injury – 20- 25% TBSA or burns involves the face , eyes ,ears ,hands , feet and perineum resulting functional cosmetic disability Moderate Burn injury – 15- 20 %TBSA Minor Burn injury – 10- 15% TBSA

28. Burn depth Superficial burns – No much complication Deep Burn- Produces severe injury. It causes systemic effects , contractures etc Size of the Burn – Determined by Rule of Nine

29. Burn location Burns to head and chest- Pulmonary complication, facial burns, corneal abrasion circumferential burns ( chest) Burns in Ears – Auricular chondritis or infection Burns of hands and joints – Vocational disability , circumferential burns Burns to perineum – Infection

30. Emergency Phase Goals Maintain and protect airway Restore the hemodynamic stability Minimizes the pain Wound care

31. 1.Maintain and protect airway Assess the oropharynx for any clinical manifestations Administer 100% oxygen if inhalational injury ( Tight fitting mask continuous until CarboxicHb level is reduced to 15%)

32. 2.Restore Haemodynamic stability Start IV line ( Subclavian, Internal and external Jugular or femoral vein) Fluid resuscitation – To restore the functions of vital organs

33. FORMUL A First 24 hours Electrolyte Colloid Dextros e Second 24 hours Electrolyte Colloid Dextrose Evans NS 1 ml/kg/% of burn 1 ml/kg/% of burn 2000ml ½ of the Ist 24 hours ½ of the Ist 24 hours 2000ml Brooke RL 1.5ml/kg/% of burn .5ml/kg/ % of burn 2000ml ½ - ¾ of the Ist 24 hour ½ - ¾ of the Ist 24 hours 2000ml Modified brooke RL 2 ml/kg/% of burn None None None 0.3- .0.5ml/kg/ % of burn Titrate to maintain urine output Parkland RL 4ml/kg/% of burn None None None 0.3- .0.5ml/kg/ % of burn Hypertoni c saline Fluid containing 250meq of Na to maintain None None

34. 3.Minimising pain IV narcotics NSAID 4. Wound care TT Clean the wound , Follow aseptic techniques Cover the wound with with sterile towel

35. Acute phase ( 48- 72 hours) Prevention of infection Auto contamination should be avoided Follow aseptic techniques PPE Antibiotics

36. Metabolic support Aggressive nutritional Support ( energy, healing ,prevention of harmful effects of catabolism ) Oral intake , enteral tube feeding, peripheral parenteral nutrition (TPN)

37. Minimizes the pain Narcotics NSAID Inhalational analgesics Patient controlled analgesics Other modalities – Hypnosis, Play therapy, Bio feed back, Music therapy etc

38. 4.Wound care Daily wound care involves cleansing , debridement , ESCHAR -removal of dead tissue and dressing of the wound 1% of silver sulphadioxide , Mafenide acetate are used. Grafting (Allograft, Autograft,Xenograft )

39. 5.Psychological care Provide psychological support Anticipatory guidance and encouragement Coping strategies

40. Management - Rehabilitation Minimizes functional loss Early wound excision Exercise – Ambulation , active exercises Splinting and positioning ( all three phases)- Static and dynamic splinting Control of scar Hypertrophic scarring results from deposition of collagen Use Custom fit anti burn support

41. Complications Shock Pulmonary complications due to inhalational injury ARF Infection and sepsis Curling’s ulcer Extensive scarring and disability Psychological trauma Cancer ( Marjolins ulcer – 21 years )

42. Nurses role/ Goals in Burns rehabilitation Promoting activity tolerance Improving body image and self concept Monitoring and managing potential complications Prevent contractures of the shoulders and hips and also to maintain their ranges. Educate care givers on passive stretches. Improve functional activities such as walking, sit to stand, rolling in bed etc.

43. Purposes of medico legal cases- Burns To ensure that the burn patient understand the nature of treatment including the potential complications To indicate that the burns patients decision was made without pressure. To protect the burn patient against unauthorised procedures To protect the hospital staff / hospital informed consent to be taken ..

44. Circumstances requiring a permit – Get consent to do all procedures including admission Consent issues – Burn patient or the responsible adult relative of the patient signs the consent form of the hospital