Burns

Care of patients with burn is highly sophisticated area of nursing.

1. BURNS
MR. Prasanth.K
MSc cardiothoracic
nursing

2. ANATOMY OF SKIN

3. The Skin
Membrane that covers entire
body
Largest, most dynamic
organ
Epidermis
Dermis
Subcutaneous layer
(superficial fascia)
Deep fascia

4. Definition
Injury to the tissues of the body caused by
heat, chemicals, electric current, or
radiation.

5. Incidence
Domestic cases – 93-95%
India – 0.4million / year
Women are more affected than men – 1.6:1
Overall mortality – 3.5/100000 popu

6. Burn wound healing
Inflammation
Proliferation
Remodeling

7. Inflammation
Platelet adhesion
Fibrin deposit
Thrombus + vasoconstriction
Hemostasis
Local vasodilatation and increase of capillary permeability
Neutrophil (24 hrs)
Monocyte
Macrophages
Consume pathogens and dead tissue
Secrete various growth factors
Proliferation of fibroblasts + deposited of a provisional wound
matrix

8. Proliferation (2-3 days post burn)
Number of fibroblasts at peak
Granulation
Reepithelialization

9. Remodeling (lasts for years)
Collagen fibers are reorganized
Scars contract and fade in color

10. When burn extends to dermal tissue scars
developed are
-hypertrophic- overgrowth of dermal tissue
remains in the boundaries
-Colloid – extends beyond boundaries

11. ETIOLOGY

12. TYPES

13. Thermal
Caused by – flash , flame , scaled, contact
with hot objects
Management – extinguish flame
Flush with cool water

14. Chemical
Agent Forms Management
Acid House hold
cleaners
HCL, oxalic,
Water
irrigation
Irrigate skin
with soup
solution
Remove the
person or
agent away.

Take self
precaution
and remove
the cloth
which contain
chemical.
Alkali Drain
cleaners
Fertilizers
Adhere to
tissue and
protein
hydrolysis
Irrigate skin
with slightly
acidic
solutions like
lemon water

15. Dry chemical –
Brush away from skin
Irrigate skin

16. Smoke and inhalation injury
Agent Injury signs and
symptoms
Management
Carbon monoxide
poisoning -
Incomplete combustion
of burning material
Cherry red skin color
10-20% - head ach ,
dizziness , nausea,
abdominal pain
21-41%- irritability ,
confusion , stupor,
hypotension ,
bradycardia, pale to dark
red skin color
41-60%- convulsion ,
coma, hypotension,
tachycardia
>60%- death
100% o2

17. Injury above glottis –
Usually thermally
produced
Inhalation f hot air ,
steam , or smoke
Especially .- burn in
enclosed space
Mucosal burning of
larynx and oropharynx
Redness
Blistering
Edema
Quick mechanical
obstruction
Singed nasal hair
Hoarseness painful
swallowing
Darkened oral and
nasal membrane
Carbonaceous sputum
Medical emergency

18. Injury below glottis –
Chemically produced
Pulmonary edema
ARDS
Close observation for
ARDS

19. Electrical burns
Damage to the nerves and vessels
Factors related to severity
voltage
Tissue resistance
Current pathways
Surface area of contact
Length of time

20. S/S
Ice berg effect
Chance of cervical spine injury (fall)
Muscle contraction – fracture
Dyarrhythmias- AF, VF
Cardiac arrest
Metabolic acidosis
Myoglobinuria lead to – acute renal tubular
necrosis

21. Management
Disconnect source of current
CPR

22. Cold thermal injuries
Frostbite – gangrene

23. Radiation
Source – solar, X ray , radioactive agent
Management
Shield
Move client away

24. PATHOPHYSIOLOGY

26. AMERICAN BURN ASSOCIATION - burn unit
referral criteria
Burn injuries that should be referred to a burn unit include the following \
1.Partial thickness burns more than 10% TBSA
2.Burns that involve s the face hands feet genitalia perineum or major joints
3.Third degree burns in any age group
4.Electrical burns including lightning injury
5.Chemical burns
6.Inhalation injury
7.Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality
8.Any patients with burns and concomitant trauma (fractures) in which the
burn injury poses the greatest risk of morbidity or mortality.
9.Patients who will require special social, emotional, or long term
rehabilitation intervention

27. CLASSIFICATION OF BURN
INJURY
Severity determined by –
Depth of burn
Extent of burn – calculated by TBSA
Location of burn
Patient risk factors

28. Classification based on depth
Superficial
Partial thickness
superficial partial thickness
deep partial thickness
Full thickness

29. Superficial burns
Involves epidermis
---- UV rays, sun burn, minor flash injury,
mild radiation
s/s
Skin color – pink – bright red
Slight edema
Chills, nausea, vomiting – in extensive burns
Management – I/V fluid treatment

30. Partial thickness
Superficial partial thickness Deep partial thickness
Affected - Dermis and papillae
of dermis
Bright red color + moist +
glistening appearance +
blisters + blanching on
pressure + pain response to
temperature and air is severe
Heal with in 21 days + minimal
or no scaring
Management – analgesics
Skin substitutes for large
disrupted blisters
Dermis +more deeper
Pale + waxy+ moist / dry large
blisters + decreased capillary
refill + less painful
Heal – more than 21 days
Complication
Necrosis may lead to full
thickness injury , contractures
Management – excision and
grafting

31. Full thickness burn
Epidermis + dermis + epidermal
appendages + subcutaneous fat+
connective tissue + muscle + bone
Pale ,waxy ,brown ,mottled ,leathery ,firm to
touch
No sensation of pain
Management –
Skin grafting

32. Classification by extent of burn
Lund- Browder chart
According to Rule of nine
( not accurate for estimating the percentage
TBSA for adults who are short, obese or
very thin. )
Sage burn diagram – computerized burn
estimation tool.
(www.sagediagram.com)

33. Classification according to ABA
Minor burn injury Moderate burn injury Major burn injury
Excludes electrical
injury, inhalation injury,
and all clients at high
risk
Partial thickness burns
of less than 15 % of
TBSA in adults
Full thickness burns of
less than 2% of TBSA
not involving special care
areas.
( eye ,ear, hand , feet,
face , joints , perineum )
Excludes electrical
injury, inhalation
injury, and all clients
at high risk
Partial thickness
burns of less than 15
%- 25 % of TBSA in
adults
Full thickness burns
of less than 10 % of
TBSA not involving
special care areas.
( eye ,ear, hand , feet,
face , joints ,
perineum )
Includes electrical
injury, inhalation
injury, and all clients at
high risk involving
special care areas.
( eye ,ear, hand , feet,
face , joints , perineum
Partial thickness burns
of more than 25 % of
TBSA in adults
Full thickness burns of
10 % or greater of the
TBSA

34. DIAGNOSTIC EVALUATION
Sodium
hyponatreamea - dilutional Hyponatreamea
Water intoxication
Potassium – hyperkalemea – renal failure
Adrenocortical insufficiancy
Massive deep muscle injury
Hypokalemea- dilution / GI wash…

35. MANAGEMENT
Pre hospital care
Emergent phase
Air way management
Fluid therapy
Wound care

36. PRE HOSPITAL CARE
Remove person from the source of burn
Self shield – by rescuers
Small burns <=10% TBSA – covered with
clean, cool, tap water-dampened towel.
Assesement and Management of ABC

37. EMERGENT PHASE
(resuscitative phase)

38. Air way management
Early Endotracheal / orotracheal intubation
Ventilatory assistance – with PEEP
 assess ABG values
Extubation- when edema resolves
Escharotomies - to relive respiratory
distress secondary to circumferential,
fulthickness burns to the neck and trunk

39. Assess lower respiratoty tract by –
fiberoptic bronchoscopy
For inhalation injury – no intubation
perfornmed
Humidified Oxygen
Position – high fowler’s position (not for pts
with spinal injury)

40. If spinal injury – reverse tendelberg position
Deep breathing and coughing exercise
Reposition every 1-2 hrs
Bronchodilators
O2 therapy until carboxyhemoglobin
become normal .

41. Fluid therapy
Pt >15% TBSA – large bore I/V access
>30% TBSA – central and arterial line
Crystalloid solutions – RL
Colloids – albumin
Calculate fluid requirement brooke’s and
(baxter) parkland formula

42. Formula First 24 hrs Second 24 hrs
Brooke
(modified)
Crystalloid colloids Glucose in
water
4ml RL X Kgbody wt X%TBSA
burn= total fluid repalcement for
1
st
24 hrs
Application
½ of total in 1
st
8hrs
¼ of total in second 8 hr
¼ of total in third 8 hr
0.3-
0.5ml/kg/%
TBSA
Amount to
replace
estimated
evaporative
losses
Parkland
formula (baxter)
RL 4ml X kgX %TBSA burn,
½ given first 8hr
¼ given each next 8 hr
20-60% of
calculated
plasma
volume
Amount to
replace
estimated
evaporative
losses

43. Wound care
Start until airway patency maintained
Cleansing and gentle debridement
Necrotic skin removed
Escharotomies ( removal of dry scab)
Fasciotomies
Hydrotherapy / cart shower
Once daily shower and dressing

44. Control of infection
Open method Multiple dressing change method
Burn covered with cover with topical
antimicrobial solution with out
dressing
Sterile dressing impregnated with
topical antimicrobial medication
changed every 12 / 24 hrs or once in
every 3 days.
Moist wound healing method

45. Skin graft
Porcine skin – hetero graft or xenograft
(different spicies)

46. Cadaveri skin – homograft or
allograft (same spicies)

47. Cultured epithelial autograft

50. Autograft – own skin

51. Porcine collagen bonded to
silicone memberane – Biobrane

54. Bovine collagen and glycosaminoglycan
bonded to silicone memberane
Acellular dermal matrix derived from
donated human skin ( Alloderm )

55. Care of facial burn
Open dressing
Ophthalmological examination – corneal
burns and edema
Periorbital edema – reassurece

56. DRUG THERAPY

57. Analgesics
I/v medications
Mrphine
Fentanyle
Morphine
NSAIDs
Oxycodone

58. Sedatives
Haloperidol
Lorazepam
Midazolam

59. Other medications
Ranitidine
Nystatin
Antacids

60. Tetanus immunization
If not had active immunization in 10 years –
go for tetanus immunoglobulin

61. Antimicrobial agents
Silver sulfadiazine
Mafenide acetate
Oral infection – nystatin mouth wash

62. NUTRITIONAL THERAPY
TPN
High protein high cal – diet

63. ACUTE PHASE
Wound care
Debridment of necrotic tissue
Enzymatic debridement
Use meshed dressing with paraffine oil
Moist dressing for donor site

64. Skin grafting
Pain management
Other pain management techniques
Guided imaginary
Relaxation therapy
Hypnosis

65. Physical and occupational therapy
ROM
Nutritional care
Psychosocial care

66. REHABILITATION PHASE
Manage emotions
Fear
Anger
Anxiety
Guilt
Depression

67. COMPLICATIONS
Contractures – abnormal condition of a joint
characterized by flexion and fixation

68. NURSING DIAGNOSIS
Impaired gas exchange related to carbon
monoxide poisoning as evidenced by labored
breathing
Ineffective air way clearance related to edema
and effects of smoke inhalation and evidenced
by ventilatory support
Disturbed body image related to disfigurement
secondary to burn as evidenced by verbalized
negative comments about appearance.

69. Fluid volume deficit related to fluid loss as
manifested by decreased serum electrolyte
level and dry skin
Acute pain related to impaired skin integrity
as manifested by facial expression and
crying.

70. Impaired skin integrity related to thermal
injury as manifested by blisters and lesions.
Activity intolerance related to weakness, as
manifested by verbalization.

71. Anxiety related to prognosis of disease
condition and disturbed body image.
Risk for infection related to impaired skin
integrity and suppressed immune response
Risk for contractures related to the burn
injury

72. Ineffective individual coping related to fear
and emotional impact of burn injury as
evidenced by increased questioning
Imbalanced nutrition less than body
requirement related to inability to intake as
evidenced by weight loss.
Hyperthermia, related to infection, as
manifested by rise in body temperature..

73. Research studies

74. The treatment of pain produced during the
management of burn injury has been an
ongoing problem for physicians caring for
these patients. The main therapeutic option
for analgesia has been the repeated and
prolonged use of opioids.

75. The adverse effects of opioids are well
known but the long term use of opioids
which produces tolerance with
accompanying dose escalation and
dependence is most problematic. Another
potentially important consequence of opioid
exposure that sometimes masks as
tolerance is that of opioid induced
hyperalgesia.

76. This syndrome is manifest as enhanced pain, sensitivity
and loss of analgesic efficacy in patients treated with
opioids who actually become sensitized to painful
stimuli. This article focuses on the treatment of burn
pain and how current analgesic therapies with opioids
may cause hyperalgesia and affect the adequacy of
treatment for burn pain. This article also provides
possible modalities to help therapeutically manage
these patients and considers future analgesic strategies
which may help to improve pain management in this
complicated patient population.