Burns

BURNS

1. RATHEESH R L

2. Definition A burn is a type of injury to the flesh or skin which can be caused by heat, electricity, chemicals, friction or radiation

3. Human skin can tolerate temperatures up to 42-44 C (107-111 F) but above these, the higher the temperature the more severe the tissue destruction Below 45 C (113 F), resulting changes are reversible but >45 C, protein damage exceeds the capacity of the cell to repair

4. Incidence About 2.4 million people suffer burns annually Account for an estimated 700,000 cases visits per year and 45,000 require hospitalizations Between 8,000-12,000 burn patients die, and approximately one million will sustain substantial or permanent disabilities

5. Etiology Thermal injury Electrical injury Chemical burns—acid/alkali Cold injury—frost bite Ionising radiation Sun burns

6. CLASSIFICATION OF BURNS

7. CLASSIFICATION OF BURNS BY CAUSATIVE AGENTS Thermal Burns Caused by flame, flash, scald, or contact with hot objects It is the most common type of burn Chemical Burns Result from tissue injury and destruction from necrotizing substances (chemicals) Most commonly caused by acids

8. Smoke Inhalation Injuries Result from inhalation of hot air or noxious chemicals Cause damage to respiratory tract Important determinant of mortality in fire victims Eg :Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials Inhaled CO displaces oxygen 200 x more powerful than oxygen CO is colorless, odorless and tasteless

9. Signs and Symptoms Presence of facial burns Singed nasal hair Hoarseness, painful swallowing Darkened oral and nasal membranes Wheezing on auscultation Edema is the nose and airways Flushing Nausea/vomiting Syncope, coma, death

10. Electrical Burns Intense heat generated from an electrical current May result from direct damage to nerves and vessels causing tissue anoxia and death Severity of injury depends on the amount of voltage, tissue resistance, current pathways, surface area, and on the length of time of the flow

11. Electrical burns in hands

12. Cold Thermal Injury ( Frostbite) Usually affects fingers, toes, nose, and ears Numbness, pallor, severe pain, swelling, edema resulting from prolonged exposure to freezing or subfreezing temperatures .

13. Classification according to the depth of tissue destruction 1. Superficial partial-thickness injuries (first degree burn): In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. The damaged skin may be painful and appear red and dry, as in sunburn, or it may blister (very minimal).

14. Typical Characteristics for Superficial thickness burn Mild to severe erythema (pink to red) NO BLISTERS Skin blanches Painful, tingling Pain responds well to cooling Lasts about 48 hours; healing in 3-7 days

15. 2. Deep partial-thickness injuries (second degree burn): A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. The wound is painful, appears red, and exudes fluid. Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial-thickness burns take longer to heal and are more likely to result in hypertrophic scars.

16. Typical Characteristics for deep partial thickness burn Large blisters over an extensive area Edema Red base with broken epidermis Wet, shiny and weeping Sensitive to cold air Healing in 2-3 weeks Grafts MAY be needed

17. Partial thickness burn in hand

18. 3. Ful -thickness injuries (third degree burn): A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because nerve fibers are destroyed. The wound appears leathery; hair follicles and sweat glands are destroyed

19. Typical Characteristics for Full-thickness burn Deep, red, black, white, yellow, or brown area Edema Tissue open with fat exposed Little to no pain Requires removal of eschar and skin grafting Scarring and contractures are likely Takes weeks to months to heal

20. Classification according to the extent of Body Surface Area injured Extent of Body Surface Area Injured Various methods are used to estimate the TBSA (total body surface area) affected by burns; among them are: the rule of nines , the Lund and Browder method , and the palm method .

21. RULE OF NINES An estimation of the TBSA involved in a burn is simplified by using the rule of nines . The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

22. LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn is the Lund and Browder method, It recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, and changes with growth.

23. PALM METHOD In patients with scattered burns, a method to estimate the percentage of burn is the palm method. The size of the patient’s palm is approximately 1% of TBSA.

24. Criteria for Classifying the Extent of Burn Injury(American Burn Association) Minor Burn Injury Second-degree burn of less than 15% total body surface area(TBSA) in adults or less than 10% TBSA in children Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints) Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients ( eg , extremes of age, concurrent disease)

25. Moderate, Uncomplicated Burn Injury Second-degree burns of 15%–25% TBSA in adults or10%–20% in children Third-degree burns of less than 10% TBSA not involving special care areas Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients ( eg , extremes of age, concurrent disease)

26. Major Burn Injury Second-degree burns exceeding 25% TBSA in adults or 20% in children All third-degree burns exceeding 10% TBSA All burns involving eyes, ears, face, hands, feet, perineum, joints All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients

27. 32 Blister may ↑size because continuous exudation and collection of tissue fluid

28. 33 Eschar:composed of denatured protein

29. Burn Photos Chemical (Acid) Burns Radiation (Flash) Burns

30. Burn Photos Electrical Burns Entrance Wounds Electrical Burns Exit Wounds Entrance wound of electrical burns from an overheated tool Severe swelling peaks 24-72 hrs after Electrical burns mummified 1 st 2 fingers later removed

31. Chemical Burn

32. Pathologic Features Zone of coagulation (necrosis): Superficial area of coagulation necrosis and cell death on exposure to temperatures >45 (primary injury) Zone of stasis (vascular thrombosis): Local capillary circulation is sluggish, depending on the adequacy of the resuscitation, can either remain viable or proceed to cell death (secondary injury) Zone of hyperemia (increased capillary permeability)

33. Zone of injury 40

34. PATHOPHYSIOLOGY

35. LOCAL AND SYSTEMIC RESPONSES TO BURNS Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. These systemic responses are due to the release of cytokines and other mediators into the systemic circulation and include the following:

36. Effects of a severe burn Local response include tissue edema effects on fluid, electrolytes and blood volume Cardiovascular Respiratory Immune Integumentary Gastrointestinal Urinary 43

37. Cardiovascular system Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein) Hypotension tachycardia Blood flow in intravascular is concentrated and cause static. Cardiac output ↓, Due to that tissue perfusion ↓,

38. Hematologic changes Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, deficit plasma clotting factors. Life span ↓RBC. Blood loss during diagnostic and therapeutic procedure.

39. Respiration system Majority of deaths from fire are due to smoke inhalation. Pulmonary damage can be from direct inhalation injury or systemic respond to the injury. Damage to cilia and cell in the airway-inflammation. Mucociliary transport mechanism not functioning-bronchial congestion and infection. Pulmonary edema, fluids escape to interstitial. Airway obstruction

40. Gastrointestinal Burn >20% experience ↓peristalsis, gastric distention and ↑risk of aspiration. Paralytic ileus due to secondary to burn trauma. Stress ulcer (stomach/duodenum) due to burn injury. Indication of stress ulcer- malena stool or hematemesis . These signs suggest gastric or duodenal erosion (Curling`s ulcer) Gastric distention and nausea may lead to vomiting.

41. CURLING’S ULCER Acute ulcerative gastro duodenal disease Occur within 24 hours after burn Due to reduced GI blood flow and mucosal damage Treat clients with H2 blockers, mucoprotectants , and early enteral nutrition Watch for sudden drop in hemoglobin 4/1/2011 49

42. Immunologic changes Skin barrier to invading organisms s destroyed, circulating levels of immunoglobulins are ↓ Changes in WBC both quantitative and qualitative. Depression of neutrophil , phagocytic and bactericidal activity is found after burn injury. All this changes in the immune system can make the burn patient more susceptible to infection

43. SUMMARY

44. Diagnosis A detailed history and physical examination is the first step . The physician will evaluate the type, duration, and timing of the burn; the burn location and severity; and associated dehydration, disfigurement, and infection . Fires in enclosed spaces should raise the suspicion for smoke–inhalation injury.

45. Lab Tests Routine blood work for a patient with a burn injury includes a complete blood count, platelet count, clotting studies, liver function studies, and carboxyhemoglobin , electrolyte, blood urea nitrogen, glucose and creatinine levels . Urinalysis may reveal myoglobinuria and hemoglobinuria . If pt. is 35 or older , he’ll also need an electrocardiogram. Chest x-rays and arterial blood gas levels allow the evaluation of alveolar function.

46. MANAGEMENT OF THE BURN INJURY Phases of Management Burn care then proceeds through three phases: Emergent/resuscitative phase (on-the-scene care), Acute/intermediate phase, and Rehabilitation phase.

47. Phase Duration Priorities Emergent or immediate resuscitative From onset of injury to completion of fluid resuscitation First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Wound assessment and initial care Acute From beginning of diuresis to near completion of wound closure Wound care and closure Prevention or treatment of complications, including infection Nutritional support Rehabilitation From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment Prevention of scars and contractures Physical, occupational, and vocational rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

48. EMERGENT/RESUSCITATIVE PHASE MGT Emergent phase - begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury

49. Emergency Procedures at the Burn Scene Extinguish the flames Cool the burn Remove restrictive objectives Cover the wound Irrigate chemical burns

50. Emergency Medical Management The patient is transported to the nearest emergency department. The hospital nurses (staff) and physician are alerted that the patient is in route to the emergency department so that life-saving measures can be initiated immediately by a trained team. Initial priorities in the emergency department remain airway, breathing, and circulation.

51. For mild pulmonary injury, inspired air is humidified and the patient is encouraged to cough so that secretions can be removed by suctioning. For more severe situations , it is necessary to remove secretions by bronchial suctioning and to administer bronchodilators and mucolytic agents. If edema of the airway develops, endotracheal intubation may be necessary.

52. Continuous positive airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation. A large-bore (16- or 18-gauge) intravenous catheter should be inserted in a non-burned area (if not inserted earlier).

53. Management of fluid loss and shock Fluid Replacement Therapy: The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. The adequacy of fluid resuscitation is determined by: Output totals of 30 to 50 mL /hour systolic blood pressure exceeding 100 mm Hg and/or pulse rate less than 110/minute.

54. Burn shock

55. Fluid Requirements: The projected fluid requirements for the first 24 hours are calculated by the clinician based on the extent of the burn injury. Some combination of fluid categories may be used: Colloids (whole blood, plasma, and plasma expanders) and Crystalloids/electrolytes (physiologic sodium chloride or lactated Ringer’s solution).

56. Fluid Requirements: Adequate fluid resuscitation results in slightly decreased blood volume levels during the first 24 post-burn hours and restores plasma levels to normal by the end of 48 hours. Oral resuscitation can be successful in adults with less than 20% TBSA and children with less than 10% to 15% TBSA.

57. Guidelines and Formulas for Fluid Replacement in Burn Patients Consensus Formula Lactated Ringer’s solution (or other balanced saline solution): 2–4 mL × kg body weight × % total body surface area (TBSA) burned. Half to be given in first 8 hours; remaining half to be given over next 16 hours.

58. The following example illustrates use of the formula in a management of a 70-kg patient with a 50% TBSA burn: Steps 1, Consensus formula: 2 to 4 mL /kg/% TBSA 2, 2 × 70 × 50 = 7,000 mL /24 hours 3, Plan to administer: First 8 hours = 3,500 mL , or 437 mL / hour; next 16 hours = 3,500 mL , or 219 mL /hour

59. Evans Formula 1. Colloids: 1 mL × kg body weight × % TBSA burned 2. Electrolytes (saline): 1 mL × body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss Day 1: Half to be given in first 8 hours; remaining half over next 16 hours Day 2: Half of previous day’s colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 mL over 24 hours. Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.

60. Brooke Army Formula 1. Colloids: 0.5 mL × kg body weight × % TBSA burned 2. Electrolytes (lactated Ringer’s solution): 1.5 mL × kg body weight × % TBSA burned 3. Glucose (5% in water): 2,000 mL for insensible loss

61. Parkland/Baxter Formula Lactated Ringer’s solution: 4 mL × kg body weight × % TBSA burned Day 1: Half to be given in first 8 hours; half to be given over next16 hours Day 2: Varies. Colloid is added.

62. Hypertonic Saline Solution Concentrated solutions of sodium chloride ( NaCl ) and lactate with concentration of 250–300 mEq of sodium per liter, administered at a rate sufficient to maintain a desired volume of urinary output. Do not increase the infusion rate during the first 8 post burn hours. Serum sodium levels must be monitored closely. Goal: Increase serum sodium level and osmolality to reduce edema and prevent pulmonary complications.

63. Nursing management Includes: infection prevention, wound cleansing and administering topical antibacterial drugs like: Silver sulfadiazine 1% ( Silvadene ) watersoluble cream, Silver nitrate 0.5% aqueous solution, Mafenide acetate 5% to 10% ( Sulfamylon ) hydrophilic-based cream, Acticoat , etc

64. ACUTE PHASE - Begins when the client is hemodynamically stable, capillary permeability is restored, and diuresis has begun - Usually begins 48 - 72 hours after the time of injury

65. - Emphasis during this phase is placed on restorative therapy, and the phase continues until wound closure is achieved - The focus is on infection control, wound care, wound closure, nutritional support, pain management, and physical therapy

66. Pathophysiology Diuresis from fluid mobilization occurs, and the patient is no longer grossly edematous Bowel sounds return Healing begins Formation of granulation tissue A partial-thickness burn wound will heal from the edges Full-thickness burns must be covered by skin grafts

67. • Wound Care Daily observation Assessment Cleansing Debridement Appropriate coverage of the graft: Fine-mesh gauze next to the graft followed by middle and outer dressings Sheet skin grafts must be kept free of blebs (small blisters)

68. Excision and Grafting Eschar is removed down to the subcutaneous tissue or fascia Cultured Epithelial Autographs (CEA): CEA is grown from biopsies obtained from the patient’s own skin Artificial Skin: used when life-threatening full-thickness or deep partial-thickness wounds where conventional autograft is not available or advisable

69. Pain Management Opioid every 1 to 3 hours for pain Several drugs in combination Morphine with haloperidol Nonpharmacologic strategies • Relaxation tapes • Visualization, guided imagery • Meditation

70. Acute Phase management Debriding Full-Thickness Burn 78

71. Acute Phase management Surgeon Harvesting Skin 79

72. Acute Phase management Donor Site After Harvesting 80

73. Acute Phase management Application of Cultured Epithelial Autograft 81

74. REHABILITATION PHASE The rehabilitation phase is defined as beginning when the patient’s burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity Complications Skin and joint contractures Hypertrophic scarring 82

75. Rehabilitation Phase Both patient and family actively learn how to care for healing wounds Cosmetic surgery is often needed following major burns Role of exercise cannot be overemphasized Constant encouragement and reassurance Address spiritual and cultural needs Maintain a high-calorie, high-protein diet Occupational therapy 83

76. Definitions Graft A skin graft is a tissue of epidermis and varying amounts of dermis that is detached from its own blood supply and placed in a new area with a new blood supply. Skin graft is a segment of skin separated from the donor site and transplanted to the recipient site devoid of its blood supply

77. Indications for Grafts Extensive wounds. Burns. Specific surgeries that may require skin grafts for healing to occur. Areas of prior infection with extensive skin loss. Cosmetic reasons in reconstructive surgeries.

78. Classification of Grafts Autografts – A tissue transferred from one part of the body to another. Homografts /Allograft – tissue transferred from a genetically different individual of the same species. Iso grafts : genetically identical donor-twins Xenografts – a graft transferred from an individual of one species to an individual of another species.

79. Types of Grafts Grafts are typically described in terms of thickness or depth. Split Thickness(Partial) : Contains 100% of the epidermis and a portion of the dermis. Split thickness grafts are further classified as thin or thick . Full Thickness : Contains 100% of the epidermis and dermis.

80. Split Thickness Used when cosmetic appearance is not a primary issue or when the size of the wound is too large to use a full thickness graft. Chronic Ulcers Temporary coverage Correction of pigmentation disorders Burns

81. Split thickness Skin Graft Advantages Can tolerate less than ideal conditions for survival Used to resurface large wounds, line cavities, resurface mucosal deficits, close donor sites of flaps, and resurface muscle flaps Can be used to achieve temporary closure Donor sites heal spontaneously Donor sites may be reharvested

82. Split thickness Skin Graft Disadvantages More fragile, especially over areas with little underlying bulk They contract more during healing Do not grow with the individual Tend to be smoother, thinner & shinier than normal skin They tend to be abnormally pigmented & lack hair growth more functional than cosmetic. produce an undesirable masklike appearance on the face The wound created at the donor site is often more painful than the recipient site

83. Full Thickness Indications for full thickness skin grafts include: If adjacent tissue has premalignant or malignant lesions and precludes the use of a flap. Specific locations that lend themselves well to FTSGs include the nasal tip, forehead, eyelids, medial canthus , concha , and digits.

84. Full Thickness Skin Graft Advantages Nearly all qualities of normal skin (color, texture and thickness) Resistant to trauma Sensation is good Esthetically is good Ideal for visible areas of the face Undergo less contraction while healing This is important on the face as well as on the hands and over mobile joint surfaces. In children are more likely to grow with the individual

85. Full Thickness Skin Graft Disadvantages limited to relatively small, uncontaminated, well-vascularized wounds Do not have as wide a range of application as split-thickness grafts Donor sites must be closed primarily or resurfaced with a split-thickness graft from another site

86. Type of Graft Advantages Disadvantages Thin Split Thickness Best Survival Heals Rapidly Least resembles original skin. Least resistance to trauma. Poor Sensation Maximal Secondary Contraction Thick Split Thickness More qualities of normal skin. Less Contraction Looks better Fair Sensation Lower graft survival Slower healing. Full Thickness Most resembles normal skin. Minimal Secondary contraction Resistant to trauma Good Sensation Aesthetically pleasing Poorest survival. Donor site must be closed surgically. Donor sites are limited.

87. Donor Sites selection The ideal donor site would provide skin that is identical to the skin surrounding the recipient area. - Colour - Thickness - Hair - Texture Acute phase of burns-- STSG

88. Donor site selection Split-thickness skin grafts are commonly harvested from the thigh, buttocks, abdominal wall, or scalp The method of harvesting the split-thickness skin graft depends primarily on the size and thickness needed for coverage Full-thickness skin grafts taken from the supraclavicular pre- or postauricular areas provide a suitable color match for defects of the face Taken from body creases allowing primary closure and hidden scars

89. Harvesting Tools Razor Blades Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian) Manual Drum Dermatomes (Padgett, Reese) **Electric/Air Powered Dermatomes (Brown, Padgett, Hall) Electric & Air Powered tools are most commonly used.

90. Padgett Dermatome

91. Goulian Blade

92. STSG Harvesting Dermatome Uniform thickness (set width and thickness) Fast Must be familiar with equipment 15 blade scalpel simulates 0.015 inches Free hand with scalpel Variable thickness Irregular edges

93. STSG

94. FTSG

95. Meshing of grafts

96. Grafting….., Preparation of the wound Fixation of the graft Vascularization of the graft

97. NURSING MANAGEMENT Maintain patent airway/respiratory function. Restore hemodynamic stability/circulating volume. Alleviate pain. Prevent complications. Provide emotional support for patient/significant other (SO). Provide information about condition, prognosis, and treatment.

98. Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry , and carboxyhemoglobin levels. Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.

99. Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output. Note and report signs of  hypovolemia  or fluid overload. Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and daily weight. Elevate the head of bed and burned extremities.

100. Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory  depression  in patient who is not mechanically ventilated. Provide emotional support, reassurance, and simple explanations about procedures.

101. Assess wound status. Support patient during distressing and painful wound care. Monitor IV and oral fluid intake; use IV infusion pumps. Measure intake and output and daily weight. Report changes (e.g.,  blood pressure ,  pulse rate ) to physician.

102. Support and address the verbal and nonverbal concerns of the patient and family. Instruct family in ways to support patient. Make psychological or social work referrals as needed.

103. NURSING DIAGNOSIS Impaired gas exchange  related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction. Ineffective airway clearance  related to edema and effects of smoke inhalation. Fluid volume deficit  related to increased capillary permeability and evaporative losses from burn wound. Hypothermia  related to loss of skin microcirculation and open wounds.

104. Pain  related to tissue and nerve injury. Anxiety  related to fear and the emotional impact of burn injury.