LECTURE 6 SURG III BURNS AND SCALDS.pptx

Presentation on burns and scalds with their preventive measures and medical treatment

1. BURNS

2. LEARNING OBJECTIVES At the end of the lesson students should be able to Describe what burns are. Enumerate some of the causes of burns. Appreciate the degrees of burns. Assess the percentage of burns. Manage patients with burns. Identify some complications of burns.

3. 13 ANATOMY OF THE SKIN

4. 14 ANATOMY OF THE SKIN

5. THE SKIN CONT. The skin, the largest organ of the body, consists of two layers-the epidermis and dermis. The depth or degree of burn depends on which layers of skin are damaged or destroyed . The epidermis is the outer layer that forms the protective covering.

6. THE SKIN CONT. The thicker or inner layer of the dermis contains blood vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the dermis is destroyed, so are the nerve endings that allow a person to feel pain, temperature, and tactile sensation.

7. FUNCTIONS OF THE SKIN Regulates body temperature. Stores water and fat. Is a sensory organ. Prevents water loss. Prevents entry of bacteria. Production of vitamin D for bone development

8. WHAT ARE BURNS Burn injury is a acute damage to the skin/body tissues caused by heat, electricity and chemical materials . Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

9. EEFECT OF BURNS ON THE SKIN When the skin is burned, these functions are impaired or lost completely. The severity of the skin injury depends upon the size of the injury, depth of the wound, part of the body injured, age of the patient, and past medical history.

10. EEFECT OF BURNS ON THE SKIN CONT. Because of the importance of the skin, it becomes clear that injury can be traumatic and life threatening. Recovery from burn injury involves four major aspects: burn wound management, physical therapy, nutrition, and emotional support.

11. 6/17/2013 24 TYPES OF BURN INJURY Thermal Chemical Electrical Radiation Light

12. CAUSES OF BURNS Thermal - including flame, radiation, or excessive heat from fire, steam, and hot liquids and hot objects. Chemical - including various acids, bases, and caustics. Electrical - including electrical current and lightning.

13. CAUSES OF BURNS CONT. Radiation - such as from nuclear sources. Ultraviolet light is also a source of radiation burns. Light - burns caused by intense light sources or ultraviolet light, which includes sunlight. NOTE Never assume the source of a burn. Gather information and be sure.

14. CLASSIFICATION OF BURNS Partial thickness burn = involves epidermis Deep partial thickness = involves dermis Full thickness = involves all of skin

15. DEGREE OF BURNS

16. CLASSIFICATION OF BURNS Superficial Superficial partial-thickness Deep partial-thickness Full-thickness

17. CLASSIFICATION CONT. Superficial : only the epidermis Superficial partial thickness: epidermis and dermis, excluding all the dermal appendages Deep partial thickness: epidermis and most of the dermis Full thickness: epidermis and all of the dermis

18. CLASSIFICATION OF BURNS Epidermal Burn: (1 st degree) No blister Erythema due to dermal vasodilation Quite painful 4 th day injured epithelium desquamate – peeling (sunburn)

19. FIRST DEGREE BURNS

20. CLASSIFICATION CONT. Superficial Partial-thickness: Second degree Includes upper layer of dermis Characteristically forms blisters (fluid accumulation between epidermis and dermis). If blisters are removed the wound is pink, wet, painful and blanch w/ pressure Heal spontaneously < 3wks with functional impairment Rarely cause hypertrophic scarring, but never completely match color of surrounding normal skin

21. SECOND DEGREE BURN

22. CLASSIFICATION OF BURNS CONT. Deep Burns: Deep Partial Thickness: (second degree) Extends into the reticular layer of the dermis with blisters but wound surface mottled pink and white color Complains of discomfort rather than pain Pressure applied --> capillary refill is slow or absent. 2 nd day wound is white and dry If not excised & grafted heals in 3 to 9 wks w/ scarring Joint function can be impaired

23. CLASSIFICATION OF BURN CONT. Deep Burns: Full Thickness: (third degree) All layers of the dermis. Appear white, cherry red or black and may or may not have deep blisters. Leathery, firm and depressed compared w/ adjoining normal skin. Develop a classic burn eschar , an intact dead and denatured dermis that separates after days or wks. Heal only by wound contracture, epithelialization from the wound margin or skin grafting.

24. CLASSIFICATION OF BURN CONT . Deep Burns: Fourth Degree: Involves also the subcutaneous fat and deeper structures. Almost always have charred appearance. Electrical burns, contact burns, immersion burns and patients who are unconscious at time of burn.

25. CLINICAL MANIFESTATION OF BURNS Dehydration. Oedema. Decreased urine out put. Dyspnea due to oedema of pharynx. Hypovolemic shock. Skin lesion(wound). Thirst. Gastrointestinal problems-paralytic ileus.

26. METHODS OF ASSESSING BURNS These are Rule of nine. Palmers method. Berkows method.

27. RULE OF NINE Adults anatomic structure Surface area Head and neck - -------------------- 9 % Anterior Abdomen- -------------- 18 % Posterior abdomen- -------------- 18 % Each leg - ----------------------------- 18 % Each arm - ---------------------------- 9 % Genitalia / perineum - -------------- 1 %

28. RULE OF NINE CONT. Children Anatomic structure Surface area Head and neck - ------------------- 18 % Anterior Abdomen --------------- 18 % Posterior Abdomen -------------- 18 % Each leg - ----------------------------- 14 % Each arm - ---------------------------- 9 % Genitalia / perineum - -------------- 1 %

29. RULE OF NINE CONT. Rule of Nines The body is divided into portions totaling 100%. Advantage of using Rule of Nines. Fairly rapid, easy. No charts required. Disadvantage. It is fairly inaccurate, especially when dealing with children because it doesn't allow for body proportion differences.

30. Rule of 9s ABA

31. PALMER METHOD Usually used to assess smaller burnt areas. The patient wears gloves and the palm use to measure the area. Each palm measurement is estimated to be equal to 1% of the total body surface area.

32. PALMER METHOD ADVANTAGE Convenient to use Involve no other items Since using patients own hand one can approximate the percentage burnt DISADVANTAGE Somebody's hand cannot be used With serious burns patient cannot own hand Difficult to assess burns in children

33. BERKOW METHOD ( Lund-Browder ) More accurate than the wallace rule of nine. Usually the assessment is done and compared with a chart for interpretation.

34. BERKOW METHOD Berkow Method ADVANTAGE Accurate for all ages DISADVANTAGE Requires time to calculate Requires table for all ages

35. CHART FOR BERKOW’S METHOD

36. BURN UNIT REFERRAL CRITERIA D eep partial thickness burns>10% burns that involve the face, hands, feet, genitalia, perineum, or major joints full thickness burns in any age group electrical burns, including lightning inhalation burns requiring intubation chemical burns that involve deep and extensive tissue burned. 6/17/2013 54

37. 55 SURVIVAL PREDICTION Depth of Burns Extent of Burns Location of Burns Age of Client Risk Factors Major versus minor Burns

38. MANAGEMENT OF BURNS IN GENERAL Treatment should begin immediately to cool the area of the burn. This will help alleviate pain. For deep partial-thickness burns or full- thickness burns, begin immediate plans to transport the victim to competent medical care. For any burn involving the face, hands, feet, or completely around an extremity, or deep burns; immediate medical care should be sought. Not all burns require immediate physician care but should be evaluated within 3-5 days. Remove any hot or burned clothing.

39. MANAGEMENT OF BURNS IN GENERAL CONT. Use cool (54 degree F.) saline solution to cool the area for 15-30 minutes. Avoid ice or freezing the injured tissue. Be certain to maintain the victim’s body temperature while treating the burn.

40. MANAGEMENT OF BURNS IN GENERAL CONT. Wash the area thoroughly with plain soap and water. Dry the area with a clean towel. Ruptured blisters should be removed, but the management of clean, intact blisters are not tempered with.

41. MANAGEMENT OF BURNS IN GENERAL CONT. If immediate medical care is unavailable or unnecessary, antibiotic ointment may be applied after thorough cleaning and before the clean gauze dressing is applied.

42. MANAGEMENT OF BURNS IN GENERAL CONT. Scalding T ypically result from hot water, grease, oil or tar. Immersion scalds tend to be worse than spills, because the contact with the hot solution is longer. They tend to be deep and severe and should be evaluated by a physician. Cooking oil or tar (especially from the “mother pot”) tends to be full- thickness requiring prolonged medical care .

43. MANAGEMENT OF BURNS IN GENERAL CONT. Scalding Remove the person from the heat source. Remove any wet clothing which is retaining heat. With tar burns, after cooling, the tar should be removed by repeated applications of petroleum ointment and dressing every 2 hours.

44. MANAGEMENT OF BURNS IN GENERAL CONT. Flame a. Remove the person from the source of the heat. b. If clothes are burning, make the person lie down to keep smoke away from their face.

45. MANAGEMENT OF BURNS IN GENERAL CONT. Flame Use water, blanket or roll the person on the ground to smother the flames. d. Once the burning has stopped, remove the clothing. e. Manage the persons airway, as anyone with a flame burn should be considered to have an inhalation injury.

46. MANAGEMENT OF BURNS IN GENERAL CONT. Electrical burns : Are thermal injuries resulting from high intensity heat. The skin injury area may appear small, but the underlying tissue damage may be extensive.

47. MANAGEMENT OF BURNS IN GENERAL CONT. Electrical burns Additionally , there may be brain or heart damage or musculoskeletal injuries associated with the electrical injuries. Safely remove the person from the source of the electricity. Do not become a victim.

48. MANAGEMENT OF BURNS IN GENERAL CONT. . Check their Airway , Breathing and Circulation and if necessary begin CPR using an AED (Automatic External Defibrillator) if available. If the victim is breathing, place them on their side to prevent airway obstruction.

49. MANAGEMENT OF BURNS IN GENERAL CONT. Due to the possibility of vertebrae injury secondary to intense muscle contraction, you should use spinal injury precautions during resuscitation. Elevate legs to 45 degrees if possible. Keep the victim warm until emergency services arrives.

50. MANAGEMENT OF BURNS IN GENERAL CONT. Chemical burns Most often caused by strong acids or alkalis. Unlike thermal burns, they can cause progressive injury until the agent is inactivated.

51. MANAGEMENT OF BURNS IN GENERAL CONT. Chemical burns Flush the injured area with a copious amount of water while at the scene of the incident. Don’t delay or waste time looking for or using a neutralizing agent. These may in fact worsen the injury by producing heat or causing direct injury themselves.

52. NURSING CARE Position Psychological support Observation Wound care - close / open method Personal hygiene Nutrition-rehydration/intake and output Elimination Rehabilitation-plastic surgery

53. KEY ISSUES TO CONSIDER IN THE MANAGEMENT OF BURNS CONT. Respiratory care Administration of fluids Wound care (debridement) Pain control Plastic surgery ( eg : skin grafts) Monitoring for complications Infections Cardiovascular Respiratory Massage & Physical therapy Posttraumatic stress

54. CALCULATING FLUID REQUIREMENTS wt in kg x % burn x 2 – 4ml / kg / % 100 kg patient with 50% TBSA burn: 100 x 50 x 2 = 10,000ml = 10 liters RL This is calculated for the first 24 hours post-burn. Give half of this in first 8 hours. Half of 10,000ml = 5000ml in 8 hrs = 400 ml / hr initially

55. CALCULATING FLUID REQUIREMENTS CONT. Half of 10,000ml = 5000ml in 8 hrs = 400 ml / hr initially How do we know if this is too much fluid, or too little? Monitor at least: urine output - in adults, around 50 ml / hr. Decreasing urine output = need for more fluids.

56. CALCULATING FLUID REQUIREMENTS CONT. 20 kg child with 30% burn: 20 (kg) x 30(%) x 2 (ml/kg /%) = 1200 ml in 24 hr Half of this in first 8 hr = 600 ml in 8 hr = 75 ml / hr initially 75 ml / hr for burn loss + normal 60 ml / hr maintenance = 135 ml / hr initially

57. OTHER FORMS OF TREATMENT Eschar = burned skin Escharotomy = cut burned skin to relieve underlying pressure

58. OTHER FORM OF TREATMENT( Fasciotomy ) Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved. Muscle can be inspected for viability.

59. IMPORTANT POINTS E valuation of area and depth for burn I njury emergency treatment principle of burn I njury treatment of burn shock management of burn wound

60. NOTE WELL Depth of injury is proportional to : Temperature applied. Duration of contact. Thickness of skin.

61. NOTE WELL Severity is related to: Burn size Burn depth Part of the body burned

62. COMPLICATIONS Shock Anemia Contracture Paralytic ileus Keloids Renal failure Delirium Peptic ulcer(curling’s ulcer)

63. COMPLICATIONS OF BURNS CONT.

64. COMPLICATION OF BURNS CONT.

65. THE END THANK YOU FOR THE COOPERATION AND UNDERSTANDING.