Management of patient with burns

Management of patient with burns

1. MANAGEMENT OF PATIENT WITH BURNS

2. D efinition Injuries that result from direct contact or exposure to any physical, thermal, chemical, electrical, or radiation source are termed as Burns.

3. STATISTICS An estimated 265000 deaths every year are caused by burns. One of leading causes of disability-adjusted life-years (DALYs) lost in low- and middle-income countries.

4. Problem Statement : India 70 lakh burn injury cases annually Over 10,00,000 people are moderately or severely burnt every year 1.4 lakh people die of burn every year. Around 70% of all burn injuries occur in most productive age group (15-35 years). Majority are women & children. As many as 80% of cases admitted are a result of accidents at home (kitchen-related incidents)

5. CLASSIFICATION

6. Etiology Based on Cause Thermal Electrical Chemical Radiation Inhalation

7. Thermal Injuries Most common Types : Dry & wet Contact Direct contact with hot object (i.e. pan or iron) Anything that sticks to skin (i.e. tar, grease or foods)

8. Flame Direct contact with flame (dry heat) structural fires / clothing catching on fire

9. Electrical Burns Usually follows accidental contact with exposed object conducting electricity Electrically powered devices Electrical wiring Power transmission lines Can also result from Lightning Damage depends on intensity of current

10. Low-tension injuries(<1000 V) Low energy burns  Minimal damage to subcutaneous tissue Entry & Exit points – fingers  small deep burns AC  Tetany within muscles, cardiac arrest due to interference with normal cardiac pacing High-tension injuries(>1000V) Earthed high tension lines  Arc over the patient  Flash burn

11. Severity depends upon: what tissue current passes through (Low voltage/ High voltage) width or extent of the current pathway AC or DC duration of current contact

12. Lightning HIGH VOLTAGE!!! Injury may result from Direct Strike Side Flash

13. Chemical Burns Usually associated with industrial exposure Accidental mishandling of household cleaners Degree of tissue damage determined by - Chemical nature of the agent - Concentration of the agent - Duration of skin contact Acids- Eg - Formic acid,sulphuric acid Alkalis - Eg . Lime, potassium hydroxide

14. Radiation Exposure Waves or particles of energy that are emitted from radioactive sources Alpha radiation Large, travel a short distance, minimal penetrating ability Can harm internal organs if inhaled , ingested or absorbed Beta radiation Small, more energy, more penetrating ability Usually enter through damaged skin, ingestion or inhalation

15. INHALATION Smoke and inhalation injury carbon monoxide poisoning inhalation injury above glottis inhalation injury below glottis

16. According Depth of burn Superficial Partial-Thickness (First Degree burn) cause- Sunburn Low-intensity flash Skin involvement- Epidermis Symptoms- Reddened, Tingling, Pain that is soothed by cooling

17. Deep Partial-Thickness (Second Degree) C ause Scalds Flash flame Contact burns chemical Skin involvement- Epidermis , upper dermis , portion of deeper dermis Manifestations- Blisters that are red, shiny. Severe pain caused by nerve injury ,mild to moderate edema Recovery in 2 to 4 weeks, some scarring and depigmentation contractures

18. Full-Thickness (Third Degree) Cause- Flame Prolonged exposure to hot liquids Electric current Chemical Skin involvement- Epidermis , entire dermis, and sometimes subcutaneous tissue; may involve connective tissue , muscle, and bone Manifestations- Dry ; pale white, Leathery, visible thrombosed blood vessels Pain free, all skin elements and local nerve endings are destroyed, surgical intervention required for healing

19. 4 th Degree E+D+S+muscles , tendons & bone

20. Extent of Body Surface Area Injured RULE OF NINES, LUND AND BROWDER METHOD, 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, which recognizes that the percentage of TBSA of various anatomic parts By dividing the body into very small areas and providing an estimate of the proportion of TBSA

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. Location of burn Burns to face, neck ,chest and back may inhibit respiratory function due to mechanical obstruction secondary to edema, eschar formation Burns to the ear, nose are susceptible to infection because of poor blood supply Burns to buttocks, genitalia are susceptible to infection because of contamination Burns on extremities cause circulatory compromise and neurologic impairment.

25. Patient risk factors

26. Zones of burn injury

27. Zones of burn injury The inner zone (known as the zone of coagulation, where cellular death occurs) sustains the most damage Necrotic area with cellular disruption Irreversible tissue damage The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury, Can survive or go on to coagulative necrosis depending on wound environment The outer zone—the zone of hyperemia—sustains the least damage

28. P athophysiology Burns> 30% Cell lysis increased capillary loss of skin barrier permeability Hemolysis Hyperkalemia inflamatory altered Na,H20,Protien process thermoreglatn Haemo / myoglobinuria shift extravascular Acute tubular neccrosis intravascular volume vasodilation hypothermia ACUTE RENAL FAILURE BURNS SHOCK HYPOTENSION ARRYTHMIAS MODS

29. MANAGEMENT

30. Phases of burn management 1. emergent phase/resuscitative phase 2.Acute phase/ wound healing phase 3. Rehabilitative phase/Restorative phase

31. PRE HOSPITAL MANAGEMENT Rescuer to avoid injuring himself Remove patient from source of injury Stop burn process Burning clothing; jewelry, watches, belts to be removed Pour ample water on burnt area ( not ice/ ice packs – skin injury & hypothermia )

32. Chemical burns: Remove saturated clothing Brush skin if agent is powder Irrigation with copious amount water to be started and continued in hospital Electrical burns: Turn off the current Use non-conductor item to separate from source

33. Small thermal burns (<10% TBSA ) may be covered with a clean, tap water-damped towel for patient comfort and protection until definite medical care instituted Cooling of injured area within 1 minute helps minimize the depth of injury If the burn injury is large (>10% TBSA) it is not advisable to immerse the body part in cool water since doing so might lead to extensive heat loss

34. Do not break blisters. Do not apply lotions, powders, grease, ghee, gentian violet, calamine lotion, toothpastes, butter and other sticky agents over the burn wound. Prevent contamination: Wrap burn part in clean dry sheet /cloth. Assess for life threatening injuries.

35. EMERGENT/RESUSCITATIVE PHASE This phase may last 24-48 hours after injury Resuscitation phase characterized by: Life-threatening airway problems Cardiopulmonary instability Hypovolemia Goal: Maintain vital organ function and perfusion

36. Assess A B C ET intubation + assisted ventilation with 100% O 2 if: Overt signs and symptoms of airway obstruction (Progressive hoarseness) Suspected inhalational injury (smoke/ carbon monoxide intoxication) Unconscious patient/ rapidly deteriorating patient Acute respiratory distress Burns of face & neck Extensive Burns (> 40% TBSA )

37. Large gauge I.V catheter Central line Insertion Venesection Foleys catheter and NG tube placement Quick assessment of extent Tetanus prophylaxis (the only IM administered inj ) Weigh the patient

38. History Mechanism of injury Time of injury Surroundings (closed space/ chemicals) Physical examination Head to toe assessment Careful neurological examination (cerebral anoxia) Labs : CBC, electrolytes, BUN Pulmonary assessment: ABG, CXR, carboxyhemoglobin

39. Pulse in extremities: manual/ doppler Loss of distal circulation Pallor/coolness/absent pulse/loss capillary refill/decreased oxygen saturation Absent pulse: emergency escharotomy to release constrictive, unyielding eschar

40. ESCHAROTOMY It is the surgical division of the nonviable skin and tissues , which allows the cutaneous envelope to become more compliant Deep 2 nd & 3 rd degree circumferential burns Chest: To allow respiratory movement Limb: To restore circulation in limb with excess swelling under rigid eschar Not in SC tissue  Exposes SC fat

41. FLUID RESUCITATION Parkland Formula Evan’s formula: Brooke formula

42. Parkland Formula Fluid of Choice Lactated Ringer’s (RL) NS can produce hyperchloremic acidosis 4 ml x % of burn x weight (Kg) in 24 hours First ½ of total volume given in the first 8 hours Remaining ½ of total volume given over following 16 hours NEXT 24 HRS Total volume ½ of first day Colloids ( 0.5 ml / kg / % ) 5 % glucose to make up the rest

43. Brooke formula( modified) 2 ml x % of burn x weight (Kg) in 24 hours First ½ of total volume given in the first 8 hours Remaining ½ of total volume given over following 16 hours NEXT 24 HRS Total volume ½ of first day Colloids (0 .3-0.5 ml / kg / % )

44. Evan’s formula Requirement for first 24 hrs Colloids : 1ml/kg/% burn Saline : 1ml/kg/% burn D5 : 2000ml Requirement for second 24 hrs ½ of first 24 hrs

45. Assessment of Adequacy of Fluid Resuscitation Monitor Urinary Output Adult: > 1 ml/ kg/ hr Daily Weight Vital Signs Heart rate and blood pressure CVP Level of Consciousness Laboratory values

46. RESUSCITATION FAILURE Delayed resuscitation Electric burns Inhalation injury Escharotomy Carbon monoxide poisoning Elderly patients

47. Wound care Wound care should be delayed until a patent airway, adequate circulation and adequate fluid replacement have been established. 2 types of wound treatment used to control infection open method multiple dressing change method

48. Closed method

49. Antimicrobial Agent Silvadene (silver sulfadiazine)1% cream- Most bactericidal agent Minimal penetration of eschar Mafenide acetate 5% to 10% ( Sulfamylon ) hydrophilic-based cream Effective against gram-negative and gram-positive organisms Diffuses rapidly through eschar In 10% strength, it is the agent of choice for electrical burns because of its ability to penetrate thick eschar

50. Silver nitrate 0.5% aqueous solution- Bacteriostatic and fungicidal Does not penetrate eschar

51. Analgesia Morphine sulphate Fentanyl Methadone Haloperidol Lorazepam Midazolam

52. ACUTE PHASE B egins 48 to 72 hours after the burn injury . In this phase the extracellular fluid start mobilize and start diuresis This phase is completes when wound is covered by skin grafts or the wounds are healed This may take weeks or many months

53. Eschar begins to separate fairly after injury Re epitheliazation begins at wound margin and appears as red/pink scar tissue Hyponatremia /hypernatremia Hypokalemia/hyperkalemia Decreased hematocrit

54. M anagement GOALS Prevention of infection and Wound care Excision and grafting Pain management Nutritional therapy Physical, psychosocial and occupational therapy

55. Prevention of infection and Wound care Burn wounds are frequently monitored for bacterial colonization Wound swab cultures and invasive biopsies Cleanse and debride the area of necrotic tissue that would promote bacterial growth

56. Debridement of the wound May be completed at the bedside or as a surgical procedure. Types of Debridement: Natural Body & bacterial enzymes dissolve eschar ; takes a long time Mechanical Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents Surgical

57. Wound/Skin Grafting If wounds are deep (full-thickness) or extensive, spontaneous re-epithelialization is not possible. Therefore, coverage of the burn wound is necessary by using patients own skin or other methods .

58. TYPES Permanent Skin Grafts Autografts Cultured Epithelial Autografts ( CEA )

59. Types TEMPORARY Biosynthetic- Homograft / allograft (cadaveric) heterograft/ Xenograft (porcine ) Artificial Skins (collagen based ) Trancyte / Integra Synthetic Biobrane / Opsite

60. Permanent skin graft Autograft Harvested from pt Non-antigenic Less expensive Decreased risk of infection Can utilize meshing to cover large area Disadvantage : lack of sites and painful

61. Permanent skin graft Cultured Epithelial Autografts (CEA) A small piece of pt’s skin is harvested and grown in a culture medium (PDGF impregnated) Takes 3 weeks to grow enough for the first graft Very fragile; immobile for 10 days post grafting Useful for limited donor sites Disadvantage : very expensive; poor long term cosmetic results and skin remains fragile for years

62. Temporary Skin Grafts Biosynthetic Homograft/Allograft Live or cadaver human donors Fairly expensive/ all the function of skin Best infection control of all biologic coverings Disadvantage : Disease transmission (HBV & HIV) Antigenic: body rejects in 2 weeks Not always available Storage problems

63. Temporary Skin Grafts BIOSYNTHETIC -Heterograft Xenograft Graft between 2 different species Porcine most common Fresh, frozen or freeze-dried (longer shelf life) Amenable to meshing & antimicrobial impregnation Antigenic: body rejects in 3-4 days Fairly inexpensive Disadvantage : Higher risk of infection

64. Temporary skin graft Artificial Skins Transcyte : A collagen based dressing impregnated with newborn fibroblasts. Integra : A collagen based product that helps to form a “ neodermis ” no anti-microbial property Synthetic Any non-biologic dressing that will help prevent fluid & heat loss Biobrane , Xeroform , OpSite or Beta Glucan collagen matrix

65. Nutritional therapy High-protein & high-calorie diet Often requiring various supplements Routes: ORAL (BEST) Enteral Gut is the preferred alternative route G-tube or J-tube (Head injury/ surgery/ unconscious) Parenteral TPN and PPN Associated with an increased risk of infections

66. Physical and psychosocial care Active and passive ROM excercises should be performed all joints Support and counselling Adjust with disabilities

67. Rehabilitation phase It starts when the patients burn wounds are healed and patient is able to resume a level of selfcare activity This occur from weeks to months GOALS resuming a functional role in society and to accomplish functional and cosmetic reconstructive surgery

68. New skin starts to appear which is flat and pink Mature healing is reached in 6 months to 2 years Scarring can happen discolouration contour - skin is no longer flat or slightly elevate but become elevated and enlarged above original burned area Apply water moisturisers and emolients to prevent dryness and itching Protect from direct sunlight for 6 to 9 months

69. C omplications EMERGENT PHASE CVS - dysrhythmias and hypovolemic shock Resp - upper RT injury, pulmonary edema, ARDS, pneumonia urinary - Acute Tubular necrosis, ARF ACUTE PHASE infection – sepsis, septicemia ( pseudomonas) G.I- Paralytic ileus, curlings ulcer REHABILITATION PHASE Contracture- abnormal condition of a joint characterised by flexion and fixation

70. Curling's ulcer     Curling ulcer  is an acute gastric erosion resulting as a complication from severe burns when reduced  plasma  volume leads to ischemia and cell necrosis (sloughing) of the  gastric mucosa . 

71. Nursing management ASSESSMENT

72. 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 the burn wound Hypothermia related to loss of skin microcirculation and open wounds Pain related to tissue and nerve injury and emotional impact of injury Anxiety related to fear and the emotional impact of burn injury

73. Fluid volume excess related to resumption of capillary integrity and fluid shift from interstitial to intravascular compartment Risk for infection related to loss of skin barrier and impaired immune response Altered nutrition, less than body requirements, related to hypermetabolism and wound healing Impaired skin integrity related to open burn wounds Impaired physical mobility related to burn wound edema, pain, and joint contractures Ineffective individual coping related to fear and anxiety, grieving, and forced dependence on health care providers