Burns

Burns don't affect the skin uniformly,

so a single injury can reach varying
depths. Distinguishing a minor burn
from a more serious burn involves
determining the degree of damage to
the tissues of the body. The following
are four classifications of burns:
First-degree burn. This minor
burn affects only the outer
layer of the skin (epidermis). It
causes redness and pain and
usually resolves with first-aid
measures within several days
to a week. Sunburn is a
classic example.

Second-degree burn. These
burns affect both the
epidermis and the second
layer of skin (dermis), causing
redness, pain and swelling. A
second-degree burn often
looks wet or moist. Blisters
may develop and pain can be
severe. Deep second-degree
burns can cause scarring.

Third-degree burn. Burns that
reach into the fat layer
beneath the dermis are called
third-degree burns. The skin
may appear stiff, waxy white,
leathery or tan. Third-degree
burns can destroy nerves,
causing numbness.

Fourth-degree burn. The most
severe form of burn affects
structures well beyond the
skin, such as muscle and
bones. The skin may appear
blackened or charred. If nerve
damage is substantial, you
may feel no pain at all.


Other clinical features:
Blisters
Pain (the degree of pain is not
related to the severity of the
burn -- the most serious burns
can be painless)
Peeling skin
Red skin
Shock (watch for pale and
clammy skin, weakness,
bluish lips and fingernails, and
a drop in alertness)
Swelling
White or charred skin
Symptoms of an airways burn:
Charred mouth; burned lips
Burns on the head, face, or
neck
Wheezing
Change in voice
Difficulty breathing; coughing
Singed nose hairs or
eyebrows
Dark, carbon-stained mucus

Diagnostic tests:
Biopsy
o refers to removing and
studying sample tissue.
In the case of burn
patients, biopsy is a
diagnostic test that is
useful because it
examines the extent of
collagen damage to the
skin, vascular damage
to the tissue, and
damage to cell proteins
in the skin.





Thermography
o Other tests used for
burn victims are less
familiar than a standard
biopsy. Thermography
is the term for studies
of burn temperature.
When attempting to
determine the exact
depth of a burn wound,
doctors can use
thermography as a
diagnostic tool because
deeper wounds are
cooler than more
superficial wounds.
There is reduced
vascular perfusion, or
blood circulation, to the
deeper wounds,
leading to a lower
temperature.

Video Angiography
o Another diagnostic test
for burn evaluation is a
process known as laser
fluorescence
videography. This
sophisticated technique
measures changes in
the perfusion of tissues
by injecting a
substance called
indiocyanine green
intravenously.
Damaged tissues have
poor circulation, which
is visualized by the
videography.






Managements:

> Thermal burns

Nursing Management:
Cool the burn area with towels
moistened with cool sterile
saline.
Avoid immersion in ice baths.
Burns of areas such as the
face are best treated by
means of an open technique.
Wash the burn area, debride
any open blisters, and cover
the wounds with topical
antibiotics.
Fingers and toes should be
wrapped individually, with
fluffed gauze separating the
digits in order to prevent
maceration and adherence.
Cover all partial-thickness
wounds with antibiotic
ointment.
Cleanse other areas with
minor burns with the use of a
mild soap and gentle
scrubbing.

Medical Management:
Silver sulfadiazine - is
commonly. Steroids have no
role in treating burn wounds.
Administer tetanus
immunization (Td) as
appropriate


> Chemical Burns

Nursing Management:
Complete removal of the
offending agent. Thorough
decontamination is key.
Adequate irrigation is difficult
to define and depends on the
amount of exposure and the
agent involved. Using litmus
paper to measure the pH of
the affected area or the
irrigating solution is helpful.
Complete removal and
neutralization of concentrated
acids and alkalis may require
several hours of irrigation.
Tap water is adequate for
irrigation.
Low-pressure irrigation is
desired; high pressures may
exacerbate the tissue injury.

**Special situations

Elemental metals: The
elemental forms of lithium,
potassium, sodium, and
magnesium react with water.
If these metals are thought to
be on the skin of a patient, do
not irrigate with water. Cover
the area with mineral oil. The
metallic pieces should be
removed manually with
forceps and placed in a
container of mineral oil.

White phosphorus: Keep the
area immersed in water and
manually remove any
phosphorus particles seen.
Visualization under a Wood's
lamp may aid in detection and
removal of retained
phosphorus particles.


Ocular exposures: The goal
for decontamination should be
to achieve a pH (of the eye
wash) of at least 7.3,
preferably 7.4. If the pH
remains below this, check the
pH of the irrigating solution.
The pH should be rechecked
30 minutes after irrigation has
been completed. If pH paper
is not available, an adequate
guideline is decontamination
with 2 L of irrigation fluid over
30-60 minutes. A Morgan lens
is recommended for irrigation.
Use a topical anesthetic prior
to use.

Caustic ingestions: Gastric
emptying is contraindicated.
Activated charcoal is not
useful and may interfere with
subsequent endoscopy.
Dilution with milk or water is
contraindicated if any degree
of airway compromise is
present. Milk may interfere
with subsequent endoscopy.
Water is benign. Some
substances, such as drain
cleaners containing sulfuric
acid or sodium hydroxide,
generate heat when diluted
with water. Local areas of
heat generation can be
minimized by diluting with a
moderate quantity of fluid
(250-500 mL). Do not attempt
to neutralize the caustic
agent. Neutralizing the caustic
agent may generate
excessive heat from the
exothermic reaction of
neutralization.

Medical Management:
Topical antibiotic therapy is
usually recommended for
dermal and ocular burns.
Calcium or magnesium salts
are used for hydrofluoric acid
burns.
Pain medications are
important for subsequent burn
care.
Polyethylene glycol 300 or
400 and isopropyl alcohol
have been recommended for
the removal of phenols and
cresols. If skin damage has
already occurred, isopropyl
alcohol may be very irritating.
Polyethylene glycol should be
diluted with water to form a
50:50 ratio prior to using. One
study showed polyethylene
glycol no more efficacious
than copious water irrigation
for phenol exposures.

> Electrical Burns

Patients with electrical injury
should be initially evaluated
as a trauma patient.
Airway, breathing, circulation,
and inline immobilization of
the spine should be performed
as a part of primary survey.
Maintain a high index of
suspicion and evaluate for
hidden injuries.
Intravenous access, cardiac
monitoring, and measurement
of oxygen saturation should
be started during the primary
survey.
Fluid replacement is the most
important aspect of the initial
resuscitation. As with
conventional thermal injury,
electrical injuries cause
massive fluid shifts with
extensive tissue damage and
acidosis; therefore, monitoring
a patient's hemodynamics is
important.
A Foley catheter is helpful in
monitoring urine output and,
therefore, tissue perfusion.



Medical Management:
Initial fluid resuscitation
should aim for urine output of
greater than 0.5 cc/kg/h if no
signs of myoglobinuria are
present and preferably greater
than 1 cc/kg/h if myoglobinuria
is present.
Based on the Parkland
formula, increase fluid
replacement by 2-3 times,
depending on the total surface
area potentially involved. For
example, increase it by 3 if the
surface area is 20% and
increase it by 2 (or less)
according to an increased
percentage of burned skin.
These formulas estimate
necessary initial resuscitation
volume over the first 24 hours
(started at the time of the
burn).
Use an isotonic balanced
saline solution (eg, Ringer's
lactate solution) for fluid
resuscitation. Closely follow
urinary output as an indicator
of hemodynamic status and
kidney function. Make
constant adjustments based
on hourly urine output.
Decrease or increase fluid
rates to maintain urine output
of 0.5-1 cc/kg/h.
Installing an indwelling urinary
catheter is mandatory.
Hematuria or dark urine
prompts the need for more
aggressive therapy to prevent
myoglobin-induced tubular
necrosis. This is treated with
fluids (initiating diuresis) and
bicarbonate.
Administer bicarbonate at 1-2
mEq/kg. With very extensive
injuries, expect acidosis and
myoglobinuria, and initiate
bicarbonate with the initial
fluid bolus.
Administer mannitol at 1 gram
per kilogram body weight to
promote an osmotic diuresis.
The target urine output is up
to 2-3 mL/kg/h, with a urine
pH greater than 6.5.
Bicarbonate treats the
underlying acidosis and
alkalinizes the urine, making
myoglobin more soluble.
Additional diuretics may be
administered. Acetazolamide
is the recognized drug of
choice because it also
alkalinizes the urine.
However, exercise this
diuresis with extreme caution
to avoid hyperosmotic
hypoalbuminemia.