BURN INJURIES Cell destruction of the layers of the skin and the resultant depletion of fluid and electrolytes.

. Burn size 1. Small burns: bodys response is localized to the injured area 2. Large or extensive burns: a. consist of 25% or more of the total body surface area (TBSA) b. bodys response to injury is systemic c. affect all of the major systems of the body Characteristics 1. Minor Burns a. Partial thickness burns are no greater than 15% of the TBSA in the adult b. Full thickness burns are < 2% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no preexisting medical condition at the time of the burn injury g. No other injury occurred with the burn 2. Moderate Burns a. Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult b. Full thickness burns are 2% to 10% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury g. No other complicated injury occurred with the burn 3. Major Burns

a. Partial thickness burns are > 25% of the TBSA in the adult b. Full thickness burns are > 10% of the TBSA c. Burn areas involve the eyes, ears, hands, face, feet, or perineum d. The burn injury was an electrical or inhalation injury e. The client is older than 60 y.o. f. The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury g. Burns are accompanied by other injuries Lund and Browder Method (Rule of Nine) - Modifies percentages for body segments acc. to age - Provides a more accurate estimate of the burn size - Uses a diagram of the body divided into sections, with the representative % of the TBSA for ages throughout the lifespan - Should be reevaluated after initial wound debridement

ASSESSMENT OF BURN INJURY Extent / Assessment of Extent Degree First Pink to red: slight edema, which subsides quickly. Degree Pain may last up to 48 hours. Relieved by cooling. Sunburn is a typical example. Second degree Superficial: Pink or red; blisters form (vesicles); weeping, edematous, elastic. Superficial layers of skin are destroyed; wound moist and painful. Deep dermal: Mottled white and red: edematous reddened areas blanch on pressure. May be yellowish but soft and elastic may or may not be sensitive to touch; sensitive to cold air. Hair does not pull out easily Destruction of epithelial cells epidermis and dermis destroyed Reddened areas do not blanch with pressure. Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar. Destruction of epithelium, fat, muscles, and bone. Reparative Process In about 5 days, epidermis peels, heals spontaneously. Itching and pink skin persist for about a week. No scarring. Heals spont. If it does not become infected w/in 10 days - 2 weeks. Takes several weeks to heal. Scarring may occur. Takes several weeks to heal. Scarring may occur.

Third Degree

Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft. For areas larger than 3-5 cm, grafting is required. Expect scarring and loss of skin function. Area requires debridement, formation of granulation tissue, and grafting.

AGE AND GENERAL HEALTH 1. Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o., and for clients over the age of 60 years. 2. Debilitating disorders, such as cardiac, respiratory, endocrine, and renal d/o, negatively influence the clients response to injury and treatment. 3. Mortality rate is higher when the client has a preexisting disorder at the time of the burn injury 4. TYPES OF BURNS A. Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects B. Chemical Burns: a. Caused by tissue contact with strong alkali, or organic compounds b. Systemic toxicity from cutaneous absorption can occur C. Electrical Burns: a. Caused by heat generated by electrical energy as it passes through the body b. Results in internal tissue damage c. Cutaneous burns cause muscle and soft tissue damage that may be extensive, particularly in high voltage electrical injuries d. Alternating current is more dangerous than direct current because it is associated with CP arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures D. Radiation Burns: caused by exposure to UV light, x-rays, or radioactive source INHALATION INJURIES A. Smoke inhalation injury : results from inhalation of superheated air, steam, toxic fumes, or smoke : Assessment - facial burns - erythema - swelling of oro / nasopharynx singed nasal hair - stridor, wheezing and dyspnea - flaring nostrils - sooty sputum and cough hoarse voice

- agitation and anxiety tachycardia

B. Carbon Monoxide Poisoning : CO is colorless, odorless and tasteless gas that has an affinity for Hgb 200 times greater than that of oxygen : O2 molecules are displaced and carbon monoxide reversibly binds to Hgb to form carboxyhemoglobin : can lead to coma and death C. Smoke Poisoning : Caused by inhalation of by-products of combustion : A localized inflammatory reaction occurs, causing a decrease in bronchial ciliary action and a decrease in surfactant : Assessment - mucosal edema in the airways - wheezing on auscultation - after several hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop - ARDS can result D. Direct Thermal Heat Injury : Can occur to the lower airways by the inhalation of steam or explosive gases or the aspiration of scalding liquids : Can occur to the upper airways, w/c appear erythematous and edematous, with mucosal blisters and ulcerations : Mucosal edema can lead to upper airway obstruction, esp. during the first 24 to 48 hours : Monitored for airway obstruction, ET intubation if obstruction occurs PATHOPHYSIOLOGY OF BURNS BURNS > INCREASED VASCULAR PERMEABILITY > 1 AND 2 1. EDEMA > DECREASED INTRAVASCULAR VOLUME > INCREASED PERIPHERAL RESISTANCE > DECREASED CARDIAC OUTPUT 2. INCREASED HEMATOCRIT > INCREASED VISCOSITY > INCREASED PERIPHERAL RESISTANCE > DECREASED CARDIAC OUTPUT

HEMODYNAMIC / SYSTEMIC CHANGES A. Initially hyponatremia and hyperkalemia occur. Followed by hypokalemia as fluid shifts occur and K+ is not replaced. B. The hematocrit level increases as a result of plasma loss; this initial increase falls to below normal at the 3rd to 4th day postburn as a result of the RBC damage and loss at the time of injury. C. Initially, the body shunts blood from the kidneys, causing oliguria; then the body begins to reabsorb fluid, and diuresis of the excess fluid occurs over the next days to weeks. D. Blood flow to the GIT is diminished, leading to intestinal ileus and GI dysfunction. E. Immune system function is depressed, resulting in immunosuppression and thus increasing the risk of infection and sepsis. F. Pulmonary hypertension can develop, resulting in a decrease in the arterial O2 tension and a decrease in lung compliance. G. Evaporative fluid losses through the burn wound are greater than normal, and the losses continue until complete wound closure occurs H. If the intravascular space is not replenished with IV fluids, hypovolemic shock and ultimately death will occur. BURN INTERVENTIONS MAINTAIN AIRWAY FLUID RESUSCITATION RELIEVE PAIN PREVENT INFECTION PROVIDE NUTRITION PREVENT STRESS ULCERATION PROVIDE PSYCHOLOGIC SUPPORT PREVENT CONTRACTURES

- includes prehospital care and emergency room care Resuscitative phase - begins w/ the initiation of fluids and ends when capillary integrity returns to near normal levels and the large fluid shifts have decreased - the amount of fluid administered is based on the clients weight and extent of injury - most fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital - the goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion 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 - 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 Rehabilitative phase - final phase of burn care - overlaps the acute care phase and goes well beyond hospitalization - goals of this phase are designed so that the client can gain independence and achieve maximal function FLUID SHIFTING IN BURNS OLIGURIC PHASE Intravascular to Interstitial Hct increased, renal output decreased, hyper K, hypo Na, hypo CHON, metabolic acidosis DIURETIC PHASE Interstitial to Intravascular Hct decreased, renal output increased, hypo K, hypo Na, hypo CHON, metabolic acidosis FLUID RESUSCITATION Indications: - Adults with burns involving more than 15% - 20% TBSA

MANAGEMENT OF THE BURN INJURY Phases of Management of the Burn Injury Emergent phase - begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours after the injury - the 1 goal is to prevent hypovolemic shock and preserve vital organ functioning

- Children with burns involving more than 10-15% TBSA - Patients with electrical injury, the elderly, or those with cardiac or pulmonary disease and compromised response to burn injury The amount of fluid administered depends on how much intravenous fluid per hour is required to maintain a urinary output of 30 - 50 ml/hr Successful fluid resuscitation is evidenced by: - Stable vital signs - Palpable peripheral pulse

- Adequate urine output sensorium

- Clear

Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion If the Hgb and Hct levels decrease or if the urinary output exceeds 50ml/hr, the rate of IV fluid administration may be decreased Generally, a crystalloid (Ringers lactate) solution is used initially. Colloid is used during the 2nd day (5% albumin, plasmate or hetastarch)

Brooke and Parkland (Baxter) Fluid Resuscitation Formulas for 1st 24hrs after a Burn Injury Formula BROOKE 2ml/kg/% BSA + 2000ml/24hr (maintenance) PARKLAND (Baxter) 4ml/kg/% BSA for 24hr period Solution crystalloid, colloid D5W maintenance crystalloid only (lactated Ringers) Infusion Rate in 1st 8 hours in next 16 hours in 1st 8 hours in next 16 hours

PARKLAND FORMULA Example: Patients weight: 70 kg; % TBSA burn: 80% 1st 24 hours: 4ml x 70kg x 80% TBSA = 22,400ml of lactated Ringers 1st 8 hours = 11,200 ml or 1,400 ml/hour 2nd 16 hours = 11,200 ml or 700 ml/hour 2nd 24 hours: 0.5ml colloid x weight in kg x TBSA + 2000ml D5W run concurrently over the 24 hour period 0.5ml x 70kg x 80% = 2800 ml colloid + 2000 ml D5W = 117 ml colloid/hour + 84 ml D5W/hour ANOTHER EXAMPLE: BROOKE: Wt: 15 kg TBSA: 12 % 2 ml x 15kg X 12 = 360 + 2000ml = 2,360ml 2,360 X 0.75 (OR ) = 1,770ml (CRYSTALLOID)

2,360 X 0.25 (OR ) = 590ml (COLLOID) > Colloid is an albumin given to replace loss of protein from the intravascular space. 1,770 / 2 (divided by 2, because first half will be given for the first 8 hours and the other half for the next 16 hours) = 885ml 885 / 8 X 60/60 (or 1) (60, because it is for pedia) = 110.625 mcgtts/min 885 / 16 X 1 = 55.3125 mcgtts/min PARKLAND: Wt: 15kg TBSA: 12 % 4 ML X 15KG X 12 = 720ml 720ml /2 = 360ml 360 / 8 x 60/60 (or 1) = 45 mcgtts/min 360 / 16 x 1 = 22.5 mcgtts/min Nutrition may be provided via enteral tube feeding, peripheral parenteral nutrition, or total parenteral nutrition Provide a diet high in protein, carbohydrates, fats and vitamins ESCHAROTOMY A lengthwise incision is made through the burn eschar to relieve constriction and pressure and to improve circulation Performed for circulatory compromise resulting from circumferential burns After escharotomy, assess pulses, color, movement, and sensation of affected extremity and control any bleeding with pressure Pack incision gently with fine mesh gauze for 24 hours after escharotomy, as prescribed Apply topical antimicrobial agents as prescribed FASCIOTOMY An incision is made, extending through the SQ tissue and fascia Performed if adequate tissue perfusion does not return after an escharotomy Performed in OR under GA, after procedure assess same as above WOUND CARE 1. The cleansing, debridement and dressing of the burn wounds

PAIN MANAGEMENT Administer morphine sulfate or meperidine (Demerol), as prescribed, by the IV route Avoid IM or SC routes because absorption through the soft tissue is unreliable when hypovolemia and large fluid shifts are occurring Avoid administering medication by the oral route, because of the possibility of GI dysfunction Medicate the client prior to painful procedures NUTRITION Essential to promote wound healing and prevent infection Maintain nothing by mouth (NPO) status until the bowel sounds are heard; then advance to clear liquids as prescribed

2. Hydrotherapy a. Wounds are cleansed by immersion, showering or spraying b. Occurs for 30 minutes or less, to prevent increased sodium loss through the burn wound, heat loss, pain and stress c. Client should be premedicated prior to the procedure d. Not used for hemodynamically unstable or those with new skin grafts 3. Debridement a. Removal of eschar to prevent bacterial proliferation under the eschar and to promote wound healing b. May be mechanical, enzymatic or surgical c. Deep partial- or full-thickness burns: Wound is cleansed and debrided and topical antimicrobial agents are applied once or twice daily

Open Method Versus Closed Method of Wound Care

Method OPEN Antimicrobial cream applied, and wound is left open to the air w/o a dressing Antimicrobial cream is applied every 12 hrs

Advantages Visualization of the wound Easier mobility and joint ROM Simplicity in wound care

Disadvantages Increase chance of hypothermia from exposure

CLOSED Gauze dressings are carefully wrapped from the distal to the proximal area of the extremity to ensure circulation is not compromised No 2 burn surfaces should be allowed to touch; can promote webbing of digits, contractures, and poor cosmetic outcome Dressings are changed every 8 12 hours

Decreases evaporative fluid and heat loss Aids in debridement

Mobility limitations Prevents effective ROM exercises Wound assessment is limited

TOPICAL ANTIMICROBIAL AGENTS FOR BURNS Silver sulfadiazine Most widely used agent and least common incidence of side effects May cause transient leukopenia that disappears 2-3 days of treatment Use with either open treatment, light or occlusive dressings Applied once or twice daily after thorough wound cleansing Mafenide acetate 10% cream or 5% solution (Sulfamylon) Painful during and for a while after application May cause metabolic acidosis, not used if >20% TBSA Cream must be reapplied 12 hours to maintain therapeutic effectiveness Solution concentration is maintained with bulky wet dressings, rewet every 2-4 hours Silver nitrate (0.5% solution) Stains everything including normal skin brown or black Monitor electrolyte balance carefully Other topical dressings Cerium nitrate Povidone iodine Gentamycin Polymixin B Bacitracin ointment WOUND CLOSURE Prevents infection and loss of fluid Promotes healing Prevents contractures Performed on the 5th to 21st day, depending on the extent of the burn AUTOGRAFTING Permanent wound coverage Surgical removal of a thin layer of the clients own unburned skin, which is then applied to the excised burn wound Monitor for bleeding following the graft because bleeding beneath an autograft can prevent adherence Immobilized after the surgery for 3-7 days to allow time to adhere and attach to the wound bed Care of the graft site

Care of the donor site TEMPORARY WOUND COVERINGS Biological Amnion Amniotic membranes from human placenta Dressing is changed every 48 hours Allograft (Homograft) Donated human cadaver skin is harvested w/in 24 hrs after death Monitor for wound exudate and signs of infection Rejection can occur w/in 24 hours Xenograft (Heterograft) Porcine skin is harvested after slaughter and preserved Rejection can occur w/in 24 72 hours Replaced every 2-5 days until the wound heals naturally or until closure with autograft is complete Biosynthetic and synthetic Visual inspection of wound is possible, as dressings are transparent or translucent Monitor for wound exudate and signs of infection