Burn Care in Developing Countries

1. Burn Care in Developing Countries Connie Jarlsberg, RN, MSN WorldVenture/Nurses Christian Fellowship Global Health Missions Conference November 2012

2. Burn Prevention • 50% of all burn accidents could be prevented • Most burns happen in an instant of carelessness • Most burn patients are victims of their own actions

3. “It’s a matter of degrees” If its HOT enough for CHAI, It’s HOT enough to BURN!

4. If your clothes catch on fire: STOP DROP ROLL

5. Communicating Prevention • Urban vs Rural Areas • Mothers/Children (big sisters) • Local Languages • Literacy • Raising the national awareness

6. Functions of the Skin Protection from infection Conservation of body fluids Temperature regulation Excretion Secretion Vitamin D production Sensation Appearance

7. Anatomy of the Skin

8. Determination of Burn Severity Extent Depth Age of the patient Past medical history Part of the body burned

9. Out Patient Care • Burns < 20% TBSA not involving the face or hands • Children over 5 years old • Adults based on assessment of their age • significant medical history Assess the patient and or family’s ability to care for the wound at home OR their ability to come for dressing changes.

10. Out Patient Care Goal: • Close the wound as soon as possible—within 3 • weeks • Decrease scar and contracture formation • Maintain function of involved joints

11. DETERMINATION OF SIZE OF BURN RULE OF NINES Head: 9% Anterior: 18% Posterior: 18% Arms: 9% each Legs: 18% each Perineum: 1%___ Total 100%

12. Calculation of Percent with age considerationBerkow Method

13. DEPTH OF BURN Superficial Partial Thickness (1st degree) Skin is red only epidermis perhaps part of the dermis is injured Usual causes: sunburn, hot liquid Should heal spontaneously within 3 weeks Deep Partial Thickness (2nd degree) Skin is red, “weepy” some blister formation Usual causes, hot thick liquids (porridge vs water)

14. Depth of Burn Con’t • Full Thickness (3rd and 4th degree) Skin appears “leathery” dry, brown, hardened all epidermis and dermis is destroyed may have destruction of sub-dermal layers, subcutaneous tissue and muscle as well. Wound will not heal, needs skin grafting often results in significant scarring even with excellent wound care.

17. Admission 15 days post burn

18. Past Medical History and History of the Burn • Does the Patient • Have a serious medical condition? • Have symptoms of an unknown disease? • Take medications? • Have allergies to food or medication? • How did the burn occur? • Source? Hot liquid, Flame? Caustic substance? • Inside or Outside? • Was there smoke? Was it inhaled?

19. Phases of Burn Care Emergent Phase: The time required to resolve immediate problems resulting from the burn injury Acute Phase: From the end of the Emergent Phase until the wound is closed Rehabilitation Phase: The entire program of burn care is focused to this phase. From day one of the injury until the patient returns to a useful place in society

20. Emergent Phase First Aid 1. Maintain airway 2. Assess for concurrent injuries (bleeding does not occur secondary to burn injuries If there is external bleeding look for other causes). NB: Burn patients are always alert and oriented, if not assess for head injury

21. Burns to face and neck especially if in an enclosed space. Edema formation—increased capillary permeability Potential for airway obstruction

22. Fluid Therapy • Large volumes of fluid escape from the burn surface causing hypovolemia in any burn greater than 20% TBSA IV Therapy: An electrolyte balanced solution Ringers Lactate (Hartman’s solution) in quantities enough to maintain adequate BP and urine output 30ml/hr in adults and 0.5ml/kg in children

23. Oral Fluid Replacement Therapy? • Effective resuscitation of small (5-10%)moderate and sometimes severe burn injury. • Where IV fluids may not be available or in situations with mass casualties with inadequate IV fluids. • Drinking or gastric infusion of buffered saline solution. Similar to WHO oral rehydration solution 1 liter of water + 8 tsps. sugar + ½ tsp salt + ½ tsp of sodium bicarbonate (baking soda) Kramer, G.C., Michel, M.W. , et al (2003) Journal of Burns and Wound Care

24. Wound Care Goal: Close the wound as soon as possible Prevent infection both in the wound and systemically Complete grafting if necessary Decrease incidence of scarring and contracture.

25. Wound Care Topical Agents: Silver sulfadiazine Other topical antimicrobials: Mafanide Acetate (TM: Furacin) Saline, Hydrogen Peroxide & Sterile water Betadine/ Iodine Honey and Ghee

26. General Considerations: Emergent Phase Pain management Nutrition therapy Positioning /Splints

27. ACUTE PHASE Avoid, Detect and Treat Complications Wound Care

28. Encourage as much activity as possible

29. Grafting

31. NURSING CARE Emotional support Rest/Comfort Diet Hygiene/Wound care Positioning

32. Sometimes its nice NOT to be the source of pain Be sure pediatric patients have at least one place they feel safe. Try to make that place their bed

33. As wounds heal, pain decreases, happiness makes a comeback.

34. Nutrition and Diet

35. Rehabilitation Phase Return the patient to a productive place in society Accomplish functional and cosmetic reconstruction

36. Reconstructive Surgery

37. Myths and Cultural Care Practices • Rabbit fur (Rwanda) • Powdered—un-reconstituted antibiotics (Uganda) • Sugar • Honey and Ghee (purified animal fat) • Worldview

38. Resources Artz, C.P.,Moncrief, J.A., Pruitt, B.A. (1979) Burns a team approach. Philadelphia, PA: W.B. Saunders. Feller, I., Archambeault-Jones, C. (1978) Teaching basic care. Ann Arbor, MI: National Institute of Burn Medicine Iwuagwu, F. C., Bailie, F. (1998) Oral fluid therapy in paediatric burns (5-10%): an appraisal. Burns 24 pp. 470-474. Jarlsberg, C.R. (1992) Management of Patients with Burn Injury in Brunner and Suddarth’s Textbook of Medical Surgical Nursing 7th ed. Eds. Smeltzer, S.C., Bare, B. G. Philadelphia: Lippincott Jarlsberg, C.R. (2006-2012) Unpublished original material

39. Resources Con’t Kramer, G. C. et al. (2010) Oral and enteral resuscitation of burn shock. The historical record and implications for mass casualty care. Republished from Journal of Burns and Wound Care (2003) 2 (19) (no longer available). (no longer available) Open Access Journal of Plastic Surgery. With thanks to Rein Zeeman and Ineka Storm International Plastic Surgery Society Holland for sharing photographs. And thanks to the patients at Mulago Hospital Kampala Uganda for their courage evidenced daily in facing the difficulty of recovering from burn injuries.