Chapter 20 BURNS

1. Chapter 20 BURNS A burn is a type of injury to flesh caused by heat, electricity, chemicals, light, radiation or friction

2. Electrical : The electrical current, being very powerful both releases heat and directly damages tissue during transit. The determination that a current injury to underlying tissue may be present is the finding of entrance and exit sites. • Chemical burns :need no source of heat, occur immediately on contact, be extremely painful, or not be immediately evident or noticeable diffuse into tissue and damage structures under skin without immediately apparent damage to skin surface • Thermal burns (from fire or flame) cause an injury to the different layers of the skin. The type of burn and the severity of the burn depends on the number of layers of skin affected. Inhalation injury P. 686 Table 20-1 Mechanisms of Burn Injury

3. Superficial (first degree) • Epidermis only or small depth of dermis • Heals in 3 to 5 days without treatment • Erythema • Not calculated for fluid resuscitation • Partial thickness (second degree) • Epidermis and most of dermis • Sub-classification • Superficial partial thickness • Deep partial thickness • Superficial partial thickness • Epidermis and limited portion of the dermis • Heals in 10 to 21 days • Deep partial thickness • Epidermis and most of dermis • Heals within 3 to 6 weeks • Full thickness (third degree) • Destruction of all layers down to or past fat, fascia, muscle, or bone • Thick, dry, leathery appearance • Insensate (no pain) Extent of injury %TBSA RULE OF 9 (P. 689) Burn Classification and Severity

4. Zone of coagulation—This occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins. Zone of stasis—The surrounding zone of stasis is characterized by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burns resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insults—such as prolonged hypotension, infection, or edema—can convert this zone into an area of complete tissue loss. Zone of hyperaemia—In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion. These three zones of a burn are three dimensional, and loss of tissue in the zone of stasis will lead to the wound deepening as well as widening.​widening.

5. Third-space fluid shift, the movement of body fluid to a non-functional space, is a frequently occurring and potentially fatal clinical phenomenon. • As the burn size approaches 15-20% total body surface area (TBSA), shock sets in if the patient does not undergo appropriate fluid resuscitation. Inflammation is a natural response to trauma. In burn victims the inflammation process continues 24 hours after incidence placing patients at risk. Intravascular fluid loss is described as BURN SHOCK Third Spacing/Response to burns

6. Pre-hospital Medical Management 2. Acute phase Onset of diuresis to wound closure 3. Rehabilitative phase Restore to functional status • 1. Resuscitative (emergent) • First 48 hours • ABCs • Includes prehospital time • Fluid management to prevent shock Three Phases of Burn Care

7. Primary Survey/Secondary Survey P. 702 & P. 703

8. (WHAT TO DO IN THE FIRST HOURS AFTER THE INJURY) INITIAL MANAGEMENT SUMMARY • INITIAL MANAGEMENT SUMMARY

9. Respiratory • Cardiovascular • Neurologic • Renal GI • Integumentary • Psychosocial Assessment in Resuscitative Phase

10. Treatment:Maintaining an adequate airway is essential for successful early management. The effect of deep face burns on airway maintenance are: Inspection of the oropharynx looking for soot or evidence of a heat injury should be done with every burn victim. P. 687 clinical alert

11. PULMONARY PROBLEMS P.686 Table20-2

12. PULMONARY PROBLEMS

13. Emergency Department Interventions Fluid Guidelines for Adults 2 to 4 ml/kg per %TBSA burned Administer half of total fluids during first 8 hours from time of injury Administer the other half over the next 16 hours from time of injury Maintain urine output of 30 to 50 ml/hr

14. Facial burns-suspect inhalation injury • Hands and Feet- • Genitalia Special Concerns

15. Surgical Excision and Grafting There are two types of skin grafts. An autologous skin graft transfers skin from one part of the body to another. In contrast, an allograft transfers skin from another person, sometimes even a cadaver.

16. General Principles of Daily Care/Wound care

17. The stress of burns will develop major changes in metabolism. Burn clients need a high calorie high protein diet. Enteral feedings first choice. Nutrition

18. Vulnerable population • Children • Geriatric • Disabled • Mentally impaired ABUSE

19. Pain Control • Infection Control • Wound care • Skin Grafts • Nutritional Support • Psychological considerations • GeriatricConsideration • http://www.burnsurgery.org/Modules/burnnutrition/sec6.htm Areas of focus

20. Some syndromes mimic burn-like injury • Detection and emergency care is absolutely necessary as both of the self-limiting diseases are life-threatening. Nonburn Injury/Toxic Epidermal Necrolysis (TEN)

21. burnsurgery.org