Metropolitan Community College Fall 2013 Jane Miller, RN MSN

1. Metropolitan Community College Fall 2013 Jane Miller, RN MSN

2. Objectives • Identify clinical manifestations of depth of burn injuries: superficial, partial thickness, and full thickness and treatment modalities. • Define importance of assessment skills and gathering of important data in determining treatment in the emergent phase of burns. • Identify burn etiology and significance in treatment • Identify vascular changes resulting from burn injuries including fluid shifts, electrolyte changes, gastrointestinal involvement, cardiac, pulmonary, skin, metabolic changes, and immunologic changes. • Identify prioritization of treatment of burns from emergent phase, acute phase, and rehabilitative phase of burn injury. • Compare and contrast the Browder-Lund chart and Rule of Nines chart in calculating total body surface area(TBSA) in a burn injury. • Apply the Parkland Formula together with the TBSA in establishing correct fluid replacement in the emergent phase • Identify airway management in burn injury

3. Identify compensatory responses to burn injury • Evaluate laboratory profiles during the emergent phase of burn injury. • Identify the role of burn centers. • Identify surgical management of burn injury. • Identify pain management in burn injury and treatments. • Define prevention of infection interventions. • Identify would care management to include debridement, dressings, and types of grafts. • Compare and contrast types of grafts available. • Identify nutrition requirements in burn injury. • Identify nursing interventions for prevention of complications such as patient position, range of motion, ambulation, pressure dressings, and post-op cares utilized to prevent complications of burns. • Identify research in the burn realm that may affect future burn interventions. • Identify current/future therapies in the treatment of burn patients.

4. Burns are… • Traumatic • Painful • Dehumanizing • Embarrassing • Holistic • Disfiguring • Incapacitating • Fatal

5. Burn Statistics • 450,000 people received treatment for burn injuries in 2011 • 55% of the 450,000 injuries were admitted to one of the 125 burn centers in the United States • 70% of burn center admissions were male • The survival rate of those admitted to a burn center was 96% • There were 3,500 fire/burn related deaths Burn Survivor Resource Center, 2013

6. Burns and Children • 85% of fires that injure or kill children occur in a residence • 2/3 of residential fires that result in the death of a child occur in homes without a working smoke detector • Fires kill more than 600 children per year and 47,000 are injured but survive. • Scald and contact burns are the most common cause of burn-related injuries in children 4 years old and under Burn Survivor Resource Center, 2013

7. Burn Etiology • Burn injuries occur when there is direct or indirect contact with a heat source • Electrical wiring, hot liquid, lightning, sun, caustic chemicals, fire • No matter the cause, the burn injury results in loss of skin integrity • Inhaling smoke causes injury to the lung known as an inhalation injury

8. Types of Burns • Thermal • Most often from fire • Extent depends on the length of exposure and temperature of the heat source • Scald • Type of thermal burn caused by hot food or liquid • Extent depends on the length of exposure and temperature of the heat source • Electrical • Tend to be deeper than other burns • Extent depends of amount of voltage, length of exposure, type of current, pathway of flow, and local tissue resistance • Difficult to assess damage

9. Radiation • Result from overexposure to the sun, radiation treatment, industrial accidents • Extent depends on how close the individual was to the source and length of exposure • Chemical • Occur when the skin contacts a caustic agent • Extent depends on length of exposure • Inhalation Injury • Result from inhaled smoke and heated air • The majority of deaths from burn injuries are due to smoke inhalation • Signs include: burns to the face and neck, singed nasal hair, dry cough, bloody/sooty sputum, labored respiration

10. Burn Prevention • Keep matches and lighters out of children’s reach • Set water heater no higher than 120o F • Lock up chemicals • Limit exposure to the sun and wear sunscreen • Have a working smoke detector in the home • Don’t overload electrical circuits • Properly extinguish cigarettes and never smoke in bed • Have an escape plan • Community education

11. Pathophysiology • When damage occurs there are 3 distinct zones of injury • Zone of coagulation • Zone of stasis • Zone hyperemia

12. Pathophysiology • Immediately after the injury third spacing begins • Edema develops in unburned tissue and organs away from the site of injury • This process starts at the time of injury, peaks in 12 to 24 hours, and continues for 49 to 72 hours

13. Vascular Dilation Decreased Blood Volume Decreased Venous Return Decreased Stroke Volume Decreased Cardiac Output Decreased Tissue Perfusion

14. Cardiac • Heart failure • Dysrhythmias and cardiac arrest from the release of potassium • Pulmonary • Pulmonary edema • Gastrointestinal • Decreased motility and nutrient absorption due to shunting of blood • Paralytic ileus • Stress gastritis and ulcerations

15. Renal • Decreased urine output • Renal failure from blocked renal tubules • Immune • Impaired immune function • Increased risk of developing opportunistic infection and death • Integumentary • Fingerprints may be lost • Permanent loss of hair growth, perspiration, and sensory abilities • Impaired temperature control and protection from infection

16. Emergency Phase • Begins with the injury and last 2 to 3 days • Goals • Maintain an airway • Treatment of concurrent injuries • Correcting fluid imbalances • Preventing infection • Conserving body heat • Relieving pain • Emotional support

17. Burn Centers in NE • Acute care • The Nebraska Medical Center • Saint Elizabeth Community Health Center • Rehabilitation • Madonna Rehabilitation Hospital

18. Initial Treatment • Remove the source of injury if possible • ABCDEF • Apply clean saline soaked towels • Copious irrigation of chemical burns • Apply a clean blanket • Do not use oils or salves • Give a tetanus shot

19. ER • Airway assessment and possible intubation • ABGs, CBC, BMP, BUN, BS, Coags • 12-lead ECG • Carotid and peripheral pulses • VS • Place 2 large bore IVs • NG tube • Assess concurrent injuries • Maintain body temperature • Prevent infection • Provide emotional support • Assess the burn

20. Treatment Plan • Based on five factors • Size of the injury • Depth of the injury • Age of the patient • Past medical history • Part of the body burned

21. Rule of Nines • Size is expressed as a percent of the total body surface area • Head and neck = 9% • Each arm = 9% • Each leg = 18% • Trunk = 36% • Perineum = 1% = 100%

23. Lund-Browder Formula • Also assess burn size • Divides the body into smaller percentage areas • Considered more accurate, especially for children

24. Question

25. Burn Depth • Partial thickness • 1st and 2nd degree • Partial destruction of skin layers • Enough epithelial cells, hair follicles, and sweat glands remain to provide a new dermis • Heal spontaneously in 2 weeks to 21 days • Little to no scar or contracture formation • Characterized by: • Pink or white, pain, blanchable, thick walled blisters, firm texture

26. Burn Depth • Full thickness • 3rd degree, involves all skin layers, subcutaneous tissue, muscles, and bone • 4th degree, some say burns that involve muscle and bone are actually 4th degree • Requires grafting • Characterized by: • White or charred black, waxy, not blanchable, charred vessel visible, no pain, no blisters, dry and leather like

27. Age • The very young and the elderly have the highest mortality rates due to burn injuries • Under 2 yrs of age • Immature immune system • High body surface area per body mass. • Elderly • Burns exacerbate previous medical problems • Less physiological reserves

28. Past Medical History • Cardiac • Respiratory • Renal • Endocrine • Substance abuse All decrease the rate of survival

29. Area Burned • Burns to the head, neck, and chest are more serious due to pulmonary complications • Burns in the perineum and upper thigh are more prone to infection • Burns to the hands, face, and neck require special care for both physical and psychological reasons

30. A general rule of prognosis If the age of the patient + the percent of the body burned = more than 100 there is little chance for survival 65 yr old + 50% burned = 115 This patient has little chance of survival

31. Medical Management • Fluid resuscitation • 0.9% NaCl or Lactated Ringers • Once stabilized begin colloids • Parkland formula • 4ml/kg x % TBSA of burn = replacement volume • ½ given in first 8 hours, ¼ in second 8 hours, and ¼ in the third 8 hours Example: 100kg male burned over 25% of his body 4 x 100 x 25 = 10000 ml

32. Fluid Resuscitation Assessment • Monitor • Mental status • Skin color and temperature • Heart rate • Blood pressure • Urine output • Specific gravity • CVP • H & H • GI function

33. Pain Management • Opioids such as morphine, fentanyl, and codeine are given on a non-pain-contingent schedule • Additional narcotics are given before dressing changes • IM needs to be avoided due to poor absorption • Anti-anxiety meds need to be given as well • Start on stool softeners Proper pain management is essential for improved healing

34. Acute Phase • Begins when the patient is hemodynamically stable and ends with wound closure • Goals • Wound cleansing and healing • Pain relief • Maintaining body temperature • Preventing infection • Promoting nutrition • Splinting • ROM

35. Wound Care • Clean the burn with chlorhexidinegluconate and gauze pads to remove dead tissue and debris • Wound debridement removes further loose tissue and eschar • Fasciotomy may need to be performed in order to restore blood flow to a limb • Apply temporary dressing • Xenograft (pigskin) • Allograft (cadaver skin) • Biosynthetic dressings • Synthetic Dressings

36. Skin Grafting • Full thickness skin graft • Entire thickness of skin down to the subcutaneous tissue is excised • Use for areas that need thicker covering to prevent breakdown or improved cosmetic result • Palm of hand, bottom of foot, joints, face • Less common • Split-thickness skin graft • Partial layer of skin is harvested with a dermatome • Is either used as a sheet or meshed • Most common skin graft

38. Maintaining Mobility • Splinting and a ROM exercise plan is essential to maintaining function and motility • Exercise begins on admission and goes until the scars are matured • PT and OT are essential members of the care team

39. Nutrition • Burn patient experience extreme metabolic stress • Their resting energy expenditure can increase by as much as 150% • Oral route is preferred • Enteral and parental nutrition may be required

40. Rehabilitative Phase • Begins when less than 20% of the wound is open • Emphasis is on physical and psychological restorative therapy • Treatments include: • PT/OT • ROM exercises • Increased strength and endurance • Pain management • Nutrition • Cosmetic reconstruction • Psychological care

41. Resources • Osborn, Wraa & Watson chapter 68 • Burn Survivor Resource Center • http://www.burnsurvivor.com/ • Split thickness skin graft video • http://www.youtube.com/watch?v=pvbxmm9inoo