BURNS *injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation *highest fatality rate

in children 4 and under and adults over age of 55- incidence has decreased *Prevention- individual changes but also legislative efforts such as stricter building codes, smoke detectors/alarms, nonflammable childrens clothing Types of burns- Table 25-1 and Table 25-2 pg. 473 o o Thermal- most common type caused by flame, flash, scald, or contact with hot objects Chemical burns- result from tissue injury and destruction from acids, alkalis, and organic compounds Household cleaners Alkali burns more difficult to manage because not easily neutralized more damage actually results when neutralized oven and drain cleaners, fertilizers. Eyes may be damaged if splashed Resp. problems, liver and kidney damage Important to remove person from burning agent and begin to quickly remove the chemical from skin if dry, brush it off flush with copious amounts of water 20 min to 2 hours postexposure remove clothing may see tissue damage up to 72 hours afterward o Smoke and inhalation injury Inhalation of hot air or noxious chemicals cause damage to tissues of resp. tract. May see redness and airway swelling Major predictor of mortality in burn patients Three types o Carbon monoxide poisoning- CO poisoning and asphyxiation account for majority of deaths at a fire scene. Binds to hemoglobin and displaces oxygen hypoxia, carboxyhemoglobinemiatreat with humidified 100% Oxygen cherry red skin.. may see no burn wounds

Inhalation injury above the glottis- thermally produced (air cools as it enters resp. tract)- inhalation of hot air, steam, or smoke mucosal burns of oropharynx and larynx (redness, blistering, edema) look for facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and clothing burns around chest/neck

Inhalation injury below glottis- duration of exposure to smoke/toxic fumes pulmonary edema 12-24 hours after burn may develop ARDS

Electrical Burns Result of intense heat generated from an electrical current. Can cause direct damage to nerves and vessels Severity depends on amount of voltage, tissue resistance, current pathways, surface area in contact with the current, and length of time current flow as sustained. Fat and bone are most resistant nerves/blood vessels least resistant If current passes through vital organs, fatality is more common May have combo if electrical sparks ignite patients clothing Transfer to burn unit most of damage is below skin (iceburg effect) Consider patient at risk for spinal cord injury (falls) cervical spine immobilization Dysrhythmias, cardiac arrest, severe metabolic acidosis, myoglobinuria (acute renal tubular necrosis- ARTN) CPR may need to be initiated immediately ABGS- sodium bicarbonate Massive muscle damage- myoglobin released.. causes kidney damage LR to keep urine output at 75-100 ml/hr until flushed mannitol

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Cold thermal injury- see frostbite notes Severity is determined by depth of burn, extent of burn calculated in total body surface area, location of burn, and patient risk factors Table 25-3- Burn Unit Referral Criteria Partial thickness .>10 TBSA

Classification of Burn injury

Face, hands, feet, genitalia, perineum, major joints 3rd degree Electrical burns Chemical burns Inhalation injury Burn injury in patient with pre-existing conditions that could cause complications Burns and concomitant trauma Special emotional, long-term rehab needs Partial-thickness Superficial (1st degree)- erythema, blanching on pressure, pain, mild swelling, no vesicles or blisters sunburn, heat flash tactile and pain sensation intact Deep (2nd degree)- fluid-filled vesicles that are red shiny, wet (if ruptured); severe pain caused by nerve injury, mild to moderate edema- can be caused by flame, flash, scald, contact burns, chemical, tar- involves epidermal and dermal

Depth of burn- Table 25-4 pg. 475

Full-thickness- 3rd and 4th degree- dry, waxy, white, leathery or hard skin; visible thrombosed vessels, insensitivity to pain because of nerve destruction, possible involvement of muscles, tendons, and bones. Caused by flame, scald, chemical, tar, or electrical current.. all local nerve endings destroyed surgical intervention required for healing- not enough skin cells to regenerate new skin

Extent of burn- Figure 25-4 pg. 476 Total body surface area (TBSA) Lund-Browder chart- more accurate because patients age in proportion to patients relative body area size Rule of Nines- easy to remember.. adequate for adult Palmar surface of hand- 1% of TBSA appx. May be revised once edema is resolved Sage Burn Diagram- computerized burn estimation tool helps calculate fluid resuscitation Location of Burn Burns to face and neck and circumferential burns to the chest/back may inhibit resp. function

Burns of hands, feet, joints, and eyes- make self-care more difficult challenging to manage because of superficial vascular and nerve supply systems

Ears and nose- susceptible to infection (poor blood supply); buttocks or genitalia (infection because of location) May develop compartment syndrome Older adult- slower healing Pre-existing cardiovascular, resp., or renal disease, DM or vascular disease General physical debilitation from chronic disease Concurrently staged fractures, head injury, or other trauma

Patient Risk Factors

Phases of Burn Management- overlap in care may be seen. Rehab begins on first day after burn has occurred Prehospital care Remove patient from source of burn and stopping the burning process Electrical- trained individual Chemical- brush then lavage (hazardous material sheets) Small thermal- burns may be covered with clean, cool tap water-dampened towels for comfort cooling helps minimize injury if small burn If large- ABCs- make sure airway is patent; assess for signs of injury to airway; adequacy of ventilation; check pulses and elevate burned limb above heart If large, dont immerse in cool water, remove all clothing a possible but if adhering, leave alone. Wrap patient in clean, dry sheet or blanket Assess for other injuries. Review emergency management on page 477, 478,479 o ABCS- 2 large bore needles and fluid resuscitation catheter may need to be tubed (esp. if facial burns), pain management, remove clothes, jewelry,etc. Chemical- irrigate; call poison control center Inhalant- may need fiberoptic bronchoscopy or intubation

Electrical- removal from source should be performed by trained individual; Thermal burns Electrical- leathery, white, charred skin burnt odor dysrhythmias Thermal burns- review symptoms of different depth of burn symptoms Chemical- redness and swelling, paraylysis Inhalation injury- Smokey breath, coughing, productive cough with black sputum, hoarseness, rapid resp.

Signs/symptoms may vary

Emergent Phase- resuscitative phase- period of time required to resolve the immediate, life-threatening problems resulting from the burn injury May last from time of burn to 3 or more days usually 24-48 hours Hypovolemic shock and edema formation is biggest concern ends WITH FLUID MOBILIZATION AND DIURESIS Pathophysiology o Fluid and Electrolyte Shifts Massive amount of fluids out of blood vessels lose water, sodium, and albumin into third space edema in nonburned areas and blisters. Intravascular volume is depleted- decreased BP, increased HR, other manifestations of hypovolemic shock- may see irreversible shock and death Also see losses of insensible loss by evaporation. Normal is 30-50 may increase greatly in the burn patient RBCs hemolyzed- elevated hemocrit then will see lowered from dilution because of fluid replacement o Inflammation and Healing- increased neutrophils and monocytes wound repair begins within 6-12 hours

Immunologic changes- widespread impairment of the immune system Bone marrow depression Defects in WBCs

Clinical manifestations- shock (pain and hypolvemia), deeper burns may be anesthesized (nerve endings), blisters may be seen edema so DHN may not be suspected at first. Paralytic ileus, absent or decreased bowel sounds, shivering. If change in MS, suspect hypoxia from smoke inhalation

Complications o Cardiovascular system- dysrhthmias and hypovolemic shock impaired circulation May need an escharotomy (a scalpel incision through the full-thickness eschar) to restore circulation o Sludging- increase in blood viscosity damage to small capillary system Respiratory system Upper respiratory tract injury- results from direct heat injury or edema formation Mechanical airway obstruction and asphyxia o o Edema-compressing airway Eschar- becomes tight and constricting Inhalation injury- direct insult of alveolar level secondary to the inhalation of chemical fumes or smoke May take up to 24 hours to see injury Fiberoptic bronch for diagnosis Assess for signs of resp. distressincreased agitation or change in rate/character of respirations Carbon containing sputum ABG values

Other resp. problems- those with preexisting resp. problems- develop resp. infection or pneumonia may develop pulmonary edema because of increased fluids

Urinary system- acute tubular necrosis(ATN)decreased blood flow from hypovolemia (renal ischemia and acute renal failure) myoglobin and hemoglobin occlude renal tubules. Fluid replacement and diuretics

Nursing and Collaborative Care for Emergent Phase- Table 2510 pg. 482 o o o Rapid and thorough assessment Must decide if needs transfer to burn center Airway management Early ET intubation- those who have face and neck burns within 1-2 hours Vent ABG Extubate when edema resolves- usually 3-6 days after injury Escharotomise of chest Fiberoptic bronch 6-12 hours after injury if smoke inhalation If not intubated, oxygen , high Fowlers position unless spinal injury, TCDB every our, chest PT, repositioning, suction, bronchodilators o Fluid therapy One or two large-bore IVs- burns greater than 30% TBSA- central line and art line Assess using Figure 25-4 pg. 476 (LundBrowder or rule of 9s) Type is determined by size and depth of burn, age of the patient, and individual considerations (DHN, previous medical conditions) May be LR or NS may need albumin Brooke Formula- LR 2.0 ml/kg/%TBSA

Give first 8 hours and then next 16 hours

Parkland Formula 4 ml/kg/%TBSA o o o first 8 hours, then given each next 8 hour For example (Table 25-12 pg. 483) 70 kg patient with 50% TBSA burn 4mlx70kgx50%= 14,000 ml 14 L in 24 hours- 7000 ml (875 ml/hr) 3500 ml (436 ml/hr) 2nd 8 hour and 3rd 8 hour

Colloidal solutions- Albumin- after 1st 1224 hours Assessment of adequacy of fluid replacement- urine output- 30-50 ml/hr in adult or 75-100 ml/hr for electrical burn patient (hemoglobinuria/myoglobinuria)

o Wound care

Monitor BP and HR

Delay until patent airway, adequate circulation, and adequate fluid replacement Cleansing and gentle debridement using scissors and forcpes hydrotherapy tub May need surgical debridement in OR Escharatomies or fasciotomies Initial wound care physically and psychologically demanding May have electrolyte imbalances from being immersed in tub with open burned areas chilling and cross-contamination of wounds many use a cart shower instead

Tap water is used may use a cleansing agent. Some new antimicrobial dressings can be left in place up to 3 days

Infection is huge risk Open method- burn covered with topical antimicrobial- no dressing Multiple dressing- sterile gauze are used with a topical antimicrobial- changed every 12-24 hours to once every 3 days (depending on agent). Moist would healing

If exposed- infection control includes gowns, gloves, masks, hats nonsterile gloves for removing but sterile for applying ointments and inner dressings.

Keep room warm. Careful handwashing and alcohol hand rinse. Thoroughly disinfect equipment.

Temporary wound closure method may be used (See Table 25-13 pg. 484)

Positioning and splinting Extend and elevate hands and arms with pillows or in slings Splints to help them maintain functional position Facial care- open method antibiotic ointments for eye burns or edema opt homology exam. May need artificial tears Keep ears free of pressure- ear burns no pillows; rolled towel Keep perineum dry and clean- F/C Routine lab tests- fluid and lytes Physical Therapy- early ROM Analgesics- IV pain meds- See Table 25-14 pg. 485 Morphine drug of choice. may build up tolerance Sedatives Individualize plan

Other Care Measures

Drug Therapy

Tetanus- given routinely to all patients

Antimicrobial agents- pg. 486- topical agents are applied Silvadene and Sulfamylon Silverimpregnated dressings can be left on up to 3 days Systemic antibiotics are initiated when clinical diagnosis of invasive burn wound sepsis is made, or when some other source of sepsis is identified Fungal in mucous membranes following antibiotics yeast Nystatin yogurt given by mouth once patient starts to eat

Nutritional therapy Fluid over nutrition in emergent phase Early and aggressive nutritional support is important if nonintubated with less than 20% TBSA burns, can meet nutritional needs orally Intubated patients- early enteral feeding check gastric residuals to monitor for paralytic ileus and delayed gastric emptying Hypermetabolic state- resting metabolic expenditure may be increased by 50-100% depending on size of burn wound- elevated temp, catecholmaines, protein breakdown need calorie-containing nutritional supplements, protein powder, and supplemental vitamins

Acute phase- begins with the immobilization of extracellular fluid and subsequent dieresis and concluded when burn area is completely covered by skin grafts or healed weeks or months Patho o o o o Dieresis- decreased edema Bowel sounds return Some healing begins and necrotic tissue starts to slough Partial-thickness heals from edges and dermal bed below Clinical manifestations

Partial thickness- form eschar re-epitheliazation occurs after eschar is removed.. red or pink scar tissue. Usually heal in 10-14 days

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Full-thickness require grafts and surgical debridement Hyponatremia- hydrotherapy (sodium exits from open wound) monitor for signs such as weakness, dizziness, muscle cramps, fatigue, headache, tachycardia, confusion

Lab Values

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May see water intoxication- dilutional hyponatremiadrink fluids other than water Hypernatremia from successful fluid replacement monitor for thirst, dried, furry tongue; lethargy, confusion, seizures

Hyperkalemia- renal failure, adrenocrotical insufficiency, or massive deep muscle inujury cardiac dysrhythmias

Hypokalemia- prolonged IV therapy loss through burn wound

Complication o Infection- first line of defense (skin) has been injured burn wound becomes colonized Will see localized inflammation, induration, and sometimes suppuration at margins organisms may cause partial-thickness to turn into fullthickness May progress to bacteremia- sepsis- Monitor for hypo/hyperthermia, increased pulse and resp., decreased BP, decreased urine output, mild confusion, chills, malaise, loss of appetite o WBC 10-20- immunosuppression Obtain culture when sepsis is suspected from all possible sources start ATBxs ASAP Cardiovascular and resp same as emergent phase

Neuro- no symptoms unless severe hypoxia may become disoriented, combative, hallucinations delirium in older patient esp.

Musculoskeletal- burns begin to heal and scar tissue forms, skin is less supple and pliant limited ROM and contractures may develop. Splinting

GI system- paralytic ileus, diarrhea, constipation (opiods) Curlings ulcer- gastroduodenal ulcer characterized by superficial lesions- generalized stress response which results in decreased production of mucus and increased gastric acid secretion decreased blood flow to GI tract 2nd to hypovolemia- prevention with antacids and H2H blockers (Zantac) PPI (nexium) may have occult blood in stool

Endocrine- increase in blood glucose levels, increase in insulin production but not adequatemay be given sliding scale insulin IV.. monitor glucose levels frequently.

Nursing and Collaborative Management o Wound care Clean and debride area of necrotic tissue and debris that would promote bacterial growth Promote wound re-epitheliazation and/or successful skin grafting Daily observation, assessment, dressing changes nonsurgical debridement may be performed enzymatic debridement (papain) Partial-thickness- protective, course or finemeshed greasy gauze dressing is applied splitthickness skin grafts may use same gauze Paraffin or petroleum based- prevents adherence of graft to dressing

Blebs may form and prevent graft from interfacing and growing to wound- evacuated by aspiration with TB syringe

Donor site care- promote rapid, moist wound healing vary among burn units- healing time is 10-14 days transparent dressing, Pigskin, Silvadene, foam dressing

Excision and grafting Mortality rates have decreased because of early grafting must have stable cardiovascular status Eschar removed down to subq tissue or fascia graft placed on clean, viable tissue. Pressure and application of topical thrombin or epinephrine wound covered with autograft May see extensive bleeding frequent observation is needed Donor skin can be meshed or applied as a sheet ne open wound Cultured epithelial autografts- large body surface area burns- limited amount of skin available- grown from biopsy specimen 18-25 days to grow tissue meticulous care to prevent shearing or infection Artificial skin- Integra used in lifethreatening, full-thickness or deep partial thickness burns when graft not available

Pain management Individualized and consistent pain therapy Continuous background pain and treatmentinduced pain continuers IV infusion of morphine or hydromorphone breakthrough doses given RTC meds anxiolytics (potentiate analgesics) Premedicate before treatment with analgesic via IV or oral keep patient as comfortable as possible Nonpharmacologic strategies

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PCA may be used relaxation techniques Exercise during and after wound cleaning passive and active ROM- splints

Physical and occupational therapy

Nutritional therapy Promote healing and adequate protein and calories Hypermetabolic state Daily estimated caloric intake adjusted by dietician Feeding tube enteral or parenteral feedings.. after extubation, speech pathologist for swallow study High carb, high protein diet increased calories Monitor calorie intake Rehab is often long, complex, costly Social work

Psychosocial care

Rehabilitation phase- when patients burn wounds have healed and patient is able to resume level of self-care 2 weeks to 7-8 months after injury Patho/Clinical Manifestations o Heal either by primary intention or grafting. New skin appears flat and pink raised and hyperemic in 4-6 weeks. If ROM not initiated, contracture. Mature healing 6 months to 2 years afterward. Skin may never regain original color o Scarring- discoloration and contour- may be elevated above burned area- pressure- stocking garments up to 24 hours a day for 12-18 months o o o Itching- water-based moisturizers and Benadryl sensitive to trauma, cold, heat, and touch Protect from direct sunlight for 6-9 months Skin and joint contractures and hypertrophic scarring Complications

Contracture- abnormal condition of joint characterized by flexion and fixation shortening of scar tissue major joints ligaments and tendons may also shrink

Elastic bandages and pressure garments to help prevent flexion

Nursing and Collaborative Care- encourage active participation. Education may need to understand wound care. Emollient based cream on healed areas exercise encouraged discuss fears of rehab and returning home Self-esteem

Geronotologic Considerations More challenges from normal aging process complications, pneumonia more common, weaning from vent hard, wound more likely to get infected

Pediatric Considerations- 701 May be a case of child abuse/neglect- splash wound vs. scald wound Leading cause of accidental death in home for children between age 1-4 Hot spots from microwave oven Differences in response of children to burn: Childs skin is thinner than that of an adult, leasing to a more serious depth of burn with lower temperatures and shorter exposure Body surface of child results in greater fluid, electrolyte, and heat loss Immature response systems in child can cause shock and heart failure Increased basal metabolic rate increases protein and calorie needs of a child Less muscle and fat in body results in protein and calorie deficiency Skin more elastic- pulling on scarring area and larger scare Immature immune system- increased risk of infection Prolonged immobilization and treatment for burns affects growth and development

Prevention- stop drop and roll Review Lund Bowder chart pg. 701- different for adult Rule of nines cant be applied because body size differs age-related charts See Table 30-2 pg. 702 classifications and first aid treatment Electrical burns in mouth common in kids- put stuff in mouth Emergency care includes stop, drop, roll, ABCs, cover burn, and transport minor wound is cleaned and antimicrobial ointment applied and covered with loose dressing tetanus and pain

Major burn- treat shock, airway, ET tube escharatomy sterile sheets IV- LR, albumin 20-30 ml/hr urine output for resuscitative phase baseline weight Curling ulcer Polysporin may be used dont remove yellow eschar No two burn surfaces should touch separate by dressings Homografts or heterografts/xenografts- temporary Autograft or isograft (identical twin) Tanner mesh graft- reduce scarring by running graft through cutting machine to allow it to provide more coverage suture graft to maintain tension

Biologic dressings- may be applied to a noninfected wound within 6 hours of injury and will peel off as wound healsneonatal foreskin fibroblast cells frozen once thawed, cant be refrozen

Posthealing- Eucerin or Nivea, cocoa butter to maintain skin moisture Use sunblock Box 30-2 pg. 706 for different topical agents used to treat Protective isolation Monitor for signs of infection Monitor for signs of fluid overload Increased calories, high protein diet may need iron therapy vitamins A,B, C and zinc accurate calorie count and monitor weight Exercise prevent foot drop Physical therapist Emotions support is important be nonjudgmental- often feel guilt referrals