Burns

Harpreet Nagi (RN) Academic Instructor CIMT College | Canadian Institute of Management & Technology

Burns
Radiation Thermal Chemical

Burns

Burns
There is tissue destruction due to : 1. Coagulation 2. Protein dematuration 3. Ionization of cellular contents This leads to : a) Increased fluid loss b) Infection c) Hyponatremia d) Scarring

Burns
Decreased immunity Change in function, appearance and body image.

Burns
Classification: 1. First degree burns AKA superficial partial thickness burns eg : sunburns. Involves epidermis, and a possible portion of dermis. Tingling, hyperesthesia, pain. Area is red. Minimum or no edema. Possible blisters.

Burns
2. Second degree AKA deep partial burns eg : scalds, flash flame. Involves epidermis, a portion of upper dermis layer and a portion of deeper dermis . Characterized by : pain, hyperesthesia, sensitivity to cold air, blisters with mottled red base, broken epidermis, weeping surface and edema.

Burns
3. Third Degree Burns AKA full thickness burns. Involves epidermis, dermis, and sometimes subcutaneous tissues, muscles and bones. Pain free. Shock, hematuria, edema. Dry, pale, white and leathery or charred skin. Grafting necessary.

Burns
Local and systemic responses to burns: 1. < 25 % TBSA : primary local response. 2. > 25 % TBSA : both local and systemic response. Systemic response is due to release of cytokines and other mediators into systemic circulation.

Burns
Decreased cardiac output Tissue hypo perfusion and organ hypo perfusion Hyper dynamic and hyper metabolic phase.

Cardiovascular response to Burns

hypovolemia Decreased perfusion and oxygen delivery.

Decreased C.O and Decreased BP

SNS releases catecholamines Increased vasoconstriction and increased pulse

Cardiovascular response to Burns

Greatest volume of fluid leak in 24 36 hrs. Peak in 6 8 hrs. Diuresis continue for several days to 2 weeks.

Edema
Maximum after 24 hrs. Begin to resolve 1 -2 days post burn. Completely resolved in 7 10 days post burn.

Compartment syndrome
Increased edema Pressure on small blood vessels and nerves. Obstruction of blood flow

Ischemia

Fluids and electrolytes imbalance

Decreased Na. Increased K ( due to massive cell destruction) initially. But later, due to fluid shifts there is inadequate K replacement. Anemia due to RBCs destruction. Increased hematocrit due to plasma loss. Thrombocytopenia.

Pulmonary effects
Early, Burn leads to release of catecholamines . They cause altered peripheral blood flow leading to decreased oxygen delivery. Later , Hypermetabolism and catecholamines release cause increased tissue oxygen consumption and hypoxia.

Pulmonary effects
Injury : 1. Upper airway due to edema and obstruction. 2. Inhalation injury below glottis due to inhalation of noxious gases ( CO, sulphur oxides. Nitrogen oxides, aldehydes, cyanide, NH4, phosgene, halogens.) 3. Irritation of pulmonary tissues.

Pulmonary effects
Ciliary action is lost Edema Hypersecretion Bronchospasm Atelactasis In case of CO poisoning , give 100% oxygen. Decreased arterial oxygen leads to respiratory acidosis. ARDS Acute respiratory failure.

Other systems
Decreased blood volume cause altered renal functions. Hematuria. If muscles are damaged, myoglobin is released in urine. Infection cause sepsis. Disturbed temperature regulation. Decrease in early hours.. When hyper metabolic state starts there is hypothermia.

Other systems
Paralytic ileus; Curlings ulcer( gastric and duodenal) Gastric distension and nausea leads to vomiting.

Management
ABCD Humidified oxygen Remove secretions with suction, bronchodilators and mucolytics. ET for edema. Assess for cervical, spinal, head injuries. Remove restrictive clothes and jewellery. Remove lens immediately.

Management
IV catheter. If TBSA > 25% , NG tube to prevent vomiting. Keep patient warm. Prevent contamination. Catheter. Laboratory values. TT prophylaxis. Pain medications.

Stages and management

Care of clients with burns starts at the time of burns. Remove the client from the source of the burn. For smaller burns, cover with clean, cool, tap water dampened towel. For larger areas, remove burnt clothing and wrap the client in a clean sheet without using any cool or ice water.

Emergent phase
AKA resuscitative phase. Starts from onset to 2 or 5 or more days following burns. In first 24 48 hours the client will lose fluid and form edema. It is then followed by fluid mobilization and diuresis. There is a risk for following:

 Hypovolemic shock due to massive fluid shift. Edema, decrease BP, increase pulse. Insensible water loss increase from 30-50 ml/hr to 200 400 ml/hr. Hemolysis of RBCs . Thrombosis. Na shift into interstitial spaces and K shift into extracellular space.

Initial management focus on: Securing airway. Supporting circulation by fluids. Comfort with analgesics. Prevent infection. Maintain body temperature. Provide emotional support.

 Airway management. Fluid management with colloids. Wound care is delayed until all above goals are met. When, time permits, clean it using hydrotherapy tub, shower, or bed. Debridement can be done. Use sterile guaze as dressing laid over topical antibiotic.

 Change dressing two to three times per day initially and then less often as the wound heals. Grafting are commonly done. Routine blood work hoe electrolyte imbalance. Early ROM exercises to prevent contractures. Analgesics.

 Tetanus immunization. Antimicrobials. Oral diet resumed once bowel sounds return.

Acute phase
This phase begins with mobilization of ECF and subsequent diuresis and ends when burned area is completely covered by skin grafts or when wounds are healed. Wound care is with daily observation, cleaning and debridement. Grafting and analgesics. Active and passive ROM. Splints help prevent deformities. A high protein, high carbohydrate diet helps meet the clients increased metabolic needs.

Rehabilitative Phase
It begins when the clients burn wounds are covered with skin or healed, and the client is able to resume a level of self-care activity. Skin and joint contractures common complications. An emollient based cream is recommended. Cosmetic surgery required.