4/1/2011

BURNINJURIES&ITS
MANAGEMENT
Dr Ibraheem Bashayreh, RN, PhD

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 BURNS
Woundscausedbyexposureto:
1.excessiveheat
2.Chemicals
3.fire/steam
4.radiation
5.electricity

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 BURNS
Resultsin1020thousanddeathsannually
Survivalbestatages1545

Children,elderly,anddiabetics

Survivalbestburnscoverlessthan20%ofTBA

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 TYPESOFBURNS
Thermal

exposuretoflameorahotobject
Chemical
exposuretoacid,alkaliororganicsubstances
Electrical

resultfromtheconversionofelectricalenergyintoheat.
Extentofinjurydependsonthetypeofcurrent,the
pathwayofflow,localtissueresistance,anddurationof
contact
Radiation

resultfromradiantenergybeingtransferredtothebody
resultinginproductionofcellulartoxins
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 CHEMICALBURN

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 ELECTRICALBURN

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 BURNWOUNDASSESSMENT
Classifiedaccordingtodepthofinjuryand
extentofbodysurfaceareainvolved
Burnwoundsdifferentiateddependingon
thelevelofdermisandsubcutaneous
tissueinvolved
1.superficial(firstdegree)
2.deep(seconddegree)
3.fullthickness(thirdandfourth
degree)

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 SUPERFICIALBURNS
(FIRSTDEGREE)
Epidermaltissueonlyaffected
Erythema,blanchingonpressure,mildswelling

novesiclesorblisterinitially
Notseriousunlesslargeareasinvolved

i.e.sunburn

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 DEEP(SECONDDEGREE)
*Involvestheepidermisanddeeplayerofthe
dermis
Fluidfilledvesiclesred,shiny,wet,severepain
Hospitalizationrequiredifover25%ofbody
surfaceinvolved
i.e.tarburn,flame

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 FULLTHICKNESS
(THIRD/FOURTHDEGREE)
Destructionofallskinlayers
Requiresimmediatehospitalization

Dry,waxywhite,leathery,orhardskin,nopain

Exposuretoflames,electricityorchemicalscan
cause3rddegreeburns

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CALCULATIONOFBURNEDBODY
SURFACEAREA

CalculationofBurned
BodySurfaceArea

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TOTALBODYSURFACEAREA
(TBSA)
Superficialburnsarenotinvolvedinthe
calculation
LundandBrowderChartisthemostaccurate
becauseitadjustsforage
Ruleofninesdividesthebodyadequatefor
initialassessmentforadultburns

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LUNDBROWDERCHARTUSEDFOR
DETERMININGBSA

4/1/2011 Evans, 18.1, 2007)

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RULESOFNINES
Head&Neck=9%
Eachupperextremity(Arms)=9%

Eachlowerextremity(Legs)=18%

Anteriortrunk=18%

Posteriortrunk=18%

Genitalia(perineum)=1%

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 VASCULARCHANGES
RESULTINGFROMBURN
INJURIES
Circulatorydisruptionoccursattheburn
siteimmediatelyafteraburninjury
Bloodflowdecreasesorceasedueto
occludedbloodvessels
Damagedmacrophageswithinthetissues
releasechemicalsthatcauseconstriction
ofvessel
Bloodvesselthrombosismayoccur
causingnecrosis
Macrophage:Atypeofwhitebloodthatingests(takesin)foreign
material.Macrophagesarekeyplayersintheimmuneresponsetoforeign
invaderssuchasinfectiousmicroorganisms.

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 FLUIDSHIFT
Occursafterinitialvasoconstriction,then
dilation
Bloodvesselsdilateandleakfluidinto
theinterstitialspace
Knownasthirdspacingorcapillaryleak
syndrome
Causesdecreasedbloodvolumeandblood
pressure
Occurswithinthefirst12hoursafterthe
burnandcancontinuetoupto36hours
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 FLUIDIMBALANCES
Occurasaresultoffluidshiftandcell
damage
Hypovolemia

Metabolicacidosis

Hyperkalemia

Hyponatremia

Hemoconcentration(elevatedblood
osmolarity,hematocrit/hemoglobin)dueto
dehydration

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 FLUIDREMOBILIZATION
Occursafter24hours

Capillaryleakstops

Seediureticstagewhereedemafluid
shiftsfromtheinterstitialspacesintothe
vascularspace
Bloodvolumeincreasesleadingto
increasedrenalbloodflowanddiuresis
Bodyweightreturnstonormal

SeeHypokalemia

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 CURLINGSULCER
Acuteulcerativegastroduodenaldisease
Occurwithin24hoursafterburn
DuetoreducedGIbloodflowandmucosal
damage
TreatclientswithH2blockers,mucoprotectants,
andearlyenteralnutrition
Watchforsuddendropinhemoglobin

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 PHASESOFBURNINJURIES
Emergent(2448hrs)
Acute

Rehabilitative

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 EMERGENTPHASE
*Immediateproblemisfluidloss,edema,
reducedbloodflow(fluidandelectrolyte
shifts)
Goals:
1.secureairway
2.supportcirculationbyfluid
replacement
3.keeptheclientcomfortablewith
analgesics
4.preventinfectionthroughwoundcare
5.maintainbodytemperature
6.provideemotionalsupport
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 EMERGENTPHASE
Knowledgeofcircumstancessurroundingthe
burninjury
Obtainclientspreburnweight(dryweight)to
calculatefluidrates
Calculationsbasedonweightobtainedafterfluid
replacementisstartedarenotaccuratebecause
ofwaterinducedweightgain
Heightisimportantindeterminingbodysurface
area(BSA)whichisusedtocalculatenutritional
needs
Knowclientshealthhistorybecausethe
physiologicstressseenwithaburncanmakea
latentdiseaseprocessdevelopsymptoms
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 CLINICALMANIFESTATIONSINTHE
EMERGENTPHASE
Clientswithmajorburninjuriesandwithinhalationinjury
areatriskforrespiratoryproblems
Inhalationinjuriesarepresentin20%to50%oftheclients
admittedtoburncenters
Assesstherespiratorysystembyinspectingthemouth,nose,
andpharynx
Burnsofthelips,face,ears,neck,eyelids,eyebrows,and
eyelashesarestrongindicatorsthataninhalationinjurymay
bepresent
Changeinrespiratorypatternmayindicateapulmonary
injury.
Theclientmay:becomeprogressivelyhoarse,developabrassy
cough,droolorhavedifficultyswallowing,produceexpiratory
soundsthatincludeaudiblewheezes,crowing,andstridor
Upperairwayedemaandinhalationinjuryaremostcommon
inthetracheaandmainstembronchi
Auscultatetheseareasforwheezes
Ifwheezesdisappear,thisindicatesimpendingairway
obstructionanddemandsimmediateintubation 33
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 CLINICALMANIFESTATIONS
Cardiovascularwillbeginimmediately
whichcanincludeshock(Shockisa
commoncauseofdeathintheemergent
phaseinclientswithseriousinjuries)
ObtainabaselineEKG

Monitorforedema,measurecentraland
peripheralpulses,bloodpressure,
capillaryrefillandpulseoximetry

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 CLINICALMANIFESTATIONS
Changesinrenalfunctionarerelatedto
decreasedrenalbloodflow
Urineisusuallyhighlyconcentratedand
hasahighspecificgravity
Urineoutputisdecreasedduringthefirst
24hoursoftheemergentphase
Fluidresuscitationisprovidedattherate
neededtomaintainadulturineoutputat
30to50mL/hr.
MeasureBUN,creatandNAlevels

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 CLINICALMANIFESTATIONS
Sympatheticstimulationduringthe
emergentphasecausesreducedGI
motilityandparalyticileus
Auscultatetheabdomentoassessbowel
soundswhichmaybereduced
Monitorforn/vandabdominaldistention
Clientswithburnsof25%TBSAorwho
areintubatedgenerallyrequireaNGtube
insertedtopreventaspirationand
removalofgastricsecretions

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 SKINASSESSMENT
Assesstheskintodeterminethesizeand
depthofburninjury
Thesizeoftheinjuryisfirstestimatedin
comparisontothetotalbodysurfacearea
(TBSA).Forexample,aburnthat
involves40%oftheTBSAisa40%burn
Usetheruleofninesforclientswhose
weightsareinnormalproportiontotheir
heights

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 IVFLUIDTHERAPY

InfusionofIVfluidsisneededtomaintainsufficient
bloodvolumefornormalCO
Clientswithburnsinvolving15%to20%oftheTBSA
requireIVfluid
Purposeistopreventshockbymaintainingadequate
circulatingbloodfluidvolume
Severeburnrequireslargefluidloadsinashorttime
tomaintainbloodflowtovitalorgans
Fluidreplacementformulasarecalculatedfromthe
timeofinjuryandnotfromthetimeofarrivalatthe
hospital
Diureticsshouldnotbegiventoincreaseurineoutput.
Changetheamountandrateoffluidadministration.
DiureticsdonotincreaseCO;theyactuallydecrease
circulatingvolumeandCObypullingfluidfromthe
circulatingbloodvolumetoenhancediuresis
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 COMMONFLUIDS
Protenateor5%albumininisotonicsaline(1/2
giveninfirst8hr;giveninnext16hr)
LR(LactateRinger)withoutdextrose(1/2given
infirst8hr;giveninnext16hr)
Crystalloid(hypertonicsaline)adjusttomaintain
urineoutputat30mL/hr
Crystalloidonly(lactatedringers)

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 NURSINGDIAGNOSISINTHE
EMERGENTPHASE
DecreasedCO
Deficientfluidvolumer/tactivefluidvolumeloss

IneffectiveTissueperfusion

Ineffectivebreathingpattern

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ACUTEPHASEOFBURNINJURY
Lastsuntilwoundclosureiscomplete
Careisdirectedtowardcontinuedassessmentand
maintenanceofthecardiovascularandrespiratory
system
Pneumoniaisaconcernwhichcanresultinrespiratory
failurerequiringmechanicalventilation
Infection(TopicalantibioticsSilvadene)
Tetanustoxoid
Weightdailywithoutdressingsorsplintsandcompare
topreburnweight
A2%lossofbodyweightindicatesamilddeficit
A10%orgreaterweightlossrequiresmodificationof
calorieintake
Monitorforsignsofinfection

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 LOCALANDSYSTEMICSIGNS
OFINFECTIONGRAM
NEGATIVEBACTERIA
Pseudomonas,Proteus
Mayledtosepticshock
Conversionofapartialthicknessinjurytoafullthickness
injury
Ulcerationofhealthskinattheburnsite
Erythematous,nodularlesionsinuninvolvedskin
Excessiveburnwounddrainage
Odor
Sloughingofgrafts
Alteredlevelofconsciousness
Changesinvitalsigns
Oliguria
GIdysfunctionsuchasdiarrhea,vomiting
Metabolicacidosis

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 LABVALUES
NahyponatremiaorHypernatremia
KHyperkalemiaorHypokalemia

WBC10,00020,000

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 NURSINGDIAGOSISINTHE
ACUTEPHASE
Impairedskinintegrity
Riskforinfection

Imbalancednutrition

Impairedphysicalmobility

Disturbedbodyimage

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 PLANNINGAND
IMPLEMENTATION
Nonsurgicalmanagement:removalofexudates
andnecrotictissue,cleaningthearea,
stimulatinggranulationandrevascularization
andapplyingdressings.Debridementmaybe
needed

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 DRESSINGTHEBURNWOUND
Afterburnwoundsarecleanedanddebrided,
topicalantibioticsarereappliedtoprevent
infection
Standardwounddressingsaremultiplelayersof
gauzeappliedoverthetopicalagentsontheburn
wound

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 REHABILITATIVEPHASEOF
BURNINJURY
Startedatthetimeofadmission
Technicallybeginswithwoundclosure
andendswhentheclientreturnstothe
highestpossibleleveloffunctioning
Providepsychosocialsupport
Assesshomeenvironment,financial
resources,medicalequipment,prosthetic
rehab
Healthteachingshouldincludesymptoms
ofinfection,drugsregimens,f/u
appointments,comfortmeasurestoreduce
pruritus
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 DIET
InitiallyNPO
Beginoralfluidsafterbowelsoundsreturn

Donotgiveicechipsorfreewaterleadto
electrolyteimbalance
Highprotein,highcalorie

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 GOALS
Preventcomplications(contractures)
Vitalsignshourly
Assessrespiratoryfunction
Tetanusbooster
Antiinfective
Analgesics
Noaspirin
Strictsurgicalasepsis
Turnq2htopreventcontractures
Emotionalsupport

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 DEBRIDEMENT
Donewithforcepsandcurvedscissororthrough
hydrotherapy(applicationofwaterfortreatment)
Onlylooseescharremoved

Blistersareleftalonetoserveasaprotector
controversial

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 SKINGRAFTS
Doneduringtheacutephase
Usedforfullthicknessanddeeppartial
thicknesswounds

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 POSTCAREOFSKINGRAFTS
Maintaindressing
Useaseptictechnique
Graftshouldlookpinkifithastakenafter5days
Skeletaltractionmaybeusedtoprevent
contractures
Elasticbandagesmaybeappliedfor6moto1
yeartopreventhypertrophicscarring

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THE END
QUESTIONS
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