Burn Emergencies

SPECIFIC OUTCOMESDescribe the assessment and classification of burnsDiscuss current trends in cleansing and dressing of burnsApply the medico-legal aspects pertaining to burn management with regard to the emergency nurseApply the above mentioned knowledge when analyzing a case scenario (paper and real life)Discuss fluid requirements of the patient with a burn injuryList the drugs used in your unit to manage burn injuriesDelineate the nursing process in the management of a patient with burn injuriesADVANCES IN BURN TREATMENTFluid resuscitationInhalation injuryWound care practiceEarly debridement and excisionIncreased nutritional supportWith the advances in burn care, practitioners can manage a patient with extensive burns. Survival rate is more likely in (high-income countries) Burn centers are the treatment centers of choice.2PathophysiologyInitiates the inflammatory responseHeatRednessPainLocalized and systemic edema formationEdemaAmount of edema correlates with the depth, extent of injury (TBSA burn), and fluids administered.Rule of nines pre-hospital for estimateLund and Browder chart more precise

This combo is BADFluid shiftEdema formationEvaporative water loss from the burn

= VI. Hypovolemia (burn shock)

LOSS OF PLASMA IS GREATEST IN THE FIRST 4-6 HOURS AFTER THE BURN INJURYFIRST AIDFirst Goal is to STOP THE BURNING PROCESS!Stop, drop and roll. Smother with blanket or douse with water. DO NOT RUN!Disconnect the person from the source of electricityRemove clothing and jewelry. Take off blanket used to smother fireCool burns or scalds by immediate immersion of water for at least 30 min. Irrigation of chemical burns should be for 1 hour.Do NOT use ice for coolingAvoid hypothermia, keep the person as warm as possible.

How do we get to where we are going?STRATEGYAssessment Primary and secondary assessment/resuscitationFocused assessmentSubjective data collectionObjective data collectionPsychological/social/environmental factorsOccupational risk factorsAlterations in ability to perceive environmental threatsSocial risk factorsEnvironmental risk factorsDiagnostic proceduresLaboratory studiesImaging studiesOther

You will see the word strategy multiple times this gets you back to the base..7Essential management points:

Stop the burning ABCDE Determine the percentage area of burn (Rule of 9s) Good IV access and early fluid replacement. STRATEGY: AssessmentPrimary:Airway / C-spineBreathingCirculationDisabilityExpose / Environmental controlsAirwayOpen airway? Singed facial or nose hairs?Soot in back of throat?Throat swollen or burned?C-spineAny trauma (fall or RTI)- concerning c-spine injury?IMMOBILIZE EARLYRemember ACLS! Jaw thrust/chin lift or Head tilt appropriate?

BreathingChest rise and fallRetractions, RateCircumferential cyanosisBreath soundsCirculationShock and tissue perfusionColor of skinBlisteringDepth of burn (degree) Capillary refill

Disability / NeurologicalLOC?AVPUAlertVerbalPainUnresponsivePERRLAPupilsEqualRoundReactiveLightAccommodationGCS?Glasgow Coma Scale : 0-15Expose / Environmental controlsStop the burning processExpose the patientKeep warmSecondary assessmentFull set of vitals, Focused adjuncts, Facilitate family presenceGive comfort measuresHistory and Head-to-Toe AssessmentInspect posterior surfaces

do not go into great detail touch on the parts for burns, How do you assess for pain? When would you expect pain to be high? 16ADVANCES IN BURN TREATMENTFluid resuscitationInhalation injuryWound care practiceEarly debridement and excisionIncreased nutritional supportWith the advances in burn care, practitioners can manage a patient with extensive burns. Survival rate is more likely in (high-income countries) Burn centers are the treatment centers of choice.17Terapi cairan luka bakar derajat 2/3 dengan luas > 25%, pasien tidak dapat minum, dihentikan bila masukan oral dapat menggantikan parenteralCara evans(1).Berat badan (kg) x % luka bakar x 1 cc nacl(2).Berat badan (kg) x % luka bakar x 1 cc larutan koloid(3).2000 cc glukosa 5% (1), (2), dan (3) 8 jam pertama sisanya 16 jam berikutnya Hari kedua cairan hari pertamaHari ketiga cairan hari keduaMonitoring penghitungan diuresisFluid resuscitationCara baxterRumus : % luka bakar x BB (kg) x 4 cc 8 jam pertama sisanya 16 jam berikutnya Hari pertama larutan RL karena terjadi hiponatremiPada hari kedua cairan hari pertamaAnalgetik morfin/petidin (IV), IM dengan sirkulasi yang terganggu penimbunan di ototLakukan pencucian luka setelah sirkulasi stabil betadine/ nitras argenti 0,5%Berikan antibiotik topikal pasca pencucian luka mencegah dan mengatasi infeksi yang terjadi pada luka (ointment) silver nitrate 0,5%, mafenide acetate 10%, silver sulfadiazin 1% / gentamisin sulfatKompres nitrat argenti dibasahi tiap 2 jam efektif (silversulfadiazin) bakteriostatik semua kuman , daya tembus yang cukup, tidak menimbulkan resistensi, dan amanBalut luka kassa gulung kering dan steril Serum anti-tetanus/toksoid ATS 3000 unit (dewasa) dan1/2 (anak)

Wound care

First aid If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with cool water to prevent further damage and remove all burned clothing. If the burn area is limited, immerse the site in cold water for 30 minutes to reduce pain and oedema and to minimize tissue damage.

If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned area (or the whole patient) to prevent systemic heat loss and hypothermia.Hypothermia is a particular risk in young children. First 4-6 hours following injury are critical; transport the patient with severe burns to a hospital a soon as possible.

Early debridement and excisionExcept in very small burns, debride all bullae.Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over the first several days After debridement,cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic.

Do not use alcohol-based solutions. Apply a thin layer of antibiotic cream (silver sulfadiazine). Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to the outer layers.

Daily treatment Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the dressing. On each dressing change, remove any loose tissue.Inspect the wounds for discoloration or haemorrhage, which indicate developing infection.

Fever is not a useful sign as it may persist until the burn wound is closed. Cellulitis in the surrounding tissue is a better indicator of infection. Give systemic antibiotics in cases of haemolytic wound infection

Healing phaseWithout infection, superficial burns heal rapidly. Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue.

Healing phaseThe depth of the burn and the surface involved influence the duration of the healing phase. Without infection, superficial burns heal rapidly. Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue.

Healing PhasePlan to provide long term care to the patient. Burn scars undergo maturation, at first being red, raised and uncomfortable. They frequently become hypertrophic and form keloids. They flatten, soften and fade with time, but the process is unpredictable and can take up to two years.

In children

The scars cannot expand to keep pace with the growth of the child and may lead to contractures. Arrange for early surgical release of contractures before they interfere with growth.

Burn scars on the face lead to cosmetic deformity, ectropion and contractures about the lips. Ectropion can lead to exposure keratitis and blindness and lip deformity restricts eating and mouth care. Consider specialized care for these patients as skin grafting is often not sufficient to correct facial deformity.

NutritionPatients energy and protein requirements will be extremely high due to the catabolism of trauma, heat loss, infection and demands of tissue regeneration. If necessary, feed the patient through a nasogastric tube to ensure an adequate energy intake (up to 6000 kcal a day).

Nutritionfeed the patient through a nasogastric tube to ensure an adequate energy intake (up to 6000 kcal a day). Eggs and peanut oil and locally available supplements are good.

Anaemia and malnutrition prevent burn wound healing and result in failure of skin grafts. Eggs and peanut oil and locally available supplements are good.

Rule of nines Head and neck Whole arm Whole arm Posterior trunk Anterior trunk Whole leg Whole legPerineum99918181818181

quick and easy estimate of TBSA- we will cover the Lund and Brower later in this discussion34Rule of 9s

Source Unknown Notice the differences between the pediatric and adult patient. Where is most of the TBSA for children?35Assessment of burnsSuperficial burn (1st degree) Superficial partial-thickness (2nd degree)Deep partial-thickness (2nd degree) Full-thickness (3rd degree)Now to differentiate between the stages or classes of burns36Superficial burn (1st degree)Only the epidermis Red and tenderMild discomfort some good over the counter (OTC) topical creams used. Aloe vera, LidocaineFirst Degree BurnOnly involves the EPI-dermis

http://www.berglundandjohnson.com/images/burn2.png

most common sunburns38Superficial partial-thickness burn(Superficial 2nd degree burn)Epidermis and part of the dermis Blistered, red, blanches with pressureOften seen with scalding injuriesSensitive to light touch or pinprickTreated on outpatient basis, heal time 1-3 weeks

Second Degree Burn

http://www.burnsurgery.com/Modules/initial_mgmt/sec_5.htm

Plasma leaking into the skin is the blisters. Most common are scald burns40Deep partial-thickness(Deep 2nd degree)Epidermis and most of the dermisAppears white or poor vascularized; may not blisterLess sensitive to light touch than superficial formExtensive time to heal (3-4 weeks)Often require excision of the wound and skin grafting Deep partial White is deeper than pink

http://www.emsworld.com/article/10320058/burning-issues

Notice the pink areas of the skin, that typically means there is still blood flow to that area. It may be difficult to class the burns before removal of skin and blisters42Full-thickness (3rd degree)Epidermis, dermis and into subcutaneous tissueDry, leathery and insensate. Typically no blisteringCommonly seen when clothes are caught on fire or skin is directly exposed to flameExtensive healing time and need for skin graftingThird Degree Burn

http://www.burnsurgery.org/Modules/silver/images/section7case2/5.jpg

Fourth degreeFull-thickness extends to muscle or boneCommonly seen with high voltage electric injury or severe thermal burnsHospital admission, maybe surgical amputation of the affected extremity Fourth DegreeElectrical burns go deep

http://www.sciencephoto.com/image/265754/530wm/M3350206-Third-degree_electrical_burns-SPL.jpg

escharotomy to allow better circulation46AssessmentPsychological / social / environmentalOccupational (firefighters, electricians)Alterations in perception (poor decision making, decreased sensation in OA)Social risk (Child abuse? , Assault, Homeless, Depression?)Environmental (cooking in enclosed area? contact with flame?)occupation i.e. firefighters,, children decision making is limited to developmental, this brings us to the social risks or child abuse, assault, initimate partner violent, homeless, depression. Environmental: contact with flame, enclosed area? inhalation injury

47What needs to be done?Diagnostic proceduresLabs:CBC, Chemistries, HbCO, Type and crossmatch, Coags, UA, U preg, ABG, Serum and urine toxicologyImaging: Chest x-ray, c-spine, CT, FAST,Other: PL, ECGFast and Peritoneal lavage for associated abdominal injuries. ECG for electrical or lightening injuries48STRATEGYAnalysis: Differential Nursing Diagnosis / Collaborative ProblemsPlanning implementationEvaluation and ongoing monitoringDocumentation or interventions and patient responseAge-related considerationsWe will now go through each bullet point individually49SRATEGY: ANALYSISAnalysis: Diagnoses and ProblemsRisk for:Ineffective airway clearanceImpaired gas exchangeIneffective breathing patternDeficient fluid volumeHypothermiaInfectionIneffective tissue perfusionActualAcute painImpaired skin integrityAnxiety related to fearSTRATEGY : PLANNINGIMPLEMENTATION/INTERVENTIONSDetermine the priorities in careFLUID MANAGEMENTWOUND MANAGEMENTPAIN MANAGEMENTTETANUSEach intervention will be broken down.51Lund and BrowderAreaAge 0151015AdultA= of head9 8 6 5 4 3 B= of one thigh2 3 44 4 4 C= of one leg2 2 2 33 3

Source Unknown while reviewing this draw a diagram on the board 52ChartHead , NeckTorso , Upper arm, Lower armHands, Upper leg, Lower leg,Feet and Genitalsyeah- I know this is a bit difficult to internalize but it took me some time to make this stick figure. Bear with me- I have a better slide coming up. The point here is that each body part has a specific percentage.53Lund and BrowderSee also: http://www.elroubyegypt.com/br/acute_burn_management.html

Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Accessed at: http://www.merckmanuals.com/professional/injuries_poisoning/burns/burns.html

54Fluid managementRemember that a formula is only an estimate and adjustments need to be made based on patients status.Fluid Resuscitation ProtocolEstablish and maintain adequate circulationBurns >20% TBS require initial fluid resuscitationUse at least one large bore intravenous catheter. Begin Ringers Lactate. Estimate initial rate according to the estimated percent of total body skin surface burned (%TBS). Estimated body weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.)Maintain: Blood Pressure>90 systolic, Urine output 0.5-1.0ml/kg/hr, Pulse 37CModify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients:- Fluid requirements are greater to prevent burn shock- Include colloid: either Hespan or Albumin in the patients from the beginningTransfer to Burn Center if a Major Burn is Present or a Moderate Burn depending on Local Resources

http://www.burnsurgery.com/Modules/initial_mgmt/sec_3.htm55PainControl pain with narcotic analgesicsProvide a dry sheet to protect nerve endings from air.TetanusIs this immunization up to date? STRATEGY: EVALUATIONAirwayBreathingCirculation/PerfusionPainTemperatureSkin integrityDocumentationAll of your interventions and patient responsepercent burnpainvitalsresponse to pain medswound descriptiondressing applied Specific burn injuriesAge-related considerationsPediatric and GeriatricThermal and inhalation burnsAssessmentAnalysisPlanning and implementation/interventionsEvaluation and on-going monitoringChemical burnsAssessmentAnalysisPlanningEvaluationElectrical/Lightning burnsAssessmentAnalysisPlanningEvaluationAge-related concernsPediatric burn patientGrowth or developmental relatedAmong the leading causes of deathSmaller airways easily leads to obstruction by edemaHigh ratio of TBSA to body mass increases heat exchange with the environmentLack of subcutaneous tissue & thin skin lead to increased heat loss and caloric expenditure Dependent on caregivers for directionMaltreatment possibleHealing responses are more rapidheat loss in skin is evaporative61Age-related concernsPearlsCurious about environmentMaltreatment: inflicted burns: both hands or both legs, brands/contact burns, cigarette and immersion burnsHypothermia may render an injured child refractory to treatment.Age-related burnsGeriatric burn patient Aging relatedLoss of subcutaneous tissue, thinning of the dermisDecreased touch receptors, pain receptors and slowing of reflexesDecreased skin growth delays wound healing and Vit D productionDecreased airway clearance, decreased cough, and laryngeal reflexesStiffening of elastin and connective tissue supporting the lungsDecreased alveolar surface areaDecreased ciliary actionIncreased chest wall stiffness with declining strength in chest muscles

thinning dermis predisposes thermal burns will like be deep63Age-related concernsPearls Altered mental status, dementia, dependant on caregiversSlowing of reflexes and decreased sensationChronic illnesses decrease the reserve to withstand the multisystem stresses of a burn injuryThermalCauses: UV light or contact with flame, flash, steam or scalding Most common type of burn.Flash burns cause the most damageto the upper airway. Injuries tend to be limited to the supraglottic airways. Heat produces edema andcan lead to obstruction of the airway.

wwarby, flickr Thermal burnsSmoke inhalation can lead to the absorption of Carbon Monoxide. CO has a higher affinity to attach to red blood cells than oxygen. This leads to impaired delivery and/or utilization of oxygen. This eventually results in systemic tissue hypoxia and death. Pulse oxygen monitor cannot differentiate between oxygen and CO. This further delays treatment of CO poisoning.Thermal burnsSoot contains elemental carbon and can absorb toxins from burning materials that are toxic to the bronchial mucosa and alveoli because of the pH and the ability to form free radicals. These compounds can cause airway inflammation and multiple complications.67Chemical burnsAcids: Drain cleanersAlkali: Rust removers, swimming pool cleanersOrganic compounds: Phenols and petroleum cleaners

Source Unknown Chemical burn

http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec8.htm

Typical appearance of chemical burn with coagulation necrosis of skin. Brown to gray appearance is characteristic. Wound depth invariably increases such that initial assessment underestimates depth.69Chemical burnsDenature protein within the the tissues or a desiccation of cells. Alkali products cause more tissue damage than acids.Dry substances should be wiped off first.Wet substances should be irrigated with copious amounts of water.All fluids used to flush should be collected and contained not placed into the general drainage system.Decontaminate patient: flush with warm water medially to laterally Protect yourselfAlkali burns go deep

http://www.burnsurgery.com/Betaweb/Modules/initial/bsinitialsec8.htm

Deep alkali burn irrigated with water for 60 minutes. Note: Surface coagulation necrosis. This wound is high risk and should be referred to burn center if possible.71Chemical burnsThe depth can be deceiving until the tissue begins to slough off days later.Because of this chemical burns should always be considered deep partial-thickness or full-thickness burns. Tar burn

http://www.burnsurgery.com/Modules/initial_mgmt/sec_6.htm

Note the white area in the exposed wound, indicating the burn to be very deep. The temperature of the tar will make the difference on depth. cooling the tar in IMPERATIVE. Pain is minimal and injury can be easily underestimated. Best removal is Neosporin contains the emulsifier Tween-80 which is useful in dissolving the tar.

73Chemicals burnsIs the pain our of proportion to the skin involvement? Consider hydrofluoric burnsHydrofluoric acid burns are unique in several waysHydrofluoric (HF) acid, one of the strongest inorganic acids, is used mainly for industrial purposes (eg, glass etching, metal cleaning, electronics manufacturing). Hydrofluoric acid also may be found in home rust removers. Dilute solutions deeply penetrate before dissociating, thus causing delayed injury and symptoms. Burns to the fingers and nail beds may leave the overlying nails intact, and pain may be severe with little surface abnormality. The vast majority of cases involve only small areas of exposure, usually on the digits. A unique feature of HF exposure is its ability to cause significant systemic toxicity due to fluoride poisoning.http://emedicine.medscape.com/article/773304-overviewTreatment of HF burnsImmerse burn area for 2 hours in 0.2% iced aqueous tetracaine benzethonium chloride (Hyamine 1622) or iced aqueous benzalkonium chloride (Zephiran).Apply towels soaked with Zephiran and change every 2-4 minutes.Ice packs to relieve painObtain serum chemistries: hypocalcemia, hyperkalemiaInsitiute cardiac monitoring: HF acid exposure can: prolong QT intervalpeak T wavesventricular dysrhythmiasHF treatmentCalcium gluconate: Apply 2.5% calcium gluconate gel to burn areaSubcutaneous infiltration: 0.5mL of 10% calcium gluconate/cm2 of burn, extending 0.5 cm beyond margin of involved tissue.IV regional: Dilute 10-15 mL of 10% calcium gluconate in 5000 units heparin, then dilute in 40 mL dextrose 5% in water (D5W)ElectricalAC- Alternating current- household current (more likely to induce fibrillation)DC- Direct current- car battery

Path of least resistance:electrical current will find the easiest way to travel through the body. Nerves tissue, muscle and blood vessels are easier to travel through than bone or fat. nervous system is particularly sensitive. damage seen in the brain, spinal cord and myelin-producing cells. Which muscle would you be most concerned about for electrical current to travel through?77Electrical burns

Source Unknown Lightning strikes

Pete Hunt, flickrhikers, campers, farmers, golfers. Tympanic membrane rupture, parathesias and fractures typical for lightning strikes.79