Burns - Level 4

Wound Care

-partial thickness burn wounds appear pink to cherry-red and are wet and shiny w serous exudate -may or may not have intact blisters that are painful to touch -only minor localized sensation from destroyed nerve endings -perform cleansing and gentle debridement with scissors and forceps -done on cart shower, regular shower, bed, or stretcher -extensive surgical debridement may be done in OR -necrotic skin is removed -infection may cause further tissue injury and sepsis -source of infection often from pts own flora -prevention of cross contamination from one pt to another is a priority -2 approaches to wound care: -1: open method, covered w topical antimicrobial but no dressing -2: multiple dressing changes, sterile gauze dressings are impregnated w or laid over a topical antimicrobial -most burn centers support the concept of moist wound healing -whenever the open wounds are exposed, wear PPE -use sterile gloves when applying ointments and sterile dressings -prevent shivering by keeping the room warm -permanent skin coverage is the primary goal for burn wound care, there is rarely enough unburned skin in the major burn pt for immediate skin grafting -this requires the use of temporary wound closure methods -allograft skin (from skin donor cadavers is used along w biosynthetic options

Wound Care in Acute Phase

-prevent infection -promote wound re-epithelialization and/or successful skin grafting -ongoing observation, assessment, cleansing debridement, dressing changes, topical antimicrobial therapy -enzymatic debridement: speeds up the removal of dead tissue from the healthy wound bed -when the partial-thickness burn wounds have been fully debride, a protective coarse or fine-meshed, greasy-base gauze dressing is applied to protect the keratinocytes -facial grafts: the unmeshed sheet graft is left open so it is possible for blebs (serosanguinous exudate) to form between the grafts and the recipient bed -prevent the graft from permanently attaching to the wound bed

Prehospital care

-remove the person from the source -stopping the burning process -small thermal burns: cover w clean, cool tap water dampened towel -cooling area within 1 min helps minimize the depth of the injury -large burns or electrical or inhalation burn: attention to ABCs -airway patency -check for presence and regularity of pulses -elevate the burned limb above the heart -prevent hypothermia: cool large burns no more than 10 mins -do not immerse the burned body part in cool water, risk for hypothermia -never cover a burn w ice, can cause hypothermia and vasoconstriction -remove as much burned clothing as possible -remove any chemical particles -chemical burns: flush the affected are w copious amounts of water for 20 mins-2hrs -if CO poisoning suspected: 100% humidified O2

Electrical Burns

-result from intense heat generated from an electrical current -direct damage to nerves and vessels causes tissue anoxia and death -severity depends on: amount of voltage, tissue resistance, current pathways, surface area in contact w the current, length of time -different tissues offer different amounts of resistance: fat and bone offer the most, nerves and blood vessels offer the least -preform rapid assessment -transfer to burn center -severity can be difficult to determine -Iceberg effect: most of the damage is below the skin -determine the electric current contact points -contact can cause muscle contractions strong enough to fracture the long bones and vertebrae -all pts w an electrical burn should be considered at risk for a potential cervical spine injury -spine immobilization until rule out -risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria -can cause immediate cardiac standstill or v fib -delayed cardiac dysthymia or arrest may also occur without warning during the first 24 hrs -myoglobin from injured muscle tissue ad hemoglobin from damaged RBCs are released into the circulation whenever massive damage occurs -can travel to the kidneys and bock the renal tubules leading to AKI

Chemical burns

-result of contact w acids, alkalis, and organic compounds -acids: hydrochloric, oxalic, and hydrofluoric acid -alkali: oven and drain cleaners, fertilizers, heavy industrial cleaners -more difficult to treat -alkalis adhere to tissue causing protein hydrolysis and liquefaction -organic compounds: phenols (chemical disinfectants, petroleum products (creosote and gasoline) -produce contact burns and systemic toxicity

Upper Airway Injury

-results from an inhalation injury to the mouth, oropharynx and or larynx -may be caused by thermal burns or the inhalation of hot air, steam, or smoke -Signs: blisters, edema, hoarseness, difficulty swallowing, copious secretions, stridor, substernal and intercostal retractions -total airway obstruction may occur from selling and constricting edema

Emergent phase

-resuscitative phase -time required to resolve immediate, life threatening problems -usually lasts up to 72 hrs -primary concerns: hypovolemic shock and edema formation -ends when fluid mobilization and diuresis begin

Location of burn

-severity also determined by location -face and neck, circumferential burns to chest or back: may interfere with breathing -hands, feet, joints, and eyes: make self care difficult and may jeopardize future function -hands and feet: challenging because of superficial vascular and nerve supply systems that need to be protected while the burn wounds are healing -ear and nose: susceptible to infection, poor blood supply -buttocks or perineum: high susceptible to infection from urine or feces contamination -extremities: may have circulation problems, possible nerve damage, may develop compartment syndrome from direct heat damage to the muscles

Depth of Burn

-skin is divided by 3 layers: epidermis, dermis, and subcutaneous tissue -epidermis: nonvascular, about as thick as a sheet of paper -dermis: below the epidermis, approx 30-45 times thicker then the epidermis -contains connective tissues w blood vessels, hair follicles, nerve endings, sweat glands, and sebaceous glands -if significant damage occurs not enough skin cells remain to regenerate new skin and a alternative is needed -subcutaneous tissue: acts as a heat insulator for underlying structures -also defined by degrees: 1st, 2nd, 3rd, and 4th -partial thickness burns -full thickness burns

Other care measures

-the face is highly vascular and can become very swollen -it is often covered w ointments and gauze but not wrapped -eye care for corneal burns or edema: antibiotic ointments -if periorbital edema prevents eye opening: instill methyl cellulose drops or artificial tears for moisture -do not use pillows for pts w ear burns -elevate the head using a rolled towel under the shoulders -elevate burned hands and arms on pillows to minimize edema -ROM exercises facilitate mobilization of the leaked fluid back into the vascular bed -IV pain med should be given in the early post burn period -opioids are the drug of choice -sedatives, hypnotics, and antidepressants can be given to for anxiety, depression, and insomnia -tetanus taxied is given routinely to all burn pts -if the pt has not received an active immunization within 10 yrs before the burn, tetanus immunoglobulin also -systemic antibiotics not routinely given for burn wound flora because the burn eschar has little or no blood supply -sepsis is still a primary cause of death -systemic antibiotic therapy is initiated when sepsis diagnosis is made or another source of infection is identified

Metabolic asphyxiation

-the result of inhaling certain smoke elements: carbon monoxide or hydrogen cyanide -oxygen delivery is impaired -hypoxia results -death results when carboxyhemoglobin blood levels are > 20% -carbon monoxide and hydrogen cyanide poisoning may occur without a burn to the skin

Immune changes

-the skin barrier is destroyed -greater risk for infection

Complications of Burns

CARDIOVASCULAR -dysrhythmias -hypovolemic shock -impaired circulation and edema formation can act like a tourniquet -ischemia, paresthesias, and necrosis can occur -escharotomy: a scalpel or electrocautery incision through the full-thickness eschar may be needed, restores circulation -sludging: a phenomenon caused by the increased blood viscosity that occurs from fluid loss and the damage to small capillaries -can be corrected by fluid replacement RESPIRATORY -may require bronchoscopy and carboxyhemoglobin blood levels to confirm an inhalation injury -examine sputum for carbon -watch for signs of respiratory distress: increased agitation, anxiety, restlessness, or a change in the rate or character of the pts breathing -CXR and ABGs may appear normal on admission but change over 24-48 hrs -if fluid replacement to vigorous: heart failure and pulmonary edema could occur -hemodynamic monitoring may be necessary -pneumonia: common, leading cause of death in pts w inhalation injury -increased risk for VTE if: advanced age, obesity, extensive or lower extremity burns, prolonged immobility -VTE prophylaxis w enoxaparin URINARY -acute tubular necrosis common -hypovolemia causes decreased blood flow to kidneys, renal ischemia, and AKI -myoglobin and hemoglobin may occlude renal tubules -fluid replacement can counteract

Extent of a burn

-2 common guides -Lund-Browder chart (considered more accurate, takes into account age and size) -Rule of Nines (often for initial assessment)

Artificial Skin

-Integra artificial skin dermal regeneration template, used when conventional autograft unavailable -composed of acellular dermis and silicone -later, silicone is removed during a second surgical procedure and replaced by the pts own epidermal autografts -AlloDerm: human allograft dermis harvested from cadavers -decellularized to render it immunogenic, then freeze dried

Lower airway injury

-an inhalation injury to the trachea, bronchioles, and alveoli -damage is related to the duration of exposure -pulmonary edema may not appear until 12-24 hrs after the burn

Pt risk factors

-any pt w preexisting cardiovascular, respiratory, or renal disease has a poorer prognosis -DM or peripheral vascular disease: high risk of poor wound healing

Clinical manifestations of burn injuries

-areas of full-thickness and deep partial thickness burns may be anesthetic due to nerve endings being destroyed -superficial and moderate burns: very painful -larger burns: pt may develop paralytic ileus w decreased or absent bowel sounds -shivering may occur: from chilling caused by heat loss, anxiety, and pain -unconsciousness or altered LOC: most often occurs from hypoxia related to smoke inhalation

Fluid therpy

-at least 2 large born IV access sites for pt w burns that are 15% or more -burns greater than 30% consider a central line for fluid and drug administration -arterial line often needed for ABGs and invasive BP monitoring -use standardized formula to estimate the pts fluid resuscitation requirements -usually crystalloid solutions: LR and colloids (albumin) -Parkland (Baxter) formula the most commonly used -even with the formula, fluids still need to be titrated based on the pt response (hourly urine output, VS) -pt w a chemical injury have greater than normal fluid requirements, may need osmotic diuretic (mannitol) -for the last 24 hrs: 2-4 mL LR/kg/%TBSA burned recommended -5% albumin recommended after the first 12-24 hrs post burn, when capillary permeability returns -replacement vol calculated based on the pts body weight and TBSA burned -adequacy of fluid resuscitation estimated by: -urine output: 0.5-1 mL/kg/hr, 75-100 mL/hr for electrical burn pt w evidence of hemoglobinuria or myoglobinuria -cardiac parameters: MAP > than 65 mm Hg, SBP > 90, HR < 120

Rehabilitation phase

-begins when the pts wounds have healed and they are engaging in some level of self-care -can occur as early as 2 weeks or as long as 7 to 8 months after -work toward resuming a functional role -rehabilitate from any functional and cosmetic post burn reconstructive surgery -burns heal either by spontaneous re-epithelialization or by skin grafting -if adequate ROM is not institutes, the new tissue will shorten causing contracture -mature healing takes about 12 months -itching frequently occurs, use water-based moisturizers, oral antihistamines (hydroxyzine) -newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch -teach pts to protect healed burn areas from direct sunlight for about 3 months -skin matures at around 1 yr

Acute phase

-begins with the mobilization of extracellular fluid and subsequent diuresis -concludes when partial-thickness wounds are healed or full-thickness burns are covered by sin grafts -may take weeks or months -diuresis from fluid mobilization occurs and the pt is less edematous -bowel sounds return -pt becomes more aware of the situation -some healing begins -necrotic tissue begins to slough off -a partial-thickness wound will from both the wound edges and the dermal bed below if kept free from infection and desiccation (dryness) -eschar begins separating fairly soon after injury -full thickness burn wounds must have the burn eschar surgically removed and skin grafts applied in order to heal -then wound margins appear as red or pink scar tissue -healing of partial-thickness burns is spontaneous and usually occurs within 10-21 days -margins of full-thickness eschar taken longer to separate

Inflammation and healing

-burn injury to tissue and vessels lead to neutrophils and monocytes accumulating at the site -fibroblasts and newly formed collagen fibrils appear and begin wound repair within the first 6-12 hrs after injury

Pain Management

-burn pts experience two kinds of pain: continuous background pain and treatment-induced pain (dressing changes, ambulation, rehab) -background pain: managed w con IV infusion of an opioid -breakthrough doses should be available -treatment induced pain: Premedicate w an analgesic and anxiolytic via IV or oral route -elimination of all pain is difficult

Smoke and inhalation injuries

-caused by breathing hot air or noxious chemical -damage the respiratory tract -3 types -metabolic asphyxiation -upper airway injury -lower airway injury -major predictor of mortality

Thermal burn

-caused by flame, flash, scald, or contact with hot objects -most common -severity depend on temp and duration

PT and OT

-con PT and OT needed throughout burn recovery needed for pt to regain and maintain muscle strength and optimal joint function -good time is during and after wound cleansing when skin is softer

Classifying Burns

-depth of burn -extend of burn (cal in percent of total body surface area) -location -pt risk factors

Airway management

-early intubation (preferably orotracheal) -pt w burns to ave and neck requires intubation within 1-2 hrs after injury -ventilatory support -extubation may be possible when the edema resolves, usually 3-6 days after injury -escharotomies of the chest wall may be needed -within 6-12 hrs after the injury when smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway -administration of 100% O2 may be needed if no intubation -high fowlers position -encourage deep breathing and coughing -provide suctioning and physiotherapy may be needed -PEEP may be used to prevent collapse of the alveoli and progressive respiratory failure

Excision and grafting

-early removal (surgical excision) of the necrotic tissue -then application of split-thickness autograft skin -many pts are taken to the OR for wound excision on day 1 or 2 -wounds covered w a biologic dressing or allograft until permanent grafting can occur -devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia -surgical excision can result in massive blood loss, to decrease topical application of epinephrine or thrombin injection of saline and epinephrine , application of extremity tourniquets or application of a new fibrin sealant is used -a graft is place on clean, viable tissue to achieve good adherence -whenever possible autograft used: persons own skin -fibrin sealant can be used to attach skin grafts to the wound bed, staples and sutures can also be used -temporary allograft can be used to test the suitability of site to accept graft -w early excision, function is restored and scar tissue formation is minimized -clots between the graft and the wound keep the graft from adhering to the wound -outer occlusive dressings apply pressure to promote adherence and help control blood -donor skin is taken from the pt for grafting by means of a dermatome: removes a thin split-thickness layer -average healing time of a donor takes 10-14 days -cultured epithelial autograft (CEA): -a method of obtaining permanent skin from a person with limited skin available for harvesting -grown from biopsy specimens obtained from the pt own unburned skin -the biopsied keratinocytes are grown in a culture medium containing epidermal growth factor -after approx. 18-25 days the keratinocytes form sheets that can be used as skin grafts -complications: a poor graft take due to thin epidermal skin, graft loss during healing, infection, and contractures

Lab values in the Acute phase

-hyponatremia: can develop from excessive SI suction, diarrhea, and water intake -symptoms: weakness, dizziness, muscle cramps, fatigue, HA, tachycardia, confusion -water intoxication: can occur from dilutional hyponatremia, encourage drinking fluids other than water to avoid this -hypernatremia: may been seen later after successful fluid resuscitation, or related to tube feedings -symptoms: thirst, dried/furry tongue, lethargy, confusion, seizures -hyperkalemia, if pt has renal failure, adrenocortical insufficiency, or massive deep muscle injury (potassium is released from damaged cells) -symptoms: cardiac dysrhythmias, arrest, muscle weakness, cramping, paralysis -hypokalemia: can occur from vomiting, diarrhea, prolonged GI suction, and IV therapy without potassium supplementation, also lost through the pts burn wounds -symptoms: fatigue, muscle weakness, leg cramps, cardiac dysrhythmias, paresthesia, decreased reflexes

Fluid and Electrolyte shifts

-hypovolemic shock: greatest initial threat -caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability -can begin as early as 20 min after burn -capillary walls become more permeable -water, sodium, and proteins (albumin) move into the interstitial spaces -colloidal osmotic pressure decreases -more fluid shifts into vascular space -second spacing: fluid accumulation in the interstitium -third spacing: fluid moves to areas that normally have minimal to no fluid (exudate and blister formation and edema in non burned areas) -burns also increase insensible losses -net result = intravascular volume depletion -clinical signs: low BP, tachycardia -shock and death could result -circulatory system effected by hemolysis of RBCs -thrombosis in the capillaries of burned tissue causes additional loss of RBCs -hematocrit initially elevated due to fluid loss -when fluid restored, drops -monitor electrolyte shifts of sodium and potassium -sodium moves into interstitial spaces -potassium shifts develop because of injured cells and hemolyzed RBCs excrete potassium -at the end of the emergent phase: capillary membrane permeability is restored if fluid replacement is adequate -diuresis occurs and urine has low specific gravity

Complications of the Acute Phase

-infection: if the levels of bacteria between the eschar and the viable wound bed rise greater than 1000000 g of tissue, the pt has a burn wound infection -inflammation, induration, and sometimes suppuration can be seen at the burn wound margins -may be treated w systemic antibiotics based on culture/sensitivity -symptoms: hyper or hypothermia, tachycardia, increased RR, decreased BP, decreased UO, mild confusion, chills, malaise, loss of appetite, increased WBC -may be immunosuppressed for many months -immediately obtain cultures if suspected from all possible sources -treat immediately w antibiotics and alter when sensitivity results are available -cardiovascular and respiratory symptom complications may continue from the emergent phase -usually has no neuro symptoms, unless severe hypoxia -pt can become extremely disoriented, may withdraw or become combative, may have hallucinations and frequent nightmare-like episodes -focus on orienting your pt -state is usually transient -musculoskeletal: as the burns begin to heal and scar tissue forms, skin is less supple and pliant, ROM may be limited -contracture can occur -due to pain, pt less likely to stretch and move -use proper positioning and splinting to prevent contractures -GI: paralytic ileus can be caused by sepsis -diarrhea may result from enteral feedings or antibiotics -constipation can occur from opioid analgesics, decreased mobility -Curling's ulcer: a type of gastroduodenal ulcer characterized by diffuse superficial lesions, caused by a generalized stress response to decreased blood flow to the GI tract -the pt has increased gastric acid secretion -prevention: feeding the pt as soon as possible, prophylactic PPIs, H2-histamine blockers, ranitidine -pts w major burns may have occult blood in their stools during the acute phase -endocrine: observe for transient increases in the pt blood glucose levels as a result of stress-mediated cortisol and catecholamine release -insulin's effectiveness is decreased -when hyperglycemia occurs treat w supplemental IV insulin

Nutritional Therapy for burns

-nutrition takes priority in the initial emergent phase after fluid therapy -early aggressive nutritional support within several hrs of the burn injury can decrease mortality -non-intubated pts with TBSA < 20% can usually meet nutritional needs -intubated pts or those w larger burns: enteral feedings (gastric or intestinal) -begin feedings at a slow rate, increase to the goal within 24-48 hrs -hypermetabolic state proportional to the size of the wound occurs in major burns -resting metabolic expenditure may be increased by 50-100% above normal -core temp is elevated -Pt may benefit from an antioxidant protocol: selenium, acetylcysteine, ascorbic acid, vit E, zinc, and multivitamin