Chapter 14: Burns
contracture
- describe the position of contracture and the prevention position for burns to the following locations - anterior neck - axilla/shoulders - cubital fossa - ankle - posterior knee
burn severity
- determined by: burn size, burn depth, age (child vs adult) - categories help determine most appropriate setting - minor burn: generally treat as out-patient; partial or full thickness involving most of hands, face, or genitalia, circumferential burns, electrical, severe or extensive chemical, inhalation - moderate burn: generally treat as in-patient; assuming burns do not cover critical areas, pain adequately controlled, and no suspicion of abuse - major burn: generally treat in specialized burn unit; greater integumentary involvement, potential for concomitant organ system dysfunctions
rule of nines
- divides the integument into areas roughly equivalent to 9% of TBSA - head, front and back of each UE, front of each LE, back of each LE all represent 9% - anterior and posterior trunk each equal 18% of TBSA - perineum is 1% - this method consistently overestimates the size of the burn injury - variability, but clinician reliability improves with experience - fastest and easiest method
medical interventions: pharmacological management
- ensure adequate control of pain and anxiety - time procedures with meds - meds to manage infection - background, procedural, and breakthrough pain - breakthrough pain is episodic and more intense, not relieved by meds - background pain is there all the time - procedural related to interventions
superficial burns
- first degree - integumentary pattern B - dry, bright red, or pink skin that blanches upon pressure - no dermal vessel damage - resolves within 3-5 days without scarring - sunburn, minor flash burn - no edema or blisters - skin may peel after several days
cardiovascular system consequences for clinicians
- fluid resuscitation is of primary importance - blood pressure generally decreases as a result of hypovolemia - resting heart rate 100-120 bpm for adults - monitor peripheral pulses - must monitor and manage edema - increased care to ensure IV lines are not compromised - lower cardiac reserves for any increase in activity - dysrhythmias common after electrical injuries - vascular occlusion may result in ischemia and necrosis
integumentary system consequences for clinicians
be aware of: - bandages that are too tight - undue pressure from splints - improper patient positioning
pathophysiology of burn injuries: immune system
- 75% of burn pt deaths due to infection - sepsis and infection common - endogenous (on skin surface, hair follicles, in glands) and exogenous (from hospital personnel and equipment) bacteria - burn injuries change normal skin microflora - decreased tissue perfusion reduces immune system effectiveness - neutrophils less effective - eschar, blister fluid, residual topical agents excellent medium for bacterial growth - open wound for extensive periods of time
procedural interventions
- ROM: 2x/d to every joint --> most effective when during dressing changes - mobility training (AD as needed) - breathing ex - aerobic ex (target HR 50-70% HRmax) - LE burns should have compression wrap before getting up - during acute stage, limit pt from exceeding 20 bpm above resting HR
chemical burn injuries
- acids, bases, industrial agents, assaults - more likely to cause full-thickness damage severity influenced by: - alkaline burns more severe - contact time (burning continues until removed/diluted, therefore thoroughly irrigate for 20-30 mins) - chemical concentration - amount of chemical
immune system consequences for clinicians
- aggressive debridement and rapid skin coverage necessary to reduce risk of infection - follow infection-control guidelines - prophylactic topical antimicrobials
surgical interventions
- all are very costly - debridement: early debridement often performed on pts with medium and large full-thickness burns - escharotomy: incision through eschar and subcutaneous tissue to release tissue constricting circulation - escharotomy indications: unidentifiable distal pulses, cyanosis, delayed capillary refill, paresthesias, increasing pain - fasciotomy: incision through fascia to release pressure/improve distal circulation; most commonly after electrical burns that result in severe muscle trauma - skin grafting: mainstay for FT or DPT burns, autografts from uninvolved areas preferred, xenografts/cadaver allografts for temporary coverage; if wound is not expected to close within 3 weeks - split-thickness graft: removes epidermis and part of dermis, meshed (spaces allow wound to drain) or sheet - full-thickness graft: more durable and most cosmetic; removes epidermis and dermis - should be bandaged with light compression if placed in dependent position - skin substitutes (AlloDerm, Biograne, Integra): bilayered dressings with epidermal and dermal analog, used donor sites and wounds; decreased wound contracture, more for cosmetic scars, incorporated after 2-3 wks, involved wound does NOT need to me immobilized (diff than skin grafts) - cultured epithelial autografts: cultures pts own cells (keratinocytes), grown in lab and stapled/sutured in place, immobilized for 2 wks
pathophysiology of burn injuries: metabolism
- basal metabolic rate doubles or triples - increase in core temp - sustained hyperglycemia - increased fat catabolism - decrease in body mass - peaks 7-17 days post major burn injury - pt will have greater nutritional needs
pathophysiology of burn injuries: cardiovascular system
- burn shock: massive fluid shift causing hypovolemia and edema - results in decreased blood volume - tissue necrosis, organ failure, and death are possible - pts with >15% TBSA burns at high risk for burn shock - additional fluid lost directly from burned areas - decreased CO right after burn - increased hematocrit and blood viscosity slow BF - tissues become deprived of oxygen - administration of large amounts of venous fluids
debridement
- debride: foreign debris, residual topical agents, exudate, hair, necrotic tissue - remove blisters - consider enzymatic debridement if appropriate - most burns require repeated bouts of mechanical, sharp, and/or enzymatic - decrease inflammatory response, control or reduce risk of infection, enhance wound healing - do not remove tar or asphalt - enzymatic generally resolved for smaller burns
benefits of skin substitutes
- decrease evaporative water loss - maintain warm, moist wound environment - provide physical barrier to reduce risk of infection - provide thermal insulation - protect deeper tissues - promote granulation tissue formation - decrease pain - allow coverage of larger areas than would be possible with skin grafting alone - cannot be rejected by host tissues - require less frequent dressing changes - allow some visualization of wound bed - allow movement due to elasticity - decrease wound contraction - enhance wound healing - result in more cosmetically appealing scar formation
deep partial thickness burns
- deep second degree burns - integumentary pattern C - mottled areas of red with white eschar, blistering possible, may have areas of insensitivity - blanches to pressure with slow capillary refill - may take 3 or more weeks to heal - scarring, pigment changes, contractures possible - severe sunburn, scald, flash burn, brief contact with dilute chemicals - epidermis and dermis - epithelialize from periphery and from islands of epithelial tissue
subdermal burns
- fourth degree - integumentary pattern E - charred, mummified appearance - exposed deep tissues - burned areas insensate to light touch - may have permanent nerve damage - require surgery (fasciotomy, escharotomy, grafting) and possible amputation - electrical burn, strong chemical burn - destruction into fat, muscle, tendon, and/or bone - dry with minimal edema
classification and characteristics of burn injuries: depth of burn injuries
- historically, described in terms of degrees - now burns are more accurately described by level of tissue involvement - burns are usually not all one depth - infection can convert a partial-thickness burn to a full-thickness burn - chemical burns take 24-72 hrs to full develop - should use depth of burn and pt and wound characteristics to make wound healing prognosis
graft failure may be due to:
- infection - eschar - insufficient mobilization - fluid collection under graft - graft take can be improved with use of negative pressure wound therapy
pt/client related instructions
- instruct pts in ways to control pain - tell pts what to expect prior to procedures - instruct how to care for wounds including positioning techniques - educate pts on importance of skin care/scar management - apply moisturizers to scar tissue, minimize friction, protect from sun exposure, daily skin checks, importance of long-term compression
electrical burn injuries
- low and high voltage currents - entrance wound: depressed or charred - exit wound: larger, explosive - skin may not be severely damaged despite deep tissue injury due to differences in resistance - causes tetanic muscle contraction, preventing release from electrifying object, prolonging contact time, and worsening the burn - low voltage injuries typically from household items - high voltage = power lines, lightning bolt - may have concomitant injuries: fx, muscle necrosis, neurological injuries, cardiac, pulmonary, other organ failure severity influenced by: - high voltage current causes more damage - AC burn injuries more severe - contact time
scar management
- moisturizer - protect from friction and shear - scar mobilization - compression: mandatory if wound takes 3+ weeks to close - consider silicone gel sheets/pads, ultrasound, paraffin - darker-skinned individuals > incidence of hypertrophic scarring and keloids - silicone may reduce or prevent scarring of healed, intact, burnt skin - silicone may be expensive - scar mobs, ultrasound, parrafin once wound is closed to remodel scar tissue
dressings
- most common: topical antimicrobial covered with nonadherent impregnated gauze, bulky gauze dressing - limit bulk to allow/encourage movement, splint use - short-stretch compression wrap to decrease edema and scarring - burn wound surfaces should not be allowed to touch each other
complications to other systems possible
- multi organ system dysfunction - CNS dysfunction: hallucinations, delirium, personality changes, seizures - acute kidney failure - GI dysfunction/peristalsis/ileus/ulcers - encourage early, controlled mobility
contraindications to ROM
- nonstabilized fx - CV instability - extubation within 8 hours of tx - exposed tendons
psychological dysfunction
- post traumatic stress disorder - anxiety/depression/disturbed sleep - extremely common - side effects of meds, disruption of normal routine, emotional trauma - fear of death and pain common for the first few days
psychological dysfunction consequences for clinicians
- pt education, control pain and anxiety - promote pt independence - involve family and friends
Vancouver scar scale
- rates 4 scar qualities: vascularity, pliability, pigmentation, height - scores range from 0-14, lower scores indicate less severe scar tissue
PT interventions: coordination, communication, and documentation
- reinforce goals set by other disciplines - participate in pt rounds - pt education - give pts controls over their rehab - explain what to expect from procedures --> pain management
thermal burn injuries
- result from direct/indirect contact with flame, hot liquid, or steam - severity influenced by: contact time, temperature, type of insult
devices and equipment
- splints/braces: immobilize and protect grafts, fxs, peripheral nerve injuries - dynamic splints: assist w/ contractures
superficial partial-thickness burns
- superficial second degree - integumentary pattern C - painful, moist, weeping, blistered skin with local erythema and edema - blanches to pressure with immediate capillary refill - heal within 10-14 days with minimal or no scarring - brief contact burns, flash burns, brief contact with dilute chemicals - extremely painful due to exposed nerve endings, particularly sensitive to air and pressure - may be pigment changes after healing due to melanocyte destruction
pulmonary system consequences for clinicians
- suspect lung involvement if singed facial hair, carbonaceous sputum, closed space injury, burns to face/neck/torso - monitor for signs of breathing difficulties - monitor oxygen saturation - encourage aggressive pulmonary hygiene
lund-browder classification
- takes into account variation of body proportion from child to adult - appropriate for children under age 16 - preferred by pediatric burn units
full thickness burns
- third degree - integumentary pattern D - initially look red then become mottled white/black, dry, leathery eschar, very painful - burned areas are insensate to light touch - scarring and contractures likely - most require surgical debridement and grafting - prolonged contact with flame, immersion scald injury - damage into subcutaneous tissue - book says there is little surface pain bc nerves are destroyed - damaged surrounding areas likely to be very painful - at risk for hypertrophic scarring and contractures - hair and glands will not be present in scar tissue
infection control
- use sterile technique for large TBSA burns - topical antimicrobials are standard (silver sulfadiazine, mefanide acetate, bacitracin) - signs of infection: increasing erythema/pain, four odor, purulence, increase in necrosis, fever, increased tachycardia - clean technique sufficient for smaller, superficial burns - increase in purulent drainage with infection
palmar method
- uses the area of palmar surface of the hand to determine burn size - highly unreliable, inaccurate
etiology of burns
- when energy is transferred from a heat source to the body - cell death when heat absorption is greater than dissipation and temp rises
physical agents and modalities
- whirlpool: remove necrotic tissue/topical agents, soften eschar, easier ROM; use liner to limit cross-contamination; additives contraindicated for chemical burns - pulsed lavage with suction: smaller wounds - ultrasound and parrafin for maturation and remodeling phase
burn severity classification
minor: - adult = <2% FT, <10% PT - child = <1% FT, <5% PT moderate: - adult = 2-5% FT, 10-20% PT - child = 1-5% FT, 5-10% PT major: - adult = >5% FT, >20% PT - child = >5% FT, >10% PT
pluronic/plurogel
nice product to use for burn pts --> healing and infection prevention
etiology of burn injuries: pulmonary system
possible consequences: - smoke inhalation, carbon monoxide poisoning, acute respiratory distress syndrome, pulmonary edema, pneumonia - CO: 200 times more affinity to bind with Hb inhalation injuries cause up to 20% of burn deaths mucociliary damage may prevent clearance of debris
estimation of burn size
rule of nines Lund-Browder classification palmar method
precautions
screen for domestic violence anticipate/prevent complications when possible: - contractures - infections - deconditioning - pulmonary dysfunction - pressure ulcers ensure adequate pain control
types of burns
thermal (most common) chemical electrical
pathophysiology of burn injuries: integumentary system
zone of coagulation: - central portion, irreparable damage - characterized by coagulation, ischemia, necrosis zone of stasis: - area of cellular injury and compromised perfusion - conversion: widening and deepening of necrosis zone of hyperemia: - outer edges, minimal cellular injury - received the least thermal injury - erythema due to vasodilation - recovers in 7-10 days