NR368 Ch. 57: Management of Patients with Burn Injury

Burn wound care: *Use of topical agents*

*Mafenide acetate* (specific to burn patients): Antimicrobial that goes through/penetrates eschar; Applied 2x a day; Can contribute to metabolic acidosis; May cause pain with application *Silver nitrate* *Silver sulfadiazine*

Management of Shock — Fluid Resuscitation

*Maintain...* - BP of >100 systolic - Urine output of 30-50 mL/hr - Serum sodium at near-normal levels Consensus formula, Evans formula, Brooke Army formula, Parkland Baxter formula, & Hypertonic saline formula - *Math formulas that determine amount fluid resuscitation*

Effects of Major Burn Injury: *Renal alterations*

*Metabolic acidosis* ... Why? Acute kidney injury/failure due to hypoperfusion - If they're losing volume, they're hypovolemic, so a burn patient is risk for AKI or AKF → expect them to have metabolic acidosis (look at their ABG)

1st Degree Burns

*Partial Thickness* Affects only the outer epidermal layer ex. Bad sunburn, Hot water burn

2nd Degree Burns

*Partial Thickness* Affects the entire epidermis + parts of the dermis

Graft sites

*Should be beefy red* - Report if it looks dusky *Immobilization* *Check tissue perfusion* (capillary refill, pulses around the area, elevate or do not elevate depending on surgeon)

Flash

*Sudden ignition of short duration* Associated with the ignition of explosives, gasoline, or combustibles

Scald burns

*Unique pattern*; *Dripping pattern* - can see where it happened

What are the effects of a major burn injury?

Fluid and electrolyte shifts Cardiovascular effects Pulmonary injury Renal alterations GI alterations Immunologic alterations Effect on thermoregulation

With electrical burns, what should we focus on

Focus on *external care* AND the *heart* (electrical activity - close cardiac monitoring) ... ... Electrical burn patients are at risk for dysrhythmias

How long does the emergent/resuscitative phase last?

From the onset of injury to completion of fluid resuscitation

What is the goal of nutritional support for burn patients

GOAL: To promote a state of nitrogen balance & match nutrient utilization

Burns: Factors to consider...

How the injury occurred (ex. flash) Causative agent (ex. flame or scalding liquid) Temperature of the agent Duration of contact with the agent (ex. hot oil has a longer exposure than water) Thickness of the skin at injury site

Effects of Major Burn Injury: *Cardiovascular effects*

If they're losing fluids & blood, their SV is going dow and HR will increase ... eventually their CO will decrease - (CO = SV x HR) Prone to dysrhythmias

Where do most burns occur?

In the home

Escharotomy

Incision made into eschar (necrotic tissue) resulting from a severe burn Relieves compartment syndrome

Fasciotomy

Incision made through the fascia to relieve pressure (deeper than escharotomy) Relieves compartment syndrome - Infection & bleeding control - Can see adipose tissue

Voltage: *High voltage*

Industrial panels >1000V

Voltage: *Low voltage*

Less than 1000V

Effects of Major Burn Injury: * Fluid & electrolyte shifts*

Losing fluids (bleeding, skin protective layer is gone, serous fluid is leaking out, part of their microvasculature) Hypovolemic state

What is done for compartment syndrome?

Escharotomy and Fasciotomy

*Acute/Intermediate Phase* of burn care

*48 to 72 hours after injury* (Fluid resuscitation is complete)

*Acute/Intermediate Phase* - Collaborative Problems and Potential Complications

*Acute respiratory failure* & *Acute respiratory distress syndrome* *Heart failure* - due to all of this fluid resuscitation *Pulmonary edema* - due to all of this fluid resuscitation *Sepsis* *Delirium* *Visceral damage* (specific to electrical burns)

Pain management for burn care

*Analgesics* (morphine, opioids) - IV use during emergent and acute phases - Morphine, Fentanyl, + others Role of anxiety in pain → May benefit from *very low anxiolytics* *Effect of sleep deprivation on pain* *Non-pharmacologic measures*

What are the types of burn pain?

*Background* or *resting* = Always there, never goes away *Procedural* = Occurs with dressing changes or therapies (premedicate them) *Breakthrough* = Moments of pain (getting out of bed)

Contact burns

*Contact with hot object* - Radiator - Heat pipe - Oven door - Hot pan or pan handle - Muffler - Playground apparatus

*Acute/Intermediate Phase* - Fluid and Electrolyte Shifts (what to expect)

*Fluid re-enters the vascular space from the interstitial space* *Hemodilution* *Increased urinary output* Sodium is lost with diuresis ad due to dilution as fluid enters the vascular space: *Hyponatremia* Potassium shifts from the extracellular fluid into the cells: *Potential hypokalemia* *Metabolic acidosis*

3rd Degree Burns

*Full Thickness* Total deconstruction of the epidermis, dermis, and underlying tissue Lack of sensation/pain (due to nerves being affected)

*Emergent/Resuscitative Phase* - Fluid and Electrotype Shifts

*Generalized dehydration* (losing fluid & blood) *Reduced blood volume* and *hemoconcentration* (H&H elevated) *Decreased urine output* Trauma causes the release of potassium into extracellular fluid: *Hyperkalemia* Sodium traps in edema fluid (interstitial space) and shifts into cells as potassium is released: *Hyponatremia* *Metabolic acidosis*

Electrical burns

*High vs Low voltage* - learn what was the voltage !! *Entry vs Exit wounds* - where did the electricity go?? + evaluate for any internal damage !!

Burn wound care: *Wound Cleaning*

*Hydrotherapy*: Specialized bathing room cycle (cleaned between patients) *Special bathtubs and showers*

What are the 3 phases of burn care?

1. *Emergent/Resuscitative* 2. *Acute* 3. *Rehabilitative*

Voltage: *Home electrical*

120V

Major burn

20-30% of more of TBSA burned - (through an assessment of the nines)

Second survey

AMPLET A- Allergies: drug and environmental M- Medications: prescription, OTC, herbal, illicit, ETOH P- Previous illness: DM, HTN, cardiac, renal disease, seizure disorder, mental illness, injury, pregnancy L- Last meal or drink (gives a sense of what to expect in their belly) E- Events/environmental related to injury T- Tetanus and childhood immunizations

*Emergent/Resuscitative Phase of Burn Injury*: Potential Complications

Acute respiratory failure (ARDs) Distributive shock Acute kidney injury Compartment syndrome Paralytic ileus Curling's ulcer

Name the kinds of grafts

Allograft & Autograft

What is the nutritional support for burn patients based off of?

Based off their pre-burned status & the percentage of TBSA burned

Pathophysiology of Burns

Burns are caused by *chemical injury* or a *transfer of heat from one site to another* Thermal (includes electrical) - Most common site: skin & mucosa of the upper airway Radiation - Think of the cancer patient → can have burn injury from radiation

Emergent/Resuscitative Phase - Potential Complications: *Compartment syndrome*

Burns can cause swelling, which can lead to poor capillary refill, cannot palpate the pulse well - (ex. A pulse deficit of 40 when comparing their arm and the machine) Burns cause swelling, which can lead to compartment syndrome *Pressure of the compartment is too high for the body to handle & circulation becomes impaired*

Emergent/Resuscitative Phase - Potential Complications: *Paralytic ileus*

Can be because of... - compartment syndrome and impending nerve involvement, - or metabolic demands of the body due to this injury If at risk for this, anticipate an order for an NG tube to decompress the GI system

What is done during the acute/intermediate phase of burn care?

Continue assessment and maintain... - respiratory and circulatory support - fluid & electrolyte balance - GI and renal function Prevention of infection Burn wound care Pain management Modulation of the hypermetabolic response Early positioning/mobility

Nutritional support for burn patients: Which route is preferred?

Enteral route - Jejunal feedings - Can use TPN (paralytic ileus, ulcer), but if their GI tract is alright they'll do a jejunal feeding (less risk of aspiration than gastrostomy tube)

Chemical burns

Damage caused to the skin by chemicals; *Prolific use of lithium batteries*... can explode, causing chemical burns

4th Degree Burns

Deep burn necrosis Extends into deep tissue, muscle, or bone (think ligaments, cartilage, etc.)

Home Care Instruction for Burn Patients

Mental health Skin and wound care Exercise and activity Nutrition Pain management Thermoregulation and clothing Sexual issues

Palmer method

Method used to estimate the extent of scattered burns Size of the patient's hand (extended) including fingers is 1% TBSA - Measure the burn area and divide by the patient's hand = TBSA

Rule of nines

Most common method to estimate TBSA burned Based on anatomic regions ex. About half of their chest burned with the majority of left arm = 18%

Burn wound care: *Wound debridement*

Natural debridement: You get a cut and your body takes care of self Mechanical debridement Surgical debridement

What are some complications of burns?

Neuropathies & nerve entrapment Wound breakdown or pressure injury formation Hypertrophic scarring Contractures Joint instability

Burn pain

One of the most severe forms of acute pain... Can lead to chronic pain Pain accompanies care & treatments (incidental pain - premedicate !!)

Psychosocial Support for burn patients

Patient's outlook, motivation, and support system are important to overall well-being and ability to progress Psychological support of patient and family Early consultation with mental health professionals Discharge planning for reintegration Support groups Organizations

*Emergent/Resuscitative Phase* - On the scene care...

Prevent injury to the rescuer Stop the injury: extinguish flames, cool the burn, irrigate chemical burns A - If fall/electrical injury, then there's a potential neck injury (cervical immobilization) B - Ventilate/Oxygenate C - Remove restrictive objects, Large bore IV (18G), Cover wounds D - If they have any disabilities E - Exposure/environment; What was the scene like D - Do a quick assessment of all body systems & obtain a history

What are the goals of burn care?

Prevention Institution of lifesaving measures for the severely burned person Prevention of disability and disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs

Why is nutritional support important for burn care?

Profound metabolic abnormalities = Great nutritional needs - stress response, hypermetabolism, and requirement for wound healing 2-3 times the normal calories per day (TPN)

*Rehabilitation Phase* of Burn Care

Rehabilitation is done as early as possible and extends for a long period after the injury *Focus on...* wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality of life both personally & socially Patient may need reconstructive surgery to improve function and appearance Vocational counseling & support groups may assist the patient

Effects of Major Burn Injury: *Effect on thermoregulation*

Risk for hypothermia

What is a risk associated with flash burns?

Risk of inhalation injuries ... If they inhale at the same time of the flash, whatever was in that exposure is flashing internally as well ... Can have internal redness & swelling → may hear diminished breath sounds, may hear stridor Do they have a cough? Are they bringing up soot? Put them on a continuous pulse ox

Name the methods to estimate total body surface area (TBSA) burned:

Rule of nines Palmer method

Effects of Major Burn Injury: *Immunologic alterations*

Skin barrier protects, now it's gone

Emergent/Resuscitative Phase - Potential Complications: *Curling's ulcer*

Stress on the body; Body is in a hypermetabolic state, meaning it is at risk for gastric ulcers) Put the patient on PPIs and decrease complications

Effects of Major Burn Injury: *Pulmonary injury*

Upper and lower airway Carbon monoxide poisoning (cherry red lips) Restrictive defects

Describe the different types of burn wound care:

Wound cleaning Use of topical agents Debridement (natural, mechanical, surgical) Wound dressing, Dressing changes, and Skin grafting

In which age groups do burns most occur?

Young children & Older adults

Zones of burn injury

Zone of coagulation Zone of stasis Zone of hyperemia

TBSA

total body surface area