Burns Chapter 25

Parkland (Baxter) Formula

•4 mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface area (% TBSA) burned = Total fluid requirements for first 24 hr after burn Application •½ of total in first 8 hr •¼ of total in second 8 hr •¼ of total in third 8 hr

Prehospital Care

•At the scene of the injury, priority is given to removing the person from the source of the burn and stopping the burning process. •In the case of electrical and chemical injuries, initial management involves removal of the patient from contact with the electrical or chemical source. •Communicate the circumstances of the injury involves being trapped in a closed space, exposure to hazardous chemicals or electricity, or a possible traumatic injury (e.g., fall).

Acute Phase

•This phase of burn care begins with the mobilization of extracellular fluid and subsequent diuresis. •It concludes when partial-thickness wounds are healed or full-thickness burns are covered by skin grafts. •This may take weeks or months.

Full-Thickness Skin Destruction (third- and fourth-degree burns)

Appearance: •Dry, waxy white, leathery, or hard skin •Visible thrombosed vessels •Insensitivity to pain because of nerve destruction. •Possible involvement of muscles, tendons, and bones. Possible Cause: •Flame, Scald, Chemical, Tar, Electric current Structures Involved: •All skin elements and local nerve endings destroyed. •Coagulation necrosis present. •Surgical intervention required for healing.

Superficial Partial-Thickness Burn (first-degree)

Appearance: •Erythema •Blanching on pressure •Pain and mild swelling •No vesicles or blisters (although after 24 hr skin may blister and peel). Possible Cause: •Superficial sunburn, Quick heat flash Structures Involved: •Superficial epidermal damage with hyperemia (excess of blood in the vessels) •Tactile and pain sensation intact

Deep Partial-Thickness Burn (second-degree)

Appearance: •Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured). •Severe pain caused by nerve injury •Mild to moderate edema Possible Cause: •Flame, Flash, Scald, Contact burns, Chemical, Tar, Electric current Structures Involved: •Epidermis and dermis involved to varying depths. •Skin elements, from which epithelial regeneration occurs, remain viable.

Nutritional Therapy: Emergent Phase

Early and aggressive nutritional support within several hours of the burn injury can: •Decrease mortality risks and complications •Optimize healing of the burn wound •Minimize the negative effects of hypermetabolism and catabolism. •Nonintubated patients with a burn of less than 20% TBSA will generally be able to eat enough to meet their nutritional needs. •Intubated patients and those with larger burns require additional support. •Enteral feedings (gastric or intestinal) have almost entirely replaced parenteral feeding. •Early enteral feeding, usually with smaller-bore tubes: Preserves GI function Increases intestinal blood flow Promotes optimal conditions for wound healing •In general, begin the feedings slowly at a rate of 20 to 40 mL/hr and increase to the goal rate within 24 to 48 hours. •If a large nasogastric tube is inserted, gastric residuals should be checked to rule out delayed gastric emptying. •Assess bowel sounds every 8 hours. •A hypermetabolic state proportional to the size of the wound occurs after a major burn injury. •Resting metabolic expenditure may be increased by 50% to 100% above normal in patients with major burns. •Core temperature is elevated. •Catecholamines, which stimulate catabolism and heat production, are increased. •Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. •Failure to supply adequate calories and protein leads to malnutrition and delayed healing. •Calorie-containing nutritional supplements and milkshakes are often given to meet the caloric needs. •Protein powder can also be added to food and liquids. •Supplemental vitamins may be started in the emergent phase •Iron supplements are often given in the acute phase

Prehospital Care: Chemical Burns

•Chemical burns are best treated by quickly removing any chemical particles or powder from the skin. •Remove all clothing containing the chemical because the burning process continues while the chemical is in contact with the skin. •Flush the affected area with copious amounts of water to irrigate the skin anywhere from 20 minutes to 2 hours postexposure. •Tap water is acceptable for flushing eyes exposed to chemicals. •Tissue destruction may continue for up to 72 hours after contact with some chemicals.

The Rule of Nines:

•Commonly used guide for determining the extent of a burn wound by calculating the TBSA affected •Back of head 4.5% •Face 4.5% • Each Arm Front 4.5% Back 4.5% •Each Leg Front 9% Back 9% •Anterior torso 18% •Posterior torso 18% •Perineum 1% (hand & fingers also 1%) •Used for initial assessment of a burn patient because it is easy to remember

Electrical Burns: Priority Management

•Contact with electric current can cause muscle contractions strong enough to fracture the long bones and vertebrae. •Reason to suspect long bone or spinal fractures is a fall resulting from the electrical injury. •All patients with electrical burns should be considered at risk for a potential cervical spine injury. •Cervical spine immobilization must be used during transport and subsequent diagnostic testing completed to rule out any injury. Electrical injury puts the patient at risk for: Dysrhythmias or cardiac arrest •The electric shock event can cause immediate cardiac standstill or ventricular fibrillation. •Delayed cardiac dysrhythmias or arrest may also occur without warning during the first 24 hours after injury. Severe metabolic acidosis Myoglobinuria •Myoglobin from injured muscle tissue and hemoglobin from damaged red blood cells (RBCs) are released into the circulation whenever massive muscle and blood vessel damage occurs. •The released myoglobin pigments travel to the kidneys and can block the renal tubules, which can result in acute tubular necrosis (ATN) and acute kidney injury.

Prehospital Care: Hypothermia Prevention

•Cool large burns (usually for greater than 10% TBSA) for no more than 10 minutes. •Do not immerse the burned body part in cool water because it may cause extensive heat loss. •Never cover a burn with ice, since this can cause hypothermia and vasoconstriction of blood vessels, thus further reducing blood flow to the injury. •Gently remove as much burned clothing as possible to prevent further tissue damage. •Leave adherent clothing in place until the patient is transferred to a hospital. •Wrap the patient in a dry, clean sheet or blanket to prevent further contamination of the wound and to provide warmth.

Nursing Management Emergent Phase: Fluid Therapy

•Establishing IV access is critical for fluid resuscitation and drug administration. •It is critical to establish IV access that can handle large volumes of fluid. •At least two large-bore IV access sites must be in place for patients with burns that are 15% TBSA or more. •For patients with burns greater than 30% TBSA, consider a central line for fluid and drug administration and blood sampling •An arterial line is often placed if frequent ABGs or invasive BP monitoring is needed. •Assess the extent of the burn wound using a standardized chart. •Then use a standardized formula to estimate the patient's fluid resuscitation requirements. •Fluid replacement is achieved with crystalloid solutions (usually lactated Ringer's), colloids (albumin), or a combination of the two. •Paramedics generally give IV saline until the patient's arrival at the hospital. •All formulas are estimates, and fluids must be titrated based on the patient's response (e.g., hourly urine output, vital signs). •Patients with an electrical injury have greater than normal fluid requirements and generally require an osmotic diuretic (mannitol [Osmitrol]) to increase their urine output and overcome high levels of hemoglobin and myoglobin in the urine. •Too much fluid and overestimation of TBSA contribute to the development of "fluid creep."

Upper Airway Injury: Assess for

•Facial burns •Singed nasal hair •Hoarseness •Painful/Difficulty swallowing •Blisters, redness, edema: can be massive and the onset rapid •Copious secretions •Stridor (high-pitched breath sound caused by a narrowed or obstructed airway) •Substernal and intercostal retractions •Total airway obstruction •Darkened oral and nasal membranes •History of being burned in an enclosed space •Clothing burns around the chest and neck. Carbonaceous sputum (???)

Lower Airway Injury: Assess for

•High degree of suspicion if patient was trapped in a fire in an enclosed space or clothing caught fire •Presence of facial burns or singed nasal or facial hair •Dyspnea •Carbonaceous sputum •Wheezing •Altered mental status •Hoarseness •s/sx of ARDS

Clinical Parameters of Adequate Fluid Resuscitation

•Hourly assessments of the adequacy of fluid resuscitation are best made using clinical parameters. Urine output (most commonly used parameter) and cardiac parameters are defined as follows. Urine output: •0.5 to 1 mL/kg/hr •75 to 100 mL/hr for electrical burn patient with evidence of hemoglobinuria or myoglobinuria. Cardiac parameters: •Mean arterial pressure (MAP) greater than 65 mm Hg •Systolic BP greater than 90 mm Hg, •Heart rate less than 120 beats/minute. •MAP and BP are best measured by an arterial line. •Manual BP measurement is often invalid because of edema and vasoconstriction.

Upper Airway Injury

•Inhalation injury to the mouth, oropharynx, and/or larynx •Caused by thermal burns or the inhalation of hot air, steam, or smoke

Metabolic Asphyxiation

•Inhaling certain smoke elements, primarily carbon monoxide (CO) or hydrogen cyanide •Oxygen delivery to tissues or consumption by tissues is impaired •The result is hypoxia and, ultimately, death when carboxyhemoglobin blood levels are greater than 20%. •Cherry-red skin color -CO levels >20% •CO and hydrogen cyanide poisoning may occur in the absence of burn injury to the skin.

Lower Airway Injury

•Injury to the trachea, bronchioles, and alveoli is usually caused by breathing in toxic chemicals or smoke •Pulmonary edema may not appear until 12 to 24 hours after the burn, and then it may manifest as acute respiratory distress syndrome (ARDS)

Rehabilitation Phase

•This phase begins when the patient's wounds have healed and he or she is engaging in some level of self-care. •This may happen as early as 2 weeks or as long as 7 to 8 months after the burn injury. Goals for the patient now are to •Work toward resuming a functional role in society •Rehabilitate from any functional and cosmetic postburn reconstructive surgery that may be necessary.

Nursing Management Emergent Phase: Airway

•Involves early endotracheal (preferably orotracheal) intubation. •Early intubation eliminates the need for emergency tracheostomy after respiratory problems have become apparent. •The patient with burns to the face and neck requires intubation within 1 to 2 hours after injury. •After intubation the patient is placed on ventilatory support, with the delivered oxygen concentration based on ABG values. •Extubation may be indicated when the edema resolves, usually 3 to 6 days after burn injury, unless severe inhalation injury is involved. •Escharotomies of the chest wall may be needed to relieve respiratory distress secondary to circumferential, full-thickness burns of the neck and trunk. •Within 6 to 12 hours after injury in which smoke inhalation is suspected, a fiberoptic bronchoscopy should be performed to assess the lower airway. •When intubation is not performed, treatment of inhalation injury includes administration of 100% humidified O2 as needed. •Place the patient in a high Fowler's position, unless contraindicated (e.g., spinal injury), and encourage deep breathing and coughing every hour. •Reposition the patient every 1 to 2 hours and provide suctioning and chest physiotherapy (as ordered). •If severe respiratory distress (e.g., hoarseness, shortness of breath) develops, intubation and mechanical ventilation are initiated. •Positive end-expiratory pressure (PEEP) may be used to prevent collapse of the alveoli and progressive respiratory failure. •Bronchodilators may be administered to treat severe bronchospasm. •CO poisoning is treated by administering 100% O2 until carboxyhemoglobin levels return to normal

Treatment of Full Thickness Burn Wounds

•Must have the burn eschar surgically removed (excised) and skin grafts applied in order to heal. •In some cases, healing time and length of hospitalization are decreased by early excision and grafting. •Many patients, especially those with major burns, are taken to the OR for wound excision on day 1 or 2 (emergent phase). •The wounds are covered with a biologic dressing or allograft for temporary coverage until permanent grafting can occur. •During the procedure of excision and grafting, devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia, depending on the degree of injury. •With early excision, function is restored and scar tissue formation is minimized

Prehospital Care: Inhalation injuries

•Observe patients with inhalation injuries closely for signs of respiratory distress. •These patients need to be treated quickly and efficiently if they are to survive. •If CO poisoning is suspected, treat the patient with 100% humidified O2 •Draw ABGs, as necessary, to determine adequacy of ventilation and perfusion in patients with suspected or confirmed inhalation or electrical injury. •Patients who have both body burns and an inhalation injury must be transferred to the nearest burn center.

Treatment of Partial Thickness Burn Wounds

•Perform cleansing and gentle debridement, using scissors and forceps, on a cart shower, regular shower, or patient bed or stretcher.

Prehospital Care: Thermal Burns

•Small thermal burns (10% or less of TBSA) should be covered with a clean, cool, tap water-dampened towel for the patient's comfort and protection until medical care is available •Cooling of the injured area (if small) within 1 minute helps minimize the depth of the injury. •If the burn is large (greater than 10% TBSA) or an electrical or inhalation burn is suspected, first focus your attention on the ABCs: •Airway: Check for patency, soot around nares and on the tongue, singed nasal hair, darkened oral or nasal membranes. •Breathing: Check for adequacy of ventilation. •Circulation: Check for presence and regularity of pulses, and elevate the burned limb(s) above the heart to decrease pain and swelling.

Priority Assessments of Facial/Head/Torso Burn Injury

•Swelling from scald burns to the face and the neck place external pressure from edema on the airway •Mechanical obstruction can occur quickly, presenting a true medical emergency •Burns to the face and neck and circumferential burns to the chest or back may interfere with breathing as a result of mechanical obstruction from edema or leathery, devitalized burn tissue (eschar). •These burns may also indicate possible inhalation injury and respiratory mucosal damage. •Burns to the hands, feet, joints, and eyes are of concern because they make self-care difficult and may jeopardize future function. •Burns to the hands and feet are challenging to manage because of superficial vascular and nerve supply systems that need to be protected while the burn wounds are healing. •Burns to the ears and the nose are susceptible to infection because of poor blood supply to the cartilage. •Burns to the buttocks or perineum are highly susceptible to infection from urine or feces contamination •Circumferential burns to the extremities can cause circulation problems distal to the burn, with possible nerve damage to the affected extremity. •Patients may also develop compartment syndrome from direct heat damage to the muscles, swelling, and/or preburn vascular problems.

Body Positioning Measures for Burn Injuries

•The face is highly vascular and can become very swollen. •It is often covered with ointments and gauze but not wrapped to limit pressure on delicate facial structures. •Eye care for corneal burns or edema includes antibiotic ointments. •An ophthalmology examination should occur soon after admission for all patients with facial burns. •Periorbital edema can prevent eye opening and is often frightening for the patient. •Provide assurance that the swelling is not permanent. •Instill methylcellulose drops or artificial tears into the eyes for moisture and additional comfort. •Ears should be kept free from pressure because of their poor vascularization and tendency to become infected. •Do not use pillows for the patient with ear burns. •The pressure on the cartilage may cause chondritis. •Further, the ear may stick to the pillowcase, causing pain and bleeding. •Elevate your patient's head using a rolled towel placed under the shoulders, being careful to avoid pressure necrosis. •Follow the same strategy for the patient with neck burns to hyperextend the neck and prevent neck wound contracture. •Extend your patient's burned hands and arms and elevate them on pillows or plastic-covered foam wedges to minimize edema. •Ask the occupational therapist and the physician if splints need to be applied to burned hands and feet to maintain them in positions of function. •Remove the splints frequently and inspect the skin and bony prominences to avoid areas of pressure from inappropriate or prolonged application. • Work in collaboration with the physical therapist to perform range-of-motion (ROM) exercises during dressing changes and throughout the day. •Movement facilitates mobilization of the leaked fluid back into the vascular bed. •Active and passive exercise of body parts also: Maintains function Prevents contractures Reassures the patient that movement is still possible •Keep your patient's perineum as clean and dry as possible after each voiding or bowel movement. •In addition to monitoring hourly urine outputs, an indwelling catheter prevents urine contamination of the perineal area. •Regular once- or twice-daily perineal and catheter care, in the presence or absence of a perineal burn wound, is essential. •Assess the need for an indwelling urinary catheter on a daily basis and remove when no longer necessary to avoid development of a urinary tract infection. •If your patient has frequent, loose stools, consider the temporary insertion of a fecal diversion device.

Emergent Phase (resuscitative)

•The time required to resolve the immediate, life-threatening problems resulting from the burn injury. •This phase usually lasts up to 72 hours from the time the burn occurred. •The primary concerns are the onset of hypovolemic shock and edema formation. •The emergent phase ends when fluid mobilization and diuresis begin

Nursing Management Emergent Phase: Wound care

•When the patient's open burn wounds are exposed, always wear personal protective equipment (PPE) •Disposable hats, masks, gowns, gloves •When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. •Use sterile gloves when applying ointments and sterile dressings. •In addition, prevent shivering by keeping the room warm (approximately 85° F [29.4° C]). •Before leaving one patient, remove your PPE. •Don new equipment before you treat another patient. •Perform thorough hand washing both before and after patient contact to prevent cross-contamination. •Permanent skin coverage is the primary goal for burn wound care.