Burns

•Hypoxia and ultimately death when CO levels are 20% or greater •CO poisoning may occur in absence of burn injury to skin

At what point does hypoxia occur with CO poisoning?

•Face, neck, chest → can cause respiratory obstruction •Hands, feet, joints, eyes → impacts self-care •Ears, nose, buttocks, perineum → infection risk

Burns to which areas of the body are considered more severe?

●Superficial partial-thickness burn •Involves epidermis ●Deep partial-thickness burn •Involves dermis ●Full-thickness burn •Involves all skin elements, nerve endings, fat, muscle, bone

How are burns classified by depth?

Offer the patient fluids other than water, such as juice, soft drinks, or nutritional supplements to drink

How can water intoxication of a burn patient be avoided?

The patient is in a hypermetabolic state proportional to the size of the wound ●Resting metabolic expenditure may be increased by 50% to 100% above normal ●Core temperature is elevated ●Caloric needs are about 5000 kcal/day

How do burns affect the patient's metabolism?

●according to depth of skin destruction •Partial-thickness burn •Full-thickness burn

How does the American Burn Association advocate categorizing burns?

•Treat with 100% humidified oxygen

How is CO poisoning treated?

•Hands and arms should be extended and elevated on pillows to minimize edema. Splints may need to be applied to burned hands and feet to keep them in positions of function. •Ears should be kept free of pressure because of their poor vascularization and tendency to become infected. The patient with ear burns should not use pillows because pressure on the cartilage may cause chondritis, and the ear may stick to the pillowcase, causing pain and bleeding. •Raise your patient's head using a rolled towel placed under the shoulders, with care taken to avoid pressure necrosis. •The same holds true for the patient with neck burns. Pillows are removed and a rolled towel is placed under the shoulders to hyperextend the neck and prevent neck contraction.

How should a burn patient be positioned?

•If grafting is necessary, protect the skin graft with the same greasy gauze dressings next to the graft, followed by saline-moistened middle dressing, and dry gauze outer dressing. •With facial grafts, the unmeshed sheet graft is left open, so it is possible for blebs (serosanguineous exudates) to form between the graft and the recipient bed. •Blebs prevent the graft from permanently attaching to the wound bed. The evacuation of blebs is best performed by aspiration with a tuberculin syringe and only by those trained in this specialized skill.

How should wound care be done with respect to grafts during the acute phase?

•Nonintubated patients with a burn of <20% TBSA burn usually be able to eat enough to meet their nutritional needs. •Intubated patients and/or those with larger burns require additional support. •Enteral feedings have almost entirely replaced the need for parenteral feeding. Early enteral feeding, usually with the use of smaller-bore tubes, preserves GI function, increases intestinal blood flow, and promotes optimal conditions for wound healing.

Through what method should a burn patient be given nutrition?

●Low-molecular-weight heparin or low-dose unfractionated heparin is started ●For burn patients who have a high bleeding risk, it is recommended that VTE prophylaxis with sequential compression devices and/or graduated compression stockings be used until the bleeding risk is decreased and heparin can be started

What VTE prophylaxis should be given to burn patients?

•Early endotracheal intubation •Escharotomies of the chest wall •Fiberoptic bronchoscopy •Humidified air and 100% oxygen

What airway management is done during the emergent phase?

●Topical agents -Silver sulfadiazine -Mafenide acetate ●Systemic agents are not usually used in controlling burn flora, but they are initiated if a diagnosis of invasive burn wound sepsis is made

What antimicrobial agents are given to burn victims?

●Result of contact with acids, alkalis, and organic compounds ●Alkali burns are hard to manage because they cause protein hydrolysis and liquefaction

What are chemical burns?

●Shock from hypovolemia ●Blisters ●Paralytic ileus ●Shivering ●Altered mental status

What are clinical manifestations of the emergent phase of a burn injury?

●Patients are at risk for dysrhythmias or cardiac arrest, severe metabolic acidosis, and myoglobinuria ●Myoglobin and hemoglobin from damaged RBCs travel to kidneys •Acute tubular necrosis (ATN) •Eventual acute kidney injury

What are complications of electrical burns?

•a method of getting permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsies obtained from the patient's own unburned skin. •This procedure is performed in suitable patients in some burn centers as soon as possible.

What are cultured epithelial autografts (CEAs)?

●Result from coagulation necrosis caused by intense heat generated from an electric current ●May result from direct damage to nerves and vessels, causing tissue anoxia and death

What are electrical burns?

•Lund-Browder chart -Considered more accurate •Rule of Nines -Used for initial assessment

What are guides for determining the total body surface area covered by a burn?

●Presence of facial burns ●Singed nasal hair ●Hoarseness, painful swallowing ●Darkened oral and nasal membranes ●Carbonaceous sputum ●History of being burned in enclosed space ●Clothing burns around neck and chest

What are indications that a person has an upper airway injury?

●Relaxation breathing ●Visualization, guided imagery ●Hypnosis ●Biofeedback ●Music therapy

What are nonpharmalogical strategies for pain from burns?

•Paralytic ileus can be caused by sepsis. •Diarrhea may result from the use of enteral feedings or antibiotics. •Constipation can occur as a side effect of opioids, decreased mobility, and a low-fiber diet. •Curling's ulcer is a type of gastroduodenal ulcer characterized by diffuse superficial lesions (including mucosal erosion). •Patients with major burns may also have occult blood in their stools during the acute phase and require close monitoring for bleeding.

What are potential GI complications during the acute phase?

•Dysrhythmias and hypovolemic shock •Impaired circulation to extremities •Tissue ischemia •Paresthesias •Necrosis •Initially, blood viscosity is increased because of the fluid loss that occurs in the emergent period. Microcirculation is impaired by damage to skin structures that contain small capillary systems. These two events result in a phenomenon termed sludging. Sludging is corrected by adequate fluid replacement. •Burn patients are at an increased risk for venous thromboembolism (VTE) if one or more of the following conditions are present: advanced age, morbid obesity, extensive or lower-extremity burns, concomitant lower-extremity trauma, and prolonged immobility.

What are potential cardiovascular complications of a burn injury in the emergent phase?

•↑ Blood glucose levels •↑ Insulin production •Hyperglycemia

What are potential complications of the endocrine system during the acute phase?

•The musculoskeletal system is particularly prone to complications during the acute phase and the involvement of the physical and occupational therapist is vitally important. •As the burns begin to heal and scar tissue forms, the skin is less supple and pliant, ROM may be limited, and contractures can occur. •Because of pain, the patient will prefer to assume a flexed position for comfort. Have the patient to stretch and move the burned body parts as much as possible. Splinting can be beneficial to prevent/reduce contracture formation.

What are potential musculoskeletal complications during the acute phase?

•No physical symptoms unless severe hypoxia from respiratory injuries or complications from electrical injuries occur •Disorientation •Combative •Hallucinations •Delirium •Transient state

What are potential neurological system complications during the acute phase?

●Edema formation ●Mechanical airway obstruction and asphyxia

What are potential respiratory complications of a burn injury in the emergent phase?

●Hypothermia or hyperthermia ●Increased heart and respiratory rate ●Decreased BP ●Decreased urine output

What are signs/symptoms that a burn patient has an infection?

●From inhalation of hot air or noxious chemicals ●Cause damage to respiratory tract ●Major predictor of mortality in burn victims ●Need to be treated quickly

What are smoke inhalation burns?

●Continuous background pain ●Treatment-induced pain

What are the 2 types of pain experienced by burn patients in the acute phase?

•Metabolic asphyxiation •Upper airway injury •Lower airway injury

What are the 3 types of smoke inhalation injuries?

●Skin and joint contractures Positioning, splinting, and exercise should be used to minimize contracture

What are the most common complications during rehab phase?

●Emergent (resuscitative) ●Acute (wound healing) ●Rehabilitative (restorative)

What are the phases in burn management?

•Hypovolemic shock •Edema

What are the primary concerns during the emergent phase?

●Thermal burns ●Chemical burns ●Smoke inhalation injury ●Electrical burns ●Cold thermal injury

What are the types of burns?

●Caused by flame, flash, scald, or contact with hot objects ●Most common type of burn injury

What are thermal burns?

-Aim to prevent Curling's ulcer by feeding the patient as soon as possible after the burn injury. -Antacids, H2-histamine blockers (e.g., ranitidine [Zantac]), and proton pump inhibitors (e.g., esomeprazole [Nexium]) are used prophylactically to neutralize stomach acids and inhibit histamine and the stimulation of hydrochloric acid (HCl acid) secretion.

What can be done to prevent Curling's ulcer?

•Sodium restrictions may be applied to IV fluids and enteral or oral feedings until levels return to safe limits.

What can be done to reverse hypernatremia?

●Heart dysrhythmias and ventricular failure ●Muscle weakness ●ECG changes

What can hyperkalemia cause?

•Same complications can be present in emergent phase and may continue into acute phase •In addition, new problems might arise, requiring timely intervention

What cardiovascular and respiratory system complications can happen during the acute phase?

•Depth of burn •Extent of burn in percent of total body surface area •Location of burn •Patient risk factors

What does the severity of a burn depend upone?

•Amount of voltage •Tissue resistance •Current pathways •Surface area •Duration of flow ●Severity of injury can be difficult to assess, as most damage occurs beneath skin

What does the severity of an electrical burn depend upon?

●Antibiotic ointment is used ●Periorbital edema may frighten patient. You must provide assurance that the swelling is not permanent.

What eye care is done for corneal burns?

•Normal insensible loss increases from 30 to 50 mL/hr in a healthy person to 200 to 400 mL/hr in a burn patient -Net result of fluid shift is intravascular volume depletion, resulting in edema, a decrease in blood pressure and an increase in pulse •RBCs are hemolyzed by a circulating factor released at time of burn, resulting in thrombosis and elevated hematocrit •K+ shift develops first because injured cells and hemolyzed RBCs release K+ into extracellular spaces •Na+ rapidly moves to interstitial spaces and remains until edema formation ends

What fluid and electrolyte shifts occur in burn patients?

•Two large-bore IV lines for >15% TBSA •Type of fluid replacement based on size/depth of burn, age, and individual considerations •Parkland (Baxter) formula for fluid replacement

What fluid therapy is given during the emergent phase?

•Neutrophils and monocytes accumulate at site of injury •Fibroblasts and collagen fibrils begin wound repair within first 6 to 12 hours after injury

What inflammatory response occurs during the emergent phase of a burn injury?

Injury to tissues of the body caused by heat, chemicals, electrical current, or radiation

What is a burn?

•Injury to trachea, bronchioles, and alveoli •Injury is related to length of exposure to smoke or toxic fumes •Pulmonary edema may not appear until 12 to 48 hours after burn -Manifests as acute respiratory distress syndrome (ARDS)

What is a lower airway injury?

Skin grafts taken from cadavers, which is typically used along with newer biosynthetic options •Only rarely is enough unburned skin left in the major (>50%) burn patient for immediate skin grafting.

What is allograft or homograft skin?

●Frostbite

What is an example of a type of cold thermal injury?

•Injury to mouth, oropharynx, and/or larynx •Thermally produced (Hot air, steam, or smoke) •Swelling may be massive and onset rapid

What is an upper airway injury?

•devitalized tissue (eschar) is excised down to the subcutaneous tissue or fascia, depending on the degree of injury. Surgical excision can result in massive blood loss. Topical application of epinephrine or thrombin, application of extremity tourniquets, and application of a new fibrin sealant (Artiss) all work to decrease surgical blood loss. •Once hemostasis has been achieved, a graft is then placed on clean, viable tissue to achieve good adherence. -Whenever possible, the freshly excised wound is covered with autograft (person's own) skin. •Grafts are attached with ●Fibrin sealant ●Sutures or staples ●Negative pressure wound therapy •With early excision, function is restored, scar tissue minimized

What is excision and grafting?

●IV infusion of an opioid ●Or slow-release, twice-a-day oral opioid

What is given for continuous background pain during the acute period?

●Analgesic and an anxiolytic

What is given for treatment induced pain during the acute period?

•Carbon monoxide (CO) poisoning •CO is produced by incomplete combustion of burning materials

What is metabolic asphyxiation caused by?

●Begins with mobilization of extracellular fluid and subsequent diuresis ●Concludes when •Partial thickness wounds are healed and/or •Full thickness burns are covered by skin grafts During this phase, ●Diuresis from fluid mobilization occurs, and patient is less edematous ●Bowel sounds return ●Healing begins as WBCs surround burn wound and phagocytosis occurs

What is the acute phase of burn injury?

●Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury ●Up to 72 hours -The emergent phase ends when fluid mobilization and diuresis begin.

What is the emergent phase for a burn injury?

•Infection from the patient's own flora is most serious threat to further tissue injury •Preventing cross-contamination is a priority

What is the most serious threat to further tissue injury during the emergent phase?

●Sterile gauze dressings are laid over topical antibiotic ●Dressings may be changed from every 12 to 24 hours to once every 14 days -Most burn centers support the concept of moist wound healing and use dressings to cover burned areas, with the exception of facial burns

What is the multiple dressing changes or closed method of wound care?

●Burn is covered with topical antibiotic with no dressing over wound ●Usually limited to the care of facial burns

What is the open method of wound care?

●Preexisting heart, lung, and kidney diseases contribute to poorer prognosis ●Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene ●Physical weakness renders patient less able to recover •Alcoholism •Drug abuse •Malnutrition ●Concurrent fractures, head injuries, or other trauma leads to a more difficult time recovering

What medical history factors affect a patient's burn prognosis and healing?

•Fluid replacement takes priority over nutritional needs •Early and aggressive nutritional support within hours of burn injury -Decreases complications and mortality -Optimizes burn wound healing -Minimizes negative effects

What nutritional therapy is recommended for burn patients?

•Skin •Eyes •Respiratory system •Liver and kidney

What parts of the body can chemical burns cause injury to?

●Assess circumstances of burn injury ●Burn survivors often experience anxiety, guilt, and depression ●New fears arise during recovery ●Self-esteem may be adversely affected ●Address spiritual and cultural needs ●Issue of sexuality must be met with honesty ●Family and patient support groups

What should be considered when meeting the emotional needs of patients and caregivers?

•In addition to providing hourly urine outputs, an indwelling catheter prevents urine contamination of the perineal area. Regular, once- to 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 needed to limit the risk of a urinary tract infection. •If your patient has frequent, loose stools, consider using a fecal diversion device.

What should be done to keep the perineum as clean and dry as possible?

●Encourage both patient and caregiver to participate in care ●The role of exercise cannot be overemphasized ●Constant encouragement and reassurance

What should be stressed during the rehab phase?

•Analgesics and sedatives •Antimicrobial agents •VTE prophylaxis

What types of meds are given to burn patients?

•Cleansing and gentle debridement, using scissors and forceps, can occur on a shower cart, in a regular shower, or on a patient bed/stretcher by you and appropriate personnel. •Extensive surgical debridement is done in the operating room (OR). During debridement, necrotic skin is removed. Releasing escharotomies and fasciotomies are done in the emergent phase, usually in burn centers by burn physicians. •Patients find the first wound care to be both physically and mentally demanding. Provide emotional support to build trust.

What wound care is done during the emergent phase?

•Enzymatic debridement (Speeds up removal of dead tissue from healthy wound bed) •Cleanse with soap and water •Cover with antimicrobial creams

What wound care is done in the acute phase?

•Physical therapy is begun immediately, sometimes during showering/dressing changes and before new dressings are applied. Movement aids the shift of the leaked fluid back into the vascular bed. Active and passive exercise of body parts also maintains function, prevents skin and joint contractures, and reassures the patient that movement is still possible.

When can ROM begin in burn patients?

●Morphine ●Hydromorphone (Dilaudid) ●Haloperidol (Haldol) ●Lorazepam (Ativan) ●Midazolam

Which analgesics and sedatives are given to burn patients?

●Successful fluid replacement ●Improper tube feedings ●Inappropriate fluid administration

Why can hypernatremia develop during the acute phase?

●Excessive GI suction ●Diarrhea ●Water intoxication

Why can hyponatremia develop during the acute phase?

●Skin barrier is destroyed ●Bone marrow is depressed ●Circulating levels of immune globulins are decreased ●WBCs develop defects

Why is the immune system challenged after a burn injury?

If patient has ●Renal failure ●Adrenocortical insufficiency ●Massive deep muscle injury -Large amounts of potassium is released from damaged cells

Why might a burn patient develop hyperkalemia?

●Vomiting, diarrhea ●Prolonged GI suction ●Lengthy IV therapy without potassium

Why might hypokalemia occur in a burn patient?

•Onset of action is fastest with this route. •GI function is slowed or impaired as the result of shock or paralytic ileus. •Intramuscular (IM) injections will not be absorbed well in burned or edematous areas, causing pooling of medications in the tissues. When fluid mobilization starts, the patient could be inadvertently overdosed from the interstitial accumulation of previous IM drugs.

Why should pain medications be administered by IV during the early postburn period?