Burns - Ch 20 : Part 2

What are the three phases of burn care?

1. Resuscitation (emergent) 2. Acute 3. Rehabilitative

What are ways to calculate %TBSA?

1. The quickest method to initially calculate %TBSA is the rule of nines. 2. Patient's Palm method - which uses the size of the patient's palm (including fingers) to calculate %TBSA - with the patient's hand representing 1% TBSA. This method can be used to estimate irregular or scattered small burns. 3. The Lund and Browder chart provides a more accurate determination of the extent of burn injury by correlating body surface area with age-related proportions. This method is used most frequently in a certified burn center.

What are the three zones of thermal injury to a burn?

1. zone of hyperemia. - The outermost area of the burn contains minimal cell injury. It has early spontaneous recovery and is similar to a superficial burn. 2. zone of coagulation - The greatest area of tissue necrosis is at the core of the burn. It is the site of irreversible skin and tissue death. 3. zone of stasis - Between the zone of hyperemia and zone of coagulation is an area where vascular damage and reduced blood flow has occurred.

What are CVP normals, and what needs to be considered with CVP in burn patients?

2-6mmHg burn patients will need higher values in order to maintain adequate Urine output

A patient presents to the emergency room following a home fire. On assessment, the patient has partial thickness burns to the entire right leg and abdomen. Full thickness burns are noted to the right hand and forearm. Calculate the % TBSA

31.5%

When does cardiac function generally start improving?

Impaired cardiac function improves approximately 24 to 30 hours after injury. The purpose of initial postburn fluid resuscitation is to aid in restoring normal cardiac output.

What is significant about burns with greater than 20%TBSA?

In burns greater than 20% TBSA, the increased capillary permeability and edema formation process not only occur locally at the site of burn injury, but also systemically in distant unburned tissues and organs. Edema is further worsened because lymph drainage flow is obstructed from either direct damage of lymphatic vessels or from blockage by serum proteins that have leaked into the interstitium. The end result of this whole process is the development of edema and burn shock.

What criteria needs to be met to initiate fluid resuscitation for a burn patient?

%TBSA over 20%

What is immediate intervention for ACS?

ACS is a life-threatening complication that mandates immediate decompression by laparotomy; otherwise, multiple organ dysfunction and death quickly ensue.

What is the physiological response to a burn injury?

Acute inflammation Intravascular coagulation (no blood flow in burn area) Cellular enzymes and vasoactive substances Activation of complement Altered vascular permeability Activation of the compliment system (our immune system) starts the beginnings of the healing process as well as apoptosis (the body's natural mechanism to degrade damaged cells).

What chemical mediators are released in an acute inflammation scenario?

Acute inflammation begins - this is from the release of inflammatory mediators like histamine, prostaglandins, bradykinins, catecholamines, and cytokines. These circulating mediators cause a variety of vasoactive, cellular, and cardiovascular effects.

What can result from intraabdominal hypertension?

An intraabdominal pressure (IAP) > 12 mm Hg, causes compression of intraabdominal contents, and leads to renal, gut, and hepatic ischemia. If not treated by trunk escharotomies, diuresis, gastric decompression, body repositioning, and/or sedation and chemical paralytics, IAH can progress to abdominal compartment syndrome or death. Keep in mind, during active fluid resuscitation, diuresis is not usually an option.

Calculate the volume of IV fluid needed for the first 8 hours after burn injury: 60 years old, 82 kg, 42% TBSA, using the higher resuscitation level.

Answer: B. 6,888 mL Age is not a factor in the calculation: 4 mL × 82 kg × 42% = 13,776 Give half of the fluid in the first 8 hours = 6,888

What are the prehospital interventions of the Resuscitation phase with EMS?

Assess circulation Assess for additional trauma Cover and prevent hypothermia Large-bore IV catheters and fluids Pain management with narcotics Vital signs and baseline assessment Minimize time on the scene

what type of fluids need to be not given during burn recovery? for how long? why?

Colloids, such as albumin, contain proteins and are used to increase intravascular oncotic pressure. If colloids are used during burn resuscitation, it is generally advocated that they not be administered within the first 12 hours of burn injury when capillary permeability is at its highest level. This is because the protein will simply leak out of the vessel into the interstitial tissues and actually potentiate third spacing because the protein pulls fluid with it!

What are guidelines for IV insertion with EMS?

First responders will initiate IV therapy with two large-bore (14- or 16-gauge) IV lines, preferably through nonburned tissue, and infusion of lactated Ringer's (LR) solution

What are GI issues that need to be considered in a burn injury?

Gastrointestinal Vasoconstriction of the gut occurs so blood can be redistributed to the heart and brain. This results in ischemia - especially in the stomach and duodenum. Stress ulcers can occur because of this ischemia and are known as Curling's ulcers. GI motility decreases and places the patient at risk for paralytic ileus. Clinical presentation of an ileus includes decreased or no bowel sounds, gastric distention, nausea or vomiting. For patients who are intubated and mechanically ventilated post burn, assessment findings are decreased or no bowel sounds and gastric distention. Confirmation of an ileus is usually made with an abdominal xray.

What are immune considerations that need to be considered in a burn injury?

Host Defense Mechanisms Patients with burns lose their skin integrity and are at increased risk for infection because of this loss. Tissue damage that occurs with burns causes activation of multiple inflammatory cascades (the complement, fibrinolytic, clotting, and kinin systems). The end result is immunosuppression, which further inhibits the burn patient's ability to fight infection. The potential for sepsis is very real with these patients.

What can cause changes in LOC in burn patients?

Hypoxia, CO poisoning, acidosis, decreased cerebral perfusion all can manifest as changes in level of consciousness. If patient is injured, the nurse should also consider increased intracranial pressure

What needs to be done in evidence of compartment syndrome formation?

If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation. If decreased perfusion is not quickly detected, ischemia and necrosis with loss of limb may occur. A fasciotomy (incision through fascia) may be indicated for deep electrical burns or severe muscle damage to restore blood flow.

Why does fluid third shift in burns?

Inflammation causes leaky vessels. Gaps between endothelial cells in vessel wall membranes develop, resulting in increased capillary membrane permeability. A significant shift of protein molecules, fluid, and electrolytes leak out of the vessels and into the interstitium (or tissues). This process is called third-spacing

What defines intraabdominal hypertension? What causes IAH? How does this compare to abdominal compartment syndrome?

Intraabdominal hypertension (IAH) can be caused by several factors. - Circumferential torso (abdominal) eschar can cause circulatory compression much like that described in the prior slide. - bowel edema from aggressive fluid resuscitation - the burn inflammatory response can lead to intra-abdominal hypertension An intraabdominal pressure (IAP) > 12 mm Hg Abdominal compartment syndrome (ACS) is the presence of sustained IAP > 20 mm Hg with or without abdominal perfusion pressure (APP = MAP - IAP) <60 mm Hg, and associated new organ system dysfunction or failure.

What creates worse cardiac instability in a burn patient?

underresuscitation (hypovolemia), overresuscitation (hypervolemia), or because of the increased afterload.

What is the fluid of choice for burn resuscitation? Why?

Lactate Ringers Isotonic solution. Crystalloid. Biproducts of lactate in the liver are alkylotic, which counteracts acidosis.

What are pulmonary considerations that need to be considered in a burn injury?

Pulmonary Vasoconstrictive mediator substances released in response to hypovolemia causes an initial temporary pulmonary hypertension. Lung compliance decreases. Patients who are intubated and ventilated make exhibit decreased lung compliance by being more difficult to ventilate or by alarming high peak airway pressures during peak inspiration on the vent.

What does the loss of cardiac output trigger in the sympathetic nervous system?

Loss in cardiac output activates the sympathetic nervous system as the body is tries to maintain equilibrium. The baroreceptors in the atria and carotid arteries notice the low return in blood volume and they stimulate the body to release catecholamines (epinephrine and norepinephrine). Epi and norepi increase the heart rate and constrict the periphery vessels. The body does this to preserve arterial blood pressure for the major organs, or to say it another way, the body "sacrifices blood flow to the extremities" in order to feed the central core. The primary signs the nurse will note here is tachycardia. If the response is adequate, blood pressure will be low, but not dangerously so. Still, resuscitation is a must as this compensation will not last.

What is the cardiovascular systemic response to a burn?

Loss of intravascular volume Decreased cardiac output Tachycardia and vasoconstriction Loss of cardiac output leads to hypoxia and acidosis. Myocardial depression with negative inotropic effect Cardiac output increase 48 hours after injury leads to diuresis

A patient presents in the ER with partial thickness burns to the lower half of the right arm and the entire left arm, as well as partial thickness burns to the chest. Also noted are superficial burns to the right front leg. What is the % TBSA?

Lower right arm = 4.5% Entire left arm = 9% Chest = 9% (1/2 of 18% for trunk) Right front leg = 0% (superficial doesn't count) Total %TBSA = 22.5%

What are Metabolic Issues that need to be considered in a burn injury?

Metabolic Response Initially the body has a diminished metabolic response which lasts until resuscitation is completed (so within 24 hours). From then on, the body goes into a hypermetabolic phase. This response is one of the most significant and persistent alterations observed after burn injury. Depending on the severity of the burn, patients may have metabolic rates that are 100% to 200% above their normal pre-burn rates. And some degree of elevation may continute for 1 to 2 years after injury. The rapid metabolic rate is caused by inflammation mediators and catecholamines as the body tries to support tissue healing and repair. The hypermetabolic state produces a catabolic effect on the body, and what is seen is skeletal muscle breakdown, decreased protein synthesis, increased glucose utilization, and rapid depletion of glycogen stores. The amount of protein wasting and weight loss that occurs is affected by several factors, including %TBSA burned, age, sex, preburn nutritional status, other health problems, exercise, and nutrient intake. Wound closure reduces metabolic expenditure. See figure 20.6 in your book.

What are the interventions once the patient reaches the ED?

Once the patient is transferred to the ED, the primary survey is repeated, followed by a more thorough secondary survey. Here is where the resuscitative phase begins. 1. ABCs are used to determine respiratory status, as well as need to intubate. 100% humidified oxygen via mask is continued. 2. If the patient has been intubated at the scene - great! If not, we need to reassess for the need to intubate. Remember - suspected inhalation injury will most likely need intubation because fluid resuscitation causes airway edema so assess for this - what are you looking for? Stridor, wheezing, hoarseness. Sooty sputum, singed nasal hair. These are indicative of inhalation injury. 3. Let's Screen the patient for carbon monoxide poisoning. Send a lab for COHgb. 4. Ciruclation is re-evaluated by checking pulses, blood pressure, and placing on a cardiac monitor. If pulses, great! If not - start CPR!

What are the components of 1L of lactate ringer?

One liter of Ringer's lactate solution contains: 130 mEq of sodium ion = 130 mmol/L 109 mEq of chloride ion = 109 mmol/L 28 mEq of lactate = 28 mmol/L 4 mEq of potassium ion = 4 mmol/L 3 mEq of calcium ion = 1.5 mmol/L none of these are enough for maintenance fluids. And lactate buildup will create alkylosis in the long term. But is great for rapid fluid infusion in trauma situation.

How does one calculate fluid necessary for burn resuscitation?

Parkland Formula %TBSA x 2-4ml / kg body weight 1/2 the amount is given in the first 8h the 2nd 1/2 is given over the following 16h

What happens if fluid resuscitation is initiated delayed?

Patients will become hypovolemic

What interventions need to be done in a circumferential full thickness burn?

Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation to legs and arms. Delayed capillary refill, taut skin, progressively decreasing or absent pulse, and other neurovascular changes (e.g., intense pain, paresthesia, paralysis) indicate impaired blood flow and developing compartment syndrome. Bladder pressure readings will help to assess compartment syndrome in the abdomen. Typically, eschar on the chest will impede expansion of the chest during mechanical ventilation and cause alarms on the vent. An ultrasonic flowmeter (Doppler) is used to auscultate radial, palmar, digital, or pedal pulses

What needs to be considered about fluid resuscitation in the ED?

Pt is weighed will be adjusted based upon vitals (BP and urine) CVCs are commonly inserted in major burn patients CVP needs to be raised higher than normal to maintain urine output

What occurs and what is the focus of the rehabilitation phase?

Rehabilitative phase occurs after wound closure. Care given in the first two phases is instrumental on reaching final rehabilitative outcomes. The primary goals here are to minimize scarring and contractures, to restore the patient to his or her function in family and society.

What are the main prehospital interventions of the Resuscitation phase?

Remove the patient from thermal source Stop the burning process Remove jewelry, belts, clothing that may retain heat Scalds, tar, asphalt burns: cool with water Identify life-threatening injuries Focus on ABCs and cervical spine Deliver humidified oxygen at 100%; intubation if needed

What are renal issues that need to be considered in a burn injury?

Renal The kidneys are very sensitive to changes in perfusion. A low cardiac output state (due to hypovolemia) will stimulate the renin-angiotensin-aldosterone cascade. Recall that this cascade causes sodium and water retention in order to increase cardiac preload. So - initially, the patient ill have a drop in urine output. - This is referred to as oliguria. If fluid resuscitation is inadequate, acute kidney injury can develop. That is why urine output is a very important monitoring point when giving fluid resuscitation to the burn patient. With adequate resuscitation (i.e. acute kidney injury was prevented), fluids will shift back to intravascular at approximately 48 hours after injury and the diuresis stage starts.

What are secondary survey interventions performed in the ED?

Secondary survey is more in-depth Maintain Airway, Breathing, Circulation Assessment of %TBSA Calculation of fluid resuscitation C-spine evaluation Chest and other x-rays Tetanus toxoid immunization Evaluation of circulation distal to burns

What should be performed prophylactically in patients with >40%TBSA, or 20% TBSA with concomitant inhalation injury, and/or those requiring fluid resuscitation volumes greater than expected?

Serial IAP measurements via bladder pressure monitoring should be performed

What is the goal of burn resuscitation?

The goal in burn resuscitation is to prevent secondary insults, - such as inadequate resuscitation, edema, or infection, that would result in this potentially salvageable area degenerating into tissue necrosis or death.

What is the overall end goal of fluid resuscitation?

The overall end point goal for fluid resuscitation is to maintain a urine output of at least 30 ml/hr and better if 50 ml/hr. The exception to this is for electrical burns, which require 75 to 100 ml/hr.

How does fluid administration change if initiated late within the 8 hours?

The rate increases, but the fluid amount stays the same. Ex: if start two hours late - infuse same amount, but over 6 hours

What occurs and what is the focus of the Resuscitation phase?

The resuscitative phase, or emergency phase, begins at the time of injury and continues for approximately 48 hours until the massive fluid and protein shifts have stabilized. The primary focus of assessment and intervention is on maintenance of the ABCs (airway, breathing, and circulation) and prevention of burn shock. The resuscitative phase spans care in the prehospital setting, in the ED, and transfer to a burn center.

What differentiates the primary survey pre hospital and the secondary survey ?

This figure summarizes the sequential steps taken in the pre-hospital primary survey. Remember, the focus is on stopping the burning process, managing airway with cervical spine precautions, ensuring the patient is breathing, and has adequate circulation. The secondary survey is brief, and includes rapid head to toe assessment, event history, and brief medical history. The history taking can occur while on the way to the hospital. The longer the time it takes to get to the hospital, the longer the delay in fluid resuscitation.

What is the peak time occurrence of edema and burn shock?

This process reaches it peak at 24 to 48 hours at which the process reverses and proteins, electrolytes and fluid moves back into the vascular space or vessel, resulting in a diuresis stage.

What are physical signs of IAP/ACS in patients that show interventions are coming too late?

Waiting for the appearance of physical symptoms (tense abdomen, decreasing urine output, elevated airway pressure, hypercapnia, hypoxemia, etc.) to diagnose IAH/ACS often delays necessary interventions and leads to adverse outcomes

What occurs and what is the focus of the Acute phase?

With the onset of diuresis approximately 48 to 72 hours after injury, the acute phase begins and continues until wound closure occurs. This phase typically occurs in a burn center and may last for weeks or months. Nursing care focuses on wound healing, the prevention of infections or complications, and psychosocial support

Why do which burn patients require greater amounts of fluid resusc? By what difference to normal?

electrical burns, which require 75 to 100 ml/hr of urine output (vs the normal 30-50) Larger fluid resuscitation volumes are also required in patients with electrical injuries to prevent acute tubular necrosis by clearing the renal tubules from precipitating myoglobin caused by skeletal muscle damage or rhabdomyolysis.

What is the primary sign to the nurse that the sympathetic nervous system is triggered, the cardiovascular system is compensating, and blood pressure is dropping?

tachycardia