Critical care (Burn)

Partial-Thickness: Deep

- 24 days post burn-elderly woman - Right hand healed on its own, Left hand was grafted Grafting helps with function and looks better

Carbon Monoxide Poisoning

- Accounts for most of the deaths (at the scene) from thermal injuries - CO is produced by the incomplete combustion of burning materials - Inhaled CO displaces oxygen (has an affinity for hgb 200x that of oxygen) > Hypoxia > Carboxyhemoglobinemia: instead of having oxygen in the hemoglobin it has CO2 in their hemoglobin Colorless and odorless During winter and when they turn on the Furness is at most risk. S/S: hoarseness, red cherry cheeks, confusion, headache, nausea,

Pain Control

- Adequate, accurate assessment tools - Opiates; IV route - PCA may be useful - Nonpharmacological strategies: meditation, environment, anti-anxiety medication.

Psychological Considerations

- Affects entire family - Long-term effects - Consider: > Preinjury personality > Extent of injury > Social support system > Home environment - Burns are one of the most complex and psychologically devastating injuries to patients and their families. Not only is there a very real threat to survival, but also psychological and physical pain, fear of disfigurement, and uncertainty of long-term effects of the injury can precipitate a crisis for the patient and family. - It is necessary to consider the complex interaction of preinjury personality, extent of injury, social support systems, cultural factors, and home environment. - Many burn injuries are the result of poor supervision, abuse, suicide attempts, assaults, illegal activities, safety code violations, inherent dangers in diverse cultural lifestyles, arson, or military involvement. - The patient may be dealing with loss of loved ones in the fire, injury event flashbacks, loss of home and belongings, job or financial concerns, societal repercussions, or fear of assailants. The patient may also be facing legal consequences. - Preinjury psychiatric disorders such as depression, mood disorders, attention-deficit disorder, psychoses, and alcohol and drug abuse frequently exist in the burn patient population. - Assess the patient's and family's support systems, coping mechanisms, and potential for developing posttraumatic stress disorder (PTSD). - Inadequate coping is demonstrated by changes in behavior, anxiety, manipulation, regression, acting out, apathy, sleep deprivation, or depression. - Interventions based on individual assessments and that incorporate cultural traditions are the most beneficial and may require assistance from support personnel such as chaplains, clinical nurse specialists, child life specialists, psychiatrists, psychologists, and social workers. Goal after the burn. Support they might need. Self image! Is important.

Fluid Resuscitation

- Based on %TBSA - IV fluid resuscitation is instituted for patients with greater than 20% TBSA - Consensus formula (Parkland) > 4 mL/kg per %TBSA burned - Administer half of total fluids during first 8 hours from time of injury - Administer the other half over the next 16 hours from time of injury One of the most widely used burn resuscitation fluid formulas is the Parkland formula. It provides an approximation of fluid replacement requirements by calculating the amount of lactated Ringer's (LR) solution to infuse during the first 24 hours after the burn injury at 4 mL/kg per %TBSA. Half of the calculated amount is given over the first 8 hours after injury, and the remaining half is given over the next 16 hours. A revised version of the Parkland formula, called the Consensus formula, is advocated by the Advanced Burn Life Support Course. Box 21-1 Calculate the burn through rule of nine IVF: LR Parkland: 4 mL/kg per %TBSA burned

Acute Phase

- Begins 48-72 hours after injury - Continue with assessments performed during resuscitative phase - Focus of interventions are to: > Promote wound healing > Prevent complications > Improve function of body systems (systemic response to burn injury) - Prevent infection, pain control, and nutrition is your priority.

Acute Phase Laboratory Assessment

- Blood and electrolytes > Fluid shifts > Electrolyte imbalances * Hemodilution: hemoglobin/hematocrit * Sodium * Potassium * Glucose * Serum protein * WBC * Coagulation studies * Acid-base balance

Determine Burn Severity

- Burn Depth - Extent of Burn (TBSA) - Area of body burned - Medical History - Age: < 2 yrs or > 50 yr - Mechanism of injury - Concurrent Trauma

Infection Prevention

- Burn patient at high risk for infection - Contact precaution to decrease the transfer > Higher risk with 30% TBSA burns > Altered skin integrity > Altered immune response (immunosuppression) > Multidrug-resistant organisms > Multiple invasive monitoring and treatment procedures High risk of infection related to burns ≥ 30% TBSA and disruption of normal skin integrity and altered immune response (immunosuppression). Development of multidrug-resistant organism outbreaks is an ongoing issue in burn units worldwide and contributes to an increased risk of sepsis. Invasive monitoring and the presence of urinary catheters, intravascular (IV) catheters, and endotracheal tubes are also potential sources of infection. The goals of infection control in burns are the following: Preserve existing immune defenses. Prevent transmission of exogenous organisms. Control transfer of endogenous organisms (normal flora) to sites at increased risk for infection.

Partial-Thickness Deep

- Can scar significantly because healing time takes longer - Waxy, white in appearance - Typically less painful then superficial partial thickness Remove the blister, then see waxy appearance to the skin.

Systemic Response to Burns

- Cardiovascular > Loss of intravascular volume low CO and O2 > Catecholamine release causes tachycardia and vasoconstriction > Initial myocardial depression with negative inotropic effect (negative inotropic: give inotropic: dopamine and dobutamine) > Cardiac output increases 48 hours after injury leads to diuresis Low O2: hypotension, low pulse ox, decrease pulses Catecholamine: tachy and vasoconstriction and see these at the late stage

Acute Phase Assessment (Cont.)

- Cardiovascular > Maintain fluid requirement > Monitor intake and output > Monitor weight - Neurological status > Changes in level of consciousness - Renal status > Urine output Cardiovascular As capillary permeability stabilizes, IV fluid requirements decrease; maintain IV fluid infusions that match overall fluid output. Monitor daily weight and intake and output. Increased fluid resuscitation requirements after debridement and grafting operations are often required because the inflammatory response is triggered by the surgical intervention. Frequent monitoring of vital signs continues. Neurological Changes in neurological status, which may indicate hypoxemia, hypoperfusion, or sepsis, are part of the ongoing assessment. Renal Postburn diuresis starts approximately 48 to 72 hours after injury. Urine output ranging from 100 to 600 mL/hr is commonly observed. After postburn diuresis, urinary output should correlate with intake of IV and oral fluids. In the absence of diabetes, glycosuria may indicate an early sign of sepsis.

Peripheral circulation

- Circumferential full-thickness burns - Compartment syndrome > Neurovascular assessment > Peripheral pulse assessment - Escharotomy or fasciotomy (TX) Circle High risk for compartment syndrome. First signs of compartment syndrome is pain. All of sudden increase in pain. You don't want to wait until pulse is absent, then it will cause amputation. Tautness of the skin. Compare other normal legs or arms. Shinny to the skin. Decrease sensation, numbness and tingling.

Intraabdominal Hypertension

- Circumferential torso injury (abdomen) - Aggressive fluid resuscitation - Intraabdominal pressure (IAP) greater than or equal to 12 mm Hg (measure it with the foley) - Tense abdomen, decreasing UOP, hypoxia, hypercarbia, respiratory distress - TX: fasciotomy and escharotomy

Negative Pressure Wound Therapy

- Consists of a sponge, suction tubing, and occlusive dressing - Creates negative pressure to: > Remove edema > Stimulate perfusion > Provide a closed system for wound healing - May be used on wounds or grafts - Negative-pressure wound therapy (NPWT) or vacuum-assisted closure (VAC) devices can be used for the treatment of grafts, partial-thickness burns, and deep surgical wounds. * NPWT consists of a sponge and suction tubing placed on the wound bed and covered with an occlusive dressing. * The device creates a negative pressure dressing to decompress edematous interstitial spaces and increase local perfusion, to help draw wound edges closed uniformly, to remove wound fluid, and to provide a closed, moist wound healing environment. * NPWT allows the collection and quantification of wound drainage. * NPWT is associated with lower wound bacterial counts, earlier re-epithelialization, prevention of burn depth progression, and a reduction in graft loss due to reduced edema and preservation of blood flow.

Scald Burns

- Cool area with water, no ice directly on burn - Consider abuse, especially of children and aging adults Water Temperature: - 156: 1 second - 149: 2 second - 140: 5 second - 133: 15 seconds - 127: 60 seconds - 124: 3 minutes don't poor ice water in scald burns Cool water 120 F set the water temperature to children and elderly

Resuscitative Phase Prehospital Interventions

- Cover and prevent hypothermia - Remove jewelry, belts, clothing that may retain heat - Scalds, tar, asphalt burns: cool with water - Large-bore IV catheters and fluids - Pain management with narcotics (IV push/Morphine: Antidote: NARCAN) - Vital signs and baseline assessment The first priority of patient care is to stop the burning process by removing the patient from the source of burning while preventing further injury.

Full Thickness -3rd Degree Burn

- Dead, dry appearing - Requires skin grafting to heal - When tendons, muscles and bones are damaged maybe called 4th degree burn > May require amputation Damage to muscles, tendons, and bones Requires amputations due to gangre and necrosis

Inhalation Injury Below Glottis

- Direct insult alveolar level > Tracheal/bronchial constriction & spasm - Watch for > change in LOC, agitation, respiratory status > Carbonaceous sputum- gray/black/bloody sputum - Onset within minutes or hours - Initially ABG/s, CXR will be normal - Can lead to ARDS Cellular level due to smoke injury See resp. status, tachypnea, Carbonaceous sputum- gray/black/bloody sputum Inside the lung start to produce mucus and coughing up material then it's a red flag. ABG and CSR looks normal so monitor for 24 hours

Rehabilitation Phase.

- Discoloration of scar fades with time - Pressure can help keep scar flat - Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch - Healed areas must be protected from direct sunlight for 1 year Pressure garment help with scars. Avoid excessive skin.

Phases of Burn Care

- Emergent/Resuscitative (First 48 Hours)_ > Begins with burn and ends with successful fluid resuscitation > ABC's > Includes prehospital time - Acute > Onset of diuresis to wound closure > Approximately 48-72 hours post injury until wound closes > Complications due to wound closure it can last longer - Rehabilitative > Begins with wound closure and ends when client returns to highest level of function > May take years

Cyanide Poisoning

- Enclosed space - S/S: Unexplained hypotension, hypoxemia, and lactic acidosis - Treatment is hydroxycobalamin Melted plastics Risk enclosed space. Can do drug test to see Antidote is hydroxycobalamin

Inhalation Injury Risk Factors

- Enclosed space - Victims asleep - ETOH or drug involvement - Soot in mouth/nose, facial burns - Direct injury from smoke inhalation to the lungs - When to suspect inhalation injury: * closed space injury * facial injury * singed nasal hair * carbonaceous sputum * wheezing * pharyngeal edema * hoarseness More common then usual Enclosed space, fire when they are sleeping Facial burn Directly breathing in the smoke

Layers of skin

- Epidermis > Dead / Living layer > Replaced q 30 days - Dermis 1-4 mm > Connective tissue - Subcutaneous > Adipose tissue

Partial-Thickness: Superficial

- Epidermis & some dermis - Burns are bright red, moist with blisters - Very painful - Heal in 7-10 days with minimal or no scarring > May have pigment changes - Skin substitutes until healed may be needed See blisters, moist, bright red. VERY PAINFUL Protect the skin and cover the skin while recovering

Partial-Thickness: Deep

- Epidermis and most of the dermis - Moist or dry > Pale/mottled - Blisters - evolving - Tactile and Pain sensors intact - Heals within 2-4 weeks > Typically grafted Dry or mottling look to it. Going deeper to the dermis Blister might be evolving. VERY PAINFUL. Heel on their own, but grafting helps with heeling.

Superficial Burn

- Epidermis only - Healing takes 3-5 days - Skin will blanch (goes back white and red) - Skin reddened, tender, dry and painful - Systemic response may include chills, headache, nausea and vomiting - Use mild analgesics, water-soluble lotions Sunburn, touching hot pan Tylenol and analgesics.

Full-Thickness

- Epidermis, dermis, and underlying structures - Tissue color varies: white, charred, tan - Leather-like eschar - No blisters - Can be painless, nerve endings destroyed - Blood Supply destroyed Going through all dermis. Eschar replaces the skin, can be leathery No blister because there is nothing to be blistered. No nerve ending so won't be painful Need to be grafted!!!

Discharge Planning

- Evaluate short- and long-term functional disabilities - Identify resources (human and financial) - Multiprofessional discharge planning - Patient, family, community education - pg. 595 actual you would do and assess. Study that chart.

Grafting Cont.

- Excision and grafting > Eschar is removed down to the subcutaneous tissue or fascia > Graft is placed on clean, viable tissue 4-7 days Wound closed as soon as possible. Grafting them hemograft or xenograft get covered and not permanent. And later use autograft when you think its going to take.

Wound Treatment

- Excision and grafting (cont'd) > Cultured epithelial autografts * Grown from biopsies obtained from the patient's own skin and growing skin. * Used in patients with a large body surface burn area or those with limited skin for harvesting Assess is it taking, does it have blood supply, adhere to the skin. Neuro check

Extent of Injury

- Expressed as percentage of total body surface area (%TBSA) - Several methods for estimating > Rule of nines: Patient's palm method > Lund and Browder chart - Different percentages for adults and children Fastest way is by rule of nine. Rule of nines: Patient's palm method. Measure the arm and added Total body surface area

Electrical Burn- After Debridement

- Extensive damage of all of the muscles of the thumb extending into the forearm - Escharotomy and a fasciotomy escharotomy: cut through the eschar and release the pressure Fasciotomy: compartment syndrome to release pressure

Inhalation Injury above Glottis

- Facial burn leads to edema - Watch for > Singed eyebrows and nasal hairs > Hoarseness > Painful swallowing > LOC - May cause obstruction after resuscitation - Stridor=intubate (don't wait) Painful swollen Resuscitate them with fluid and they can edema. Monitor 24 hrs You see swelling just intubate!!!

Special Concerns

- Facial burns: risk of respiratory injury; oral hygiene; promote healing, risk for bleeding - Ears: prevent infection and breakdown (cartilage involved) - Eyes: ophthalmology consult as needed, keep moist (swelling prevent eye exam, so do eye exam initially) - Hands and feet or major joints: adequate circulation; maintain function - Genitalia and perineum: meticulous wound care to prevent infection Get the tube in before all the edema is very essential!!

Thermal Burns

- First Stop the burn - ABC's - Remove clothing, jewelry - Keep warm and dry - Never apply ice Remove clothing and jewelry due to swelling. Stabilize and don't cause complication Keep dry (not warm blanket bc they lost skin barrier)

Fluid Shifts

- Fluid shifts to extravascular space - Primarily seen in burns greater than 20% TBSA > Edema in burned and unburned areas - Maximum edema occurs 24-48 hours after injury * There is rapid and dramatic edema formation. Cellular swelling also occurs as a result of a decrease in cell transmembrane potential and a shift of extracellular sodium and water into the cell. * The leaking of proteins into the interstitial dramatically lowers intravascular oncotic pressure, which draws even more intravascular fluid into the interstitium and contributes to the development of edema and burn shock (shock from intravascular volume loss, created by the sudden fluid and solute shifts immediately after burn injury). - hypovolemic: distributive and hypovolemic shock (burn shock)

Acute Phase Assessment (Cont.):

- GI system > Stress ulcer > Nutritional considerations - Integumentary system > Wound healing > Infection Gastrointestinal System Monitored for the development of a stress ulcer. Tolerance of enteral feedings is assessed. Nutritional considerations are a treatment priority. Integumentary System The burn wound becomes the major focus of the acute phase of burn recovery. Assessment continues to include monitoring for burn wound healing, burn wound depth conversion, and signs of infection (increased pain; change in amount, color, odor of wound drainage; delayed healing or regression in healing; fever; elevated WBC).

Systemic Response to Burns

- Gastrointestinal (GI) > Ischemia due to redistribution of blood > Curling's ulcers > Paralytic ileus: no bowel sounds and distended/ nausea. TX: NGT (perform decompression) to prevent aspiration and NPO for 1-2 days. - Metabolic > Hypermetabolic state after initial resuscitation (after 48 hours) > Metabolic rates are 100% to 200% above basal rates > Lasts up to 1-3 years after burn (need incredible amount of calorie) Ischemia of the gut and get curling's ulcer

Skin Grafts

- Grafts for deep partial-thickness and full-thickness burns - Autograft is the only permanent method of grafting (permanent) > Donor site created: surgical wound - Homografts (cadaver) and xenografts (animal) - Sheet (nonmeshed) grafts used on face and hands - Meshed grafts (take out more space)

Blood and Electrolyte

- Hemodilution with an associated decreased hematocrit may result from reentry of fluid into the intravascular compartment and from loss of red blood cells destroyed at the burn injury site. - Hyponatremia from diuresis may occur, but it usually resolves within 1 week of onset. Hypokalemia may develop as potassium reenters the cells. - Hypoproteinemia and negative nitrogen balance may occur from an increase in metabolic rate and insufficient nutrition. - Leukopenia may develop from administration of the topical antimicrobial agent silver sulfadiazine. - Hyperglycemia associated with infection and excessive carbohydrate loading may occur. - An increase in the white blood cell count, prolonged coagulation times, and a decreased platelet count may result from infection or sepsis.

Systemic Response to Burns

- Host defense mechanism > Immune suppression > Increased risk of infection - Pulmonary > Transient pulmonary hypertension > Effect of direct injury - Renal > Hypoperfusion & decreased GFR lead to oliguria (48hours) > Diuresis as fluid shifts & CO increases( after 48 hours due to fluid shifting) Lost your protective barrier so increase risk for infection Direct lung injury: subglottic

Rehabilitation Phase:

- In approximately 4 to 6 weeks the area becomes raised and hyperemic - Mature healing is reached in 6 months to 2 years - Skin never completely regains its original color Not be able to get their original color.

Introduction

- Initial management affects long-term outcomes - Burn Centers - Multidisciplinary approach - Burns with the highest morbidity > Covering more than 50% of BSA > Inhalations injuries > Very young and elderly patients PT, OT, nutrition, and psychosocial component OA: decrease sensation, dementia, Low socioeconomic status more likely to be in the situation, more people living in one place, smoking in the place Children: curious

Physiological Response Table 21-4

- Intravascular coagulation - Altered vascular permeability - Dramatic shifts in intravascular fluid - Mediator activation - Hyperexaggerated inflammatory cascade: when all body system try to compensate and help out causes more chaos. - Massive Edema LOOK AT 21-4 MUST KNOW!!! Shift in the intravascular fluid : third spacing =edema

Electrical Injury Complications

- Irritation to myocardium > Arrhythmias, cardiac arrest up to 24-48 HRS - Metabolic acidosis due to tissue damage - Long bone fracture - Myoglobinuria - Neurological deficits Long bone fracture traveling through body Myoglobinuria: breakdown of muscle in your urine (muscle pee)/debris enough to make patient go to kidney failure

Rhabdomyolosis

- Large amounts of cellular debris being excreted thru kidneys - Leads to renal failure (ATN) - In electrical burns- Goal of 100-150 ml/hr output Dark urine, muscle breakdown in the urine Rhabdomyolosis Decrease UO and dark urine. All the protein going through affects the kidney. Electrical burns we're MOST concern with the UO. We want to see 100-150ml/hr because if we can dilute then we can see myoglobin in the urine but if we don't then might need dialysis, While the electrical travels the muscles breakdown and trying to remove it by the urine.

Fluid Guidelines for Adults

- Maintain UOP 30-50 ml/hr - Place IV access in nonburned areas - Hold colloids for 8-12 hours after injury (cell walls are leaky, then giving albumin will leak) - Inhalation injury (always think about inhalation injury and re-measure it later) - Electrical injury=higher volumes of fluid needed > Keep UOP 75-100 ml/hr > Risk: myoglobinuria Oliguria, then might increase the fluid. IO. For the burn patient.

Wound Treatment::Medications

- Medications > Collagenase (Santyl) > Silver sulfadiazine (Silvadine) > Mafenide acetate (Sulfamylon) > Analgesics > Systemic Antibiotics—Only when needed > Tetanus * Know about this medication!!

Chemical Injury (continued)

- Methamphetamine-related chemical burn injury > Clandestine "laboratories" - Thermal and chemical burn injury pattern - Assess for: > A vague or inconsistent injury history > Burns to the face and hands > Signs of agitation or substance withdrawal Methamphetamine: Both thermal and chemical burns

Chemical Injury

- Methods of Injury > Contact > Inhalation of fumes > Ingestion or injection - Assess ABC's before decontamination - Protect self during decontamination - OSHA /MSDS for information - Brush off dry chemicals then lavage copiously - Monitor for systemic effects Brush off the chemical, don't put water if the chemical is still there it can activate the chemical Transferred to larger hospital to manage decontamination. Chemical can be acid, alkali, organic Sulfaric acid (working in lab), Li (breakdown tissue/most destructive), protrolium (organic)

Laboratory Assessment in the Resuscitation Stage

- Monitor serum electrolytes > Sodium > Potassium > Blood urea nitrogen > Glucose > Lactate - HCT/Hgb > Hemoconcentration: blood is thick. And diuresis blood is thin. Serum sodium levels typically approach the concentration of the resuscitation fluid being administered. (Give LR because NS has tons of sodium) Serum potassium levels may be increased as a result of release from injured tissue. And during the diuresis phase the potassium goes down. The blood urea nitrogen level may also be increased when excessive protein catabolism occurs, and hyperglycemia may occur as a result of catecholamine release and glucose go up. Lactates go up. Arterial blood gas values and serum lactate levels are evaluated frequently because metabolic acidosis can indicate inadequate tissue perfusion. Blood is thick

Thermal Burns

- Most common type of burn - Types > Open flame/flash > Hot liquids, tar, scalds > Steam > Ultraviolet: from the sun

Nonburn Injury Cont.

- Necrotizing soft tissue infections (NSTIs) > Necrotizing fasciitis - Risk factors - Rapid progression - Pain management

Wound Treatment: Nutrition

- Nutrition > Client with a major wound is hypermetabolic and catabolic > Require 4,000 to 6,000 calories/day > Enteral feedings are best * Start within 24 to 48 hours of injury * Contraindicated if Curling's ulcer present > TPN is an option * Clients tend to be in negative nitrogen balance due to not enough protein May need tube feeding at night because 4000-6000 calorie is a lot. Don't give calorie when they have paralytic ileus TPN: Infection rate increases. So be careful. High caloric food, frequent snacks, and tube feeding via NGT or peg. They need protein.

Geriatric Considerations

- Older patients are more adversely affected by burn injuries - Multiple variables affect outcomes - Target interventions to maintaining quality of life - Prevention is essential - Safe water heater is 120F

Wound Treatment Cont.:

- Other care measures (cont'd) > Hands and arms should be extended and elevated on pillows or slings > Ears should be kept free of pressure * No use of pillows > Perineum must be kept as clean and dry as possible > Early ROM exercises every hour to prevent contractures.

Notes:

- Pain is a tormenting consequence of burn injury not limited to immediately after the injury, but also throughout the wound healing process. - Pain experienced during the acute phase of recovery consists of a constant background or resting pain, as well as a shorter peak of excruciating pain (procedural or breakthrough pain) often associated with activity and therapeutic procedures. - Many aspects of burn treatment produce pain, including dressing changes, debridement, surgical intervention, application of topical antimicrobials, and physical and occupational therapy. - Valid and reliable assessment tools are needed to assess, treat, and evaluate effectiveness of pain treatment interventions. Involve the patient in creating an individualized analgesic treatment plan. Pain levels should be assessed frequently as "the fifth vital sign," with additional assessments before, during, and after all procedures and treatments. See Chapter 5. - Opiates are the agents of choice because of the rapid onset and mechanism of action. Subcutaneous or intramuscular injections are ineffective in the resuscitative phase because of impaired circulation in soft tissue. Absorption is sporadic, increasing the risk of undermedication or narcotic overdose. - Hypermetabolism associated with burn injury may require higher or more frequent medication administration to treat pain. It is not uncommon that the quantities of analgesics required by burn patients often exceed those of standard dosing guidelines. - Patient-controlled analgesia (PCA) may be beneficial in involving patients in their care, providing them some independence or "control" over their pain management regimen. - The ideal pain management regimen must incorporate treatment of both pain and anxiety. Fear and a loss of control over their lives and schedules increase patients' anxiety. Anxiolytics are commonly administered in the acute care phase. - Use of virtual reality technology (immersive 3-D computer-simulated environments in real or imaginary worlds) and techniques such as relaxation, hypnosis, distraction, and guided-imagery also serve as useful adjuncts for reducing anxiety and enhancing pain relief.

Wound Treatment:

- Prevent contractors > Positioning, splints, exercise - Support garments > Tight, elastic garments which can help to prevent overgrown of scarring > Garments are worn 24/7 for 6 months to a year

Acute Care Interventions

- Primary and secondary surveys - Ongoing Assessment > VS (pulses, pulse oximetry) > UOP - Hemodynamic monitoring: CVP (low fluid volume then have low CVP/ ART line: frequent ABG/ PA: monitor CO and fluid status) - Gastric pH; occult blood - Prevent hypothermia: during dressing change keep the temp to 85-95 degree because they can't auto-regulate) - VTE prophylaxis: blood stasis, decrease coagulation - Maintain joint function and mobility: risk for contractures by PT and active/passive ROM hourly

Carbon Monoxide Poisoning

- Pulse oximetry will not be accurate - Treat with > 100% humidified oxygen > Hyperbaric Chamber - CO poisoning may occur in the absence of burn injury to the skin > Skin color described as "cherry red" in appearance Specific item that will measure carboxyhemoglobin because normal pulse ox can't detect carboxyhemoglobin. Humidified oxygen because you're infusing 100% oxygen/ non-breather Hyperbaric chamber: for scuba diving injury

Rule of Nines

- Quick approximation - Palm of hand 1% to estimate smaller burns

Wound Treatment

- Remove nonviable tissue - Promote re-epithelialization and wound healing - Cover the burned area; graft as needed - Prewarm room prior to wound care - Clean and debride wounds - Hydrotherapy - Application of antimicrobial agents > Silver-based agents (antimicrobial agent) > See Table 20-4 - Open versus closed method Goal is to remove all nonviable tissue. (debridement) Pre warm the room before dressing change.

Assessment in Resuscitative Phase:

- Respiratory > Assess for hypoxemia > Carbon monoxide poisoning > Assess for direct injury > Maintain cervical spine precautions - Cardiovascular > Assess for fluid volume status > Vital signs > Prevent heat loss - GI > Assess for occult bleeding - Neurological > Changes in level of consciousness - Renal > Urine output - Integumentary > Document extent of injury > Measure severity of burn (rule of nines or patient's palm method) - Psychosocial > Assess response to injury > Pain assessment A history of the injury event occurring in a closed space alerts the clinician to the high potential for inhalation injury. Any suspicion of inhalation injury requires immediate intervention for airway control while maintaining cervical spine immobilization precautions (if indicated by the injury event). Respiratory stridor indicates airway obstruction and mandates immediate endotracheal intubation at the scene. Patients with severe facial burns are prophylactically intubated because delayed or later endotracheal intubation will be difficult or impossible as edema develops.

Acute Phase Assessment

- Respiratory system > Signs of respiratory compromise * Pneumonia * Acute respiratory failure/ARDS > Chest x-rays > Fever > Secretions > WBC count: normal is 4.5-11 Assessment continues for signs of respiratory compromise and pneumonia. Inhalation injury and ventilator management place patients at higher risk for pneumonia. Tachypnea, abnormal breath sounds, fever, increased white blood cell count, purulent secretions, and infiltrations on chest x-ray films indicate developing pneumonia. Risk for aspiration. So intubate them. Leukopenia for burn patients use Silver sulfadiazine (Silvadine)

Rehabilitation Phase ...

- Skin and joint contractures > Most common complications during rehab phase - Hypertrophic scarring

Nonburn Injury

- Some syndromes mimic burn-like injury - Severe exfoliative disorders > Toxic epidermal necrolysis > Stevens-Johnson syndrome > Erythema multiforme > Staphylococcal scalded skin Toxin and venom can be treated in burn unit. Don't really need to know!

Electrical Injuries

- Sources > Lightening > Electric wires > Utility lines - Additional injury r/t falling or thermal injury - Electricity does not travel over the surface of the skin- travels through the body > Iceberg effect - Entrance/exit points Current flows and exit one point Go through soft tissues or organs so you'll see enter wound and exit wound. Assess them for other trauma. Iceberg effect because you don't see extent of the effect.

Resuscitative Phase Prehospital Interventions

- Stop the burning process - Identify life-threatening injuries - ABCs and cervical spine - Oxygen 100%; intubation if needed - Assess circulation (2 Large bore-18g/IVF: LR) - Assess for additional trauma - Minimize time on scene The priorities of prehospital care and management are to extricate the patient safely, stop the burning process, identify life-threatening injuries, and minimize time on the scene by rapidly transporting the patient to an appropriate care facility. As with any other type of trauma, the primary survey is used to provide a fast systematic assessment that prioritizes evaluation of the patient's airway, breathing, and circulatory status.

Classification of Burns (Depth of Injury table 21-3)

- Superficial (1st Degree Burn) - Partial-Thickness (2nd Degree Burn) > Superficial > Deep - Full Thickness (3rd Degree Burn)

Tar, Asphalt, Melted Plastic

- Tar, asphalt, and melted plastics can be difficult to remove - Remove clothing if possible - Maintain airway * Cool with water * Leave material in place * Assure airway - Tar hot and burning, then cool it with water if not just leave it and secure the airway

Types of Burns

- Thermal (flame, scald or contact) - Electrical > Dry or moist - Chemical > Acid, Alkali, organic compounds (toxic exposure) - Inhalation (exposed to thermal like house fire) Thermal burns most common Electrical and chemical less common

Partial-Thickness: Deep

- This hand healed without surgical intervention - Cosmetically and functionally impaired - Impact appearance and function.

3 Types of Inhalation Injury

- Toxic Gases > CO poisoning > Cyanide - Inhalation above glottis (supraglottis) - Inhalation below the glottis (subglottis) Airway injuries: - carbon monoxide poisoning: S/S may vary - Inhalation injury above the glottis: singed nasal hair, facial burn, and carbonaceous sputum - Inhalation injury below the glottis: s/s may not be immediate

Transfer to Burn Center

- Transfer patient to a burn center early, according to the criteria below: > Partial thickness > 10% TBSA > Full-thickness burns > Burns on face, hands, feet, genitalia, perineum, and joints > Chemical and electrical > Inhalation > Comorbidities > Associated trauma Skin grafted!! Joints are tricky due to contractures.

Electrical Burn- Entrance Point

- Typical entrance wound to hand - Underlying tissue injury - Limb loss common

Wound Treatment Cont.

- Various types of biological and biosynthetic dressings - Biological Dressings: Allograft (homograft) and xenograft (heterograft) (come from people or animal) - Biosynthetic Dressing: (skin substitute) - Epidermal replacements (Epicel, Epidex, MySkin, etc.) - Dermal substitutes: AlloDerm; Integra; TransCyte - Bilayer dermo-epidermal substitutes (Apligraf, OrCel)

Abuse

- Vulnerable population > Children > Geriatric > Disabled > Mentally impaired - Identification of potential cases > Elicit history > Note wound appearance and pattern > Take photos > Observe interaction > Assess for other injuries Mandatory report is due to vulnerable adults, children, and geriatric. Where is located, does it fit with the story?

Partial and Full Thickness

- White area=full-thickness burn - Pink and reddened area=Deep Partial-thickness

Zones of Injury

- Zone of hyperemia > Minimal injury - Zone of stasis > Potentially reversible damage - Zone of coagulation > Greatest injury Goal: prevent secondary insults

A 54-year-old male was working on his car, and the carburetor exploded. He presents with singed nose hairs and red, painful blisters on his face and bilateral forearms and hands. What type and depth of burn injury do you suspect?

A. Inhalation injury below the glottis with superficial burns B. Inhalation injury above the glottis with superficial partial-thickness burns C. Deep partial-thickness burns and carbon monoxide poisoning D. Full-thickness burns and inhalation injury above the glottis ANS: B. Inhalation injury above the glottis with superficial partial-thickness burns The heat generated by the carburetor explosion and proximity of the patient's face under the hood of the car created a closed space and potential inhalation injury. The intensity was brief and resulted in singed nose hairs and an above-the-glottis inhalation injury. Red, painful blisters are consistent with epidermal and superficial dermal tissue loss, or a superficial partial-thickness burn injury (second-degree burn).

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

ANS: 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 is an appropriate intervention in the prehospital setting in the management of an unconscious patient who was pulled from a house fire. His vital signs are BP 100/82 mm Hg, HR 122 beats/min, RR 26 breaths/min, SpO2 100%.

ANS: C. Apply 100% humidified oxygen. The patient most likely has carbon monoxide poisoning as he was pulled unconscious from a house fire. Pulse oximetry may not be accurate in acute inhalation injuries because the pulse oximeter cannot distinguish between carbon monoxide and oxygen attached to the hemoglobin. Patients are monitored for clinical signs of decreasing oxygenation such as changes in respiratory rate or neurological status.

Electrical Burn- Exit Wound

Amputation often necessary because of extensive muscle necrosis

Skin grafting is placing skin on the excised burn wound.

Autograft (skin from oneself that is transferred to a new location on the same individual's body; i.e., the patient's own skin) Allograft, which is also called homograft (skin from another human; e.g., cadaver skin) Xenograft (skin from another animal; e.g., pigskin) Autografts are the only permanent type of skin grafting (Table 21-7). Homografts and xenografts are temporary biological dressings (see Table 21-6). With autografts, a partial-thickness wound called a donor site is created where the skin was harvested or removed from the patient. (Table 21-8 reviews donor site dressings.)

Selected Images

Figure 21-8: Note facial edema. Figure 21-10: Note thoracic escharotomies required because of full-thickness chest injuries compromising ventilation.

SKIN

Primary Defense Mechanism & Thermoregulation: - 1st line of protection from infection - Self Esteem & identity - Prevention of loss of body fluids - Production of Vitamin D - Sensation reception - Face transplant Skin primary defense mechanism. Important for thermoregulation Prevention of loss of body fluid!!

Emergency Department Interventions

Primary Survey Secondary Survey ABCs and C-spine evaluation Chest and other x-rays Evaluation of TBSA and depth of burn injuries Calculation of fluid requirements (starts at the time of the burn) Tetanus toxoid immunization (Only IM shot that would be given to BURN pt. due to rhabdo) - Not get good absorption due to decrease tissue perfusion.

Resuscitative Phase

Review the resuscitative phase. ECG on patients with electrical injury is super important!!!

Electrical Burn-Back

Severity of injury can be difficult to assess as most damage is beneath the skin Damage you see is this but damage can be worse : iceberg effect

Skin Grafts (Cont.)

Surgical application of the meshed graft. B, Well-adhered meshed skin graft. C, Well-healed meshed skin graft. Skin from donor site is harvested with a tool called a dermatome.

Skin Grafts (continued)

Surgical application of the meshed graft. B, Well-adhered meshed skin graft. C, Well-healed meshed skin graft. Skin from donor site is harvested with a tool called a dermatome. Put holes in it so it can take more space in it. Good healing.

Introduction::

The first priority of patient care is to stop the burning process by removing the patient from the source of burning while preventing further injury. Flame burns are extinguished by rolling the patient on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water. Ice is never applied to the wounds because further tissue damage may occur as a result of vasoconstriction and hypothermia. Jewelry is immediately removed because metal retains heat, causing continued burning. Scald, tar, and asphalt burns are treated by immediate removal of the saturated clothing or immediate cooling with water if available, or both. No attempt is made to remove adherent tar at the scene. Adherent clothing (clothing that is burned into and stuck to the skin) is not removed because increased tissue damage and bleeding may occur; however, water is applied to cool the clothing material. IV therapy is initiated with the insertion of two large-bore (14- or 16-gauge) IV lines, preferably through nonburned tissue, and infusion of lactated Ringer's (LR) solution. Obtain baseline vital signs and past medical history to include allergies and prescription medications. Administer short-acting narcotic agents such as morphine sulfate IV for pain relief. No intramuscular medications are given during the resuscitative phase because perfusion of edematous tissues is poor and produces sporadic narcotic absorption. The patient should not receive anything by mouth before or during transport because of the potential for vomiting and aspiration.

Rehabilitation Phase

The rehabilitation phase is defined as beginning when the patient's burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity Covered and healing. Able to do their normal activity. 4-6 weeks but varies to the extent of the burn.

Fluid Shifts- Emergent Phase

Third spacing (EDEMA) Fluid losses