burns: pearson notes

extent of burns

% of TBSA. rule of nines-QUICK method of ESTIMATION: EMERGENCY care phase. 5 surface areas of body-head, trunk, arms, legs, perineum; % equaling sum of 9. different for KIDS.. -NOT good for adults who are short, OBESE, or very THIN. -only for PT/FT burns(NOT for superficial!) -once get to hospital, ICU, or BURN center-use more ACCURATE method! like LUND AND BROWDER METHOD-surface area msmt according to AGE of pt. or use EXTENT and DEPTH of injury to classify burns as MINOR, MODERATE, or SEVERE.

partial thickness burns

- destruction of epidermis and part of the dermal layer - painful, stimulation of nerve endings - blisters quickly - red to pale, moist surfaces - heals quickly <21 days - usually no scarring deeper than SUPERFICIAL -either SUPERFICIAL or DEEP PT***

planning

-3 priorities: airway, breathing, cv circulation. -ABG/pulse ox normal, clear unobstructed airway -no dysrhythmias -adequate nutrition -adequate fluid volume, hourly UO correct***(best indicator***) -BP/HR WNL -adequate wound healing! -adequate pain control! <3 -no HAI -full ROM after recovery!

debridement

-BURNED tissue releases chemicals that stimulate PHAGOCYTOSIS to digest DEBRIS from necrotic tissue. must be REMOVED by: 1. mechanical, 2. enzymatic, 3. surgical debridement. 1. surgical: cut necrotic tissue. 2. mechanical: remove dead tissue, gauze dressings(wet to dry/wet to moist) or with HYDROTHERAPY, IRRIGATION, scissors/tweezers(sharp debridement) -pain, damage to granulation tissue but easiest! -hydrotherapy PREFERRED.(immersion tank, shower, spray table), washed with mild antimicrobial soap/wound cleanser SOLUTION, separates ESCHAR. RINSED off w/WARM saline/tap water. -body hair shaved around wound edges. blistered skin-grasped with dry GAUZE and removed gently. edges of blister/eschar TRIMMED w/blunt scissors, wound covered with TOPICAL antimicrobial agent. -enzymatic debridement is similar: TOPICAL agent to dissolve/remove necrotic TISSUE and LIFT eschar. enzyme preparation: collagenase(santyl), papain, papain-urea, fibrinolysin-deoxyribonuclease(ELASE) in THIN layer within the wound. covered with ONE layer of fine mesh gauze! topical antimicrobial applied/covered with BULKY WET dressing, wound IMMOBILIZED with expandable MESH gauze.

tetanus: pharm for burns, antacids

-tetanus toxoid: IM in acute phase! to prevent clostridium tetani. if older than 5 yrs since last one, get BOOSTER! -antacids: hyperacidity! to prevent CURLING ULCER! NGT: emergent phase, gastric aspirant q hour! gastric pH: above 5 good! histamine H2 blockers(famotidine-pepcid) or PPI(pantoprazole(protonix) IV, intermittent or continuous! once have BS, put on antacid regimen!

temporary skin substitutes: more

-transcyte and apligraf. transcyte: bioengineered from human fibroblast cells grown in the mesh. dermal collagen, matrix proteins, growth factors secreted! frozen! for surgically DEBRIDED FT/deep PT burns, alternative to SILVER SULFADIAZINE and cadaver skin!

3 phases in CV system with burns >40% TBSA

1. inc Microvascular permeability at burn site 2. impaired CELL WALL f'n, IC edema 3. inc OSMOTIC pr of burned tissue, FLUID accumulation. shift of FLUIDS with BURN SHOCK-dec cell wall integrity and in capillary bed. fluid leaks from CAPILLARIES INTO IS compartments. DEC fl volume in IV space. plasma PRO/Na+ into ISF inc EDEMA. CO dc, BP dec.

metabolism

2 phases of metabolic response to BURN. 1. ebb phase-first 3 days of injury-dec o2, fluid imbalance, shock, dec o2. 2. flow phase: burn RESUSCITATION. protein CATABOLISM, inc cell activity, lipolysis, gluconeogenesis. BMR inc, body wt/heat drop!* hyperMETABOLISM.

Fluid replacement

24h-4mL/kg with 50% in 8h. Kids: get d5(need dextrose)-use parkland or Galveston. -hourly UO best indicator of fluids! Electrical: harder to tell, so give 500mL/hr until get foley, then calculate based on UO-1mL/kg/hr -shock=marrow pulse pressure*** and UO. Hr Better than bp in peds. -May need hemodynamic monitoring.

Severe burns

3 stages: emergent/resuscitation, acute, rehabilitative. 1. Emergent/resuscitative:onset of burn to giving fluids! Estimate extent of burn, first aid, give fluids! Assess for shock and resp distress. insert IV line. Intubate! Decide if need to send to burn center! Who to tx at burn centers: over age 50 with 2/3rd degree burns or >10% TBSA; younger than 50 with 2/3rd degree on >20% TBSA. Adults with 3rd degree or more than 5%, electrical, chemical, inhalation burns, circumferential burns of ext/chest; preexisting illness, fx, or other trauma.

heart rhythm alterations

>40% of TBSA: dec contraction of heart/dec CO* release of anaerobic radicals/substances from wound and ischemic myocardial CELLS. electrical burns-dysrhythmias and cardiopulmonary arrest from HEAT damage to heart!

RF

AGE, 4 and younger, 65 and OLDER. -hot TAP water, ELECTRICAL outlets. -kids are CURIOUS! matches, lighters, fireworks, MICROWAVES, STOVES. SPILLS/hot surfaces-reaching, etc. -ABUSE. up to 40%! -older: slow rxn times, dec mobility, sensory impairment. DEMENTIA, THIN skin-DEEP burns -gender: MALE -LOW SE status.-unsafe homes, NO smoke detectors, portable HEATING devices(like old hotels) -smokers, tobacco, drugs, etOH! -physical/mental disabilities-dec rxn times, physically can't escape! -workers: chemicals, GASOLINE, ELECTRICITY, extreme heat sources(welders-COLE) -preexisting cardiac, pulm, renal, DM, alcoholics: more COMPLICATIONS!

systemic effects: burn injuries

ALL body systems, lose SKIN-INFECTION, F/E limb, HYPOTHERMIA. -INHALATION injury -DYSRHTYHMIAS: circ failure -CATABOLISM, dec GI motility, alt NUTRITION, paralytic ILEUS, hyperACIDITY-gastric/duodenal ulcerations. DEHYDRATION slows GFR-ATN, renal failure.

FT burns

ALL layers-bottom right, yellowish/brown(2 layers shown-looks like skin peeled back), ALL layers of skin, epidermis, dermis, epidermal APPENDAGES. UNDER skin-SQ fat, connective tissue, muscle and BONE. PROLONGED contact w/flames, steam, chemicals, high VOLTAGE electric current(DC, like lighting), pale, waxy, yellow, brown, mottled, charred, NONBLANCHING red. dry, leathery, firm SURFACE. can see BV under wound. no SENSATION-pain receptors DESTROYED. tx: HAVE to have SKIN grafts to heal!

Emergency/acute care

Assess airway and breathing, inhalation/severe: tracheal intubation, bp, hr, ecg. Hx of injury, depth/extent est, fluids, ventilation. Analgesics. Then icu/burn unit-meds, pain, wound care, nutrition. -airway: intubate for chest, face, neck burn. Prevent atelectasis. -hob 30, q2 turn so no pna -suction, IS hourly, tcdb q2h -intubate-obstruction, ETT for short term vent, long term:> 3 wks-trach -humidify RA/o2 so don't dry tracheal secretion. Abg results, face mask, steam collar, t piece, vent with peep, high freq jet ventilation. -meds-dilate bronchial passages(IV or inhalant) so no bronchospasm or wheezing. Mucolytics-liquefy sputum to expectorate. -arterial line: for burn, continuous abg. PAP cath for pvr, pap, pawp, svo2(mixed venous o2)

Collaborstion

Burn team-acute/rehab phases. Minor: most outpatient. Goals: wound healing, comfort, mobility, no infection. Sunburn most common. Mild lotion, inc fluids, warmth! Older/kids-monitor dehydration. Sunscreen, no sun before 10/after 3. Skin dressings, antibiotic. Nutrition for healing. Mild analgesic. Blistering: left intact OR debrided!

immune system

CAPILLARY leak-early on, impairs cell-mediated(t cells) and humoral(b cells). humoral: b cells produce antibodies/IG. protein-low. dec t-dec cytotoxic activity. RISK INFECTION. 1-4 wks after burn most risk* OI may be FATAL.

peripheral vascular compromise

Circumferential burns are those that result from an injury that encircles the whole extremity. As scar tissue forms it tightens like a rubber band reducing blood supply below the burn. -impaired circulation to ext. from edema, vasoconstriction from BURN SHOCK. ACS can result!(Mr. Garrison went over)-acute compartment syndrome! extreme severe, sudden pain! tissue PRESSURE in muscle compartment, interrupts CELL PERFUSION!

superficial burns

EPIDERMAL layer, sunburn, UV light, MINOR flash injury(ignition/explosion), mild radiation: CA tx. skin INTACT, not calc into est of burn EXTENT(don't use parkland formula), pink to bright RED, EDEMA over burned area(slight) -may even have CHILLS, HA, n,v. heal in 3-6 days, dry/peeling outer LAYER and NO SCARS. tx: mild ANALGESICS, water-soluble LOTIONS. extensive: may need IVF, esp in elderly.

Surgery-burns

Escharotomy Surgical debridement Autografting Escharotomy: circumferential-ext or chest, like tourniquet, dec circulation. Gangrene. Electrocautery or scalpel removes. Sterile surgical incision. Releases taut skin, longitudinal. Expansion from edema. 24h after-packed with fine mesh gauze. Then after 24h: topical antimicrobial.

Surgical debridement

Excise wound to fascia(fascial excision) or remove thin slices of wound to viable tissue(tangential excision). Fasciectomy: rids fat and lymphatic tissue too, reserved for FT burns only*** mostly use electrocautery. Tangential uses dermatome. May bleed, if not do another layer of skin. After this, returned to burn unit.

Circulatory, fluids

Ivf for hypotension with acute period of inc cap permeability(so no burn shock). For >15% tbsa. Crystalloid-16G or 14G through unburned skin. >40%: 2 lg bore better. -WARM LR during 24h-close to body ecf. Parkland formula used, also modified Brooke formula.

lower airway thermal injury

LESS common, larynx, below VOCAL CORDS uncommon. steam/gas inhalation, aspirate HOT liquids, sputum with soot, carbon. SMOKE poisoning: gas, particulates-combustion, CYTOTOXIC! product of combustion: CO-asphyxiant

flashover effect

LIGHTING BOLT flashes over person, current travels over MOIST surface of skin rather than deeper structures, saving from death!

papillary layer

Outermost layer of the dermis, directly underneath the epidermis

interventions: pain management, skin integrity, prevent infection

PT and superficial burns: painful! PT/wound care too. anxiety-inc pain. -msr pain level -pain med before painful procedures, PCA maybe. -IV opioid analgesics -explain procedures -nonopioid for pain: relaxation, massage, distraction. -verbalize pain! skin integrity: clean wound, control infection -estimate depth/extent, recalculate extent q wk -daily wound care-debridement, dressing, meds. remove dead tissue, control inf, re-epithelialization. -elev burned/skin grafted ext***at/above heart-prevents edema, inc venous return -immobilize skin graft site 3-5 days, move slowly across bed sheets-no shearing/dislodging skin graft.

Dx tests

Pulse ox-not for CO though(hgb bound to it so false reading) Carboxyhemoglobin msmt-msr %hgb bound to CO. Abg-low/normal bicarbonate, high or low ph. Dec o2 and co2. 12 lead ecg-hypokalemia and hyper. Dysrhythmia Cxr-24-48 h after burn, atelectasis, ARDS, pulm edema U/A: renal perfusion, nutrition, nitrogen in urine-catabolism. 24h urine, myoglobinuria-dark brown (ATN). Proteinuria-dehydrated, high USG. Glycosuria-burns. -CBC: hct high, fluid shifts, hgb dec(hemolysis) WBC high-Inf Serum electrolytes: sodium dec, k high burn shock, dec after burn shock. -renal function: bun high, dehydrated, creatinine high

Debridement

Remove necrotic material(loose tissue, wound debris, eschar) from wound. 2x daily dressing change with topical ointment, ROM, weekly appt until wound heals.

Acute stage

Start of DIURESIS(recovery, diuresis after fluid leaves tissues back to vessel-get HTN-so recovering), ends with CLOSURE of wound! By natural healing OR skin GRAFT! Therapies: wound care(hydrotherapy and excision and grafting of FT wounds ASAP!) -nutrition therapy:enteral/parenteral started early! -infection PREVENTION: topical/systemic antimicrobials! -pain: opioids before invasive procedures for comfort, dec anxiety(debridement and PHYSICAL therapy)*

asphyxiant

Substance (such as a toxic gas) or event (such as drowning) that creates a lack of oxygen in the body. CO-carbon monoxide, colorless, tasteless, odorless gas. more affinity for hgb than o2. EASILY displaces o2 and binds w/HGB, forming CARBOXYHEMOGLOBIN*-hypoxia. sx: HA, nausea, dizzy, coma, DEATH.

Svo2 and CO

Svo2-% of hgb bound with o2 in venous blood. Reflects tissue use of o2. Pulse ox used. Pvr and pap-RISE with hypoxia* -CO: poisoning, COHgb monitored. False NORMAL or high pulse ox reading. High flow 100% o2 by nrb. COHgb >15% need hyperbaric o2 too to replace CO***

Other labs-nutrition

Total protein, albumin, transferrin, prealbumin, retinol binding protein, a1 acid glycoprotein, c reactive protein: nutrition status labs. Better during rehabilitative stage when pt's fluid is more stable. -creatine kinase-high from electrical burn. Muscle damage** -blood glucose-high after major burns***(stress on body)

more recent advancement in tx burns

VAC-neg pressure to dressing over wound, draws wound edges to center of site. removes excess fluid-edema, inc cell growth, inc blood flow, inc healing. PREPARE before SKIN GRAFTING! :) also use honey! biologic wound dressing-inc healing! Manuka honey! debridement(autolytic), dec inflammation

Rehabilitative stage

Wound closure, ends with return to health(May take YEARS)! Focus is psychosocial! -prevent contractures/scars -maintain work, family, social roles with PT, OT, vocational support and rehab. -ROM for mobility and injured joints.

nur process: burns

acute: support life, monitoring! healing: cope w/scars, hair loss, powerlessness. alt body image, lose independence. assessment: time of burn, hx of injury, causative agents, early tx used. med hx-meds, age, body weight! EMERGENT PHASE! get as much right away bc may have dec sensory abilities after first few hours of occurrence! :( -info gathering: time of injury-fluid calculations based on time of injury*** -cause of injury: determines priority action -first-aid tx: home remedies? liquids, immobilizing devices-splints for fx, etc. -PMH: resp, cardiac, renal, metabolic, neurologic, GI, skin diseases, alcohol abuse, altered immune states, allergies! -meds taken: blood levels, tox screen -age: kids, elderly are more risk! -body weight: acute/rehab phases-20% of preburn weight lost!

diuresis phase

after BURN shock, when water moves from ISF(edema) back to vessel-creates HTN! inc CO, BP, INC UO! healing! hard for elderly, CV disease pt

interventions: fluid balance

airway potency, ventilation, circulation. fluid/nutrition, pain, wound care, no infection. assessment of healing, pt/family feelings about injury/effects. -fluid volume balance:adjusted periodically, emergent phase! need more fluids: fluid in lung tissue if had inhalation injury, electrical injury-FT. -monitor I/O hourly, report dec UO -assess narrow PP***-SHOCK! -hemodynamic status-dec CVP/PAWP if not enough fluids! -weigh daily! calculates fluid! -test stools/emesis for blood. occult blood-GI bleeding! -warm environment, hypothermia-shivering, lose body fluid more! inc energy expenditure, catabolism -monitor FVO-older pt, cardiac disease or HF-risk!

homograft

aka allograft, skin graft from cadaver or another person, human skin. stored in SKIN BANK around nation! frozen skin, expensive, short supply. sterile technique. rejection a concern. rejection in 14-21 days after application if not accepted. dec INFECTION, promotes healing

pharm: antimicrobials, tetanus prophylaxis, antacids

antimicrobials: topical, for SURFACE of wound, not applied until ADMITTED to unit! mafenide acetate(sulfamylon) cream, silver nitrate 0.5% SOAKS, silver sulfadiazine(silvadene) cream. (ALL BROAD-SPECTRUM!), either open to air or CLOSED with bulky dressings! -***HIGH risk sepsis/septic shock with MAJOR burns. given prophylactic abx. systemic preop/postop with excision/autografting! postop: d/c in 24h***

biological dressing

assist with wound healing and stimulate epithelialization. These dressings may be used as donor site dressings, to manage a partial-thickness burn and to cover the clean, excised wound before autografting. are called?

biological and biosynthetic dressings

biological: and biosynthetic: TEMPORARY material that RAPIDLY adheres to wound bed, promotes HEALING, preps BURN wound for autograft coverage. inexpensive, non antigenic, elastic, easy to apply! DEC PAIN, BACTERIAL barrier, inc HEALING PROCESS! applied to wound ASAP! eliminates loss of WATER through evaporation, dec INFECTION, inc WOUND healing! homograft(allograft), heterograft(xenograft), amnionic membranes, synthetic materials.

special skin care

clean burns-eyes with NS or sterile water so no corneal/conjunctival drying. contracture of eyelid: drops/ointments so no corneal abrasion -wipe burns of lips with saline pads. antibx ointment, mouth care routinely. oral endotracheal tube-reposition often so no pressure ulcer in mouth!*** -debride burns of nose gently-mafenide acetate(sulfamylon) cream*** -position NGT/nastotracheal tubes to prevent excess pressure!*** -apply mafenide acetate(sulfamylon) cream to burns of ear! gently debride/clean wound w/water spray! don't cover ears w/dressings***do nOT use pillows! use foam doughnut, burns of ears: infection, special positioning devices-dec pressure ulcers on ears!

biosynthetic dressing

combo biosynthetic and synthetic materials.(biobrane) for partial thickness clean superficial scalds. made of nylon fabric embedded in silicone film. adherence til epithelialization occurs and allows exudate to pass through

split-thickness skin graft (STSG)

cutting the skin from a donor site and using a graft mesher to expand the graft. The graft is then transplanted on to the surgical site. Nervous System and Sense Organ, epidermis and part of dermis are replaced.

another product of combustion

cyanide GAS, from plastic, polyurethane, nylon, silk is BURNED. dec cell respiration. brain/HEART most vulnerable to poisoning! sx: HA, dizzy, seizures, tachycardia, dysrhythmias.

dermal replacement

deep PT/FT: integra: synthetic substitute of dermis alloderm: human cadaver allograft(homograft) dermis: put IN the wound, split thickness autografts placed OVER dermal replacement. TEMPORARY wound coverage, dec PAIN, help HEALING.

sx of burns

depend on source, TYPE, severity. determined by 2 factors(damage is): 1. DEPTH(how many LAYERS of tissue affected), 2. EXTENT of burn(% of BSA involved). DEGREE: 1,2,3. now replaced by DEPTH of burn. -depth: which PARTS of skin damaged. depends on TEMP of agent, LENGTH of contact. SUPERFICIAL, PARTIAL THICKNESS, FULL THICKNESS

deep PT burn

dermis as well and epidermis, but DEEPER than SUPERFICIAL PT burn, past papillary layer into RETICULAR layer. hair follicles, sebaceous glands, epidermal sweat glands INTACT still. hot liquids/solids, flash flame, DIRECT flame, radiant ENERGY, chemical agents. surface is PALE and waxy, moist OR dry(superficial usually red/blistered). EASILY RUPTURED LG blisters, or FLAT AND DRY. dec CAP refill(dec perfusion!), LESS pain than superficial, dec SENSATION. >21 days to HEAL, may convert to FT if necrosis! contractors are POSSIBLE, or hypertrophic SCARRING. tx: may excise wound/skin grafting to dec SCARRING

burn

exposure to heat, chemicals, electricity, radiation. energy transferred to human body, tissue destruction, minor epidermis, to multi system injuries. aseptic-burn center. or first aid.

transcyte and apligraf

forms transparent protective barrier over wound. applied only once! transcyte applied within 24h of injury! apligraf: bilayer from neonatal foreskin.

physical mobility, balanced nutrition, empowerment; evaluation

get pg 1616

acute phase of burn

hard crust-eschar forms-NECROTIC tissue. leathery/RIGID, removal-HEALING!

lifespan: burns

heat, also electricity, radiation, chemical exposure. most minor. lg areas of body, critical body parts, ped/geriatric-need SPECIALIZED tx in burn center!(like southport), infants/kids: hot liquids, objects, fires, chemicals, radiation(sunburn), electricity. most in home! -5 and under: fire in home, scald deaths(hot liquid/steam) -child abuse: glove/stocking burn, flexor surface burns spared, contact burns-curling irons, cigarettes, irons, zebra burn lines-hot grate! -be careful not to accuse parents-may feel guilty! -take PHOTOS to document injuries, or CHILD NEGLECT!

resp system

hot gases/smoke breathed in, lethal-inhalation injury. resp inflammation/pulm failure-ARDS. heat, asphyxiants, smoke. local inflammation-hyperEMIA(inc blood), cells destroyed, cilia INACTIVE. BRONCHIAL congestion/INFECTION. pulm EDEMA-to IS compartment. surfactant INACTIVATED-atelectasis and ALVEOLAR collapse. sloughing lung TISSUE-DEBRIS, AIRWAY obstruction

biosynthetic dressings

hydrocolloid-protect HEALING tissue from drying, liquefy necrotic tissue, ABSORB wound drainage. if DERMIS lost from deep PT or FT, integra or alloderm can be used as dermal replacement

nutritional support

hypermetabolic/catabolic state! with major burns! HEAT loss from BURN, pain, infection. caloric needs: 4000-6000kcal/day!!! negative nitrogen balance. enteral feedings: nastointestinal feeding. within 24-48 hours after burn! improve nitrogen balance. dec SEPSIS. placed under FLUOROSCOPY-tip past PYLORUS to prevent reflux/aspiration, enteral preferred but CONTRAINDICATED in curling ulcer, bowel obstruction, feeding intolerance, pancreatitis, septic ileus. CVC may be used-subclavian or jugular vein-TPN***

Autografting

in surgical suite, healthy skin removed, put over wound area. grafted area then IMMOBILIZED. site assessed daily for adherence. pt resumes ROM exercises 5 days post graft! wound heals: itching common, mild LOTIONS can be used. -cultured epithelial autographing: skin cells removed from unburned site on body, minced, put in culture medium for growth. 5-7 days, then grows 50 times size of initial biopsy. cells separated, put in new culture medium again. 3-4 wks to grow enough SKIN. attached to PETROLEUM jelly gauze backing, applied to BURN site. INFECTION risk! and lack ATTACHMENT possible.

dx

ineffective airway clearance impaired gas exchange risk for aspiration(if don't hear any lung sounds anymore after wheezing before-BAD!!! immediate intubation! rapid response!) dec cardiac tissue perfusion deficient fluid volume ineffective renal perfusion risk for inf imbalanced nutrition: less acute pain impaired physical mobility powerlessness

burn wound healing

inflammation, proliferation, remodeling, lasts longer than normal wound healing. -inflammation: starts RIGHT after burn, plts in contact w/damaged TISSUE, aggregation. FIBRIN deposits, traps plts, THROMBUS forms. vasoconstriction-hemostasis-walls off wound! -local vasodilation, inc CAP PERMEABILITY, neutrophils, peak in 24h, monocytes! macrophages, consume dead tissue, growth factors-fibroblasts, wound MATRIX

other issues: electrical burns

lighting-high voltage DC-brain injury, lose consciousness, coma, eye/ear injury, temporary paralysis, NERVE damage, metal jewelry/coin burns. many have AMNESIA but ongoing SX-LIKE SEIZURES!

preventing infection

lose external barrier, monitor daily-wound infection, remove topical meds and wound exudate to examine whole wound! ink-swelling, inflammation of skin around the wound, change color, odor, amt of exudate, inc pain, lose skin grafts that were previously healed! -monitor for pos blood cultures-bacteremia-sepsis! -monitor hyperemia(red skin, inc blood flow), cough, chest pain, dec o2, wheezing, rhonchi, purulent sputum-pna -mon bacteriuria, fever, urgency, frequency, dysuria(painful/difficult urination), suprapubic pain-UTI -obtain daily WBC, leukocyte-IS function, inc infection*** -tetanus status-risk anaerobic inf with clostridium tetani -high calorie diet, nutrition to inc IS/healing -aseptic env, standard precautions-gloving, downing, sterile also, strict isolation-so no hai! may need to gown! -culture wounds/body secretions. c/s identify infectious microbes/indicate antimicrobial therapies needed! -give antimicrobial meds-dec wound inf!

integumentary system

lose skin in burn issues. common results: -lose WATER from evaporation(dehydration a rest-why need fluids based on parkland formula for moderate/severe!) -infection from losing skin integrity, pathogens enter body -can't maintain body temperature from HEAT loss from open WOUNDS -burns: bull's-eye appearance, less severe-on periphery. 1-3 concentric 3 dimensional zones depending on severity!

pharm therapy: analgesics, antimicrobials

meds for PAIN, prevent INFECTION(and tetanus), dec PUD! IVF-severe -analgesia: emergent-morphine, oxycodone, fentanyl. morphine is CHOICE-PO or IV. fentanyl: IV, PO, transmucosally(intranasal spray or lozenges-buccal mucosa). oxycodone: PO/IV. AVOID PO or trans mucosal until normal HEMODYNAMICs and NORMAL GI emptying! IV/TRANSMUCOSAL FASTER AND PREFERRED!*** -acute stage: opioids AROUND THE CLOCK! Tylenol, NSAIDs, PCA -anxiety: benzos-lorazepam dec pain perception too, 1h BEFORE wound care!*** -antimicrobials: systemic INFECTION most common cause of death! with MAJOR burns. gram POS mostly-MRSA, gram neg-pseudomonas aeruginosa and klebsiella.***fungal: candida albicans: after broad spectrum abx or DELAYED wound care! routine wound cultures not shown to actually help.

path of burns, types

most common injuries, types: heat, chemicals, electricity, radiation. 4 types. thermal: heat-dry(flames) or moist(steam, hot liquids). most common burn-kids, elderly. aka SCALD burns-infants mostly***direct exposure to HEAT with THERMAL burns-cell destruction, charring of vessels, bones, muscle, nerves. -chemical burns: direct contact between SKIN and ACIDS, ALKALINE agents(worse), or ORGANIC compounds. destroy PROTEINS in tissues=NECROSIS***hydrochloric acid-necrosis of SUPERFICIAL tissue. alkalis-LYE-liquefaction necrosis. ORGANIC compounds-petroleum by dissolving LIPID MEMBRANES. alkalis-harder to neutralize, deeper/more severe. ORGANIC COMPOUNDS also bad-renal/liver failure. electrical, radiation

causes of burns

most from fires, one of top 6 accidental deaths in kids 1-14***, 8th-adults over 65, MORE common than we think! under 4-hot surface(like SAM), SCALDING LIQUID. older: flames. causes in home fires: COOKING, HEATING, SMOKING. 3/5-fire deaths with houses w/o SMOKE detectors/NOT working.

GI system

mouth to anus, 20% or more TBSA-dec peristalsis, gastric distention, risk aspiration. dec BS, paralytic ileus(adynamic bowel). gastric distention, N,V, hematemesis* -stress ulcers(curling ulcers) in stomach/duodenum after burns. abd pain, acidic gastric pH, hematemesis, blood in stool!

best method to assess shock in burn pt

narrow pulse pressure(better than HR/BP)

nonpharm

nutrition/wound care -close wound within 5 DAYS after burn!*** daily topical WOUND care, wound monitoring, wound EXCISION/CLOSURE! debridement, dressings! -debridement, dressing the WOUND, using BIOLOGICAL/BIOSYNTHETIC DRESSINGS, and NUTRITIONAL support!

dressing the wound

once cleaned/debrided, dressed in 1 of 2 methods! OPEN method-1(open to AIR), covered with TOPICAL antimicrobial. EASY access to wound. reapplied FREQUENTLY bc they rub off on bedding! inc risk HYPOTHERMIA! 2. closed method: topical antimicrobial to wound, covered w/GAUZE/nonadherent dressing, wrapped with gauze roll bandage! dressed 2x daily and prn! -circumferentially applied! DISTAL to PROXIMAL! fingers/toes wrapped SEPARATELY! stockinettes hold dressings in place! NO Tape! closed method: LESS heat loss but may IMPAIR ROM! -uniform PRESSURE: prevent hypertrophic scarring! TUBULAR SUPPORT bandages-applied 5-7 days post graft to maintain TENSION from 10-20mmHg*** may also wear custom-made ELASTIC pressure garments-jobst pressure garments for 6 MONTHS to a YEAR post graft!

zones of burns

outer zone of hyperemia-unburned tissue, blanches, heals 2-7 days after burn. -medial zone of stasis: moist, red, blistered, blanches, pale/necrotic or recovers 3-7 days after from dec perfusion/INFECTION -inner zone of coagulation: leathery, coagulated. may merge w/middle zone of STASIS from 3-7 days postburn. -thickness of dermis/epidermis varies from each body area.

contracture

permanent shortening of a muscle resulting in immovable joints, with DEEP PT burns can occur, functional impairment can occur!

preventing burns

precautions in home -HANDLING of CHEMICALS at work-spills, fire, accidents. -electricians: SAFETY equipment -planned ESCAPE routes. -SMOKERS: heat-resistant ASHTRAYS, everything COOL before put in trash. no SMOKING in bed or when SLEEPY or drinking etOH or MEDS-DROWSINESS. -out of children's reach, working SMOKE detectors-in ROOMS where smoking occurs***

proliferation, remodeling

proliferation: 2-3 days after burn, fibroblasts, peak in 14 days, granulation tissue, re-epithelialization, epithelial cells cover wound, cell stretches. or use SURGICAL interv during this stage! -remodeling: lasts years, COLLAGEN fibers laid down. scars contract, HYPERTROPHIC scar-overgrowth of dermis in wound boundary, KELOID: beyond boundaries of wound. dark skin-greater risk

urinary system

renal blood flow, GFR dec in EARLY stages of burn, from dec BP/IV volume, ADH release from posterior pituitary(to inc fluid), UO dec, creatinine/BUN inc. dark brown concentrated pee-myoglobinuria or hemoglobinuria.-muscle DAMAGE, DEAD erythrocytes(RBC), liver can't keep pace, pigments pass through GLOMERULI, can occlude renal TUBULES-renal FAILURE, esp when DEHYDRATION, ACIDOSIS, SHOCK ALSO PRESENT!

radiation burns

sunburn, radiation-CA. superficial usually*EPIDERMIS. mild systemic: HA, chills, n,v, local discomfort. nuclear power accidents: worse!

burns in teens/pregnant women/elderly

teens: thermal, chemical, electrical, radiation: sunbathing. 14 and under: flammable liquids, risk taking. edema, include family! -pregnant: rare -elderly: flame, scalding burns(hot water/grease), accidental-slower rxn time, dec mobility, visual deficit, dec smell, forgetful, impaired sensation. stoves, hot water, hot food, irons, cookware, heating pads. cognitive impairment, dementia leaving foods cooking unattended. clothes catching fire, tap water too hot. **greatest risk death**thin skin, inhalation injury-most common death with burns. risk inf bc delay tx! and chronic conditions complicate healing. DM, CV disease, respiratory disease, kidney disease, arthritis. live alone. -have relative/neighbor routinely CHECK for odor of gas, check smoke DETECTOR battery once a month! wear CLOSE-fitting clothing when cooking and use COOKING timer with LOUD alarm to prevent fires from burned foods! don't put items over a heating device. temp of water heater no higher than 120! to prevent SCALD burns, anti scald devices in bathroom plumbing!**DO NOT SMOKE in house!

lifespan: infants

thermal burns-liquids, hot bath, house fires, thermal burns: hot liquids/grease. electrical: biting electrical cords, contact burns/chemical burns: ingest cleaning agents. -preschool: scalding/contact with curling irons/ovens -school-age: thermal, electrical, chemical. matches, fireworks, high voltage towers, climbing trees-electrical wires, combustion experiments. -play therapy: recovering from burns is ENCOURAGED, an OUTLET for coping!

resp issues

thermal injury of UPPER airway-above GLOTTIS, heated AIR/chemicals in water. singed FACIAL, SCALP, NASAL hair. soot, charring, edema, blisters, ulcers on mucous lining of oropharynx/larynx. EDEMA in airway-24-48h later. HOARSE, DYSPNEA, STRIDOR-airway obst from EDEMA.

electrical burns

vary in severity depending on TYPE and DURATION of current/amt of VOLTAGE. follows path of LEAST resistance, hard to assess! muscles, bone, BV, nerves, may not see sx until weeks AFTER the event. ENTRY and EXIT wounds from ELECTRICITY. necrosis=GANGRENE, AMPUTATION! -AC: alternating current-in households, REPEATED contractions inhibiting RESP efforts-RESP ARREST! clamp down on power source too(ELECTRICAL CORD-from contractions) -DC: from lighting BOLT, very HIGH voltage for an instant(used in older homes, not as common), may have loss of consciousness, amnesia, tingling with mild. moderate: seizures, resp arrest, cardiac standstill. high voltage/severe: camrdiopulm ARREST, flashover effect in some

CV system

vascular issues, hypovolemic shock(BURN shock), dysrhythmias(VFIB), cardiac arrest, vascular compromise. -hypovolemic shock: burn shock, within min. after major burn, FLUID SHIFTS from IC to IV to ISF. burn SHOCK-CAP integrity restored 24-46 hours after!

other issues: cardiac

vasoconstriction, vascular system compensates, plt aggregation, WBC accumulate-ischemia and thrombosis. RBC/WBC inc in circulation(hemoconcentration) -FLUID in ISF-IV hypovolemia(dec BP), edema. NECROSIS bc of edema. hypokalemia-K leaves cell-dysrhythmias* BURN SHOCK continues until 24 h after(why give fluids for 24h after). when cap integrity RESTORED. BURN SHOCK REVERSES-fl from ISF back to vessels! BP INC, CO INC, UO INC. DIURESIS-several days to 2 wks after burn. FVO-older pt/CV disease pt

superficial PT burn

with blisters, pic with blisters in pearson top left. surface of skin to PAPILLARY layer of dermis, flash flame, dilute chemical agents(bleach), hot surface. -bright RED, MOIST, GLISTENING appearance w/BLISTERS, BLANCHES on pressure, painful with touch! SEVERE pain w/temp and AIR. heal <21 days, no scarring(or minimal) -pigment CHANGES common! -tx: analgesics, lg blistered areas disrupted: may use SKIN substitutes

heterograft

xenograft, from animal, usually a pig. porcine. frozen mostly used. softening, lysis from enzyme action in wound. high INFECTION with this type! SILVER NITRATE-TX PORCINE HETEROGRAFT dec microbial growth. synthetic: biobrane-nylon mesh with silicone, temporary for 2/3rd degree, only for CLEAN wounds, not dirty ones! secured w/tape or steri-strips. spontaneously separates when tissue HEALS! hydrocolloid are type of BIOSYNTHETIC dressing-wafers of gum materials, water resistant outer layer for covering donor site.