Initial Care of Burns

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Initial Care of Burns

• Connie Handel RN
• University of Wisconsin Hospital and Clinics

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Objectives

• Discover whos getting burned?
• Discuss Burn pathophysiology.
• Understand why some treatments are better than
  others.
• Review treatment options.

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Skin Structures

• Epidermis outermost layer of keratinized cells
• Dermis contains skin appendages, vascular
  supply and nerve endings
• Subcutaneous Tissue

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Functions of the Skin

• Barrier to infection
• Protection from external injury
• Temperature control

• Control of body fluids
• Sensory organ
• Determines identity

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What is a burn?

• Cutaneous injury caused by heat, electricity,
  chemicals, friction, or radiation.

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Burn Depth
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First Degree Burns

• Epidermis affected only
• Red or pink, dry, painful, blanches to touch
• Epidermis is intact
• Spontaneous healing within 7 days. Outer injured
  epithelial cells peel
• Seldom clinically significant

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Superficial Partial Thickness

• Entire epidermis portion of dermis (Papillary
  dermis)
• Homogenous pink
• Painful
• Blisters
• Blanches
• Hair usually intact
• Does not scar, may pigment differently

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Sup 2nd degree
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Deep partial thickness

• Reticular dermis
• Mottled red and white
• Not painful to pinprick or pressure
• Does not blanch
• Heals gt 3 weeks
• Usually scars
• Need to excise and graft

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Deep Partial Thickness
x
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Deep dermal
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Full Thickness 3rd degree

• May go into fat or deeper
• Red, white, brown, black
• Inelastic and leathery
• painless or numb
• Heals only from the periphery
• Always excise and graft

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Full-thickness
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Etiology
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Types of burns
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Circumstances of injury
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Where do burns occur
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Admissions by age
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of admissions vs. burn size
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Inhalation Injury

• Exposure to heat and toxic products of combustion
• 50 of fire deaths are related to inhalation
  injuries
• Asphyxia/Carbon Monoxide displacement of oxygen

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Inhalation injury diagnosis

• Closed-space fire
• Face burns

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Terminology

• Inhalation injury nonspecific
• Thermal injury
• Upper airway
• Heat and toxic fumes
• Local chemical irritation
• Throughout airway
• Primarily toxic fumes
• Systemic toxicity
• CO

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Signs and symptoms

• Lacrimation
• Cough
• Hoarseness
• Dyspnea
• Disorientation
• Anxiety
• Wheezing

• Conjunctivitis
• Carbonaceous sputum
• Singed hairs
• Stridor
• Bronchorrhea

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Pathophysiology

• The main factor responsible for mortality in
  thermally injured patients
• Carbon monoxide the most common toxin
• 200 times greater affinity
• Competitive inhibition with cytochrome P-450

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Poison management CO

• 500 unintentional deaths each year
• Persistent Neurologic Sequelae
• May improve over time
• Delayed Neurologic Sequelae
• Relapse later

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Carbon Monoxide Poisoning

• 10 COHb asymptomatic, seen most often in
  smokers, truck drivers, traffic police
• 20 COHb - headache, nausea, vomiting, loss of
  dexterity
• 30 COHb - confusion lethargy, possible ECG
  changes
• 40-60 COHb - coma
• 60 - usually fatal

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Poison management CO

• Treatment
• CO level means nothing to predict outcome
• Length of hypoxia is the determining factor
• Oxygen
• HBO
• No studies show benefit in treatment

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Reduction of CO
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Determine Burn Severity

• BSA involved
• Depth of injury
• Age
• Associated/pre-existing disease or illness
• Burns to face, hands, genitalia

xx
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Difficulties with accurate initial assessment of
burn size depth

• Soot, blisters, adherent clothing or debris
  obscure wound
• Burns are dynamicProgression is always a risk

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Burn Extent

• Total Body Surface Area (TBSA)?
• Rule of nines
• Lund and Browder chart
• Patients palm about 1 TBSA

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Extent of Burn Rule of Nines

• Adult anatomical areas 9 BSA (or multiple)
• Not accurate for infants or children due to
  larger BSA of head smaller BSA legs.
• Burn diagrams illustrate adult child differences

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Lund Browder Chart
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Extent of Burns
Patients palmar surface (hand fingers) 1
TBSA
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Burn Depth

• Factors
• Temperature
• Duration of contact
• Dermal thickness
• Blood supply
• Special Consideration Very young and very old
  have thinner skin

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Burns begin at 44 degrees C

• 6 hours for burns to occur at
• 111 degrees F (44 C)
• 1 second of burns to occur at
• 140 degrees F (60 C)

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Time For Full Thickness Burns To Occur In Scalds

• 5 seconds in water _at_ 140 F (60 C)
• 30 seconds in water _at_ 130 F (55 C)
• 5 minutes in water _at_ 120 F (49 C)

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Pain control
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Ice Pack-----DO NOT USE EVER

• DOES NOT
• Reverse temperature
• Inhibit destruction
• Prevent edema
• DOES
• Delay edema
• Reduce pain

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Non-medication methods

• Cover burns with plastic wrap
• Wet dressings will stick and cause more pain
• Other burn dressings are expensive and not
  necessary
• Quik Clot is expensive and will not provide any
  patient benefit

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Medication

• Medications
• Opioids
• Narcotics
• Pain medications
• IV Analgesia

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Resuscitation
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IV access

• lt 15 TBSA oral resuscitation
• 15 40 TBSA one large bore IV
• gt 40 -- two large bore IVs
• IVs should be in the upper extremities
• Suture IVs started through burns

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Field resuscitation

• Start IV with LR, through burn OK
• lt 6 years 125mL/hr
• 6-13 years 250mL/hr
• gt13 years 500mL/hr

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Contact
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Contact Burn
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Scald Burn
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Flame Burn
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Grease Burn
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ABA Burn Referral Criteria

• The ABA identifies the following as injuries
  requiring a Burn Center referral
• 2nd degree burns gt 10 TBSA
• Burns to face, hands, feet, genitalia, perineum,
  major joints
• 3rd degree burns
• Electrical injury
• Chemical burns
• Inhalation injuries
• Burns accompanied by pre-existing medical
  conditions
• Burns accompanied by trauma, where burn injury
  poses greatest risk of morbidity or mortality.
• Burns to children in hospitals without pediatric
  services.
• Patients with special social, emotional or
  rehabilitative needs.

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UWHC Burn CenterVerified by the American
Burn Association

• 7 ICU beds
• General care bed expansion available as needed
• Open to all burns, all ages, all times
• Capability of providing specialized care for all
  patients, from pediatrics to geriatrics

• Full time Surgical
• Staff, House Staff, Nursing, Respiratory,
  Occupational and Physical Therapists, Social
  Worker, Nutritionist, Health Psychologist, Child
  Life and Pharmacist

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UWHC Burn CenterVerified by the American
Burn Association

• Closely integrated inpatient, rehabilitation and
  outpatient services

• Outreach programs
• Burn Support Group
• Burn Camp
• Burn Buddies
• Juvenile Fire Starters Program
• School Reintegration
• Burn Education to School and Community Groups