BURNS

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BURNS

• Adult Health II

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Anatomy of Skin

• Largest body organ
• More than just a passive covering

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Skin Functions

• Sensation
• Protection
• Temperature regulation
• Fluid retention

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Anatomy

• Two layers
• Epidermis
• Dermis

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Epidermis

• Outer layer
• Top (stratum corneum) consists of dead, hardened
  cells
• Lower epidermal layers form stratum corneum and
  contain protective pigments

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Dermis

• Elastic connective tissue
• Contains specialized structures
• Nerve endings
• Blood vessels
• Sweat glands
• Sebaceous (oil) glands
• Hair follicles

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Burn Epidemiology

• 2,500,000/year
• 100,000 hospitalized
• 12,000 deaths

Third leading cause of trauma deaths
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Pathophysiology

• Loss of fluids
• Inability to maintain body temperature
• Infection

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Critical Factors

• Depth
• Extent

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Burn Depth

• First Degree (Superficial)
• Involves only epidermis
• Red
• Painful
• Tender
• Blanches under pressure
• Possible swelling, no blisters
• Heal in 7 days

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Burn Depth

• Second Degree (Partial Thickness)
• Extends through epidermis into dermis
• Salmon pink
• Moist, shiny
• Painful
• Blisters may be present
• Heal in 7 to 21 days

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Burn Depth

• Burns that blister are second degree.
• But all second degree burns dont blister.

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Burn Depth

• Third Degree (Full Thickness)
• Through epidermis, dermis into underlying
  structures
• Thick, dry
• Pearly gray or charred black
• May bleed from vessel damage
• Painless
• Require grafting

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Burn Depth

• Often cannot be accurately determined in acute
  stage
• Infection may convert to higher degree
• When in doubt, over-estimate

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Burn Extent

• Rule of Nines

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Burn Extent

• Adult Rule of Nines

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Burn Extent

• Pediatric Rule of Nines

For each year over 1 year of age, subtract 1
from head, add equally to legs.
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Burn Extent

• Rule of Palm
• Patients palm equals 1 of his body surface area

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Burn Severity

• Based on
• Depth
• Extent
• Location
• Cause
• Patient Age
• Associated Factors

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Critical Burns

• 3rd Degree gt10 BSA
• 2nd Degree gt 25 BSA (20 pediatric)
• Face, Feet, Hands, Perineum
• Airway/Respiratory Involvement
• Associated Trauma
• Associated Medical Disease
• Electrical Burns
• Deep Chemical Burns

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Moderate Burns

• 3rd Degree 2 to 10
• 2nd Degree 15 to 25 (10 to 20 pediatric)

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Minor Burns

• 3rd Degree lt2
• 2nd Degree lt15 (lt10 pediatric)

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Associated Factors

• Patient Age
• lt 5 years old
• gt 55 years old
• Burn Location
• Circumferential burns of chest, extremities

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MANAGEMENT
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Management

• Varies according to burn severity
• Three stages of treatment
• Emergent stage
• Acute Stage
• Rehabilitation Stage

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Emergent Stage

• Emergent stage At the time of injury, the
  burning process must stop.
• Clothes are removed, wound is cooled with tepid
  water and covered with clean sheets to decrease
  shivering and contamination

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Emergent Stage

• Onset of injury to completion of fluid rescitation

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Prioritization

• Burn wound takes lowest priority to the ABCs
  (airway, breathing and circulation) of trauma
  resuscitation.

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Emergent Treatment

• Intravenous fluids are given to prevent
  hypovolemic shock.
• Normal Saline in a large bore needle 16g or 18g
• Pain management with appropriate IV opioid
  analgesics. PCA is very effective

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Acute Stage

• Multidisciplinary plan of care
• Wound closure with no infection minimum
  scarring, maximum function, maintenance of
  comfort, nutritional support, fluid
  electrolyte, acid electrolyte balance

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Skin Management

• Escharotomy Linear excision through eschar to
  superficial fat that allows skin expansion and
  improved blood flow.
• ie Circumferential burn

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Skin Management

• Epithelialization Formation of new tissue
  growth. Granulation tissue appears pink-red and
  initially will be reflected in the peri-wound
  area as new tissue growth.

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Rehabilitation Stage

• Two important facts
• Most comfortable position (flexion) is the
  position of contracture.
• Burn wound will shorten until it meets an
  opposing force.

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Rehabilitation Process

• To avoid contractures Initiate exercise program
  early. 24-48 hrs after injury, along with
  splinting devices in order to maintain proper
  positioning

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Assess Airway/Breathing

• Start oxygen if
• Moderate or critical burn
• Decreased level of consciousness
• Signs of respiratory involvement
• Burn occurred in closed space
• History of CO or smoke exposure
• Assist ventilations as needed

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Assess Circulation

• Check for shock signs /symptoms

Early shock seldom results from effects of burn
itself. Early shock Another injury until proven
otherwise
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Obtain History

• How long ago?
• What has been done?
• What caused burn?
• Burned in closed space?
• Loss of consciousness?
• Allergies/medications?
• Past medical history?

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Rapid Physical Exam

• Check for other injuries
• Rapidly estimate burned, unburned areas
• Remove constricting bands

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Treat Burn Wound

• Cover with DRY, CLEAN SHEETS
• Do NOT rupture blisters
• Avoid application of vaseline and items that are
  gel like as well as home remedies of butter and
  oils.

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Special Considerations

• Pediatrics
• Geriatrics

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Pediatrics

• Thin skin, increased severity
• Large surface to volume ratio
• Poor immune response
• Small airways, limited respiratory reserve
  capacity
• Consider possibility of abuse

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Geriatrics

• Thin skin, poorly circulation
• Underlying disease processes
• Pulmonary
• Peripheral vascular
• Decreased cardiac reserve
• Decreased immune response

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Geriatrics

• Percent mortality Age BSA
  Burned

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Inhalation Injury
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Problems

• Hypoxia
• Carbon monoxide toxicity
• Upper airway burn
• Lower airway burn

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Carbon Monoxide

• Product of incomplete combustion
• Colorless, odorless, tasteless
• Binds to hemoglobin 200x stronger than oxygen
• Headache, nausea, vomiting, roaring in ears

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Carbon Monoxide
Exposure makes pulse oximeter data meaningless!
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Upper Airway Burn

• True Thermal Burn
• Danger Signs
• Neck, face burns
• Singing of nasal hairs, eyebrows
• Tachypnea, hoarseness, drooling
• Red, dry oral/nasal mucosa

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Lower Airway Burn

• Chemical Injury
• Danger Signs
• Loss of consciousness
• Burned in a closed space
• Tachypnea (/-)
• Cough
• Rales, wheezes, rhonchi
• Carbonaceous sputim

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Chemical Burns

• A chemical burn is when some kind of topical
  substance comes in contact with the skin surface.

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Concerns

• Damage to skin
• Absorption of chemical systemic toxic effects

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Management

• Remove chemical from skin
• Liquids
• Flush with water
• Dry chemicals
• Brush away
• Flush what remains with water

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Chemical in Eyes

• Flush with NS or Ringers
• No other chemicals in eye
• Flush out contacts

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Electrical Burns

• High current electrical wires.

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Considerations

• Intensity of current
• Duration of contact
• Kind of current (AC or DC)
• Width of current path
• Types of tissues exposed (resistance)

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Electrical Burns

• Conductive injuries
• Tip of Iceberg
• Entrance/exit wounds may be small
• Massive tissue damage between entrance/exit

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Other Complications

• Cardiac arrest/arrhythmias
• Respiratory arrest
• Spinal fractures
• Long bone fractures

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Management

• Make sure current is off!
• Check ABCs
• Assess carefully for other injuries
• Patient needs hospital evaluation, observation