THE BURN WOUND AND BURN WOUND CARE

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THE BURN WOUNDAND BURNWOUND CARE

• Deborah Cary, RN,MSN,BC
• Professor, BCC

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Statistics

• Over 1 million burns patients present to EDs
  annually
• Only 3-5 are life-threatening
• Major burns - significant M/M
• 20,000 die annually from burn injuries
• Death rate higher children lt5yrs.
• adults gt65

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• USA has the highest rates of fire
• deaths in the western world!

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Burn/Fire deaths have declined since the 60s
.why?

• Improved burn centers
• Recognition/management of burn shock
• Improved wound management
• Antibiotics less burn wound infections
• USE OF SMOKE DETECTORS

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AGE RELATED FACTORS

• Minor burns more common young adults
• Cooking/occupational exposure
• Teen males at increased risk
• Younger children

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Prevention

• Education, education, education!!!!
• Nothing placed on cooktop except pots/pans
• Care with use of generators
• Alert to carbon monoxide poisoning

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What are burns?

• Injuries to skin
• Result from application of energy to the tissue
  at a rate faster than can be dissipated
• Results in tissue destruction
• Burns result from exposure to
• chemical agents, ionizing radiation,
• electromagnet radiation and electric
• current

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Causes of Burns

• Flame Burns
• Contact Burns
• Scalds
• Steam Burns
• Electrical burns

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History

• Mechanism of Burn Injury
• ..how sustained flame, chemical,
  electrical,etc.
• Major Point
• Was victim confined to area of fire? Higher
  possibility of inhalation injury

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CLINICAL FINDINGSPHYSICAL ASSESSMENT

• Classification of burns
• Depth
• Type
• Extent

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Depth of Burns

• First Degree
• Second Degree (Partial thickness)
• Third Degree ( Full Thickness)

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Considerations

• The more BSA involved, gt M/M
• Can estimate in field by the palmar method
  each palm represents 0.5-1 of the TBSA
• Only 2nd and 3rd degree are measured

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Rule of Nines

• Body divided into groups 9BSA
• Head and neck 9
• Each arm9
• Each leg18
• Front/back torso18 each
• Perineum1
• DO NOT USE for children since different
  proportions

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Lund-Browder Classification

• More accurate assessment of extent of burns
• Takes age-related BSA into consideration
• Different numbers given for infants/children

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Pre-hospitalization Tx

• Immediate goal remove victim from source of
  burn without endangering rescue personnel
• Following extrication, follow basic principles of
  trauma resuscitation. Complete a rapid primary
  assessment A.B, Cs

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2 Prehospitalization

• STOP the burning process
• Remove charred clothing
• Cool tissues with saline or clean H2O
• Place victim in dry, sterile sheets
• Dont prolong irrigation with cold fluids -
  prevent hypothermia
• Assess for signs of inhalation injury
• O2 by high flow-mask secure airway
• Minor burns cool with running tap H2O and dress

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Initial Treatment

• Do Not use creams
• Give adequate analgesia M/S 3-5mg IV
• if transport to a burn center delayedgt12 hrs,
  debridement should take place to loosen tissue
  and clean wounds with mild soap and water
• Apply thin layer sulfadiazine to all open areas
• Tetanus

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American Burn AssociationRecommendations

• TRANSPORT WITH FOLLOWING CONSIDERATIONS
• lt10yrs or gt50yrs gt10TBSA
• Burns of face,hands,feet, genitalia, perineum or
  major joints
• Third degree burns gt5
• Electrical burns, including lightning
• Chemical Second degree burns covering gt20 TBS
• Inhalation injury

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ABA guidelines continued

• Severe burns if pre-existing medical diseases
• Co-existing traumatic injuries
• Children if the hospital lacks appropriate
• equipment for children
• Those patients who require extensive rehab

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Emergency Department

• Assess extent and depth of injury
• Early intubation in pts with singed nasal hairs,
  facial burns, oral burns, sooty sputum or
  respiratory difficulty
• May need to do a fiberoptic laryngoscopy or
  bronchoscopy to assess airway involvement

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Local Burn Care

• Cleanse minor burns
• Controversial re whether to leave blisters intact
• Debride open blister
• Treat with topical antibiotic/dress
• Neosporin
• Silvadene antipseudomonal properties
• avoid use on face wash to remove previous
• before application
• Do Not use in newborns or late pregnancy
• due to risk BUN/Creatinine force fluids

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Fluid Replacement

• Aggressive fluids if injury gt15 of total BSA or
  if burns on face or hands
• Place 2 large-bore IVs (14-16 g) if you must
  use burned area, thread cannula high due to
  impending edema which can push hub out
• Formulas vary in quantity/composition

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Fluid Resuscitation

• Fluids replaced with burns gt15 TBSA
• Colloidal solutions such as warmed Ringers
  Lactate, NS
• first choice for fluids may need packed red
  blood cells also depending on status
• Prepare to initiate invasive hemodynamic
  monitoring if oliguria persists despite fluids,
  if cardiac or renal disease, or if pt very young
  or very old A line used

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Formulas for Fluids

• Parkland formula and modified Brooke Formula
• Dosage 2- 4ml/kg/ TBSA burned using R/L
  solution Brooke 2ml Parkland- 4ml
• ex pt wgt70kg (154lbs.) burned over 50 body
  would need 14,000ml fluid (4x70x50) -
• in first 24 hrs. under modified Brooke.
• Give half of 7,000ml during first 8 hrs. by
  setting infusion pump at rate of 875ml/hr give
  remaining volume over next 16 hrs.

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Physiological changes

• CARDIOVASCULAR
• HR increases CO decreases - gt40 significant
  
• BP not reliable indicator of fluid status
• Release O2 free radicals
• FLUIDS elderly gt5-15 and childrengt10-15
• Burn shock gt40TBSA

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Pulmonary changes

• Increased pulmonary vascular resistance
• Decreased pulmonary perfusion
• Causes initially due to inhalation later due
  to infection
• Circumferential full-thickness burns - incr.
• risk for compartment syndrome - tx
• escharotomy if CS fasciotomy
• Carbon monoxide poisoning

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GI/Metabolic

• R/T size of burn injury
• Curlings ulcer
• RX decompression if gt20
• antacids
• Bacterial translocation MODS
• Hypermetabolism

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Renal

• Initially oliguria/anuria
• Increased UO with fluids
• Adults 30-50 normal
• Child l ml/kg/hr if wgtlt30kg
• over 30kg same as adults
• Muscle damage myoglobin in urine

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Nursing Considerations

• Emotional support pt/family
• VS q1hr or more frequently
• UO q1hr foley with urimeter
• Titration of fluids ordered
• Assessment lung sounds - hourly
• Dysrhythmias due to electrolyte shift
• Assessment chemistries, ABGs
• Assessment CXR
• Observe for compartment syndrome CMS pulses
  distal to wound
• Pain control!!!! (strong pt input) MS preferred
  drug always given IV
• Versed commonly used prior to dressing change

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Lab Findings

• Pre-Resuscitation
• K increases
• Na decreases
• Albumin leaves vascular space
• RBC decrease D/T lysis
• Increased HCT D/T viscosity blood

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Surgical Procedures

• Escharotomy at bedside
• Fasciotomy in OR

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Infection

• Burn wound excellent medium for bacterial growth
• Eschar is devitalized so systemic antibiotics,
  antibodies or leukocytes can reach area
• More than 1billion/gram of tissue, bacteria can
  appear..gtblood stream

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Sources of Infection

• Primary
• Pts own GI tract
• Secondary
• The environment
• Sterile technique/meticulous asepsis

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Other considerations

• Antibiotics seldom given prophylactically to
  prevent promoting resistant strains
• Tissue specimens for culture regularly to monitor
  colonization swab surface or tissue biopsy
• Systemic antibiotics when Cultures are neg

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Wound Care

• Goals are
• A. To cleanse/debride necrotic tissue
• B. Minimize further destruction viable skin
• C. Promote wound re-epithelialization
• D. Promote patient comfort

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Types of Grafts

• Autografts
• Homografts
• Heterografts

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Autografts

• Come from patients own skin
• Full Thickness and Pedicle flaps more common for
  reconstructive surgery done months to years post
  injury
• Cultured Epithelium cells are cultured in lab
  then attached to burn wound encouraging results
• Split thickness applied in small sections of in
  sheets meshed grafts
• Contribute to scar formation wear Probst body
  stockings to affected part

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Homografts

• Human grafts taken from cadavers

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Nursing Care - Autografts

• Occlusive dressing common initially, help
  mobilize grafts
• First drsg. Change 3-5 days earlier if purulent
  drainage/odor
• If graft dislodged, keep moist c N/S til can be
  reattached
• Donor site moist pressure type drsg

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Heterografts

• Skin taken from animals, usually pigs
• Available from commercial suppliers
• May be fresh, frozen or freeze dried
• May be impregnated with a topical ung
• Used in large burns for temporary coverage
• Debridement adheres
• Provides immediate coverage/barrier

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Pressure Garments

• Purpose to prevent contractures/scarring
• Major difficulty is with compliance due to the
  difficulty with wearing hot/hard to put on
• Most common one ordered are the Jobst Pressure
  garments
• Must wear 23 hrs/day

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Burn Centers

• Miami
• Tampa
• Gainesville - Shands
• Shriners Hospitals