Initial Care of Burns Connie Handel RN University

Initial Care of Burns Connie Handel RN University of Wisconsin Hospital and Clinics

Objectives l l Discover who’s getting burned? Discuss Burn pathophysiology. Understand why some treatments are better than others. Review treatment options.

Skin Structures l l l Epidermis – outermost layer of keratinized cells Dermis – contains skin appendages, vascular supply and nerve endings Subcutaneous Tissue

Functions of the Skin l Barrier to infection l Control of body fluids l Protection from external injury l Sensory organ l Determines identity l Temperature control

What is a burn? l Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

Burn Depth

First Degree Burns l l l 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

Superficial Partial Thickness l l l l Entire epidermis & portion of dermis (Papillary dermis) Homogenous pink Painful Blisters Blanches Hair usually intact Does not scar, may pigment differently

Sup 2 nd degree

Deep partial thickness l l l l Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft

Deep Partial Thickness

Deep dermal

Full Thickness: 3 rd degree l l l 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

Full-thickness

Etiology

Types of burns

Circumstances of injury

Where do burns occur

Admissions by age

% of admissions vs. burn size

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

Inhalation injury diagnosis l l Closed-space fire Face burns

Terminology l Inhalation injury “nonspecific” – Thermal injury l l – Local chemical irritation l l – Upper airway Heat and toxic fumes Throughout airway Primarily toxic fumes Systemic toxicity l CO

Signs and symptoms l l l l Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing l l l Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea

Pathophysiology l l 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

Poison management = CO l l 500 unintentional deaths each year Persistent Neurologic Sequelae – l May improve over time Delayed Neurologic Sequelae – Relapse later

Carbon Monoxide Poisoning l l l 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

Poison management = CO l Treatment – – CO level means nothing to predict outcome Length of hypoxia is the determining factor Oxygen HBO l No studies show benefit in treatment

Reduction of CO

Determine Burn Severity l l l % BSA involved Depth of injury Age Associated/pre-existing disease or illness xx Burns to face, hands, genitalia

Difficulties with accurate initial assessment of burn size & depth l l Soot, blisters, adherent clothing or debris obscure wound Burns are dynamic…Progression is always a risk

Burn Extent Total Body Surface Area (TBSA)? l l l Rule of nines Lund and Browder chart Patients palm = about 1% TBSA

Extent of Burn : “Rule of Nines” l l l 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

Lund & Browder Chart

Extent of Burns Patient’s palmar surface (hand + fingers) = 1% TBSA

Burn Depth Factors l l l Temperature Duration of contact Dermal thickness Blood supply Special Consideration: Very young and very old have thinner skin

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

Time For Full Thickness Burns To Occur In Scalds l 5 seconds in water @ 140 F (60 C) l 30 seconds in water @ 130 F (55 C) l 5 minutes in water @ 120 F (49 C)

Pain control

Ice Pack-----DO NOT USE EVER l DOES NOT – – – l Reverse temperature Inhibit destruction Prevent edema DOES – – Delay edema Reduce pain

Non-medication methods l 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

Medication l Medications – – Opioids Narcotics Pain medications IV Analgesia

Resuscitation

IV access l l l < 15% TBSA – oral resuscitation 15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s should be in the upper extremities Suture IV’s started through burns

Field resuscitation l Start IV with LR, through burn OK – – – < 6 years = 125 m. L/hr 6 -13 years = 250 m. L/hr >13 years = 500 m. L/hr

l Contact

l Contact Burn

l Scald Burn

l Flame Burn

l Grease Burn

l

ABA Burn Referral Criteria The ABA identifies the following as injuries requiring a Burn Center referral: l l l l l 2 nd degree burns > 10% TBSA Burns to face, hands, feet, genitalia, perineum, major joints 3 rd 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.

UWHC Burn Center Verified by the American Burn Association l l 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 l Full time Surgical Staff, House Staff, Nursing, Respiratory, Occupational and Physical Therapists, Social Worker, Nutritionist, Health Psychologist, Child Life and Pharmacist

UWHC Burn Center Verified by the American Burn Association l Closely integrated inpatient, rehabilitation and outpatient services l Outreach programs – – – Burn Support Group Burn Camp Burn Buddies Juvenile Fire Starters Program School Reintegration Burn Education to School and Community Groups