Download Emergency Care of Burn Injuries

Initial Care of Burns
Connie Handel RN
University of Wisconsin Hospital and Clinics
Objectives
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Discover who’s getting burned?
Discuss Burn pathophysiology.
Understand why some treatments are better
than others.
Review treatment options.
Skin Structures
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Epidermis – outermost layer of keratinized cells
Dermis – contains skin appendages, vascular supply
and nerve endings
Subcutaneous Tissue
Functions of the Skin
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Barrier to infection
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Control of body fluids
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Protection from external
injury
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Sensory organ
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Determines identity
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Temperature control
What is a burn?
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Cutaneous injury caused by heat, electricity,
chemicals, friction, or radiation.
Burn Depth
First Degree Burns
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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
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Entire epidermis & portion of
dermis (Papillary dermis)
Homogenous pink
Painful
Blisters
Blanches
Hair usually intact
Does not scar, may pigment
differently
Sup 2nd degree
Deep partial thickness
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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:
3rd degree
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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
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50% of fire deaths are related to inhalation injuries
Asphyxia/Carbon Monoxide displacement of oxygen
Inhalation injury diagnosis
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Closed-space fire
Face burns
Terminology
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Inhalation injury “nonspecific”
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Thermal injury
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Local chemical irritation
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Upper airway
Heat and toxic fumes
Throughout airway
Primarily toxic fumes
Systemic toxicity
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CO
Signs and symptoms
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Lacrimation
Cough
Hoarseness
Dyspnea
Disorientation
Anxiety
Wheezing
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Conjunctivitis
Carbonaceous
sputum
Singed hairs
Stridor
Bronchorrhea
Pathophysiology
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The main factor responsible for mortality in
thermally injured patients
Carbon monoxide the most common toxin
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200 times greater affinity
Competitive inhibition with cytochrome P-450
Poison management = CO
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500 unintentional deaths each year
Persistent Neurologic Sequelae
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May improve over time
Delayed Neurologic Sequelae
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Relapse later
Carbon Monoxide Poisoning
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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
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Treatment
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CO level means nothing to predict outcome
Length of hypoxia is the determining factor
Oxygen
HBO
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No studies show benefit in treatment
Reduction of CO
80
Room Air
100% Oxygen
3 ATM
% CO
60
40
20
0
0
20
40
Time in Minutes
60
80
Determine Burn Severity
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% BSA involved
Depth of injury
Age
Associated/pre-existing
disease or illness
Burns to face, hands,
genitalia
Difficulties with accurate initial
assessment of burn size & depth
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Soot, blisters, adherent clothing or debris
obscure wound
Burns are dynamic…Progression is always a risk
Burn Extent
Total Body Surface Area (TBSA)?
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Rule of nines
Lund and Browder chart
Patients palm = about 1% TBSA
Extent of Burn :“Rule of Nines”
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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
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Temperature
Duration of contact
Dermal thickness
Blood supply
Special Consideration: Very young and
very old have thinner skin
Burns begin at 44 degrees C
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6 hours for burns to occur at
111 degrees F (44 C)
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1 second of burns to occur at
140 degrees F (60 C)
Time For Full Thickness
Burns To Occur In Scalds
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5 seconds in water @ 140 F (60 C)
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30 seconds in water @ 130 F (55 C)
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5 minutes in water @ 120 F (49 C)
Pain control
Ice Pack-----DO NOT USE EVER
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DOES NOT
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Reverse temperature
Inhibit destruction
Prevent edema
DOES
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Delay edema
Reduce pain
Non-medication methods
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Cover burns with plastic wrap
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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
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Medications
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Opioids
Narcotics
Pain medications
IV Analgesia
Resuscitation
IV access
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< 15% TBSA – oral resuscitation
15 – 40% TBSA – one large bore IV
> 40% -- two large bore IV’s
IV’s should be in the upper extremities
Suture IV’s started through burns
Field resuscitation
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Start IV with LR, through burn OK
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< 6 years = 125mL/hr
6-13 years = 250mL/hr
>13 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:
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2nd degree burns > 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.
UWHC Burn Center
Verified by the American Burn Association
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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
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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
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Closely integrated
inpatient, rehabilitation
and outpatient services
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Outreach programs
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Burn Support Group
Burn Camp
Burn Buddies
Juvenile Fire Starters
Program
School Reintegration
Burn Education to School
and Community Groups