Burn Managment

Burn Managment

Phases of Burn Care

Assessment

Referrals to Burn Centers

• 2° burns Partial Thickness: >10 % of the TBSA

• Any 3° burns Full Thickness in any age group

• Burns that involve: Face, joints, feet, genitalia, perineum, or major joints

• Electrical (including lightning), chemical burns or inhalation injuries

• Burn injury in patients who also have preexisting medical

disorders that could complicate management, affect

mortality, or recovery.

• Any patient with burns & trauma (i.e., fx, etc.).

*If the trauma is greater threat to life, initial treatment

is at a trauma center initially to be stabilized before transport to a burn center.

Interventions

1st priority: ABC’s (Airway, Breathing, Circulation)!

Situation History

• Mechanism of the burn: fire/flame, electrical, chemical, lightning, radiation, scald, steam, frostbite, other

• Circumstances: "Did the burn occur in a closed space vs open space?" - Helps determine possible inhalation injury (Ex.’s; cooking, hot oil, explosion, hot object, hot water, burning car, electrical, campfire, use of smoking material, use of accelerants)

• Time of injury

• What was the length of time exposed to burning agent?

• Any initial treatment/first aid rendered.

• Past medical /medication history

• Burn assessment (rule of 9’s, location, size, depth)

• Neurologic: LOC (confusion-carbon monoxide poisoning, hypoxia,..)

• Pain

Addtional Assessment Info

Goal: Stop the burning Process

At the Initial Scene

In the ED

Eliminate burn source

• Thermal burn

Dry: Remove burnt clothing,

Moist: Apply cool running water for 20 min

• Chemical burn: Remove the clothing, rinse with water at least 20 min

• Electrical burn: 1st be safe/disconnect electrical source, then check for responsiveness (CPR)

• Stabilize the patient’s condition:

- If unresponsive: circulation, airway, breathing

- If responsive: airway, breathing, circulation

• ID type of burn

• Prevent heat loss: Wrap in dry clean sheet or blanket

• Reduce wound contamination

• Transport!

• ABC’s (stabilization): Open and assess airway, breathing & circulation, provide oxygen, auscultate breath sounds, continuous Pox, vitals & ECG

• Estimate extent/depth of burn: Determine if Burn Center referral is needed

• Assess & address other injuries

• Get the Situation History: Circumstances surrounding injury - Time of injury/duration of exposure, Source (chemical, fire, oil, scald), & the Situation (Ex; smoke inhalation, enclosed space = at risk for carbon monoxide CO, cyanide pois)

• Obtain the patient’s pre-weight, health history (Ex: Vaccine: Tetanus), and info about the events occurring from the time of the burn to admission

• Start 2 large bore IVs & insert a foley catheter

*Signs of CO poisoning: Headache, Dizziness, N&V, Confusion, Fatigue, SOB & CP*

Emergent

(Resuscitative phase)

Acute

(Wound healing phase)

Rehabilitative

(Restorative phase)

Time of injury & continues for 24-72 hours - ends when fluid mobilization & diuresis begins.

Hypovolemic shock & edema are the main concerns in this phase as there is a massive fluid shift out of the blood vessels

Priorities

• Assess airway patency/breathing: for inhalation injury, resp rate & depth, dyspnea, adventitious breath sounds

• Establish airway: Prepare for possible intubation early before swelling gets worse (intubation indicated for burns to chest, face, or neck)

• Administer high flow O2/humidified

• Keep NPO

• Vitals

• HOB elevated (high fowler’s)

• Monitor ABGs

• Bronchodilators

Maintain Airway

Signs of possible smoke inhalation - (May progress to rapid obstruction within a short time - Intubate early!)

• Persistent cough, stridor, or wheezing

• Hoarseness

• Singed scalp hair, nasal hair, eyelids, eyelashes

• Nares with inflammation

• Blistering or edema of the oropharynx

• Facial or neck burns

Fluid Resuscitation

Goal: Maintain optimal end-organ perfusion

• Circulation (fluid volume replacement): Assess pulses-rate & rhythm, BP, CRT, skin color & temp; obvious bleeding - ​​​​Monitor for Over Resuscitation!

IV fluid: Crystalloid

• 1st 24 hrs: lactated ringer’s (LR)

• After adequate resuscitation - D5.45NS with 20 mEq K+

• Signs of adequate fluid resuscitation: SBP> 100, P<110/min, CVP 3-8, good CRT, intact cognition, adaquete foley urine output (adult 0.5-1 mL/kg/hr or 30-50 mL/hr & peds 1-1.5 mL/kg/hr)

Fluid Volume Requirements

Parkland Formula: estimates the fluid requirements for critical burn patients in the first 24 hours after injury using the patient's body weight and the percent of total body surface area that is affected by thermal burns - (Give ½ fluid in the1st 8 hours then the remaining ½ over next 16 hrs)

4 mL / kg / % TBSA burn

Ex: 4 mL x 70kg x 20 TBSA

Pain management

Pharmacologic: Scheduled Opioids & Anxiolytics to maintain a steady state

• Opioids: morphine, dilaudid via IV route & PCA pump

• Anxiolytics: Benzodiazepines (lorazepam) given for anxiety

*Partial thickness = extremely painful*

Wound care

Clean burn wounds (embedded bits, etc.):

•Mild soap and sterile water

•Start daily showers

•Give tetanus (if not had within 10 yrs)

Remove ruptured blister

•Dressings: nonadherent, mesh gauze (i.e., Telfa) that is applied in strips not around, f/b tubular bandage lightly applied

Positioning

Place patient in position that prevents contracture formation and promotes function

Ex: Head positioned above the level of the heart to manage edema, the neck positioned midline (no rotation), supported by pillows, etc.

Nutrition

Assess nutritional need - feed by the most appropriate route

Check Labs before admin of IVF

Hgb & Hct: Increased d/t fluid volume loss

BUN: Increased d/t fluid volume loss

Glucose: Increased d/t stress response & altered uptake at injury site

Na+: Decreased d/t loss through plasma leakage & trapped in fluid

K+: Increased d/t K+ shifts out of cell & RBC destruction

Cl-: Increased d/t fluid loss & reabsorption of Cl- in urine

Protein, total: Low d/t loss from burn wound

Albumin: Low d/t lost from wound & vascular membrane d/t increased permeability

Blood Gases (pH, Pa02, PaCO2, COHb):

• pH - Low (metabolic acidosis)

• PaO2 - slightly decreased

• PaCO2 - slightly increased from respiratory injury

• Carboxyhemoglobin - elevated (>10%) with inhalation of smoke & carbon monoxide

Cardiovascular:

• Dysrhythmias & hypovolemic shock

• Impaired circulation with circumferential burn, if untreated (compartment syndrome)

• Venous thromboembolism ​​​​​

Urinary

• AKI d/t decrease blood flow​

Respiratory

• Upper/lower airway injuries

• Carboxyhemoglobin

• Respiratory distress

Skin

• Loss of water/electrolytes

• Difficulty maintaining body temperature​​​​​​

Complications

Begins after the fluid shift resolves (36-48 hours) & ends with wound closure (can take weeks to months).

Focus shifts to facilitate wound healing

Wound Care

Goal: keep wound moist to facilitate healing & prevent infection

•Daily showers - observe for infection

•Dressing changes 2 times/day using sterile technique

•Pre-medicate prior to wound care!

Debridement-major focus: Removes eschar & other

cellular debris (i.e., surgical, hydrotherapy).

Dressings (standard, biologic or synthetic):

•Sterile mesh gauze dressing soaked with antimicrobial such as Silver product, Silver sulfadiazine, Silvadene or polysporin ointment

• PermeaDerm (synthetic)

May require skin grafts:

•Autograft: pt’s own skin

•Allograft: from another person; temporary

•Mesh graft: donor skin perforated with small slits or holes

Continue to assess for proper nutrition to aid in wound healing

Determine most appropriate route

• Non-intubated: able to eat

• Intubated: enteral feedings

*May require TPN, if GI not working*

Provide increased calorie & increased protein diet

*4,000-6,000 cal/day (RMR-↑50-100%)*

• Harris–Benedict equation x Activity Level x Stress factor (Estimates calorie needs)

Nutrition

Comfort/Rest

Promote Comfort & Rest by Managing Pain

Opioids (IV route):

*Opioid tolerance frequently occurs requiring

doses that exceed typical dosing

(hypermetabolism)*

•Patient-controlled analgesia PCA pumps promote control over care

Non-opioid:

•Precedex & ketamine provide short-term

analgesia & sedation for debridement and dressing change procedures

•Tylenol &NSAIDS can supplement opiates.

•Benzodiazepine can be taken w/ opiods to decrease anxiety and improve post procedure pain

Non-pharmacologic:

•Music, virtual reality, positioning, video game,

relaxation techniques

•Keep room temp high (85°) to maintain body temperature

•Manage pruritus (itchiness): with Topicals such as aloe vera, cocoa butter, mineral oil, & glucocorticoids

•Antacids used to prevent Curling’s ulcer

Physical & Occupational

Therapy

:

Short Term Goal: To preserve the client’s ROM &

functional ability

Long Term Goal: to return client to independent

living

• Early passive ROM & mobilization

• Pressure garments used to decrease scarring & edema

• Splinting & proper positioning to prevent

joint contractures

• Assess ADL ability

• Elevate extremities, place limbs anti-contracture positions & avoid prolong pressure.

Prone position may be utilized to protect skin grafts on the posterior surface of the body.

Psychological

/ Emotional

Support

Challenges:

• Depression

• Self esteem/body image concerns

• Sleep issues

• Worries about the future, finances, loss of

independence

• PTSD (flashbacks)

Treatment options:

• Support from family, stay contacted with friends, support groups, stay active

• Professional - psychiatrists, psychologist, social

workers, pastoral

• Psychological therapies such as CBT, Stress management, Coping strategies

Complication

Infection: Colonized with patient’s own organisms that were on skin prior to burn

GI Complication:

• Diarrhea: tube feedings/antibiotics

• Constipation: opioids

• If septic: paralytic ileus

• Curling’s ulcer

Pain & Neurological Complications

• Sleep problems

• Anxiety/stress

Musculoskeletal Complications

• Scar tissue forms, less pliable

• ROM may be limited. Contractures can form

Begins when the majority of the burn area heals & ends when at highest level of functioning

Treatment: continues beyond the acute hospital phase - can be several years long.

• Wear Pressure Garments & Ace Wraps to minimize scarring & contractures

• Continue with PT, OT, ROM,exercise & splinting at prescribed times

• Care for healing skin - keep moist!

• Reconstructive surgeries

• Pain (neuropathies can develop

from scar tissue)

• Address physical & psychosocial challenges - provide support