Management of Patients with Burn Injury

ARNAZER D, GAN RN MAN

RN must play an active role in the prevention of burn injuries by teaching PREVENTION concepts and promoting SAFETY legislation 4 Major Goals Related to Burns  Prevention  Institution of life-saving measures for the severely burned person  Prevention of disability and disfigurement through early specialized and individualized care  Rehabilitation through reconstructive surgery and rehabilitation programs

Causes of BURN: Thermal Burn  Dry heat such as flames  Moist heat such as steam and hot liquids Mechanical Burn  Caused by the friction or abrasion that occurs when skin is rubbed harshly against a coarse surface Electrical Burn  Faulty electrical wiring  Immersion in water that has been electrified  Lightning strikes Chemical Burn  Result from direct contact, ingestion, inhalation or injection of various substances: acid or alkali Radiation Burn  Typically associated with sunburn or radiation therapy as for cancer treatment

Classification of Burns: BURN DEPTH Burn injuries are described according depth of the injury and the extent of the body surface area injured. Burns are classified according to the depth of tissue destruction as superficial- partial thickness injuries, deep partial thickness injuries or full thickness injuries. Superficial Partial Thickness Burns / First Degree  Involve superficial injury to the epidermis marked by an uncomplicated erythematous area  Localized pain  Skin barrier remains intact; fluid and electrolyte loss not a problem Deep Partial Thickness Burns / Second Degree  Involve damage to the epidermis progressing to the dermis  Blisters present  Mild to moderate edema and pain

 Possible capillary damage  Possible regeneration of the epithelial layer  Fluid and electrolyte imbalances associated with second degree burns that cover significant areas of the body Full Thickness Burns / Third Degree  Involve all skin layers  Regeneration impossible  Skin elasticity lost, appearance altered significantly (color varies from red to black to white)  No blister present  No pain if nerve endings are damaged  Carry greatest risk of fluid and electrolyte imbalance

Determining the Severity of Burns: MAJOR BURN Require care in a special burn facility and include:  Second degree burns on > 25% of an adults BSA or more than 20% of childs BSA  Third degree burns on > 10% of BSA regardless of body size  Burns of the hands, face, eyes, ears, feet or genitalia  All inhalation and electrical burns  Burns complicated by fractures or other major trauma  All burns in high risk patients, such as children younger than age 2, adults older than age 60, and patients who have preexisting medical conditions such as heart disease MODERATE BURN Require care either burn care facility or a general health care facility and include:  Third degree burns on 2% - 10% of the BSA regardless of body size  Second degree burns on 15% - 25% of an adults BSA and 10% - 20% of a childs BSA

 MINOR BURN Can be treated on an out patient basis and include:  Third degree burns on < 2% of the BSA regardless of body size  Second degree burns on < 15% of an adults BSA and on < 10% of a childs BSA

Phases of Burn  Fluid Accumulation Phase / Hypovolemic Phase:  Last for 36 to 48 hours after a burn injury  Fluid shifts from vascular compartment to interstitial space; process called 3rd space shift  Edema caused by shifter fluid (which typically reaches maximum extent within 8 hours after injury)  Circulation possibly compromised and pulses diminished from severe edema  Several reasons for fluid imbalances: Damage to capillaries from the burn injury Diminished kidney perfusion Production and release of stress hormones such as aldosterone and anti diuretic hormone in response to burn injury (cause kidneys to retain Na and water) ALERT !!! FLUID IS PRIOTY TO PREVENT SHOCK

CONTINUATION  Respiratory Problems occurs secondary to compromised edematous airway or because of circumferential burns and edema of the neck or chest can restrict respirations and cause shortness of breath  Muscle and tissue injury cause release of acids that can cause a drop in pH level and subsequent metabolic acidosis  GI problems including Curlings ulcer occur as result of decreased blood flow to stomach  Electrolyte imbalances (hyperkalemia, hyponatremia, hypernatremia and hypocalcemia) due to bodys hypermetabolic needs and priority that fluid replacement takes over nutritional needs during emergency phase

 Fluid Remobilization Phase / Diuretic Phase:  Starts about 48 hours after the initial burns  Fluid shifted back to vascular compartment  Edema at burn site decreased, blood flow to the kidneys increased  Sodium lost through increase in diuresis, potassium either moved back into the cells or lost through urine  Fluid and electrolyte imbalances present during the initial phase after burn: can change during fluid remobilization phase may include hypokalemia, hypervolemia and hyponatremia

 Convalescent Phase:  Begins after 1st two phases have been resolved  Characterized by healing or reconstruction of burn wound  Major electrolyte imbalances exist as result of inadequate dietary intake  Anemia common at this time (severe burns typically destroy RBC)

SHOCK will occur? Tissue destruction = coagulation / protein denaturation / ionization of cellular contents

Tissue hypoperfusion = due to DEC. Cardiac output Burns < 25% TBSA produce a primarily local response. Burns > 25% may produce a local and systemic response and are considered major burns. Systemic response includes release of cytokines and other mediators into the systemic circulation. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction

Cardiovascular Response  Burn Shock/hypovolemia (as fluid loss continues and vascular volume decreases, cardiac output continues to fall and blood pressure drop).  Cardiac output decreases before any significant change in blood is evident  In response to symphathetic nervous system releases catecholamines resulting in an increase pulse peripheral resistance (vasoconstriction) increases pulse rate.  Peripheral vasoconstriction further decreases cardiac output  Myocardial contractility may be suppressed by the release of inflammatory cytokine necrosis factor Management: Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output to prevent shock Normal range only to prevent EDEMA

Burn Edema Burns involving less than 25% TBSA The loss of capillary integrity and shift of fluid are localized to the burn itself, resulting in blister formation and edema only in the area of injury Severe burns OR < 25% TBSA massive systemic edema will developed NOTE: Edema is usually maximal after 24 hours. It begins to resolve 1 to 2 days post-burn and usually completely resolved in 7 to 10 days post-injury IF REMAIN INCREASE : Pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. AKA compartment syndrome MANGEMENT : ESCHAROTOMY, a surgical incision into the eschar (devitalized tissue(SCAB) resulting from a burn), to relieve the constricting effect of the burned tissue.

Effects on Fluids, Electrolytes, and Blood Volume:  Circulating blood volume decreases dramatically during burn shock. In addition evaporative fluid loss through the burn wound may reach 3 to 5 liter or more over a 24hr. period until the burn surface is covered.  During burn shock, serum sodium levels vary in response to fluid resuscitation.  Usually hyponatremia is present. Hyponatremia is also common during the first week of the acute phase, as water shifts from the interstitial to the vascular space  Immediately after burn injury, hyperkalemia results from massive cell destruction. Hypokalemia may occur later with fluid shifts and inadequate potassium replacement.  At the time of burn injury, some red blood cells may be destroyed and other damaged, resulting in anemia  Despite this, the hematocrit may be elevated due to plasma loss.  Abnormalities in coagulation including a decrease in platelets and prolonged clotting and prothrombin times also occur with burn injury.

Pulmonary Response: Inhalation injury is the leading cause of death in fire victims  Bronchoconstriction caused by release of histamine, serotonin, and thromboxane, a powerful vasoconstrictor, as well as chest constriction secondary to circumferential full-thickness chest burns causes this deterioration.  hypoxia (oxygen starvation in tissue) may be present (how?) catecholamine release in response to the stress of the burn injury alters peripheral blood flow, thereby reducing oxygen delivery to the periphery. Later, hypermetabolism and continued catecholamine release lead to increased tissue oxygen consumption, which can lead to hypoxia MANAGEMENT: airway management and oxygen may be needed.

UPPER AIRWAY INJURY (Usually carbon monoxide poisoning) Upper airway injury results from direct heat or edema may occur for 2 days after burn injury Mechanical obstruction of the upper airway, including the pharynx and larynx ( below the glottis ) Because of the cooling effect of rapid vaporization in the pulmonary tract, direct heat injury does not normally occur below the level of the bronchus. MANAGEMENT: Treated by early nasotracheal or endotracheal intubation.

Other gasses cause upper airway injury sulfur oxides, nitrogen oxides, aldehydes, cyanide, ammonia, chlorine, phosgene, benzene, and halogens Cause loss of ciliary action, hypersecretion, severe mucosal edema, and possibly bronchospasm.The pulmonary surfactant is reduced, resulting in atelectasis (collapse of alveoli). Expectoration of carbon particles in the sputum is the cardinal sign of this injury

CARBOXYHEMOGLOBIN Carbon monoxide combining with hemoglobin = hypoxia Management: intubation and mechanical ventilator 100% oxygenation needed. Indicators of possible pulmonary damage include the following: History indicating that the burn occurred in an enclosed area Burns of the face or neck Singed nasal hair Hoarseness, voice change, dry cough, stridor, sooty sputum Bloody sputum Labored breathing or tachypnea (rapid breathing) and other signs of reduced oxygen levels (hypoxemia) Erythema and blistering of the oral or pharyngeal mucosa Diagnostic exam for inhalation injury Serum carboxyhemoglobin levels, Arterial blood gas levels, Bronchoscopy and xenon-133 (133Xe) ventilation-perfusion scans Complications = ARDS & ARF if untreated

Other Systemic Responses kidney  Renal function may be altered as a result of decreased blood volume  Destruction of red blood cells at the injury site results in free hemoglobin in the urine (hematuria)  Myoglobin is released from the muscle cells and excreted by the kidney (If muscle damage occurs) MANAGEMENT: Adequate fluid volume replacement restores renal blood flow, increasing the glomerular filtration rate and urine volume UNTREATED: The hemoglobin and myoglobin occlude the renal tubules, resulting in acute tubular necrosis and renal failure Loss of the skin integrity Exhibit low body temperatures in the early hours after injury. Hypermetabolism resets core temperatures, burn patients become hyperthermic for much of the postburn period, even in the absence of infection

The immunologic defenses of the body are greatly altered by burn injury Sepsis remains the leading cause of death in thermally injured patients Gastrointestinal complications Paralytic ileus Curlings ulcer Absence of intestinal peristalsis Acute gastroduodenal ulcer

Clinical manifestations : occult blood in the stool, regurgitation of coffee ground material from the stomach, or bloody vomitus

Diagnostic Findings: Rule of Nines

LUND AND BROWDER METHOD A more precise method of estimating the extent of a burn Recognizes that the percentage Of TBSA of various anatomic parts, especially the head and Legs, and changes with growth The initial evaluation is made on the patients arrival at the hospital and is revised on the second and third post-burn days because the demarcation usually is not clear until then. PALM METHOD The size of the patients palm is approximately 1% of TBSA. Other diagnostic test  ABG levels maybe normal in early stages, may reveal hypoxemia and metabolic acidosis in later stages  Carboxyhemoglobin level; may reveal extent of smoke inhalation due to presence of CO

Phases of Burn Injury

Emergent or resuscitative phase Onset of injury to completion of fluid resuscitation First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Wound assessment and initial care Acute or intermediate phase From beginning of diuresis to wound closure Wound care and closure Prevention or treatment of complications, including infection (goal) Nutritional support Rehabilitation phase From wound closure to return to optimal physical and psychosocial adjustment Prevention of scars and contractures Physical, occupational, and vocational rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

Medical Management( IN GENERAL)  Removal of smoldering clothing (soaking first in NSS if stuck to patients skin), rings and other constricting items  Immersion of the burned area in cool water or application of cool compresses (wrap cool towel intermittently)  Pain medications as needed or an anti inflammatory drug  Coverage of the area with an antimicrobial and a non sticky bulky dressings (after debribement)  Prophylactic tetanus injection as needed  Prevention of hypoxia by use of several steps: Maintaining an open airway Assessing airway, breathing and circulation Checking for smoke inhalation immediately Assisting with ET insertion Administering 100% oxygen  Coverage of partial thickness burns over 30% of BSA or full thickness burns over 5% of BSA with a clean, dry, sterile bed sheet

 Immediate IV therapy to prevent hypovolemic shock and maintain cardiac output  The Parkland Formula is a commonly used formula for calculating fluid replacement in patients with burns. Always base the volume of fluid replacement on the patients response, especially his urine output. Urine output of 30 50 ml/ hour is a sign of adequate renal perfusion  Over 24 hours: 4 ml of LR x kg of body weight x % of BSA burned (using Rule of Nines or Lund Browder Classification)  Give of the total over the 1st 8 hours after the burn and the remainder over the next 16 hours  Day 2 : Varies. Colloid is added.  Antimicrobial therapy  Insertion of NGT to decompress the stomach and avoid aspiration of stomach content  Irrigation of wound with copious amounts of NSS (chemical burns)  Surgical intervention including skin grafting and more through surgical cleaning (major burns)

Nursing Management(IN GENERAL)  Assess airway obstruction  Provide oxygen therapy as ordered  Assess cardiac and hemodynamic status (hypovolemia and hypervolemia)  Assess skin for location, depth and extent of the burn  Administer IV fluid therapy as ordered  Assess for signs and symptoms of metabolic acidosis  Monitor ECG readings  Assess fluid and hydration status monitor ABG values and serum electrolyte levels  If bowel sounds are present, provide a diet high in potassium, protein, vitamins, fats, nitrogen and calories to maintain the patients preburn weight  If necessary, feed the patient enterally until he can tolerate oral feedings; if he cant tolerate oral or enteral feedings, administer TPN  Monitor for signs and symptoms of infection

Management of the Patient with a Burn Injury: Emergent / Resuscitative Phase of Burn Care Onset of injury to completion of fluid resuscitation  Assess Airway, Breathing and Circulation  Breathing must be assessed and a patient airway established immediately during the initial minutes of emergency care  Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen  If such a high concentration of oxygen is not available under emergency condition oxygen by mask or nasal cannula is given initially  No food or fluid is given by mouth and patient is placed in a position that will prevent aspiration of vomitus Emergency Medical Management(ER)  Initial priority ABC  After adequate respiratory and circulatory status has been established attention is directed to the burn wound itself  All clotting and jewelry are removed  Flushing of chemical burns with water is continued

Transfer to Burn Center  The depth and extent of the burn are considered in determining whether the patient should be transferred to a burn center  If the patient is to be transported to a burn center, the following measures are instilled before transfer  A secure IV line is placed with fluid infusing at the rate required to attain urine output of at least 30 ml/hr  A patent airway is secured  Adequate pain relief is attended  Adequate peripheral circulation is established in any burned extremities.  Wounds are covered with clean dry sheet and the patient is kept comfortably warm

Acute or Intermediate Phase (begins 48 to 72 hours) From beginning of diuresis to wound closure Nurse should assess for sign of infection Wound Care Open Method: Closed Method:

 A topical agent or wound  The nurse places the topical covering is placed on the wound agent or wound covering on the and left exposed to the air. wound and covers it with gauze wrap  Superficial burns Allows the nurse to visualize the wound  Promotes adherence of the more readily and assists in topical agents to the wound and range of motion because of limits fluid loss and wound absence of constricting drying. dressings  Disadvantages: heat loss and accidental removal of the topical agent Nurse should change dressing quickly as possible to reduce pain and discomfort

Topical Agents Silver Sulfadiazine

Indications

Implications

Deep Partial to Full Penetrates eschar to inhibit bacterial thickness burn. growth.MINIMAL ONLY Soothes pain in layer applied directly Inhibits epithelial tissue development May cause slimy, grayish discoloration with repeated application. Side Effects: Skin rash on unburn areas Decrease WBC for 24 48 hours

Mafenide Acetate Deep Partial to Penetrates thick eschar and Full thickness cartilage; inhibits epithelial burn. electrical tissue development burn Side Effects: Pain on application Metabolic Acidosis Hypersensitivity, Rash Fungal growth

Silver Nitrate

Deep Partial Poor penetration to eschar to Full thickness Side Effects: Black stain on wounds burn. Pain on application Decreases electrolytes

Wound Cleaning Hydrotherapy  Using shower tub or a spray table facilitates the removal of topical medications and loosens debris, sloughing eschar and exudates  Wound care in a tub permits immersion of the patient into water or antimicrobial solutions  Soaking help remove topical agents and eschar, and facilitates range of motion.  Therapy is limited to 30 minutes intervals to prevent heat loss.  Tub therapy is avoided in critically ill patient and those with wound infection

Wound Dbridement As debris accumulate in the wound = retards keratinocyte GOALS = to remove tissue contaminated with bacteria = to remove devitalized tissue or eschar in preparation for grafting & wound healing Types : Natural eschar seperation, affected by topical anti-bacterial Use of scissors/scalpels/forceps to separate eschar Done every dressing change Done even in pain / bleeding occurs Excision of eschar to level of fascia/shaving Occlusive dressing applied/ skin graft Disadvantage extensive blood loss/ anesthesia effects

Mechanical

Surgical

Grafting the Burn Wound= spontaneous reepithelialization is not possible (full-thickness burn) Cadaver or organ donor tissue Used to cover deep or partial thickness burn Enables blood supply to regenerate but carries some risk for disease transmission Pig skin most commonly used Closes and protects wound while permanent options are being considered

Homograft/ allograft

Temporary

Heterograft/ Xenograft

Temporary

Synthetic Substitutes

Biobrane adheres to the wound fibrin, which binds to the nyloncollagen material. Trimming of separated biobrane is necessary in healing

Temporary

Autograft

Patients own unburned skin removed and applied to wound

Permanent

Cultured epithelial Autograft (CEA) Integra (Artificial Skin)

Patients own skin removed in small squares and grown into larger pieces in laboratory((Keratinocytes) Two layer man made membrane used to replace dermis(animal collagen) and covered with autograft, forming functional dermis and epidermis Man made collagen matrix used to provide dermal layer covered with autograft

Permanent

Permanent

Alloderm

Permanent

Graft Care:  Staples prevent movement of the graft  Dressing covered with large, occlusive, bulky dressing to hold new skin securely in place  Splints are applied to help provide immobilization and maintain the position of the grafted areas  Fluid can be removed by aspiration with a needle, rolling the fluid with a cotton tip or cutting a small slit in the graft to drain the fluid.  Dressing is removed slowly and carefully to that graft is not disturbed.

Pain Management

Burn pain = one of the most severe forms of acute pain Pain accompanies care and treatments such as wound cleaning and dressing changes. Types of burn pain Background or resting exists on a 24-hour basis. caused by procedures such as burn wound care or range of motion exercises Occurs when blood levels of analgesic agents fall below the level required to control background pain

Procedural

Breakthrough

Analgesics IV use during emergent and acute phases Morphine It is titrated to obtain pain relief based on the patients self-report of pain using a standardized pain rating scale. Prevent addiction Particularly procedural burn pain

Fentanyl

Anxiety and pain go hand in hand for burn patients. Sedation with anxiolytic medications such as lorazepam (Ativan) and midazolam (Versed) may be indicated in addition to the administration of opioids. Music therapy has gained interest recently in the treatment of pain

Nutritional Support Burn injuries produce profound metabolic abnormalities. Patients with burns have great nutritional needs related to stress response, hypermetabolism, and wound healing. GOAL= a state of (+)nitrogen balance Effective nutrition management depends on how well the energy expenditure due to the burn injury can be estimated and matched with appropriate amounts of micronutrients, carbohydrates, lipids, and protein.

Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

Nursing Process: Care of the Patient in the Emergent Phase of Burn Care: Diagnosis Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction Goal: Maintenance of adequate tissue oxygenation  Provide humidified oxygen. Humidified oxygen provides moisture to injured tissues; supplemental oxygen increases alveolar oxygenation.  Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. These factors provide baseline data for further assessment and evidence of increasing respiratory compromise.  Observe for the following: a. Erythema or blistering of lips or buccal mucosa b. Singed nostrils c. Burns of face, neck, or chest d. Increasing hoarseness e. Soot in sputum or tracheal tissue in respiratory secretions These signs indicate possible inhalation injury and risk of respiratory dysfunction.

 Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels. Increasing PCO2 and decreasing PO2 and O2 saturation may indicate need for mechanical ventilation  Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately. Immediate intervention is indicated for respiratory difficulty.  Prepare to assist with intubation and escharotomies. Intubation allows mechanical ventilation. Escharotomy enables chest excursion in circumferential chest burns.  Monitor mechanically ventilated patient closely. Monitoring allows early detection of decreasing respiratory status or complications of mechanical ventilation.

Nursing Diagnosis: Ineffective airway clearance related to edema and effects of smoke inhalation Goal: Maintain patent airway and adequate airway clearance  Maintain patent airway through proper patient positioning, removal of secretions, and artificial airway if needed. A patent airway is crucial to respiration  Provide humidified oxygen Humidity liquefies secretions and facilitates expectoration.  Encourage patient to turn, cough, and deep breathe. Encourage patient to use incentive spirometry. Suction as needed. These activities promote mobilization and removal of secretions

Nursing Diagnosis: Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound Goal: Restoration of optimal fluid and electrolyte balance and perfusion of vital organs  Observe vital signs (including central venous pressure or pulmonary artery pressure, if indicated) and urine output, and be alert for signs of hypovolemia or fluid overload. Hypovolemia is a major risk immediately after the burn injury. Overresuscitation might cause fluid overload.  Monitor urine output at least hourly and weigh patient daily. Output and weight provide information about renal perfusion, adequacy of fluid replacement, and fluid requirement and fluid status.  Maintain IV lines and regulate fluids at appropriate rates, as prescribed. Adequate fluids are necessary to maintain fluid and electrolyte balance and perfusion of vital organs.

 Observe for symptoms of deficiency or excess of serum sodium, potassium, calcium, phosphorus, and bicarbonate. Rapid shifts in fluid and electrolyte status are possible in the postburn period.  Elevate head of patients bed and elevate burned extremities. Elevation promotes venous return.  Notify physician immediately of decreased urine output, blood pressure, central venous, pulmonary artery, or increased pulse rate. Because of the rapid fluid shifts in burn shock, fluid deficit must be detected early so that distributive shock does not occur.

Other interventions  Promote early ambulation to prevent DVT