Central Philippine University School of Graduate Studies Jaro, Iloilo City

Zone of stasis (B) Zone of coagulation (C)

Systemic Response to Burn Injury Hypovolemic shock associated with:

Management of Clients with Burns and Shock

Objectives Describe incidence, patterns, sources of burn injury Describe local and systemic responses to burn injury Classify burn depth, extent, severity Discuss pathophysiology of signs and symptoms of burn shock Describe management of burn injury Formulate nursing care plans for patients with burns

Decrease in venous return Decreased cardiac output Increased vascular resistance (except in zone of hyperemia) Renal failure may occur due to: o Hemolysis (destruction of RBCs) o Rhabdomyolysis (muscle necrosis)

Depth of Burn Injury First- and second-degree burns are partial-thickness burns o Usually heal without surgery Third-degree burns are full-thickness burns o Usually require skin grafts

Skin Anatomy Epidermis-Outermost skin layer Dermis-Directly beneath the epidermis helps contain the body and support the functions on the epidermis. Subcutaneous Tissue-Body layer beneath the dermis

First-Degree Burn ,Second-Degree Burn ,Deep partial-thickness Involves basal layer of dermis Sensation in and around wound may be diminished May appear red and wet or white and dry, depending on the degree of vascular injury Major complication is wound infection

Local Response to Burn Injury Burn injury destroys cells or completely disrupts their metabolic functions Cellular death ensues Cellular damage is distributed over a spectrum of injury

Third-Degree Burn, Full-thickness burn Epidermis and dermis destroyed Eschar present Sensation and capillary refill absent Skin grafts needed for timely and proper healing

Major burns have three zones of injury : Appear in bulls-eye pattern: Zone of hyperemia (A)

Fourth-Degree Burn

Included in some burn classifications Full-thickness injury that penetrates Subcutaneous tissue,Muscle,Fascia,Periosteum and Bone.

Rule of Nines Divides total body surface area (TBSA) into segments that are multiples of 9% Rough estimate of burn size Most accurate for adults and children >10 y/o

following burn injury are secondary to inadequate fluid resuscitation. Burn shock is both a hypovolemic and cellular shock Primary goal is to restore intravascular volume to preserve tissue perfusion and avoid ischemia Burn shock is complicated by obligatory burn edema secondary to transvascular fluid shifts

Maximal edema formation seen: 8-12 hours in smaller burns 12-24 hours in larger burns

Lund and Browder Chart Accurate method to determine area of burn injury Assigns numbers to each body part Used to measure burns in infants and young children The Palmar Surface (including the fingers) of the patients hand represents approximately 1% of the patients body.

Fluid resuscitation is aimed at supporting pt throughout the initial 24-48 hour period of hypovolemia Consensus is to: 1) provide the least amount of fluid necessary to maintain adequate organ perfusion 2) continually titrate fluid to avoid underresuscitation as well as over-resuscitation TIME = 0 HOURS PRIMARY/SECONDARY SURVEY Airway, Breathing and Circulation are evaluated and stabilized Airway supplemental oxygen or intubation Breathing inhalation injury, pneumothorax Circulation begin Parkland formula

Burn Shock Shock results from: Edema and accumulation of vascular fluid in the tissues in the area of injury Systemic fluid leak

Assessment and Management Fluid resuscitation paramount during initial time period after burn. In 1940s hypovolemic shock or shock induced renal failure was leading cause of death after burn injury. Even in 2009, approximately 50% of all deaths that occur within first 10 days

Parkland formula begins from time injury has occurred. This is where primary survey of trauma pt differs from burn pt.

TIME = 0 HOURS Obtain a history Circumstances of the burn Condition of the patient at the scene Alert?, conscious?, ambulatory?, coding? If patient unable to provide info, discuss with EMS personnel. Actions that may have led to other injuries o Jumped out of building o Explosion o Chemicals o Motor vehicle accident o Falls after electrocution

Breathing may/will worsen with time secondary to inhalation injury and inflammation of burn.

Problem with an inhalation injury Hypoxia Fire consumes O2 Leading cause of death in house fires Reason for smoke detectors Hypoxia causes body to starve for oxygen (anaerobic metabolism ensues) Hypoxia directly related to amount of carbon monoxide toxicity.

Carbon Monoxide Carbon monoxide (CO) Binds HB 200 times > O2 Major contributor to mortality Poisons Combustion of plastics/textiles produce many poisons Cyanide toxicity can be as lethal as CO poisoning

Airway Always have stable airway This takes precedence to all other issues Intubate if question- its your call o -Depends on time for transport and size of burn - Longer transport, larger burn intubate patient - Attach tube securely (extubation can be fatal)

Measurement of CO (Reliable tests) Carboxyhemoglobin levels (from ABG) - < 10% is normal - > 40% is serious Suggestive signs of CO poisoning Persistent acidosis o relates to anaerobic metabolism and production of lactic acid.

. Breathing Ensure bilateral breath sounds Pneumothorax may complicate resuscitation 100% oxygen if inhalation injury or intubation Critical to provide oxygen in pts with Carbon monoxide toxicity

Carbon monoxide has various effects depending upon levels Must check levels on Blood Gas analysis - 0-10% can be seen in smokers

- 10-20% patients can have headache - 20-30% patients develop severe headache, nausea, vomiting, CNS collapse - 30-40% patients present with syncope, convulsions,depressed cardiac activity and respiratory function -40% and greater death may ensue within hours Treatment of CO Poisoning Circulation Place IVs in any site Easier if placed earlier Unburned area preferred, but not required Central lines if expertise exists Cut downs as a last resort Utilize lactated Ringers solution Resuscitation formulas only for getting started Will take precedence over next 24-48 hours Fluid rates based on patients urine output Too much fluid can lead to complications - Compartment syndromes Multiple formulas, choose the one that will allow for ease in resuscitation (ex. The Parkland Formula) Remove patient from CO source Administer 100% O2

TIME 0-48 HOURS In burns, resuscitation is vital as pt has lost ability to maintain fluids within the intravascular space : the capillary leak

Capillary leak may continue for 24-72 hours Resuscitation is vital to maintain blood pressure and end-organ perfusion With critically ill burn pt (unless there is concomitant trauma) resuscitation takes precedence (pt does not go emergently to surgery .

The Basics Initial 24-48 hours is time when resuscitation is vital for the burn pt Most burn patients require 2-4 days of and stabilization prior to any operation (rarely does any burn surgery occur before 72-96 hrs)

Parkland formula is the formula needed for resuscitation during the initial 24-48 hours post-burn Parkland Formula 4 x % TBSA burn x pt weight (in kg) First is given in first 8 hrs Capillary leak most significant during this time Second is given in remaining 16 hrs

8 hrs
deficit

8 hrs
deficit

8 hrs
deficit

24 hrs
maintenance both children & adults

Add maintenance in children

Prevents development of Curlings ulcer Burn Shock Criteria for adequate resuscitation of burn shock urine output: Adults: 0.5cc/kg/hr Children: 1-2cc/kg/hr Place Foley Catheter Best indicator of adequate hydration-Urine Output Adequate urine output 0.5 cc/kg/hr for adults 1-2 cc/kg/hr for small children Prevents bacterial translocation (and sepsis) Eyes Usually reflexes protect eyes Check for corneal abrasions Best dressings are closed eyelids

Pain Management Give IV meds No PO, IM or SQ meds Narcotics/benzodiazepines Have respiratory depression as side effect Use with caution in non-intubated patient

Maintain Temperature Keeping patient warm takes priority Loss of skin makes temperature control difficult Wet dressings always cool the patient Dry and clean dressing are best for transfer Keep ambient temperature as warm as possible Cover all exposed areas Hypothermia can allow for worsening coagulopathy.

Other Medications Tetanus prophylaxis Never give systemic antibiotics Will build antimicrobial resistances Other medications can wait until admitted

Wound Care Dry, warm and clean dressing best for transfer Once at Burn Center Wash wounds with soap (chlorhexadine) and water Sterility not necessary, but preferred Apply ointments or creams Silvadene with collagenase tend to be mainstay of therapy Covering wound decreases pain, decreases risk of infection

Place NG Tube/Feeding Tube Protect against aspiration Gastric distention may worsen in patients priorto intubation with bagging of patient Once stomach decompressed, begin tube feedsimmediately

Prevents malnutrition (pts are catabolic)

The Basics

Initially wounds are placed in topical antimicrobials to prevent burn wound Infection Silvadene applied to all areas except face Silver nitrate use in sulfa allergic patient Acticoat use in sulfa allergic patient Sulfamyalon utility with exposed bone/cartilage Bacitracin use on face in conjuction with xeroform

If pulse gone, damage has already occurred

Escharotomy : Incision made with a scalpel or electrocautery into the full thickness of eschar; becomes necessary to allow underlying tissue to expand and enhance blood flow as burned tissue has lost elasticity and tissue edema worsens with worsening capillary leak. TIME=48-96 HOURS ARDS MAY COMPLICATE BURN May occur in any size burn Increased tissue permeability is main issue

TIME=0-48 HOURS COMPARTMENT SYNDROMES At times, complications arise which require some urgent therapy which can occur at the bedside or in the OR. Compartment syndromes A complication of fluid resuscitation, massive tissue edema, and loss of skin elasticity Seen mostly with circumferential burns Can occur at any time during acute resuscitation

Inhalation Injury Tracheo-bronchial disease Poisons/particles settle distal bronchioles Mucosal injury cilia damage sloughing distal atelectasis Increased pneumonia risk Impaired alveolar macrophage function

Extremity compartment syndrome put limbs at risk of tissue loss Chest/Thoracic compartment syndrome pt unable to ventilate secondary to eschar Abdominal compartment syndrome edema of bowels, ascites and circumferential burns of abdomen act to prevent perfusion of tissues via decreased venous return and ultimately diminished cardiac output. Treat with escharotomy Cut through burned skin, not through fascia May require fasciotomy at times in conjunction with escharotomy

TIME = 96-120 HOURS Tissue edema subsides as pt now mobilizes third space fluids Depth of burn now evident and determinations for surgery to debride all non-viable tissues made (i.e. All third degree burns) Plan for OR with debridement and grafting

Skin Grafting After 2-3 week time period, wounds that fail to heal tend to cause worse scarring Provide daily wound care for wounds with indeterminate depth to facilitate Scarring leads to poor functional and cosmetic outcomes Early grafting prevents such poor outcomes Grafting paramount in management of full thickness (third degree) burns after 4-5 days Assists with decreasing inflammatory process

2.Burn Characteristics

Depth

Epiderm al

Superfici al Dermal

Deep Dermal

Full Thickness

Colour

Red

Pale pink

Blotchy red

White

Blister s Capilla ry refill

No

Present

Positive/ negative

No

Present

Present

Absent

Absent

++++++++++++++++++++++++++++++++++++++ ILLUSTRATIONS AND CHARTS 1. RULW OF NINES

Sensat Present References: ion

Painful

Absent

Absent

BURNS,Copyright 2007, by Mosby, Inc., an affiliate Yes Healin of Elsevier Inc. Yes No no
g

BURN CARE: The First 120 Hour by Stathis Poulakidas, M.D.,F.A.C.S. Rush University. Burn Management & Assessment, Shenandoah Co. Fire and Rescue, EMS Training Nov.2006 BURNS MANUAL, A manual for health workers 2nd edition,2008,Dr E J van Hasselt. http://www.nlm.nih.gov/medlineplus/ency/article/0000 30.htm http://rnspeak.com/nursing-care-plan/burns-nursingcare-plan-risk-for-fluid-volume-deficit/ http://www.enurse-careplan.com/2012/02/nursingdiagnosis-for-burns-risk-for.html

Prepared by: Junah Marie S. Rubinos, R.N