Management of Patients with Burn Injury

1
Management of Patients with Burn Injury
2
Burns Major Goals

• Prevention
• Institution of lifesaving measures for severely
  burned person.
• Prevention of disability and disfigurement
  through early, individualized treatment
• Rehabilitation through reconstructive surgery and
  rehabilitative programs.

3
Burn Classifications

• Superficial
• Least destruction
• Only epidermis injured
• Partial-thickness
• Epidermis destroyed
• Varying depths of dermis damaged/destroyed
• Superficial partial-thickness
• Erythematous and moist with vesicles
• painful
• Deep partial-thickness
• Red and waxy without blisters
• Moderate edema, lesser degree of pain
• Hypoxia and ischemia can cause extension of wound

4
Burn Classifications

• Full-thickness
• Entire epidermis and dermis involved
• No viable epithelial cells, grafts required
• Hard, dry leathery eschar
• Deep full-thickness
• Extend beyond skin into underlying fascia and
  tissues
• Muscle, bone and tendon damage with exposure to
  surface
• Blackened and depressed, little or no sensation
• Early excision and grafting beneficial

5
Illustrations of Burns

• Superficial partial-thickness

• Deep partial-thickness

6
Illustration of Burns

• Full Thickness

• Deep Full Thickness

7
Burn Classification

• Extent of Body Surface Area Injured
• Rule of Nines
• Lund-Browder
• Palm method

8
Pathophysiology of Burn Injury

• Tissue destruction can lead to
• Fluid/protein losses
• Sepsis
• Multiple system disturbances
• Metabolic
• Endocrine
• Respiratory
• Cardiac
• Hematologic
• Immune

9
Pathophysiology of Burn Injury

• Extent of local and systemic disruption depends
  on
• Age
• General health status
• Extent of injury
• Depth of injury
• Area of body injured
• (morbidity and mortality of burn clients is
  related to a lack of or delay in healing)

10
Vascular Changes

• Fluid Shift
• Period of inflammatory response
• Vessels adjacent to burn injury dilate ? ?
  capillary hydrostatic pressure and ? capillary
  permeability
• Continuous leak of plasma from intravascular
  space into interstitial space
• Associated imbalances of fluids, electrolytes and
  acid-base occur
• Hemoconcentration
• Lasts 24-36 hours

11
Vascular Changes

• Fluid remobilization
• Capillary leak ceases and fluid shifts back into
  the circulation
• Restores fluid balance and renal perfusion
• Increased urine formation and diuresis
• Continued electrolyte imbalances
• Hyponatremia
• Hypokalemia
• Hemodilution

12
Other System Changes

• Cardiac
• Decreased cardiac output
• Need fluid resuscitation and support with O2
• Pulmonary
• Respiratory insufficiency as a secondary process
• Can progress to respiratory failure
• Aggressive pulmonary toilet and oxygenation
• Gastrointestinal
• Decreased or absent motility (may need NG tube)
• Curlings ulcer formation
• H2 histamine blockers, mucoprotectants and
  enteral nutrition

13
Other System Changes

• Metabolic
• Hypermetabolic state
• Increased oxygen and calorie requirements
• Increase in core body temperature
• Immunologic
• Loss of protective barrier
• Increased risk of infection
• Suppression of humoral and cell-mediated immune
  responses

14
Compensatory Responses

• Inflammatory Compensation
• Initiates healing
• Contributes to fluid shift (? capillary
  permeability)
• Local tissue reaction due to release of chemicals
  by wbcs
• Sympathetic Nervous System Compensation
• Stress Response (Figure 71-8, p. 1625)

15
Phases of Burn Injury

• Emergent/Resuscitative
• First 48 hours
• Acute
• Approximately 48 hours after injury to complete
  wound closure
• Rehabilitative
• Begins with wound closure and ends when client
  returns to highest possible level of functioning

16
Emergent/Resuscitative Phase

• Goals
• Maintain open airway
• Ensure adequate breathing/circulation
• Limit extent of injury
• Maintain function of vital organs
• Prevent potential complications

• Transfer to Burn Center
• Major burns
• Very young or elderly
• Coexisting health problems that could affect
  recovery
• Circumstances that increase risk of acute and
  long term complications

17
Acute Phase

• Interventions aimed at
• Maintenance of cardiovascular/respiratory system
• Nutritional status
• Burn wound care
• Pain control
• Psychosocial interventions

18
Rehabilitative Phase

• Emphasis
• Psychological adjustment of client
• Prevention of scars and contractures
• Resumption of pre-burn activity
• Work
• Family
• Social

19
Clinical Manifestations of Burns

• Respiratory
• Direct airway injury
• Carbon monoxide poisoning
• Thermal injury
• Smoke poisoning
• Pulmonary fluid overload
• External factors
• Cardiovascular
• Hypovolemic shock and ? cardiac output
• Impaired circulation/tissue perfusion
• Potential for ECG changes

20
Clinical Manifestations

• Renal/urinary
• Changes R/T ? renal perfusion and debris
• Fluid shift ? GFR and urine output
• Fluid remobilization-- ? GFR and diuresis
• Tubular blockage from myoglobin and uric acid
• Fluid resuscitation should maintain output at
  30-50 mL/hour
• Integumentary
• Size of injury is important to diagnosis and
  prognosis
• Rule of Nines
• Lund-Browder method
• Specific treatments dependent upon depth of injury

21
Decreased CO, Deficient Fluid Volume,
Ineffective Tissue Perfusion

• Interventions
• Non-surgical
• IV fluid therapy
• Plasma exchange
• Drug therapy
• Surgical
• Escharotomy

22
Ineffective Breathing Pattern

• Interventions
• Non-surgical
• Airway maintenance
• Promotion of ventilation
• Monitoring gas exchange
• Oxygen therapy
• Drug therapy
• Positioning and deep breathing
• Surgical
• Tracheostomy
• Chest tubes
• escharotomy

23
Acute Pain

• Interventions
• Non-surgical
• Drug therapy (opioids) (anesthetic agents)
• Complimentary/alternative therapies
• Environmental manipulation
• Surgical
• Early surgical excision of burn wound

24
Impaired Skin IntegrityWound Care Management

• Non-surgical
• Debridement
• Mechanical
• Enzymatic
• Cleaning
• Stimulating granulation and revascularization
• Dressings

25
Dressings

• Standard
• Multiple gauze layers over topical agent or
  antibiotic
• Biologic
• Homograft (allograft) from cadaver
• Heterograft (xenograft) from animal (pig)
• Amniotic membrane
• Cultured skin
• Artificial skin
• Two-layer product which creates an artificial
  dermis
• Synthetic dressing
• Solid silicone and plastic membrane
• Can see through to monitor wound status

26
Impaired Skin IntegrityWound Care Management

• Surgical management
• Surgical excision
• Treatment of choice for deep partial-thickness
  wounds
• Wound coverings
• Permanent skin coverage by autograft
• Split thickness
• Successive reharvesting
• Meshing of split thickness graft

27
Risk for Infection

• Non-surgical management
• Drug therapy
• Tetanus Toxoid and Topical Antimicrobials
• Organism specific drugs
• Isolation
• Environmental manipulation
• Secondary prevention/early detection
• Surgical management
• Aggressive surgical incision of infected wound

28
Additional Interventions

• Imbalanced Nutrition
• Calculate calorie needs and provide adequate
  calories and nutrients
• Calorie requirements can exceed 5000 per day
• Impaired Mobility
• Interventions to maintain pre-burn ROM and
  prevent contractures
• Disturbed Body Image
• Grief counseling
• Encouraging independence