Burns

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2.1

• Burns

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Fire and Burn Death and Injury

• Deaths
• 4,000 deaths a yearfrom fire and burns
• Injuries
• 25,000 hospitalized in burn centers
• 600,000 burn injuries treated in hospital EDs
• (Close to half of all burn injuries treated in
  hospital emergency departments and one-third of
  admissions to burn centers are scald injuries)

(Sources National Fire Protection
Association,National Center for Health
Statistics American Burn
Association, National Burn Repository, 2005)
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• 40 years ago 9,000 people died of burns each
  year. Those with burns of more than 20 Total
  Body Surface Area usually died.
• Today, 4,000 die and some with 90 Total Body
  Surface Area burns survive.
• Survival rate burn centers 94.4

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Clinical Application

• Dale
• 24
• 176 lbs.

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Clinical Application - Burns

• Priority of Urgent Care (On Scene)

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Clinical Application - Burns

• Cool Water
• Problems with cooling water?

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Clinical Application - Burns

• Why remove clothing and jewelry

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Clinical Application - Burns

• Dale is awake, VS stable, EMTs immobilize him,
  start IV, put on O2 and transported

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Dale Arrives in your ER

• He has burns to face and anterior neck, singed
  hair and hoarseness
• A-B-Cs

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Clinical Application - BurnsCirculation

• Burns Hypovolemia
• Why?

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Fluid Shifts Hypovolemic Shock
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1st
Superficial
2nd
Deep
3rd
4th
Deep
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Superficial (1st Degree burn)- Heal 3-5 days
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Partial-Thickness Superficial-(2nd Degree) Heal
2-4 Weeks
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Deep Partial Thickness Full-Thickness weeks to
months
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Deep Full thickness (4th Degree) Burn weeks to
months on small area Need skin grafts for other
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Clinical Application - BurnsRule of 9s

• Dale
• 1. Partial thickness to anterior right trunk
• 2. Right upper anterior leg
• 3. Most of right arm
• 4. Anterior neck and face

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Clinical Application - BurnsFluid Replacement

• Parkland (Baxter)
• Lactated Ringers Solution
• 4 ML x Kg x Burn

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Clinical Application - BurnsFluid Replacement

• 1/2 to be given in First 8 hours
• 1/4 in EACH of the next 8 hours
• Start of the FIRST 24 hours is FROM TIME OF
  INJURY

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Clinical Application - BurnsFluid Replacement

• Dales total need for first 24 hours is
  ???? ML then How ML per hour
  for the first 8 hours?
• How many ML per hour if you started fluid
  replacement 2 hours after injury?

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Clinical Application - BurnsFluid Replacement

• What do we do about fluid replacement after the
  first 24 hours?

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Clinical Application - BurnsFluid Replacement

• Urinary Output
• Serum sodium
• Cardiopulmonary Factors
• Level of conscience

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Burn Classification
Major Burn Injury 25 TBSA lt 40 years of
age 20 TBSA gt 40 years of age 20 TBSA lt10
years of age OR Burn involving face, eyes, ears,
hands, feet, or perineum OR High voltage OR
Concomitant inhalation or major trauma
Moderate Burn Injury 15-25 TBSA lt 40 years of
age 10-20 TBSA gt 40 years of age 10-20 TBSA lt
10 years of age Minor Burn Injury lt15 TBSA lt 40
years of age lt10 TBSA gt 40 years of age lt10
TBSA lt 10 years of age
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Clinical Application - Burns

• What else do we need to do to care for Dale?

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Clinical Application - BurnsMajor Organs Affected

• Cardiovascular
• Respiratory

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78 of burn deaths are related to Toxins
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• Renal
• GI
• Immune system

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Clinical Application - BurnsWound Care

• Goals as we clean and debride
• Minimize further destruction of viable skin
• Patient comfort
• Prevent Infection

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Clinical Application - BurnsSkin Grafts

• Autograft (Patient own)
• Homograft or Allograft (Cadaver skin)
• Heterography or xenograft (Pigskin)
• Synthetic coverings

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Clinical Application - BurnsSkin Grafts

• Dale has split thickness skin grafts to his
  right arm. Donor site is left leg.
• Nursing management of donor site and graft sites.

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Clinical Application - BurnsWound Healing

• Jobst pressure garments
• Contractors

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Pressure Garments
The continuous wearing of pressure garments
prevents the thickening, buckling, and nodular
formations seen in hypertrophic scars (Keloids).
A soft pliable elastic scar develops which allows
for normal joint movement. The external pressure
applied by the garments decreases inflammatory
response and the amount of blood in the scar,
reducing itching and prevents collagen from
synthesizing. Additionally pressure garments
provide protection against injury.
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Clinical Application - Burns

• Nutritional care -
• Ulcers
• Diabetics
• ROM exercise
• PAIN

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Clinical Application - BurnsPsychological Care

• Body image
• Role
• Relationships
• Lifestyle
• Occupation

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Burns - Phases

• Emergency - 24-48 Hours to a week
• Acute - Weeks to months
• Rehabilitation - Few to several months to years

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Burns - Phases

• AND THIS ONLY CONSIDERS THE PHYSICAL !!

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Chemical Burns

• Brush or Wash off and neutralize
• Water
• Respiratory up to 72 hours

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Electrical Burns

• Voltage, Time, Pathway
• Entrance exit wounds
• Severe metabolic acidosis
• Myoglobinuria (Kidneys)

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Electrical Burns

• High Voltage John touched TV antenna to power
  line. Entrance hands, exit foot
• Low voltage (house current 110 volts) Carl
  touched with BOTH hands. Entrance and exit
  wounds small

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Setting a Safe Hot Water Temperature

• Time and temperature relationship required to
  scald a healthy adult

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Nursing Staff in Burn Units

• Protective equipment
• Temp - 85 - 88o F
• Humidity gt 50
• Isolation
• Physical and Psychological challenging