Management of Clients with:

Burns and Shock

Click to edit Master subtitle style

Objectives

Describe incidence, patterns, sources of burn injury Describe local and systemic responses to burn injury

Discuss pathophysiology of signs and symptoms of burn shock

Describe management of burn injury

Discuss signs and symptoms and management of patients with: Formulate nursing care plans for patients with burns

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

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

Major burns have three zones of injury :

Appear in bullseye pattern: Zone of hyperemia (A) Zone of stasis

Hypovolemic shock associated with:

Systemic Response to Burn Injury

Decrease in venous return

Decreased cardiac output Increased vascular resistance (except in zone of hyperemia)

Renal failure may occur due to: Hemolysis (destruction of RBCs) Rhabdomyolysis (muscle necrosis)

Depth of Burn Injury

First, second, and third degree (some include fourth degree)

First- and second-degree burns are partial-thickness burns

Usually heal without surgery

Third-degree burns are fullthickness burns

Usually require skin grafts

First Degree Burn

Involves only the epidermis

Reddened skin

Pain at the

Second-Degree Burn
Superficial partialthickness Blisters

Extends through epidermis to dermis.

-If no infection, generally heals without scarring

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

Deep partial-thickness

Third-Degree Burn

Full-thickness burn Epidermis and dermis destroyed Eschar present Sensation and capillary refill absent Skin grafts needed

Fourth-Degree Burn

Included in some burn classifications Full-thickness injury that penetrates

Subcutaneous tissue Muscle Fascia

Full-thickness injury

VIDEO ON BURNS CLASSIFICATI ON AND

Depth

Epiderm Superfici Deep Full al al Dermal Thicknes Dermal s Colour Red Pale Blotchy White pink red Blisters No Present Positive/ No negative Capillary Present Present Absent refill Sensatio Present Painful Absent n Healing Yes Yes No Absent Absent no

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

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.

Lund and Browder Chart

Burn Shock

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

Burn shock

Emergent phase Fluid shift phase Hypermetabo lic phase Resolution phase

Concentra tion of blood cells Blood viscosity

Possible inhalation injury hypovole mia hyponat remia

Myocardial depressant factor Peripheral vasoconstr iction tachycardi a afterloa d Cardiac

BP

hemolysi s

Hyper K

hemoglobin./myoglo bin in urine

Risk for acute renal failure

Thermoregu lation problem

Tissue perfusion

Renal blood flow

G.I blood flow

Anaerobic metabolism

Tissue damage

Cellular dysfunction

Risk of acute renal failure

Risk of ileus

Metaboli c acidocis

Potential tissue necrosis

Cell swelling

Click to edit Master subtitle style

Assessme nt and Managem ent

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

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 trans-vascular fluid shifts Maximal edema formation seen:

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

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 Parkland formula begins from time

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 -Jumped out of building -Explosion - Chemicals -Motor vehicle

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

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 Breathing may/will worsen with time

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

Problem with an inhalation injury

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

Measurement of CO

Reliable tests Carboxyhemoglobin levels (from ABG) - < 10% is normal - > 40% is serious Suggestive signs of CO poisoning - Persistent acidosis

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,

Treatment of CO Poisoning

Remove patient from CO source Administer 100% O2

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

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 2472 hours Resuscitation is vital to maintain blood pressure and end-organ perfusion

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

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

8 hrs 8 hrs 8 hrs 24 hrs maintenance both children deficit maintenance in children deficit deficit & adults add
maintenance with DW 5% and NS * 2 x kg + 10 = cc/hr

* beware of hyponatraemia and hypoglycaemia in children

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

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

Place NG Tube/Feeding Tube

Protect against aspiration Gastric distention may worsen in patients prior to intubation with bagging of patient Once stomach decompressed, begin tube feeds immediately Prevents malnutrition (pts are catabolic)

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 nonintubated patient

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

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

TIME=0-48 HOURS COMPARTMENT SYNDROMES arise which At times, complications

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

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

Treat with escharotomy Cut through burned skin, not through fascia May require fasciotomy at times in conjunction with escharotomy 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

Inhalation Injury

Pathophysiology Tracheo-bronchial disease Poisons/particles settle distal bronchioles Mucosal injury cilia damage sloughing distal atelectasis Increased pneumonia risk

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 nonviable tissues made (i.e. All third degree burns) Plan for OR with debridement and

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-

VIDEO ON SURGICAL DEBRIDEMEN T

SKIN-GUN