Professional Documents
Culture Documents
Muchtar
Definition
Injury to the skin and deeper tissues caused
by hot liquids, flames, radiant heat, direct
contact with hot solids, caustic chemicals,
electricity, or electromagnetic (nuclear)
radiation.
burn injuries.
deaths.
Most
Populations
Burn Injuries
Potential
complications
Injuries
Inhalation
Contact
Direct contact with hot object (i.e. pan or iron)
Anything that sticks to skin (i.e. tar, grease or foods)
Scalding
Flame
Direct contact with flame (dry heat)
i.e. structural fires / clothing catching on fire
Chemical
Strong acids or alkaloids
i.e. household cleaning products
Management specific to chemical involved
Cold
Injuries
Frostbite
Burn Classification
1st
observation
Vital dyes
Laser doppler
Burn biopsy
Burn Classifications
1st
Burn Classifications
Burn Classifications
2nd
degree (2)
Wound Appearance:
Red to pink
Extremely painful
Wound Healing:
In 2 weeks (spontaneous)
Wound Appearance:
Mottled: Red, pink, or white area
Moist
No blisters
Moderate edema
Painful; usually less severe
Has thin eschar
Wound Healing:
May heal spontaneously 2-6 weeks
Hypertrophic scarring / formation of contractures
Wound Management:
Burn Classifications
Full-Thickness Burns (3 )
o
Involves
Wound Appearance:
Dry, leathery and rigid
+ Eschar (hard and in-elastic)
Red, white, yellow, brown or black
Severe edema
Painless & insensitive to palpation
Pain is due to intermixing of 2nd degree
May be minor bleeding
No blisters (bullae)
Full-Thickness Burns (3 )
o
Wound Healing:
No spontaneous healing;
Wound Management:
Surgical excision & skin grafting
Burn Classifications
Burn Injuries
Often
Rule of Nines
A quick method to evaluate the extent of burns
Major body surface areas divided into multiples of nine
Modified version for children and infants
Lund-Browder Method
Most Accurate; based on age (growth)
Can be used for the adult, children & infants
Palm Rule
1%
to Consider
Depth or Classification
Body Surface area burned
Age: Adult vs Pediatric
Preexisting medical conditions
Associated Trauma
blast injury
fall injury
airway compromise
child abuse
age
complication
Burn
configuration
PATHOPHYSIOLOGY
Zone
of Coagulation
Inner Zone
Area of cellular death (necrosis)
Zone
of Stasis
Zone
of Hyperemia
Pathophysiology
Sub Acute
phase
(Late) phase
Acute/Emergent/
Resuscitative Phase
Lasts
Respiratory System
Vulnerable
to 2 types of injury
1. Upper airway burns
obstruction of the
airway
2. Inhalation injury can show up 24 hrs later-watch for
resp. distress : increased agitation or change in rate
or character of respiration
Preexisting problem (ex. COPD) more prone to get
resp. infection
Pneumonia is common complication of major burns
Overload fluids
pulmonary edema
Respiratory System
Chest
Respiratory compromise
secondary to circumferential eschar around the
thorax
Cardiovascular Systems
Pathophysiology
Fluid Shift
Massive
Pathophysiology
Fluids
Net
Phatophysiology
Fluid
Pathophysiology
Hypovolemic Shock
Occurs
Renal System
Most
after injury.
Cardiac
Inflammatory
healing.
Sympathetic nervous system compensation
occurs when any physical or psychological
stressors are present.
C)
Tachycardia (P: > 90 x/m)
Tachypnea (RR : > 20 X/m) /PaCO 2) < 32
mmHg
Leukocytosis (L >12000), Leukopenia ( <4000)
or Neutrofyl > 10 % in immature form
(2 or more days)
o
Sever
e
sepsis
Septc shock
Pathophysiology
Usual
Pathophysiology
Pulmonary
etiologies
shock, aspiration, trauma, thoracic restriction
inhalation injury; increases mortality 35-60%
diffuse capillary leak reflected at alveolar level
CNS
Pathophysiology
High
Gut
Pathophysiology
Anemia
is common
Pathophysiology
Immunologic
dysfunction is pleiotropic
b. Keloids
c. contracture
TREATMENT
Pre-Hospital Care
Remove
If
Other precautions...
Burn
Transport
Considerations
Appropriate Facility
Burn Center or Not
Factor to consider
Burn Patient Severity Criteria
Critical, Moderate, Minor Burn Criteria
Confounding factors
Transport resources
* water compress
* Analgesic
2. Treatment of wound
* 1st degree : - Moisturized cream
* 2nd degree: - Blister treatment
Treatment
Blister
management
Aspiration or multiple incisions
Non-vital epidermal layer encapsulating
blister should be retained as a biological
dressing (skin is the best wound
coverage)
Tulle: water-based
Dressing (bulky) and pressure bandage will
let the graft take
* Rest
* Diet : calorie , protein
* Medicines : - Oral Antibiotic
(second degree)
- Topical antimicrobial
- Vit. A, D, E, C & Zn
Hospitalized indications :
1. 20 > 15% for adult & > 10% for children
2. 20 or 30 at face, hand, foot, & perineum
3. 30 > 2% for adult, & every 30 for children
4. Burn with visceral trauma, fracture, &
airway problem
Ensure
breaths
Breathing
Assessment/Support
Ensure
adequate oxygenation
level preferred
humidified 100% FiO2 emperically
Assess
Breathing Assessment/Support
NG
Ventilatory
evaluation/support
6-12
products
injuries
Escharotomy of circumferential eschar on thorax region
Pneumothoraks or hematothoraks WSD (Water Sealed
Drainage)
Status
shock
If shock is present, look for other injuries
Circumferential burns may cause decreased
perfusion to extremity
Evans Formula
First 24 hr : 1 ml/kg BW/% burn colloid
1 ml/kg BB/% burn NS (Normal Saline)
2000 ml D5W
( is given in the first 8 hr, remaining
delivered over the next 16 hr)
Second 24 hr : 0,5 ml/kg BW/% burn colloid
0,5 ml/kg BB/% LB NS
2000 ml D5W
Brooke Formula
First 24 hr : 0,5 ml/kg BW/% burn colloid
1,5 ml/kg BW/% burn NS (Normal Saline
2000 ml D5W
( is given in the first 8 hr, remaining
delivered in second 16 hr)
Second 24 hr : 0,25 ml/kg BW/% burn colloid
0,75 ml/kg BW/% burn NS +
2000 ml glukosa
Pediatric resuscitation
protocols
Shriners Burn Institute (Cincinnati) - 4 mL/kg per
Consider
>10% BSA 30
>15% BSA 20
>30-50% BSA 10 with accompanying 20
Monitoring
Objective
HR < 110/minute
Normal sensorium (awake, alert, oriented)
Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)
Resuscitation formulas provide estimates, adjust to individual
patient responses
CVP (< 2)
Hb/Ht
extremities preferred
Monitor for Pulmonary Edema
Analgesia
Antibiotic Broad Spectrum
Morphine Sulfate
2-3 mg repeated q 10 minutes titrated to adequate
ventilations and blood pressure
0.1 mg/kg for pediatric
May require large but tolerable total doses
Burn Wound
Treatment
Low priority - After ABCs and initiation of IVs
Do not rupture blisters
Cover with sterile dressings
Moist: Controversial, limit to small areas (<10%) or
limit time of application
Dry: Use for larger areas due to concern for
hypothermia
Cover with burn sheet
the wound
an Antimicrobial Agent
Potential to resistant
MEBO
Herbal
Stem cell activator
gauze dressings.
Special Considerations:
Joint area lightly wrapped to allow mobility
Facial wounds maybe left open to air
of the wound
Natural
Body & bacterial enzymes dissolve eschar; takes a longtime
Mechanical
Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
Surgical
Operating room / general anesthesia
Surgical Management
Skin
Grafting
The
post-operative client
Nutritional Support
Burn
Nutritional Status
Nutritional Support
Routes
of Nutritional Support
Parenteral
i.e. TPN and PPN
Associated with an increased risk of infection
Rehabilitation Phase
Begins
Major
areas of focus:
Contracture Formation
Shrinkage
Management
is opposing force:
Psychosocial Considerations
Alterations
in Body Image
Loss of Self-Esteem
Returning to community, work or school
Sexuality
Supports Services
Psychologist, social work & vocational counselors
Local or national burn injury support organizations
Nursing Considerations
Encourage client & family to express feelings
Assist in developing positive coping strategies
Psychosocial Considerations
Nursing
Considerations
SPECIAL BURNS
Inhalation Injuries
Suspect inhalation injury when:
Burn occurred within a closed space
Burns to face or neck
Singed nasal hair or eyebrows
Hoarseness, voice changes, wheezing or stridor
Sooty sputum
Brassy cough or drooling
Labored breathing or tachypnea
Erythema and blistering of oral or pharyngeal mucousa
Often requires intubation & mechanical ventilation
Inhalation Injuries
Carbon Monoxide Poisoning
Management: 100% O2
Face mask or mechanical ventilation
Inhalation Injury
The pathophysiology of inhalation injury is complex
Routinely demonstrate :
1) Upper airway obstruction secondary to progressive
edema;
2) Distal airway injuries are usually caused by aerosolized
toxins rather than thermal injury
3) Reactive bronchospasm from aerosolized irritants;
4) small airway occlusion initially from edema and
subsequently from sloughed endotracheal debris and
loss of ciliary clearance mechanisms;
Inhalation Injury
5) Microatelectasis from the loss of surfactant and
alveolar edema;
6) Interstitial and alveolar edema secondary to loss of
capillary ntegrity
and Ventilation
bronchospasm present
Diuretics not appropriate for pulmonary edema
Other Considerations
Assess for other Burns and Injuries
Treat burn soft tissue injury
Treat associated inhalation injury/poisoning * Antidote
kit, Positive pressure ventilation,
Hyperbaric chamber (CO poisoning)
Transport considerations
Burn Center
Hyperbaric chamber
Pediatric patients
Thinner
Greater
Reduce
Small
Immature
Delicate
Geriatric Patients
Skin
ELECTRICAL INJURIES
Electrical Injury
Occurs
Hands
Adults
system
Paralysis of the respiratory muscles
Electrical
Lightning
US
Morbidity 5-10 times higher than that due to
other forms of electrical injury
Iatrogenic electrical injury in the ICU:
defibrillators, pacemakers, electrosurgical
devices
Principles of Electricity
Electricity:
Voltage:
Utility
Pathophysiologic effects of
Different Intensities of
Electrical Current
Electrical
Lightning is a form of DC
Occurs
Voltage
>1,000,000 V
Currents of >200,000 A
Transformation of the electrical energy to
heat generated temperatures as high as
50,000F
Extremely short duration prevents from
melting
law:
Current = Voltage/Resistance
Exposure
The
Moist
Focal
or diffuse
Widespread, discrete, patchy contraction
band necrosis involving the myocardium,
nodal tissue, conduction pathways and
coronary arteries
A current
Cardiac
dysrhythmias reported in
survivors of electrical injuries
pathogenesis is rather unclear,
multifactorial
Possible
mechanisms:
Large
Clinical Manifestations
Cardiac standstill, ventricular fibrillation:
most serious
Sinus tachycardia, nonspecific ST- and Twave changes: much better prognosis
Conduction defects, various degrees of
heart blocks, BBB and QT interval
Supraventricular
Nervous System
Loss
Respiratory System
Direct injury to the respiratory control
center ---- cessation of respiration or
suffocation secondary to tetanic
contractions of the respiratory muscles
Acute respiratory dysfunction syndrome
secondary to ischemia, aggressive fluid
resuscitation, ventilator-associated
pneumonia
Other Systems
Kidneys
Lightning hazards
Do not go near patient until current is off
ABCs
Ventilate and perform CPR as needed
Oxygen
ECG monitoring
Treat dysrhythmias
Considerations
Fluid?
Dopamine?
Assess
Patient Monitoring
Most severe cardiac complications present
acutely
Very unlikely for a patient to develop a
serious or life-threatening dysrhythmia
hours or days later
Asymptomatic normal ECG do not need
cardiac monitoring
Preexisting
Fasciotomy
Fasciotomyis to be
carried out as early as
possible to restore
deep vascular flow in
such a compartment
LIGHTNING STRIKE
Lightning
HIGH VOLTAGE!!!
Injury may result from
Direct Strike
Side Flash
Severe injuries may
result
LIGHTNING STRIKE
Usually
superficial
injury
Victims die from
cardiac arrest
Resuscitate the dead
Patients who are
CHEMICAL BURNS
Chemical Burns
Usually
treatment?
Burning
Chemical Burn
2 types of chemical burns
acids-can be neutralized
lyes, etc...
Chemical Burn
Different types of
burns
1 Outer skin layer
2 Middle skin layer
3 Deep skin layer
4 First degree burn
5 Second degree burn
6 Third degree burn
Remember.
With
Chemical Burns
Acids
Immediate coagulation-type necrosis creating
Chemical Burns
Bases
(Alkali)
Dry
Chemicals
off!
Begin washing immediately - removal the
patients clothing as you wash
Watch for the socks and shoes, they trap
chemicals
Chemicals
Dry
Chemicals
Flush
Flush
Remove
contact lenses
lime
Brush off
Dry lime is water activated
Then flush with copious amounts of water
Phenol
Not water soluble
If available, use alcohol before flushing except in eyes
If unavailable, use copious amounts of water
Specific Chemical
Considerations
Sodium/Potassium
metals
Sulfuric Acid
Generates heat on exposure to H2O (exothermic)
Wash with soap to neutralize or use copious amounts H 2O
Tar
Burns
later
CHEMICAL BURNS
Injure
the skin
May be absorbed into the body and damage
internal organs
May be inhaled into the lungs and cause
lung tissue damage
May have minimal skin injury and yet cause
severe systemic injury
FACTORS CAUSING
TISSUE DAMAGE IN
CHEMICAL BURNS
Type of chemical
Concentration of
chemical
Amount of chemical
Duration of contact
Manner of contact
Mechanism of action
ACID BURN
TREATMENT OF CHEMICAL
EXPOSURE
Accident
protocol
Remove and bag all contaminated
clothing
Brush off dry chemical
Flush with copious amounts of water or
any drinkable liquid
Wipe or scrape any retained chemical
and irrigate again
THE SOLUTION TO
POLLUTION IS DILUTION
The end