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burns with total body surface (TBS) >20% is of concern
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4 burn sources
- thermal
- chemical
- electrical
- radiation (sun)
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classification of burns
superficial (1st) just epidermis
- superficial partial thickness and
- deep partial thickness (2nd) includes dermis
full thickness (3rd) gets into muscle
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calc of burn size is based on what?
the rule of nines
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rule of nines:
head
chest
back
groin
legs
- head: front= 5%, back= 4%
- chest: 2x9= 18%
- back: 2x9= 18%
- groin: 1%
- legs: front and back = 9% each
- arms: 9% each
equals 100%
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color tagging system for burn levels:
<20% = yellow tag, intermediate risk, walky-talkys
>20% = Red teg, major burn
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major problems with burns:
Skin injury results in loss of
1-6
- protection from infection
- body fluid loss
- temp control
- sweat glands and hair follicles
- sensory receptors
- scarring and keloid formation
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3 zones of injury
Center= zone of coag - most severe damage
Middle = zone of stasis - impaired circulation
outer = zone of hyperthermia - least damage
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Burn shock is the same as HYpovolemic shock
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3 stages of burn management
ermergency mangmnt / resuscetation phase (thru completion if fluid stability)
reparative care (begining of diuresis thru would closure)
rehab (wound closure on)
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ermergency mangmnt / resuscetation phase:
Primary survey of ABCD's
- Airway
- Assess for signs of inhalation injury
- -progressive airway edema over 24-48 hrs
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Sx of inhalation injury
look for soot or sx of inhalation of smoke and shit
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Primary Survey:
breathing
- assess rate, depth, sounds, SpO2
- Escharectomy may be needed
- eschar is non viable tissure impeding skin excursion
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CO poisoning:
HbCO2 levels
- 10-15% = HA
- 15-60% = toxicity, inc Sx's
- >60% = coma, death
- Sx= dizzy, N/V
- =weak, memory loss, dec LOC
- =confusion -> coma
- = Skin Pink to cherry red - shows perfusion, but is CO2 perfusion
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primary survey:
circulation
- basic assessment:
- HR and sounds
- cardio monitor
- BP
Assess pulses and circumferential extremity burns
loss of pulses or dec quality = Escharectomy
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circulation priority: IV fluids
Parkland formula
4mL LR x kg x TBSA% (as a whole #) = volume in first 24hrs from time of injury
- 1/2 given in first 8hrs
- 1/2 given in next 16 hrs
4ml x 75kb x 30 (drop the %) = 9000
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UO is the bed indicator for fluid status
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what lab results do we monitor?
- K, Ca, Na imbalances
- Bun and Creat
- bld glucose
- dec Hgb d/t hemolysis
- inc Hct d/t dehydration --> dilutional dec Hct
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risk fx for morbidity and mortality
- age + TBSA = >100 poor prognosis
- <2, >65 inc risk
- location of burn (hand, feet, face, balls)
- Hx of illness
- inhalation injury
- -Primary cause of death in first 24 hrs
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Secondary survey
- burn estimate, % and depth
- -expose wounds, leave ahereing clothing in place
- -remove clothing and jewelry is possible
- Comple H&P (peripheral and lung focus)
- Prevent Hypothermia
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Chemical burns: special considerations
- injury greater than appears
- brush off chemical powders
- FLUSH SKIN WITH H2O FOR 15-30 MINUTES
- Blisters ARE broken with chem burns (only burn)
brush, flush, and break
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electrical burns
Tx
- assess enterance and exit
- muscle damage (rhabdomyolysis) - burgendy (port wine) colored urine
- - kidney failure high risk
Tx= INC IV fluids to maintain UO of 100-150 ml'hr
acidosis and arrythmias occur
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Reparative phase goal
wound closure, infection prevention, minimal scar formation
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GI and nutritional needs
- Ileus risk
- curling (stress) ulcers with >20% TBSA
- INC protein diet b/c of hypermetabolic state and wound healing
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sepsis is a threat and primary cause of heath during the reparative phase of care
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no exudate seen with a partial thickness burn
clean with chlorihexidine and flush with h2o
topical AB ointment
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Exudate seen with deep partial thickness
cleanse same as partial thick
use Silver Sulfadiazine like icing a cake = penetrates eschar, can cause bone marrow depression
Sulfamylon = topical AB, can be painful for up to 30 minutes
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open dressing for face and neck
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signs of wound infection
- rapidly seperating eschar
- purulent pockets or inc exudate
- unclear demarcation of wound edges
- sustained inc fever or WBC's
- -antibios and cultures are NOT routine
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hydrothereapy for 20-30 mins/day
debrisment can be:
mechanical
enzymatic
surgical grafting
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5 types of surgical grafts
- autograft - own skin
- heterograft/xenograft - animal skin (pig)
- Homograft/allograft - hhuman donors
- -partial or full thickness
- synthetic skin
- CEA - cultured endothelial Autograft
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Grafted site care
- immobilize site for 3-7 days
- sheet grafts are left open to air
- elevate limb
- no contact: pressure or shearing at site
- medicate for icthy and pain
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Graft complications
reportable assessments
- rejection
- contractures - position in extension, ROM for 5min Qhr
- Reportable assessments:
- inc pain or redness
- inc temp or purulence
- loss of distal pulse
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graft donor site care
- skin creates a wound similar to partial thickness burn
- prevent infection
- site heals in 1-2 weeks
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Rehab phase
goals
- begins after wound closure is complete
- may last for several years
- goals= physical and emotional healing
- =scar managemnt, minimize hypertrophic scars
- =maximize functions
- =return to community, workplace
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pressure garments
- on grafted site after 5-7 days
- custom made garments made and worn 23/24 hrs for 6-12 months
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PT started within 24 hrs of burn
ROM at least Q4
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