CC Burns

• Heat: flames, scolding water
• Chemicals: battery acid, cleaning fluid
• Radiation: sun, equipment
• Inhalation: smoke
• Vulnerable populations include children and the elderly

• Intact skin protects from infection
• Prevention of loss of bodily fluids
• Thermoregulation
• Production of vit D
• Excretion (sweat)
• Sensation reception

• Duration of contact
• Temperature of agent
• Amount of tissue exposed
• Age of patient

• Contact
• Inhalation or fumes
• Ingestion or injection
• *can have both local and systemic effects and must be  completely neutralized or damage continues

• Severity determined by:
• type of agents
• volume of agent
• duration of contact
• concentration of agent
• Alkaline vs. Acid

basic interventions- remove chemical (if dry, simply brush off do not wet!) and remove clothing. Call poison control asap

• High voltage is >1000 wats, low voltage is <1000wats
• Alternating Current (AC): flow of electrical charge periodically reverses direction. higher probability of cardiac arrest
• Direct Current (DC): unidirectional flow of electrical charge. Damage from batteries, electric machines

• Type and path of current (look for entry and exit wounds (exit is worse), always get EKG)
• Duration of contact
• Environmental factors (wet?)
• Tissue resistance

• Exposure to large amounts of radioactive material
• Severity:
• type of radiation
• distance from source
• duration of exposure
• absorbed dose
• depth of penetration

• Such as carbon monoxide, smoke, bleach fumes
• Assess for above the glottis and below the glottis injuries
• Soot in note, throat can cause obstruction
• Edema in airway can cause obstruction

• Assess airway patency
• Administer oxygen
• Cover with blanket (prevent heat loss)
• Keep NPO
• Elevate the extremities if no fractures are obvious
• Vital signs
• Initiate 2 large bore IVs for fluid replacement
• Administer tetanus shot
• Head to toe assessment

• Smother the burns
• Remove smoldering clothing and all metal objects

• If dry chemicals are present on the skin, brush them off (do not wet them!!)
• Remove clothing
• Determine the chemical causing the burn
• Do no attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available

• At the scene, separate patient from the electrical current
• Smother any flames that are present
• Initiate cardiopulmonary resuscitation
• Obtain an ECG

• remove patient from radiation source
• If the patient has been exposed to radiation from an unsealed source, remove the patient's clothing (using tongs or lead protected gloves)
• If the patient has radioactive particles on their skin, send the patient to the nearest designated radiation decontamination center
• Assist the patient in bathing or showering

• Type of burn
• Burn wound characteristics
• Other injuries
• clients age
• Preexisting health status

• Epidermis only
• Heals in 3-6 days without treatment
• Erythema, blanching or pressure, pain and mild swelling
• Not calculated for fluid resuscitation

• Second degree burns involve both the epidermis and the dermis and blistering is common
• Superficial partial thickness
• Deep partial thickness

• Superficial partial thickness is the epidermis and a portion of the dermis
• Heals in 10-21 days
• Moist, pink or mottled red, very painful due to exposed nerve ends blisters form
• Deep partial thickness burns involve the epidermis and most of the dermis
• Heal in 3-8 weeks
• Pale, mottled, pearly red/white, less painful due to more nerve destruction
• Scars form and grafts may aid in healing
• BOTH may have blisters
• BOTH are candidates for fluid resus

• Destruction of all layers down to or past fat, fascia, muscle or bone (no hair or nerves)
• Dry, thick leathery, black/brown, cherry red or white
• No pain due to nerve destruction
• Does not heal due to dermis destruction, requires grafting

• Total body surface area perfect (TBSA%)
• Patient's palm method
• Lund-Brower chart
• Rule of nines (different for adults and children)
• 

• face, neck, chest: risk for resp obstruction
• Hands, feet, joint: risk for self care deficits
• ears, nose: risk for infection
• Circumferential burns can cause compartment syndrome and need to be released with an escarotomy to prevent damage to vessels and nervses
• * always assess CMS distal to burn site

• Older adults heal slowly
• Preexisting cardiovascular, respiratory, renal disease
• DM
• alcohol and drug abuse
• Malnutrition
• Concurrent fractures, head injuries or other trauma

• Acute inflammation
• Intravascular coagulation (hemoconcentration)
• Altered vascular permeability (capillary leak syndrome)
• *direct cell injury leads to release of potassium leads to immediate hyperkalemia, followed by hypokalemia, anemia (hemodilution) and hyponatremia during capillary leak

• Fluid shifts within 24 hours due to capilarry leak syndrome
• Edema occurs in both burned and unburned areas for TBSA 20% or more
• Maximum third spacing occurs 24-48 hours followed by diuretic phase
• Burn shock- combination of distributive and hypovolemic shock (mixed shock with increased HR, decreased BP)
• During fluid shift, hyponatremia, hypokalemia, and anemia (hemodilution) occurs

• Uses LR (crytalloid only solutions)
• Fluid resus used for the first 24 hours AFTER burn (need to calculate from time of burn, not from time of arrival to ED)
• 
• Use the tule of 9's to get TBSA%
• Fluid given by 2 large bore IVs or Central line
• 1/2 of total fluid given during first 8 hrs, remainder given over 16 hrs
• (for Gordon, round to 10th from the beginning of the equation!!)

• Cardiovascular:
• -loss of intravascular volume
• -decreased cardiac output
• -tachycardia and vasoconstriction
• Pulmonary:
• -pulmonary hypertension
• -effect of direct injury, such as pulmonary edema and obstruction (may lead to ARDS)

• Hypermetabolic state may lead to a low grade fever
• Increased caloric intake up to 5000 kcal/day, increased protein intake to aid in healing
• Hypermetabolic state can last 9-12 months after burn

• ischemia due to redistribution of blood to brain and heart
• May result in a paralytic ileus
• May result in a Curling's ulcer within 24hrs due to decreased blood flow to GI tract

• Sensitive to decreased cardiac output
• Initial decrease in urine output related to decreased GFR and third spacing
• Followed by diuresis as fluid shifts

• Prehospital care, emergent (resuscitative), acute, rehabilitative
• Prehospital care:
• -remove the person from the source of the burn and stop the burning process
• -caregiver needs to protect from becoming part of the incident (Safety assessment)

• Emergent phase is the period of time required to resolve the immediate problems resulting from the burn injury
• From the time of burn until 5+ days, but usually first 48 hrs
• Phase begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begins
• Pathophys includes F/E shifts, inflammation and healing, and immunologic changes
• S/S include hypovolemic shock, shock from pain, blisters, adynamic ileus, shivering, altered mental status
• Complications include cardiovascular, respiratory, urinary

• Airway management: intubation, humidified/100% O2, escharotomy
• Fluid Therapy: two large bore IVs or central line, Parkland (Baxter) formula for fluid replacement
• Colloidal Therapy: D5W, Albumin
• Wound care:: delayed until airway is secure, cleaning and debridement, may use immersion tank or shower, risk for infection is a serious threat. Open or closed method. May use allograft/homograft or xenograft
• Other: manage self care deficits, routine lab tests, early ROM exercises

• Analgesics and sedatives
• Tetanus immunization
• Antimicrobial Agents
• Fluid replacement takes priority, oral intake not until bowel sounds return usually 48-72 hrs after injury
• 5000 kcal/day

• Acute phase begins with the mobilization of extracellular fluid and subsequent diuresis
• Concluded when the burned area is completely covered by skin grafts r when the wounds are healed
• Pathophys includes diuresis from fluid mobilization, return of BS, formation of granulation tissue and necrotic tissues sloughs
• Partial thickness heals from the edges while full thickness is covered by skin grafts
• S/S include necessary removal of eschar from partial thickness wounds (epithelization then occurs, 10-14 days) which full thickness burns will require debridement
• Lab values to monitor include sodium (hyponatremia due to fluid shift) and potassium (hyperkalemia immediately followed by hypokalemia during cap leak)
• Complications include infection, cardiovascular, respiratory, neuro, musculoskeletal, GI, and endocrine

• Wound care: daily assessments, cleansing, debridement
• Excision and grafting: graft dressings, eschar removal, cultured epithelial autograft, artificial skin
• Pain management: pharm and nonpharm
• PT and OT: passive and active ROM, exercise during, after hydrotherapy. Prevents contractures
• Nutritional: high calorie, supplements, daily weights
• Psychosocial: social work, nursing staff, partoral care

• Begins when the patient's burn wounds are covered with skin or healed and the pt is able to resume a level of self-care activity
• Pathophys includes wound healing wither by primary intention or grafting, layers of epithelization begin to rebuilding tissue structures, collagen fibers add strength to weakened areas, 4-6 areas are rained and mature healing occurs 6mo-2yr.  Skin never completely returns to orig color, pressure can prevent keloid scarring, newly healed areas can be hypo/hypersensitive, protect from direct sunlight for 1 yr
• Complications include skin and joint contractures (PT and OT) and hypertrophic scaring

• Patient and family education on woundcare
• Emollient based creams should not be used
• Plastic surgery may be an option
• Education on the importance of exercise
• Continuous encouragement/reassurance
• Address spiritual/cultural needs
• High calorie, high protein diet
• OT and PT

• Patient assessment
• Financial assessment
• Evaluation of family resources
• Weekly meetings/followups
• Psych referral
• Patient and family learning (home care needs)
• Development of a teaching plan for patient and family
• Educating client and family on wound care
• Rehab referrals
• Home assessments for home care/accessibility needs
• Medical equip/prosthetic needs
• Evaluation of community resources
• Re-entry programs for school or work
• Auditory and speech therapy

• Family members need to understand the importance of reestablishing the pt's independence
• Encourage family to participate as team members
• Early psych intervention
• Assess psycho-emotional cues
• Common emotional response is regression
• Issues of sexuality should be met with honesty
• Family and patient support groups

• Cardiac output restored to normal
• Pain alleviated or reduced
• No further skin integrity lost and skin integrity restored
• No infection
• Adequate nutritional intake
• Acceptable perception of body

• Nurse cares for patients and family members who at times may be unpleasant, hostile, apprehensive and frustrated
• Nurses new to burn unit often find it difficult to cope and need new coping skills