Burns

Question 1

Management of Patients with Burn Injuries

Most burns occur in _____

Answer 1

the home.
Prevention is key!

Question 2

Functions of the skin

Answer 2

Protection from infection and injury
Prevents loss of body fluids
Regulates body temp
Provides tactile sense

Question 3

The strongest predictors for mortality

Answer 3

Increased % TBSA
Presence of inhalation injury
Increased age

Question 4

Types of burns

Answer 4

Thermal
Chemical
Electrical
Radiation
Inhalation

Question 5

Thermal burns:

Answer 5

: exposure to heat- flame, flash, scald, or contact with hot objects

Question 6

Chemical burns

Answer 6

acids, alkaline agents, or organic compounds

Question 7

Electrical burns:

Answer 7

severity based on voltage and length of exposure. Risk for potential cervical spine injury

Question 8

Radiation exposure:

Answer 8

thermal effect; damage to the cellular DNA

Question 9

Inhalation injuries:

Answer 9

inhalation of thermal and/or chemical irritants (upper vs lower airway injury)

Question 10

_____ is the most common type of burn.

Especially:

Answer 10

Thermal
85% of all burns are thermal.

scalding in children (very curious) and elderly.

Question 11

Chemical – tissue continues to burn until:

-\_\_\_\_\_\_ must begin immediately \_\_\_\_\_\_\_ ***outcome improved for victim

Answer 11

chemical is completely removed. Dust off dry chemical. Remove clothing articles touching the skin.

Continuous irrigation
at the scene

Question 12

Electrical- make sure:

Severity difficult to assess, may have:

Answer 12

scene is safe and victim no longer in contact with source.

exit and entrance wound, organ damage.

Question 13

Zones of burn injury

At the center is the zone of ______, zone of most damage, tissue is ______

Zone of _____, injured cells, potentially salvageable, but with ______, necrosis can occur

Zone of _____: minimal injury, full recovery

Answer 13

Zone of coagulation
not viable

Zone of stasis
persistent ischemia

Zone of hyperemia

Question 14

burn can evolve and worsen over time

Question 15

At the center is the zone of coagulation, zone of most damage, tissue is _____

Answer 15

not viable

Question 16

Zone of stasis, injured cells, potentially salvageable, but with persistent ________________

Answer 16

ischemia, necrosis can occur

Question 17

Severity of Burn Injury

Answer 17

Depth of burn
Extent of burn
Location of burn
Age
Risk factors

Question 18

Burn Depth Classifications

Answer 18

Superficial thickness (1st degree)

Partial thickness (2nd degree)

Full thickness (3rd & 4th degree)

Question 19

Layers of skin affected :

1st- 4th

Answer 19

1st- epidermis

2nd- dermis

3rd- subcutaneous

4th- muscle

Question 20

First Degree - Superficial

Involves only _____

Causes:

S&S:

Treatment:

Answer 20

epidermis.

Causes: radiation burn or brief exposure to heat source.

S&S: Redness, pain, moderate to severe tenderness; minimal edema, peeling, itching

Treatment: Mild analgesics, cool compresses, skin lubricants; heals within a few days

Question 21

Second Degree - Partial Thickness

Involves:

Causes:

S&S:

Treatment:

Answer 21

epidermis & dermis; may extend into hair follicles.

scalds, flash flame, contact

Moist blebs, blisters, edema, mottled white, pink to cherry-red, moderate to severe pain

Usually heal 2-3 weeks, depending on depth and area; may require grafting

Question 22

Third Degree -

Includes:

Causes:

S&S:

Treatment:

Answer 22

Full Thickness

epidermis, dermis, and sometimes subcutaneous tissue; may involve connective tissue and muscle

Causes: flame, prolonged exposure, electrical, chemical, contact

S&S: Dry, leathery, eschar, waxy white, dark brown, or charred appearance, strong burn odor
No pain at burn sites due to loss of nerve endings; severe pain in surrounding areas.

Surgical intervention required.

Question 23

Fourth Degree –

Includes:

______ appearance

Causes:

Treatment:

Answer 23

Full Thickness

deep tissue, muscle, and bone

Charred

Causes: prolonged exposure or high voltage, electrical injury

Amputations likely; grafting of no benefit

Question 24

Inhalation injury

Caused by inhalation of _____ and/or _____ irritants

Upper vs lower airway injury:

History of injury important
Hx of injury: suspect inhalation with _________ and burns of ____, ____, and ____

Burns of the face, mouth, anterior neck

Clinical signs:

_______ for definitive diagnosis

Answer 24

thermal and/or chemical

Upper vs lower airway injury: Upper airway above the glottis, lower airway below the glottis

enclosed spaces

face, mouth, anterior neck

singed facial hair, carbonaceous sputum, hoarse voice, stridor

Bronchoscopy

Question 25

Extent of Burn – Rule of Nines Expressed as a percent of total body surface area (TBSA). Divide body surfaces into multiples of nine.

Answer 25

Head- 9% Left arm- 9% Right arm- 9% Anterior chest 18% Posterior chest 18% Left leg- 18% Right leg- 18% Genital region- 1% Note: anterior and posterior of head 9%. Anterior chest 9 + abd 9 =18% If approximately half of arm were burned, the TBSA burned = 4.5%; anterior thigh + anterior lower leg = 4.5 % (total 9%)

Question 26

_______ is another method and is more accurate for children With all methods, estimate at initial evaluation and again _________

Answer 26

Lund-Browder chart 72 hours later.

Question 27

Children and burns Prevention! Splash and spill burns from hot food off stove is common Hallmark signs of child abuse:

Answer 27

Definite line of demarcation Frequent or repetitive hospital visits Symmetrical burn wounds Cigarette burns

Question 28

Other vulnerable populations

Answer 28

The elderly patient Clients with reduced mental capacity People with reduced mobility and/or sensory impairments

Question 29

Electrical- make sure scene is safe and victim no longer in contact with source. Severity difficult to assess, may have exit and entrance wound, organ damage. Monitor:

Answer 29

ECG- arrhythmias possible

Question 30

_____ of burn determines treatment- surgical grafting?

Answer 30

Depth

Question 31

Do not put anything on a burn!!!!! Any burn that is circumferential- all around the arm- worried about:

Answer 31

compartment syndrome- check pulses, cap. Refill.

Question 32

Burn Centers Most minor burn injuries can be managed in community hospitals Statewide: Jaycee Burn Center - Chapel Hill, NC Wake Forest Baptist Medical Center Burn Center - Winston Salem, NC Burn Center Referral Criteria -

Answer 32

Partial thickness burns greater than 10% total body surface area (TBSA).

Question 33

On the Scene Care

Answer 33

Prevent injury to rescuer Stop injury: extinguish flames or remove from the source Cool the burn Remove restrictive objects Cover the wound Irrigate chemical burns Primary survey: ABCDE

Question 34

On the Scene Care Treat patient with falls and electrical injuries as for potential ______ injury. Don’t touch person if still in contact with the _______ Do:

Answer 34

cervical spine electrical current assessment surveying all body systems and obtain a history of the incident and pertinent patient history

Question 35

Airway management Administer _______ if carbon monoxide poisoning suspected Consider_____ & ______ (esp. burns to the face & neck) Place in ______ position (unless spinal cord injury) _______ if needed to relieve resp. distress Turn, cough, deep, breath Provide suctioning & chest physiotherapy Bronchoscopy _______ to treat severe bronchospasm

Answer 35

100% humidified O2 early intubation and ventilator support high Fowlers Escharotomy Bronchodilators

Question 36

Why consider early intubation and ventilator support for burns to face and neck? Edema? What is escharotomy? – Dead tissue- cutting in to dead tissue to allow for expansion Signs and symptoms of carbon monoxide poisoning?

Answer 36

Dull headache Weakness Dizziness Nausea or vomiting Shortness of breath Confusion Blurred vision Loss of consciousness

Question 37

carbon monoxide Odorless, tasteless, colorless, gas, binds to O2 molecule..?

Question 38

Phases of Burn Injury

Answer 38

I. Emergent: onset of injury to completion of fluid resuscitation II. Acute: from beginning of diuresis to near completion of wound closure III. Rehabilitative: from wound closure to return to optimal physical and psychosocial adjustment

Question 39

Emergent Phase: (____ days) Onset of ______ and _____

Answer 39

0-3 days Onset of hypovolemic shock and edema

Question 40

Emergent Phase Fluid & Electrolyte Shifts Increased ____________ loss of intravascular proteins & fluids into the _______ _____ and _____ Increased insensible water loss by ______ Hemolysis of RBCs (elevated Hct from ______) Major electrolyte shifts:

Answer 40

CAPILLARY PERMEABILITY interstitial compartment edema and decreased blood volume evaporation HEMOCONCENTRATION HYPERkalemia, HYPOnatremia

Question 41

What does Increased capillary permeability mean? Fluid loss from burn skin 5-10 times greater from undamaged skin Peak fluid leak at ___, but continues up to ___

Answer 41

Water, electrolytes, proteins leak out of vasculature=EDEMA 6-8 hr 36 hr

Question 42

Massive fluid shift ***Electrolyte shift– sodium and potassium switch leading to hyperkalemia and hyponatremia Low sodium- <135 Hyperkalemia- >5

Question 43

Burn Shock Fluid shifts + fluid losses = What do you think vital signs will look like in burn shock?

Answer 43

Intravascular volume depletion Low bp, high hr

Question 44

Emergent Phase Pathophysiology continued Inflammation & healing ______ occurs-repair begins within ______ Immunologic changes ____ immune response Burns < ___ TBSA produce primarily a local response; burns > ___ = local and systemic response (includes release of cytokines and other mediators) Burns cause the proteins inside the cells to denature and coagulate, resulting in a form of cell death known as ________

Answer 44

Coagulation necrosis - 6-12 hrs after injury Reduced 25% coagulative necrosis.

Question 45

CV: Pulmonary: Kidney: Thermoregulatory: GI:

Answer 45

CV: decreased cardiac output, decreased BP, increased HR, edema Pulmonary: inhalation injury, upper and lower airway injury Kidney: function may be affected with hypovolemia Thermoregulatory: inability to regulate body temp (low at first, then elevated) GI: organ ischemia and dysfunction

Question 46

Management of Emergent Phase

Answer 46

Fluid resuscitation (next slide) Pain management Foley catheter NPO or NGT to low intermittent suction Continuously monitored ECG with electrical burns Emotional support NGT with burns > 25% TBSA

Question 47

Therapeutic Management:Fluid resuscitation ___ of injury _____ or ____ preferred for major burns ___ during first 24 hours Fluid calculation based on BSA ex. ABA Indicator of adequate fluid resuscitation: Baseline ____

Answer 47

Time Large bore IV or central line LR urine output: 0.5-1 mL/kg/hr* *more for electrical burns Rely on urine output instead of BP (bc BP is not an accurate estimate) Want at least 30 ml/hr weight

Question 48

Fluid resuscitation formula Don’t have to memorize. Just know a massive amount of fluids are given ~1400 ml in 24 hrs

Question 49

Acute phase (_______) Begins with: Concludes when:

Answer 49

Acute phase- 48-72 hrs to weeks to months Begins with mobilization of extracellular fluid and diuresis Concludes when partial thickness wounds are healed, or full thickness burns are covered by skin grafts lymphatics reabsorb fluid=diuresis

Question 50

Acute Phase Fluid and Electrolyte Shifts Fluid reenters the vascular space from the interstitial space (______) Increased _____ Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia, varies Potassium shifts from extracellular fluid into cells: potential _____ Metabolic ____

Answer 50

HEMODILUTION urinary output HYPOkalemia acidosis

Question 50

Acute Phase Fluid and Electrolyte Shifts Fluid reenters the vascular space from the interstitial space (______) Increased _____ Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia, varies Potassium shifts from extracellular fluid into cells: potential _____ Metabolic ____

Answer 50

HEMODILUTION urinary output HYPOkalemia acidosis

Question 51

What happens if you were overaggressive with fluid resuscitation during emergent phase?

Answer 51

SOB, crackles, …listen to lungs

Question 52

Acute Phase Healing Partial thickness wounds: healing begins, after: Full thickness wounds: require _______________ to heal Early excision (surgical removal) reduces effects of _______

Answer 52

eschar is removed, re-epithelization begins, heals within 10-21 days surgical debridement and skin grafting inflammatory mediators

Question 53

Rehabilitation Phase Begins once: May happen within 2 weeks or even months later. Depends on ____ of burns Rehab goals: Common Complications:

Answer 53

the client's wounds have healed and client is prepared to engage in self care extent Resume functional role in society Rehabilitate from reconstructive surgery (cosmetic or functional) contractures and scarring

Question 54

Therapeutic Management:Pain management: Poor _______, IV in small repeated doses May give _____ prior to dressing changes

Answer 54

Opioids NSAIDs Anxiolytics Sedatives Anesthetic agents Antidepressants tissue perfusion PO meds

Question 55

What’s the difference between background pain, procedural pain, and breakthrough pain?

Question 56

Therapeutic Management:Wound care

Answer 56

Wound cleaning Topical antibacterial therapy Wound dressing Wound debridement (4 types)

Question 56

Therapeutic Management:Wound care

Answer 56

Wound cleaning Topical antibacterial therapy Wound dressing Wound debridement (4 types)

Question 57

Wound debridement (4 types)

Answer 57

Natural- from dressing removal Mechanical- done in bath (keep room warm) Chemical- topical Surgical- go to OR

Question 58

Therapeutic Management:Wound grafting Types (autograft, homograft, xenograft) Care of donor site Care of graft site

Question 59

Therapeutic Management:Prevention of infection ____ is the #1 issue.

Answer 59

Infection controlled environment Monitor temperature (hyperthermia common after BI) Tetanus vaccination Antibiotic or antifungal per wound culture results Controlling hypergylcemia. A lot of patients will develop insulin resistance Sepsis

Question 60

Therapeutic Management:Restoration of function

Answer 60

Proper positioning Specialty beds Passive and active ROM Splints of functional devices Compression garments OT and PT Functional and cosmetic reconstruction

Question 61

Compression garments: wear __________, to minimize __________

Answer 61

most of the day, up to a year contractures and scarring

Question 62

Complications Resp.: Cardio: GI: Kidney :

Answer 62

Sepsis Respiratory: acute resp failure, ARDS Cardiovascular: heart failure, pulmonary edema GI: paralytic ileus, Curling’s ulcer, translocation of bacteria, abdominal compartment syndrome Kidney: myoglobinuria-> ATN (ATN- acute tubular necrosis )

Question 63

Nutrition ________ state – feed as soon as able to eat When oral route used: Intubated patients – Three-fold increase in basal metabolic rate

Answer 63

Hypermetabolic high-protein, high calorie meals and supplements enteral feedings

Question 64

Emotional/psychological needs Remember, a burn injury can be a crisis for a family. Elicit patient wishes as early as possible.

Question 65

Start enteral nutrition therapy early:

Answer 65

blunts the metabolic response, maintain gut viability, decrease bacterial translocation

Question 66

Burn patients with >20% TBSA injury suffer long and severe response to injury:

Answer 66

hyperdynamic and hypermetabolic response (catabolic state, muscle wasting)

Question 67

Inflammatory response can remain elevated for ____ after injury

Answer 67

months

Question 68

Electrical injuries require:

Answer 68

baseline ECG and heart monitoring, larger fluid volume resuscitation (4ml/kg/TBSA) and want greater urine output, potential for cervical spine injury

Question 69

Skin reproducing cells are located along shafts of hair follicles and sweat glands. Burn depth determines if spontaneous re-epithelization will occur

Question 70

Smoke inhalation is major predictor of mortality: inhalation injury disrupts the supply of oxygen to the body by immense swelling of the upper respiratory tract, chemical irritation of the lower respiratory tract, and injuries resulting from noxious gases, such as carbon monoxide and cyanide

Question 71

_________ is best indicator of adequate fluid resuscitation

Answer 71

Urine output

Question 72

Early _____ reduces effects of inflammatory mediators

Answer 72

excision

Question 73

Need ________ pain assessment and management

Answer 73

around the clock

Question 74

Goal of ______ with insulin resistance

Answer 74

normoglycemic