burns

Burns

Burn injury occur when energy from a heat source is transferred to tissue of the body. Injuries that result from direct contact with or exposure to any thermal, chemical, electrical, radiation sources and scald (burn caused by contact with hot liquid or steam or gases (water, oil, gases).

Disruption of skin lead to increased fluid loss, infection, hypothermia, scarring, changes in function, appearance, body image.

Causes of Burn

1. Thermal burn

Exposed with flame, hot liquid, steam, hot object, scald injuries, residential fire.

2. Chemical burn

Tissue contact with strong acid, alkalis/base, caustic chemical (sodium hydroxide, Silver nitrate, sulfuric acid.

3. Electrical burn

Electric shock, heat generated by electrical energy passes through body. Work place energy, use of ECG leads without conductive gel.

4. Radiation burn

UV light, X-ray, radiation therapy, sunburn

5. Inhalation burn

Poisoning gas

Classification of Burns

A. According to burn depth

1. First-degree burn

Damage epidermis (skin surface).

For example; sun burn (pink or reddish color on burned skin and very sensitive to touch, skin is dry without blister).

2. Second degree burn

Affect both epidermis and dermis layer causing redness, pain, swelling and blister. Affect sweat glands and hair follicles. Break open area wet looking with bright pink or cherry red colour.

3. Third degree burn

Affect epidermis, dermis, subcutaneous layer, deep scar, skin surface waxy white. Both epidermis and dermis distroy and other organ, tissues, muscles, bones may involved. No pain or feel numb due to nerve damage.

4. Fourth degree burn

Deep injury damage muscle, bone and tendon. Burn occurs with deep flame, electrical and thermal injuries, nerve ending are destroyed.

B. According to burn severity

1. Minor burn

All first degree burns/second degree burns. Involve less than 10% of body surface.

2. Moderate burn

Burn involve hands, feet, face or genitals. Second degree burns involve more than 10% of body surface area.

3. Severe burn

Burn surface involvement of 25% body surface area. All third degree burn, deep burns of haad, hands, feet, perineum, inhalation injury, chemical or high-voltage electrical burn. 

3. According to extent of body surface area injured (TBSA; total body surface area)

1. The Rule of Nine

Adult total; 100%

Head 9%; Front (4.5%) and  back (4.5%)

Chest; 18%

Back; 18%

Right arm; 9%

Left arm; 9%

Perineum; 1%

Right leg; 18%

Left leg; 18%

Child total ; 100%

Head; 18% - front 9% and back 9%

Chest; 18%

Back; 18 %

Right arm; 9%

Left arm; 9%

Perineum; 1%

Right leg; 13.5%

Left leg; 13.5%

2. Palm method

Estimation of small burns

Patient's palm including fingers is equal to 1% of their total body surface area (TBSA).

3. Jackson's burn model

1. Zone of coagulation

Nearest heat source is primary injury.

2. Zone of stasis

Inflammation occurs and vascularity impaired.

3. Zone of hyperaemia

Increase blood flow in vessel to supply tissue, intense vasodilation.

Burn stages

1. Hypovolemic stage

Begins at the time of injury and lasts for first 48-72 hours.

Increased capillary permeability.

2. Diuretic stage

Begins in 48-72 hours after burn injury, capillary membrane integrity returns and edema fluids shift back from interstitials space into intravascular space.

Pathophysiology of Burn

Thermal burn injury

Inflammation

Histamine release

Vasoconstriction.    Increase capillary permeability.   Increase protein leakage 

Increase blood pressure.                                                  Hypoproteinemia

Increased blood flow to injury.          Fluid leakage                Decreased plasma

                                                          and loss from injury site          osmotic pressure 

                                                     Decreases intravascular fluid

                                                        Hypovolemic shock

Burn syndrome

1. Fluid and electrolyte imbalance

Release of chemical mediators of inflammation, result in systemic intravascular losses of water, sodium, albumin and red blood cells.

2. Metabolic distrubance

Increases O2 consumption, excessive nitrogen loss and weight loss.

3. Bacterial contamination of tissues

Infection or invasion of microorganisms, increase risk of septic shock.

4. Complication from vital organs

Renal insufficiency; hypoperfusion

Pulmonary dysfunction; progressive respiratory insufficiency 

Small bowel ischemia and stasis

Multi-ststem organ failure 

Diagnostic studies in Burn

1. Complete blood count (CBC)

Increase hematocrit

Leukocytosis

2. ABG analysis

Acidosis occur because reduced renal function and loss of compensatory respiratory mechanism. Decreased PaO2, Increased PaCO2.

3. Carboxyhemoglobin (COHb)

Elevation of more than 15% indicates carbon monoxide poisoning/inhalation injury.

4. Serum Electrolytes

Potassium level elevated because of injured tissue/RBC destruction.

Hypokalemia occur when diuresis start

5. Alkaline phosphatase

Elevated because of interstitials fluid shifts/ impairment of sodium pump.

6. Serum glucose

Elevated reflects stress response.

7. Serum albumin

Albumin/ globulin ratio result loss of protein edema fluid.

8. Urine

Presence of albumin, hemoglobin (Hb) and myoglobin indicates deep tissue damage and protein loss. Reddish black colour of urine is due to presence of myoglobin.

9. Chest X-ray

For inhalation injury

10. Fiberoptic bronchoscopy

Diagnosing extent of inhalation injury, include; edema, hemorrhage/ ulceration of upper respiratory tract.

11. Flow volume loop 

For inhalation injury

12. Lung scan

Determine extent of inhalation injury

13. ECG

Signs of myocardial ischemia/dysrhythmia occur with electric burn.

14. Photograps of Burns 

Provides documentation of burn wound and comparative baseline to evaluate healing.

Management of burn

1. First aid for minor burn (first degree burns)

a. If skin not broken, run cool water over burned area or soak in cool water bath.

(Not ice water)

If burn occurs in cold environment, clean, cold, wet towel help to reduce pain 

2. After cover burn with sterile non-adhesive bandage or clean clothes.

3. Protect burn from friction and pressure.

4. Pain medication; relieve pain, reduce inflammation and swelling.

2. First aid treatment for severe burn (second and third degree burn)

1. Don't remove burn clothing unless easily come off.

2. Ensure victim not contact with burning material.

3. Don't apply any ointment and avoid breaking blister.

4.  Don't use blanket/towel, use sheets best for large wound.

5. Cover burn with cool moist sterile bandage or clean cloths

6. If victim is not breathing, present respiratory block, open the airway, if necessary begin CPR.

7. If finger or toe burn; separate them with dry sterile non-adhesive dressings.

8. Protect from friction and pressure

9. Continue to monitor vital signs.

10. Steps to prevent shock

Lay victim flat, elevates feet about 12 inches.

Management of Burn according to Burn Phase

1. Immediate management of Burn

1. First aid

2. Prevention of shock

3. Prevention of respiratory distress

4. Detection and treatment of injuries

5. Wound assessment and wound care

a. Airway management

Observed laryngeal edema and airway obstruction.

b. O2 therapy

c. Endotracheal intubation

d. Mechanical ventilation

e. Elevation of head and chest; reduce neck and chest wall edema by 20-30 degrees.

For Second and third degree burn

Escharotomy

Emergency surgical procedure involving incision through area of burnt skin to release eschar and allow ventilation of patient.

2. Hyperbaric oxygen therapy (HBOT)

Hpoxia prevent the wound healing.

Non-invasive mode, patient entirely enclosed in pressure chamber filled with oxygen at pressure greater than one atmosphere.

HBOT support wound healing. HBOT is used in treatment of smoke inhalation; COHb (carboxyhemoglobin) lead to hypoxia and decrease oxygen delivery to tissue.

3. Fluid management

Losses fluid through burn wound and adjacent tissues in form of edema.

1. Replacing body fluid

Fluid therapy started within hours after severe burn; to prevent hypovolemic shock.

Fluid administered during first 48 hours; given to maintain circulating blood volume.

a. Colloids, plasma and plasma expanders

b. Electrolytes; Nacl, RL

c. Distilled water with 5% glucose

Fluid calculation for burn patient's

1. Parkland/ Baxter formula 

4ml X Kg body weight X % body surface are (BSA) burned

Administered in first 24 hours;

a. Give half of solution in first 8 hours.

b. Remaining half for next 16 hours.

IV maintenance fluid; 4:2:1 rule

2. Brooke formula

In first 24 hours;

Electrolytes; 

1.5 ml X Kg body weight X % body surface area (BSA) burned

Colloids; 0.5ml X Kg body weight X % body surface area (BSA) burned

Non Electrolytes fluids; Glucose 5% in distilled water (2000ml glucose in distilled water)

a. Half given in first 8 hours

b. Remaining half next 16 hours

3. Evans formula

In first 24 hours

Electrolytes; 

0.5ml X Kg body weight X % body surface area (BSA) burned

Colloids; 1ml X Kg body weight X % BSA burned

Non Electrolytes; 2000ml glucose in distilled water.

a. Half to given first 8 hours 

b. Remaining half to given next 16 hours.

4. Consenus formula

In first 24 hours;

Lactate ringer solution

(2-4) ml X Kg body weight X % BSA burned

a. Half of fluid given first 8 hours.

b. Half of fluid given next 16 hours 

5. Hypertonic solution

Reduce edema and pulmonary complications.

Burn Wound Management

1. Cleanase wound to eliminate or decrease dead tissue and debris; source as media for bacterial growth.

2. Prevent distraction of skin

3. Determine burn area depth and then debridement ( remove necrotizing tissue and contamination), cleaning and then dressing.

4. Circumferential burns of digits, limbs or chest, need surgical release of burnt skin, Escharotomy; to prevent problem with circulation and ventilation.

Analgesics and sedation; ibuprofen/acetaminophen and narcotics.

2. Intermediate phase

a. Infection prevention and treatment of complication

b. Burn wound care;

Wound cleaning

Topical antibiotic therapy

Wound dressing

Dressing changes

Wound debridement

Wound grafting

c. Pain management

d. Nutritional support

c. Clean burn area and change bandages.

d. Skin graft need to cover burns 

Topical Antibiotics

1. 0.5% silver nitrate

2. Silver sulfadiazine

3. Mycostatin

4. Bacitracin/ polymyxin B 

5. Mefenide acetate

6. Mupirocin

7. Povidone-iodine (betadine) ointment (10%)

8. Gentamicin 

Note - Mycostatin not combined with mefenide; both became inactived.

Wound Care

Prevent from infection

Limiting pain of exposed burn surface

1. Wound Covering

Cover wound with dressing or graft.

Wet dressing used with silver nitrate or normal saline application.

A single layer of fine mesh gauze placed over the wound, coverd with thick gauze pads to maintain moisture. Dressing must kept wet.

Types of scar

1. Keloid scar

Overgrowth of scar tissue.

2. Hypertrophic scars

Red, thick and raised scars.

3. Contractures

Permanent tightening of skin. Elastic connective tissue replaced by inelastic fiberous tissue.

Make tissue resistant to stretching and prevent normal movement of affected area.

Management for Burn Patient

1. Medical management

1. Topical Antibiotics

a. Neosporin

b. Silvadene

2. Analgesics

Ibuprofen (advil), acetaminophen 

For severe pain; morphine sulfate, vicodin, Demerol, anaprox

Drug used in Reconstructive and cosmetic surgery

1. Bacterial protein synthesis inhibitors; topical

Altabax (Retapamulin)

2. Immunosuppressants

Amevive (Alefacept)

3. Avita gel

Topic form of retinoic acid

4. Topical Antibiotics

Bactroban 2% Ointment 

5. Benzamycin (erythromycin 3% / benzoyl peroxide 5%); topical gel

6. Botox cosmetic (injection)

Directly given into effected area.

Blocking nerve impulse and relax contraction.

Nursing management of Burns

Nursing assessment

1. Assess ABCDE (airway, breathing, circulation, disability, exposure; prevent hypothermia) and need for fluid resuscitation.

2. Assess severity of burn and conscious level.

3. Establish tha cause 

4. Assess associated factor; injury, fracture and internal injury.

5. Asses the possible inhalation injury.

6. Assess any pre-existing illness, any drug therapy, allergy and drug sensitivities.

7. Establish patient tetanus immunization.

8. Body surface area; rule of nine

9. Palmer surface of patient's hand including finger.

10. Depth of burn (first degree burn, second degree burn, third degree burn)

11. Assess pain, redness of area, absence or presence of blister, swelling, capillary refill time, reduced or absence sensation according to degree of burn.

12. Circumferential extremity burn

Assess circulation, checking for cyanosis, impaired capillary refilling.

13. Assessment of peripheral pulses.

14. Assess Neurological signs

Nursing Diagnose

1. Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation and upper airway obstruction.

2. Ineffective airway clearance related to edema and effect of smoke inhalation.

3. Fluid volume deficit related to increased capillary permeability and evaporation losses from burn wound.

4. Hypothermia related to loss of skin and open wounds.

5. Pain related to tissue injury

6. Risk of infection related to loss of skin barrier and altered immune response.

7. Impaired nutrition; less than body requirement related to hypermetabolic response to burn injury.

8. Impaired skin integrity related to open burn wounds and surgical interventions.

9. Impaired physical mobility related to edema, pain, skin and joint contractures.

10. Anxiety related to fear and emotional impact of burn injury.

Role of nurse in burn Management

1. Restoring normal fluid balance

IV therapy, oral intake, infusion pump

Monitor changes in fluid status 

2. Preventing infection

Burn wound care

Aseptic technique used for wound care procedures.

Protect patient from source of infection or contamination.

3. Maintaining adequate nutrition

Dietician plan; protein and colorie rich diet

Home made food

NG feeding tube inserted; continuous or bolus feeding of specific formula.

Patient weight

4. Promoting skin integrity

Wound care and dressing changes

Wound Management

Teach the patient and family by instruction, encourage to active part in dressing changes and wound care.

5. Relieving pain and discomfort

Assessment of pain (scale and intensity)

Analgesics and antianxiety medication

Dressing changes to reduce pain and discomfort

Teach patient and family; wound care relaxation technique

6. Promoting physical mobility

a. Prevent complication resulting from immobility.

b. Deep breathing, turning, changing position

Prevent; atelectasis, pneumonia

Control edema

Prevent pressure ulcer and contractures 

c. Initiate both active and passive ROM within prescribed limitation.

7. Strengthening coping strategies

Effective coping strategy

Self care, self feeding, assistance with wound care procedures, excercise, relaxation techniques.

Assess tha ability of patient, cope with information.

8. Educate the patient and family