Burn

Burn The incidence of burn injuries had been declining during the past several decades. Approximately 2 million people require medical attention for burn injury. Young children and elderly people are at particularly high risk for burn injury. The skin in people in these two age groups is thin and fragile; therefore, even a limited period of contact with a source of heat can create a full thickness of burn. Most injuries occur in the home, usually in the kitchen while cooking and in the bathroom by means of scalds or improper use of electrical appliances around water sources. Careless cooking is the one of the leading cause of fires in all over the world. Burn Prevention Tips • • • • • • • • • • • • •

Keep matches and lighters out of reach of the children Never leave unattended around fire or in bathroom/bathtub Install and maintain smoke detectors in the home Develop and practice and practice home exit fire drill Set the water heater temperature no higher than 120F Do not smoke in bed. Do not fall asleep while smoking Do not throw flammable liquids on to an already burning fire Do not use flammable liquids to start fires Do not remove radiator cap from a hot engine Watch for overhead electrical wires and underground wires when working outside Never store flammable liquids near a fire source, such as a pilot light Use caution while cooking Keep a working fire extinguisher in your home

Characteristics of Burn According to Depth Burn and causes Superficial Partial Thickness (1st degree burn)

Skin involvement Epidermis; possibly a portion of dermis

Symptoms

Deep Partial Thickness (2nd degree burn)

Epidermis; upper dermis’ portion of deeper dermis

Pain Hyperesthia Sensitive to cold air

Full Thickness (3rd degree burn)

Epidermis; entire dermis, and sometimes subcutaneous tissue; may involve connective tissue, muscle, and bone

Pain free Shock Hematuria (blood in the urine)and possibly hemolysis (blood cell destruction) Possibly entrance and exit wounds (electrical burn)

Tingling Hyperesthia Pain that is soothed by cooling

Wound appearance Reddened; blanches w/pressure dry Minimal or no edema Possible blisters Blistered; mottled red base; broken epidermis; weeping surface Edema

Recuperative course Complete recovery within a week, no scarring Peeling

Dry; pale white leathery, or charred Broken skin with fat exposed Edema

Eschar sloughs Grafting Scarring and loss of contour and fxn; contractures Loss of digits or extremity possible

Recovery in 2 to 4 weeks Some scarring and depigmentation contractures Infection my convert it to full thickness

Local and Systemic Response to Burns • •

Burns that do not exceed 25% TBSA produce a primarily local response Burns that exceed 25% TBSA may produce both a local and systemic response and are considered major burn injuries

Cardiovascular Response • • •

Hypovolemia is tha immediate consequence of fluid loss resulting in decreased perfusion and oxygen delivery Cardiac output decrease before any significant change in blood volume is evident The greatest volume of fluid leak occurs in the first 24-36 hours after the burn, peaking by 6-8 hours

Burn Edema • • •

Edema maximal after 24 hours It begins to resolve 1-2 days post burs and usually is completely resolved in 710 days post injury Edema increase in circumferential burns, pressure on small blood vessels and nerve in distal extremities cause and obstruction of blood flow and consequent ischemia

Effects on Fluids and Electrolytes and Blood Volume • • •

Evaporative fluid loss through the burn wound may reach 3 to 5 L or more over a 24 hour period until the burn surfaces are covered Hyponatremia is most common during the first week of the acute phase, as water shifts from the interstitial to the vascular space Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokelamia (potassium depletion) may occur later with fluid shifts from the interstitial to the vascular space

Pulmonary Response • • •

Inhalation, bronchoconstriction caused by release of histamine, serotonin and thrombaxane a powerfull vasoconstrictor, as well as chest constriction secondary o circumferential full thickness chest burns caused this deteoriation Pulmonary, upper airway injury results from direct heat or edema, manifested by mechanical obstruction of the upper airway Carbon monoxide, the pathophysiologic effects due to tissue hypoxia, a result of carbon monoxide combining with hemoglobin to form carboxyhemoglobin, which competes with oxygene for available hemoglobin binding sites

Other Systemic Response • • • •

Renal fxn may be altered as a result of decreased blood volume, destruction of red blood cells at the injury site results in free hemoglobin in the urine Significant impairment of the production and release of granulocytes and macrophages from bone marrow after burn injury. The resulting immunosup resion places the burn patient at high risk of sepsis Loss of skin also results in an ability to regulate body temperature. Burn patients may therefore exhibits low body temp. in the early hours after injury Two potential gastrointestinal complications may occur, paralytic ileus and Curling ulcer, gastric distention and nausea my lead to vomiting unless gastric decompression is initiated.

Phases of Burn Care Phase Emergent or immediate resuscitative

Duration From onset of injury to completion of fluid resuscitation

Acute

From beginning of diuresis to near completion of wound care

Rehabilitation

From major wound closure to return to individuals optimal level of physical and psychosial adjustment

Emergency Procedure at the Burn scene • • • • •

Extinguish the flames Cool the burn Remove restricted objects Cover the wound Irrigate chemical burns

Priorities • First aid • Prevention of shock • Prevention of respiratory distress • Detection and tx of comcominant injuries • Wound assessment and initial care • Wound care and closure • Prevention or tx of complication, including of infection • Nutritional support • Prevention of scars and contractures • Physical, occupational, and cosmetic reconstruction • Psychosocial counselling

Emergency Medical Management • • • • • • • • • • • • •

Transport to the nearest emergency department Priorities the airway, breathing, and circulation Administer humidification, bronchodilator, mucolytic agents Continuous + airway pressure and mechanical ventilation may also be required to achieve adequate oxygenation Asses for cervical spinal injuries Asses for burn and wound Insert IVP and NGT, and suction the pt. to prevent vomiting Practice aseptic technique to prevent infection Asses for TBSA Fluid replacement Asses for Acute Respiratory and Renal Failure Transfer to a burn center Management of fluid loss and shock

Acute or Intermediate Phase of Burn Care Infection prevention • • • • • • • •

Phase occur 48-72 hours after burn injury Asses for electrolytes imbalance, and gastrointestinal fxn Infection prevention wound cleaning, topical antibacterial therapy, wound dressing, wound debridement, and wound grafting Pain management and nutritional support Asses for airway obstruction caused by upper airway edema Asses for capillaries integrity Monitor fever for the signs of infection Monitor for infection like staphylococcus, proteus, pseudomonas, Escherichia coli, kliebsuella, candida albicans,

Wound Cleaning • Hydrotherapy

• •

Use tap water Tub baths

Topical Antibacterial Therapy • • • •

Silver sulfadiazine (silvadene) Mafenide acetate (sulfamylon) Silver nitrate Acticoat

Wound Dressing • •

1st topical agent is applied then covered by a several layers of dressing A light dressing is also applied areas for which a splint has been designed to conform to the body contour the proper positioning

Dressing Change • •

Dressings are changed in the pt. units hydrotherapy room, or tx approximately 20 min after and analgesics agent administered They may also changed in the OR after the pt. administered anesthesia

Wound Debridement • • • • •

To remove tissue contaminated by bacteria and foreign bodies, thereby protecting the pt. from invasion of bacteria To remove devitalized tissue or burn eschar in preparation for grafting and wound healing Natural debridement Mechanical debridement Surgical debridement