Burning Fire!!!!

BURNS

Emergency and Disaster Nursing Course

BURNS

Contents  Objectives  Introduction  Mechanism of injury and Biomechanics of

burns  Types of burn injuries  Signs and symptoms based on the pathophysiology  Nursing process application

Objectives At the end of this scientific presentation , each one of the students shall be able to : Identify burn traumas, types and degrees.  Discuss the common mechanisms of injury associated with burn traumas.

Discuss the pathophysiologic changes according to burn effects and manifestations. Apply the nursing process in dealing with burn clients including “assessment, diagnosis, planning ,implementation and evaluation .

Introduction Burn patients experience lots of disastrous problems , embarking from the initial events of the injury , and through periods of hospitalizations and rehabilitation .

Caring of burn victims in any emergency department is very stressful and challenging for the health team members including nurses , physicians , occupational therapist and even psychiatrists and dietitians,

The Skin Overview

Mechanism of injury & Biomechanics The energy agents that can cause burns are:

Energy

Thermal

Chemical

Electrical

Pathophysiologic Changes  Skin and soft tissue injury

Zone Of Coagulation Area of coagulation affected Zone Of Stasis Capillary occlusion, decreased perfusion Edema formation 24-48 hrs Zone Of Hyperemia Increased blood flow results from inflammatory processes

Pathophysiology Plasma loss and vascular

responses Intravascular volume loss Diminished tissue perfusion Release of vasoactive agents Capillary semipermiability Lost

Moving of fluids and substances like proteins from the intravascular to interstitial space Hyperemia hypovolemia

Hemodynamic changes Lessened circulating blood volume

results in decreased cardiac output initially and increased pulse rate. There is a decreased stroke volume as well as a marked rise in peripheral resistance (due to constriction of arterioles and increased hemoviscosity).

This results in inadequate tissue perfusion, which may in turn cause acidosis, renal failure, and irreversible burn shock.

Hemodynamic Electrolyte imbalance may also

occur. Hyponatremia usually occurs during the 3rd to 10th day due to fluid shift.

The burn injury also causes hyperkalemia initially due to cell destruction, followed by hypokalemia as fluid shifts occur and potassium is not replaced.

Metabolic Demands

Catecholamine release

appears to be the major mediator of the hypermetabolic response to burn injury.

"Burn fever" is common and is dependent on depth of burn and percentage of TBSA involved. Temperatures of 102°F to 103°F (38.8°C–39.4°C) are common as "fever spikes."

Healing a large surface area requires much energy; glucose is the primary metabolic fuel.

Because total body glucose stores are limited and stored liver and muscle glycogen is exhausted within the first few days postburn, hepatic glucose synthesis (gluconeogenesis)

Glomerular filtration may be decreased in extensive injury. Without resuscitation or with delay, decreased renal blood flow may lead to high oliguric renal failure and decreased creatinine clearance

Renal changes

Hemoglobin and myoglobin,

present in the urine of patients with deep muscle damage often associated with electrical injury, may cause acute tubular necrosis and call for a greater amount of initial fluid therapy and osmotic diuresis.

Pulmonary Changes hyperventilation and increased

oxygen consumption are associated with major burns. The majority of deaths from fire are due to smoke inhalation. 

fluid resuscitation and the effects of burn shock on cell membrane potential may cause pulmonary edema, contributing to decreased alveolar exchange.

Initial respiratory alkalosis resulting from hyperventilation may change to respiratory acidosis .

)Pulmonary )CO poisoning  Carbon monoxide

(CO) is a colorless, odorless, tasteless, nonirritating gas produced from incomplete combustion of carbon-containing materials.  Affinity of hemoglobin for CO is 200 times greater than for oxygen.

Hematologic Changes Release of thromboxane A2

leads to Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, inhibition of fibrinolysis, and a deficit in several plasma clotting factors occur postburn.

Anemia results from the direct effect of destruction of red blood cells due to burn injury, reduced life span of surviving red blood cells, and blood loss during diagnostic and therapeutic procedures

The loss of the skin barrier and presence of eschar favor bacterial growth. Hypoxia, acidosis, and thrombosis of vessels in the wound area impair host resistance to pathogenic bacteria.

Immunologic change Burn wound sepsis The wound will be fully

colonized in 3 to 5 days. Seeding of bacteria from the wound may give rise to systemic septicemia.

Gastrointestinal changes As a result of sympathetic

nervous system response to burn trauma, peristalsis decreases, and gastric distention, nausea, vomiting.

Ischemia of the gastric mucosa and other etiologic factors put the burn patient at risk for duodenal and gastric ulcer, manifested by occult bleeding and, in some cases, lifethreatening hemorrhage.

Extend of burn

Extend of burn First degree Pink to red: slight edema, which

subsides quickly. In about 5 days, epidermis peels, heals 

Pain may last up to 48 hours; relieved by cooling.spontaneously. (Sunburn is a typical example.)

Extend Second degree

Superficial Pink or red: blisters form

(vesicles); weeping, Takes several weeks to heal.

edematous, elastic. Scarring may occur. Superficial layers of skin are destroyed; wound moist and painful.

Second degree

Deep dermal white and red: edematous reddened Takes several weeks to heal.

areas blanch on pressure. Scarring may occur. Hair does not pull out easily

May be yellowish but soft and elastic—may or may not be sensitive to touch; sensitive to cold air.

Third degree Destruction of epithelial cells—

epidermis and Eschar must be removed. Granulation tissue dermis destroyed.forms to nearest epithelium from wound

Reddened areas do not blanch with pressure.margins or support graft. Not painful; inelastic; coloration varies from For areas larger than 3-5 cm.

tissue is called eschar.Expect scarring and loss of skin function. Destruction of epithelium, fat, muscles, and Area requires debridement, formation of bone.

Rule of nine

Thermal injuries The most common

Type of injuries Varies according to

severity The prognosis is better.

Electrical injuries The type of current Duration of contact to electrical

source Location of electrical source Causes necrosis in skin , tetany, cardiac dysrhythmias

Chemical burns Chemical agents either

alkaline or acidic, or petroleum based products. (alkaline penetrate more than acidic)  painful Identify neutralizing agent

Inhalation burns May be upper airway

(supraglottic) and incur injury in minutes to hours or may involve lower airway and cause adult respiratory distress syndrome (ARDS). This can occur in as little as 4 hours of burn

Nursing care for burn patients  Assessment

with all trauma victims, a primary and secondary trauma survey, including assessment of airway, breathing, and circulation as well as vital signs, is done.

Other assessment parameters specific to the burn injury focus on extent and severity of burn injury and inhalation injury.

Nursing process Nursing assessment Severity of Burns

Severity of burns is determined by: Area of the body burned—face, hands, feet, perineum, and circumferential burns require special care.

Depth—first, second, third degree Extent—percentage of TBSA

Nursing diagnosis Impaired Gas Exchange related

to inhalation injury

Ineffective Breathing Pattern related to circumferential chest burn, upper airway obstruction, or ARDS

Risk for Infection related to loss of skin barrier and altered immune response Body Image Disturbance related to cosmetic and functional sequelae of burn wound

Nursing interventions

Stop the burning process if

possible Remove all clothing and jewelry

Ensure patent airway Prepare for incubation Cannulate two veins

Fluid resuscitation formulas First 24 hours—4 mL of

Ringer's lactate weight in kg % TBSA burned.

One-half amount of fluid is given in the first 8 hours, calculated from the time of injury. If the starting of fluids is delayed, then the same amount of fluid is given over the remaining time. Remember to deduct any fluids given in the prehospital setting

 Patient's weight: 70 kg % TBSA burn:

80%  4 mL 70 kg 80% TBSA = 22,400 mL of Ringer's lactate  1st 8 hours = 11,200 mL or 1,400 mL/hour  2nd 16 hours = 11,200 mL or 700 mL/hour

Treatment Hydration therapy Escharotomy Grafts Flabs

summary Burn is not traumatic not only

for the patient, but also for the family , so the care giver must ensure the the holistic care approach dealing with the victim.