Burns & Escharotomy

King Saud University College of Nursing

Burns & Escharotomy By Hatem Alsrour (nursing college)

Burns Burns are caused by a transfer of energy from a heat source to the body. Major burns have a significant risk of morbidity & death. The pre-hospital care is a major contributor to patients final out come.

Burns The skin is the largest organ in the body It provides Thermal regulation & prevention of fluid loss by evaporation. Hermetic barrier to infection. Contains sensory receptors that provide information about the environment.

Skin Anatomy The skin is divided into 3 layers Epidermis- outer layer of cornified epithelial cells. Dermis- the middle layer, mostly connective tissue. Contains capillaries, nerve endings, & hair follicles. Hypodermis- a layer of fat & connective tissue between skin & underlying tissue

Anatomy

Approach to Burn Patient Age History Duration of exposure Type of fire Consider Abuse in pediatrics Determine depth, type & extent of injury

Consider Abuse

RULE OF NINES RULE OF NINESA estimation of the TBSA involved in a burn is simplified by using the rule of nines. The rule of nines is a quick way to calculate the extent of burns. The system assigns percentages in multiples of nine to major body surfaces.

Types of burns With a first-degree burn, the epidermis (top layer of skin) is destroyed. A second-degree burn causes injury to the epidermis, the upper layers of the dermis (deeper portion of skin), and some injury to the deeper portions of the dermis. The dermis is totally destroyed in a third-degree burn, and in some cases, so is a lot of the underlying tissue, including portions of bone. In the case of an extensive burn, cover the area with a clean, dry sheet or towel. Do not let the burn victim eat or drink anything on the way to the hospital.

Burn Patients Burn patients need lots of medical skill You must identify the amount of burn You must define degree of burn You must identify associated injuries You must establish events preceding the injury Establish basic care first

Treatment Airway- establish early Fluids- Two (2) big bore IV’s Consider Foley for fluid management Protect from further injury No food or fluid is given by mouth, and the patient is placed in a position that will prevent aspiration of vomitus because nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury. Arrange appropriate referral &/or treatment

Burn Patients

Care of the Patient During the Emergent/Resuscitative Phase of Burn Injury 1. Maintenance of adequate tissue oxygenation.

Maintain patent airway and adequate airway clearance. 2. Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. 3-Observe vital signs (including central venous pressure or pulmonary artery pressure, if indicated) and urine output, and be alert for signs of hypovolemia or fluid overload. 4. Maintain IV lines and regulate fluids at appropriate rates, as prescribed. 5-Restoration of optimal fluid and electrolyte balance and perfusion of vital organs. 6-Maintenance of adequate body temperature.

continue 7. Elevate burned extremities. 8.Control of pain 9.Monitor arterial blood gas values, pulse oximetry readings, and carboxyhemoglobin levels. 10. Prepare to assist with intubation and escharotomies 11. Monitor mechanically ventilated patient closely.

Airway, Fluids & Urine

Fluids (4 ml crystalloid) X (% BSA burn) X (body wt in Kg) Ex a man weighting 70 Kg with 30% BSA would require (30) X (4ml) X 70 = 8400 ml in 1st 24 hr. Half of the fluid is given in the first 8 hr. with the balance given in the next 16 hr. Maintain urine output at 1 ml/kg/hour

Escharotomy Indications: Circumferential full thickness & deep dermal burns of the chest or limbs with circulatory or respiratory compromise Needed when there is a full thickness burn involving the extremities or chest.

Escharotomy Limb Escharotomy is indicated when the circulation is compromised due to increased pressure in the burned limb and can not be relieved by simple elevation of the limb. Chest Escharotomy should be considered when a circumferential burn of the chest wall results in respiratory compromise by restricting normal chest wall movement.

Procedure Limbs: incisions should be performed in the “mid axial line” bilaterally • Generally no anaesthetic is required in adults- the patient should be appropriately sedated and given adequate pain relief. General anaesthetic should be used for children. • Always start and finish the incision one centimetre into unburned healthy tissue where possible (use local anaesthetic for the unburned skin) • Sterile procedure with adequate drapes. • Before starting, the upper limb should be in the supine position, and the lower limb in the neutral position.

Procedure • For the chest, incisions along the mid axillary

lines, continuing over the abdominal wall if the burn extends to this region. • Draw a line where you will make the incision • Full thickness incision into subcutaneous fat sufficiently to see obvious separation of the wound edges • Incision needs to be on both sides of limb or chest to restore circulation • haemorrhage control

Visuals

Incision Lines

First Degree

Second Degree

Second & Third Degree

One Hour Difference

30 Min After Procedure

Note: Chest Incisions

Fat Bulging

Chest

Foot

Leg

REMEMBER Be early Be aggressive Airway Control IV’s, adequate fluids Consider other injuries Escharotomy Temperature control