Management of Patients With Burn Injury

• Keep matches and lighters out of the reach of children.

• Emphasize the importance of never leaving children unattended around fire.

• Develop and practice a home exit fire drill.• Set the water heater temperature no higher

than 70°C.• Don’t smoke in bed, and caution against falling

asleep while smoking.• Caution against throwing flammable liquids

onto an already burning fire.

• Caution against using flammable liquids to start fires.

• Caution against removing the radiator cap from a hot engine.

• Watch for overhead electrical wires and underground wires when working outside.

• Keep hot irons out of reach of children.• Caution against running electric cords under

carpets or rugs.• Avoid storing flammable liquids near a fire source.• Caution when cooking.• Keep a working fire extinguisher in the home, and

to know how to use it.

Results in ??? deaths annually Survival best at ages 15-45 Children, elderly, and diabetics are at

higher risk Survival best when burns cover less

than 20% of TBA

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Thermal Exposure to flame or a hot object (i.e. hot water) Chemical Exposure to acid, alkali or organic substances Electrical Result from the conversion of electrical energy

into heat. Extent of injury depends on the type of current, the pathway of flow, local tissue resistance, and duration of contact

Radiation Result from radiant energy being transferred to

the body resulting in production of cellular toxins

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Classified according to depth of injury and extent of body surface area involved

Burn wounds differentiated depending on the level of dermis and subcutaneous tissue involved

1. Superficial (first-degree) 2. Deep (second-degree) 3. Full thickness (third and fourth

degree)

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Epidermal tissue only affected Tingling, Hyperesthesia, pain that is

soothed by cooling Wound: Reddened; blanches with

pressure; dry, minimal or no edema, Possible blisters

Complete recovery within a week; no scarring, Peeling

i.e. sunburn

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• Involves the epidermis and deep layer of dermis

• Pain, hyperesthesia, sensitive to cold air.• Blistered, mottled red base; weeping surface;

edema • Recovery in 2 to 4 weeks, some scarring and

depigmentation, contractures• Infection may convert it to full thickness• Hospitalization required if over than 25% of

body surface involved• i.e. scald burn, flame

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Destruction of all skin layers Requires immediate hospitalization Dry, waxy white (or charred), leathery,

or hard skin, no pain, edema Exposure to flames, electricity or

chemicals can cause 3rd degree burns Grafting necessary, scarring and loss of

contour and function; contractures,loss of digits or extremity possible

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Calculation of Burned Body Surface Area

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Superficial burns are not involved in the calculation

Lund and Browder Chart is the most accurate because it adjusts for age

Rule of nines divides the body – adequate for initial assessment for adult burns

Palm rule

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4/1/2011 22Evans, 18.1, 2007)

Head & Neck = 9% Each upper extremity (Arms) = 9% Each lower extremity (Legs) = 18% Anterior trunk= 18% Posterior trunk = 18% Genitalia (perineum) = 1%

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• Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents.

• skin and the mucosa of the upper airways are the sites of tissue destruction

• Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image.

• Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response

Hypovolemia is the immediate consequence of fluid loss and results in decreased perfusion and oxygen delivery.

Cardiac output decreases and BP decrease. SNS releases adrenaline, resulting in peripheral

vasoconstriction and increase in HR. Patient needs immediate fluid replacement. Most of fluid (in first 24-36 hr) leaks out of blood

vessels.

As the capillaries begin to regain their integrity, burn shock resolves and fluid returns to the vascular compartment.

As fluid is reabsorbed from the interstitial tissue into the vascular compartment, blood volume increases.

If renal and cardiac function is adequate, urinary output increases.

Diuresis continues for several days to 2 weeks.

Local edema occurs if burn area is less that 25% TBSA Generalized edema if burn area is more than 25% TBSA Maximal edema is after 24 hours. Begins to resolve 1 to 2 days after the burn and usually is

completely resolved within 7 to 10 days. As edema increases, pressure on small blood vessels and

nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia.

This complication is similar to a compartment syndrome. The physician may need to perform an escharotomy, a

surgical incision into the eschar (devitalized tissue resulting from a burn), to relieve the constricting effect of the burned tissue

Circulating blood volume decreases during burn shock.

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.

Usually, hyponatremia is present. Immediately after burn injury, hyperkalemia results

from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

Occurs after 24 hours Capillary leak stops See diuretic stage where edema fluid

shifts from the interstitial spaces into the vascular space

Blood volume increases leading to increased renal blood flow and diuresis

Body weight returns to normal ? Hypokalemia if no potassium

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At the time of burn injury, some red blood cells may be destroyed and other damaged, resulting in anemia

Despite this the hematocrit may be elevated due to plasma loss

Blood loss during surgical procedures, wound care, diagnostic studies and ongoing hemolysis further contribute to anemia

Blood transfusions are required periodically to maintain adequate hemoglobin levels for oxygen delivery

Abnormalities in coagulation, including a decrease in platelets (thrombocytopenia) and prolonged clotting and prothrombin times occur with burn injury

Inhalation injury is the leading cause of death in fire victims

Half of these deaths could have been prevented with use of a smoke detector

Burn victims make it out of a burning home safely

Once they are outside they may realize that loved ones or valuable items are still inside the burning home

They then reenter the burning home and are overcome with toxic smoke and fumes and become disoriented or unconcious

Pulmonary imjuries fall into several categories, upper airway injury, inhalational injury, including carbon monoxide poisining, and restrictive defects

Upper air way injury results from direct heat or edema

It is manifested by mechanical obstruction of the upper airway, including the pharynx and larynx

Upper airway injury is treated by early nasotracheal or endotracheal intubation

Inhalation injury below the glottis results from inhaling products of incomplete combustion (Burning) or noxious gases: carbon monoxide, sulfer oxide, nitrogen oxide, & benzene

The injury results directly from chemical irritation of the pulmonary tisues at the alveolar level

Inhalation injuries below glottis cause loss of ciliary action, hypersecretion, severe mucosal edema and bronchospasm

The pulmonary surfactant is reduced, resulting in atelectasis (collapse of alveoli)

Expectoration of carbon particles in the sputum is the cardinal sign of this injury

The pathophysiology effects are due to tissue hypoxia a result of carbon monoxide combining with hemoglobin to form carboxyhemoglobin which competes with oxygen for available hemoglobin sites

The effinity of hemoglobin for carbon monoxide is 200 times greater than that for oxygen

Treatment usually consists of ealy intubation and mechnical ventilation with 100% oxygen

Administering 100% O2 is essential to accelerate the removal of carbon monoxide from the hemoglobin molecule

restrictive defects arise when edema develops under full-thickness burns encircling the neck and thorax

Chest expansion may be greatly restricted resulting in decreased tidal volume

In such situation escharotomy is necessary More than half of all burn victims with pulmonary

involvement do not intially demonstrate pulmonary signs and symptoms

Any pat with possible inhalation injury must be observed for at least 24 h for respiratory complications

Airway obstruction may occur very rapidly in hours Decreased lung compliance, decreased arterial

oxygen levels and respiratory acidosis may occur gradually over the first 5 days after a burn

History indicating that the burn occured in an enclosed area

Burns of the face and neck Hoarseness , voice change, dry cough, stridor. Bloody sputum Labored breathing or tachypnea (rapid breathing) and

other signs of reduced oxygen levels Erythema and blistering of the oral or pharyngeal

mucosa

The immediate intervention is intubation and mechanical ventilation

If ventilation is impaired by restricted chest excursion, immediate chest escharotomy is needed

ARDS may develop in the first few days after the burn injury secondary to systemic and pulmonary responses to the burn and inhalation injury

Renal function may be altered as a result of decreased blood volume

Destruction of red blood cells at the injury site frees hemoglobin in the urine

If muscle damage occurs (from electric burns e..) myoglobin is released from the muscle cells and excreted by the kidney

Adequate fluid volume replacement restores renal blood flow, increasing the glomerular filtration rate and urine volume

If there is inadequate blood flow through the kidneys, the hemoglobin and myoglobin occlude the renal tubules, resultinh in acute tubular necrosis and renal failure

The immunologic defences of the body are greatly altered by burn injury

Serious burn injury diminishes resistance to the infection

As a result, sepsis remains the leading cause of death in thermally injured patients

The loss of skin integrity is compounded by the release of abnormal inflammatory factors, altered levels of immunglobulins, impared neutrophil function and a reduction in lymphocytes (lymphocytopeni)

Research suggest that burn injury results in loss of T-helper.cell lymphocytes

Loss of skin results in an inability to regulate body temperature

Burn patients may therefore exhibit low body temperature in the early hours after injury

As of hypermetabolism, core temperature increase. Burn patients become hyperthermic for much of the

postburn period, even in the abscence of infection

Paralytic ileus (absence of intestinal peristalsis): ◦decreased peristalsis and bowel sounds are

manifestations of paralytic ileus resulting from burn traumaand

◦Gastric distention and nausea may lead to vomiting unless gastric decompression is intiated

Curling´s ulcer (gastric or deuodenal erosion) ◦Gastric bleeding secondary to massive physiologic stress

may be signaled by occult blood in the stool, regurgitation of coffee ground material from the stomach or bloody vomitus