Upload
smacc-conference
View
692
Download
0
Embed Size (px)
Citation preview
Sue TaggartCNC Burns SupportCRGH
BURNS UNCOVERED
COVERED
Assessment of burns % Total Body Surface Area burntBurn depth
Initial management of the burn woundImportance of burn wound closureDescribe acute burn wound products
BURNS UNCOVERED - COVERED
TOTAL BODY SURFACE AREA (TBSA) RULE OF 9’S
Palmar MethodPalm & fingers of the patient = 1% TBSA
LUND AND BROWDER
5
Epidermis
Dermis- capillaries- nerves
Fat
Epidermal
Superficial Dermal
MidDermal
DeepDermal
Full Thickness
Assessment of Burn Depth
SUMMARY OF BURN DEPTH ASSESSMENT
©EMSB
Depth Colour Blisters Cap Refill
Sensation
Healing
Epidermal
Red No Present Present Yes
Superficial Dermal
Pale Pink
Small Present Pain + Yes7-10d
Mid-dermal
Dark Pink
Present Sluggish Pain + Usually21d
Deep Dermal
Blotchy Red
+/- Absent < Pain >3 wks
Full thickness
White No Absent <Pain No
Assess tissue perfusion- Blanching & capillary refill
BURNS UNCOVERED - COVERED
BURNS UNCOVERED - COVERED
Zone of injury – (stasis)Zone of stasis
Jacksons Burn Model
BURNS UNCOVERED - COVERED
Assess co morbidities
BURNS UNCOVERED - COVERED
Day 5
Day 1 - 86yr F 18% bath scald
Day 10
BURNS UNCOVERED - COVERED
LOOK
DO
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
FLUIDSANALGESIATESTSTUBES
Assess TBSARule of 9’sIV FluidsParkland formulaIDC/NGIV OpioidsEUC/FBC/ABG/COAGXrays
A.M.P.L.E. History
Head to Toe Examination
EscaharotomyTetanus
Documentation and Transfer
Support
C spine O2Haemorrhage
control I.V.AVPU & Pupils
Environmental Control
Primary Survey First Aid Secondary Survey
Emergency Management of Severe Burns (ANZBA 2014)
First Aid will provide pain relief as it decreases the inflammatory response, oedema, decreases cell damage◦Cold tap water 20 minutes, within 3hrs injury◦Aware of hypothermia (Cuttle and Kimble 2010)
BURNS UNCOVERED - COVERED
Cold tap water Burn Aid™
BURNS UNCOVERED - COVERED
Escharotomy
http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/162634/Burns_Transfer_Guidelines_2013-14_-_web.pdf
Analgesia / sedation
BetadineIncise medially
/laterally avoiding nerves/veins
Calcium alginateAntimicrobial
dressing
BURNS UNCOVERED - COVERED
BURNS UNCOVERED - COVERED
Prontosan -.1 % Betaine (surfactant) and Polihexamethylene Biguanide PHMB (antimicrobial ) $12. 50 bottle
Efective against Staphylococcus aureus, methicillin-resistant S. aureus, S. epidermidis, Pseudomonas aeruginosa, Escherichia Coli, and Klebsiella pneumonia,Anti fungal
Cleansing
BURNS UNCOVERED - COVERED
Epidermal burn/1°/ErythemaPain, red, intact, heal within <7 daysMoisturise, protective dressing
BURNS UNCOVERED - COVERED
Cleanse, silicone dressing eg Mepilex Lite™, retain with hypafix, elevate
Superficial dermal/2°/Superficial Partial
BURNS UNCOVERED - COVERED
Mid Dermal / 2 ° / Partial Thickness/ heals 7 - 10 days
Incise blister, leave epidermis intact . 5% chlorhexidine with paraffin gauze Bactigras. - $12 roll
BURNS UNCOVERED - COVERED
Deep Dermal burn /2°/Deep partial thickness burnPink/white, pain , capillary refill >3 seconds. 2 - 3 weeks to heal, may require a graft
Hydrocolloids dressings• gelatin, pectin, carboxymethylcellulose• Facilitates autolytic debridement
Examples, Duoderm, comfeel wafer (10 x 10 cm2 $3.40 )
BURNS UNCOVERED - COVERED
Full thickness burns / 3° white, leathery, charred, cherry red, no capillary refill, requires grafting
BURNS UNCOVERED - COVERED
• Day 4 post flame burn• 93 yr old • 20% burn
Full Thickness Burn / 3 °
Silver - Acticoat™
Nano crystaline silver Acticoat™ 40cm x 40cm $164Reduces bacterial count by blocking
the respiratory enzyme system and impairs DNA replication
two layers of high-density polyethylene silver net with an inner layer of rayon
Broad spectrum antimicrobial including gram pos/neg, MRSA, anti fungal
slowly releases silver over 2 – 3 days if kept moist with water
BURNS UNCOVERED - COVERED
BURNS UNCOVERED - COVERED
Cling wrapMepilex Lite™ Solosite gel™
Hypafix™ border /sprayMoist kerlix™H2O
BURNS UNCOVERED - COVERED
BiobraneTemporary skin substitute
Day 1 – Contact burn 7% Dermal burnInk cartridge exploded when thrown into fire
Cost $41.17 per 100cm2 13cm x 38cm = $223 medium glove = $800
BURNS UNCOVERED - COVERED
10 days post burn
Biobrane: The use of biosynthetic dressings is associated with a improved healing and a reduction in pain during burn dressings changes (Level I evidence Wasiak , 2009 Cochrane review)
BURNS UNCOVERED - COVERED
Early Excision and Split Skin Grafting
BURNS UNCOVERED - COVERED
SSG applied after debridement and surfasoft appliedSurfasoft - polyamide transparent dressing$3.48 100cm2
BURNS UNCOVERED - COVERED
3 days post graft, surfasoft intact, reduces shearing allows exudate to move from wound to outer dressings
Burns uncovered - covered
BURNS UNCOVERED - COVEREDAutologous SSG Allograft – donor screenedArrive frozen – 135c cryopreserved and streptomycin & penicillin. Thawed, rinsed, applied40% TBSA $19,925
BURNS UNCOVERED - COVERED
Kaltostat - $2.73 10 x 10 cm 2Calcium/Sodium Alginateabsorbent haemostatic fibre
Aquacel Ag $20.07 10cm2Broad spectrum CMC fibre
Mepilex Transfer $ 7.42 10 x 10 cm
Duoderm $2.34 10 x 10 cm
Donor Sites
BURNS UNCOVERED - COVERED
93 yr femaleDay 10 post flame burnDay 1 post op, SSG, BiobraneDay 15 deceased
Surgery – early excision ?
BURNS UNCOVERED - COVERED
Day 5 post full thickness burn – delay in surgeryFlammacerium applied. Flammazine provides Antimicrobial cover and the cerium nitrate hardens the eschar – reduces inflammatory Response
Flammacerium
Flammazine plus Cerium Nitrate$295 tub
Negative Wound Pressure TherapyVACFoam $60, Cannister $65, Rent $65 day
Burns uncovered - covered
BURNS UNCOVERED - COVERED
Discharge7 days post surgery 10 days post surgery
BURNS UNCOVERED - COVERED
Full thickness burn Neo Dermis applied - Pelnac™
7 days post Pelnac 6 months post surgery
53 days post Pelnac25 days post SSG
Conclusion Assess % Total Body Surface Area
Rule of 9’s in the initial primary assessment Lund and Browder Chart
Assess depth History Clinical examination - colour Capillary refill
Burn wounds are dynamicTopical wound management can aid wound healing,
control microbial activity, reduce pain Early excision of full thickness burn ideal
BURNS UNCOVERED - COVERED
a nurse participant in Rudge’s (1998) study explained “... i t ’s such a horrif ic area to work in, visually... deal with the wound, wrap it up and they’re a person again”
Mother of 21-year-old (32% flame burn) explained (Gull ick et al 2014),
“ It took my breath away. It took everything I had not to cry... I had to think ‘This is your child, he’s no different’...
A patient who had sustained a 36% flame burn (Skylas, Taggart, Gull ick 2014)
‘ I ts hard and traumatic experience. I just wanted to get knocked out and just forget about it ’ .
BURNS UNCOVERED - COVERED
1. Herndon 2014 . Tota l Burn care Herndon, D. Tota l Burn Care, 2012. Forth Edi t ion. Harcourt L td
2. Latenser B 2009. Cr it ica l Care of the burns pat ient : the first 48hrs: Cri t ica l Care Medic ine Vol 37 no. 10
3. Cutt le L and Kimble R. (2010) First a id t reatment of burn in jur ies . Wound Pract ice and Research, Vol. 18, No.1.
4. Orgi l l , D. P. and Piccolo N. , Escharotomy and decompression therapies in burns. J Burn Care and Research, 2009. 30(5) :p .759-68
5. Wasiak J , C le land H, Campbel l F. (2009) Dress ings for superficia l and part ia l th ickness burns (Review). The Cochrane Col laborat ion. I ssue 1.
6. Macintrye PE, Scott DA, Schug SA, Visser E J , Walker SM. (2010) Acute pa in management: Sc ient ific evidence. Austra l ian and New Zealand Col lege of Anaesthet is ts .
7. Greenwood JE, C lausen J , Kavanagh S. (2010) Exper ience with Biobrane; uses and caveats for success. Wound Pract ice and Research, Vol .18, No. 1 , pp 50-56.
8. http: / /www.aci .hea lth .nsw.gov.au/__data/assets/pdf_file /0004/162634/Burns_Transfer_Guide l ines_2013-14_-_web.pdf
9. Gu l l ick J , Taggart S , Johnson R, Ko N 2014, The Trauma Bubble: Pat ient and fami ly exper ience of ser ious burn in jury, Internat iona l Journal of Burn Care and Research.
10. Rudge T. Sk in as cover: the d iscurs ive effects of 'cover ing ' metaphors on wound care pract ices . Nurs Inq 1998;5:228-237.
BURNS UNCOVERED - COVERED
Biobrane and Full thickness burns
Burns uncovered - covered
BURNS UNCOVERED - COVERED
Day 5
Day 1 - 86yr F 18% bath scald
Day 10
DOMESTIC BATHROOM SCALDS IN THE ELDERLY
• When elderly patients were ‘not fit for surgery’ the use of Versajet ™ successfully removed adherent burn tissue
• Treatment continued with the application of hydrocolloids which supported autolytic debridement and epithelialisation
Patient D 12 weeks post burn 4 weeks post Versajet ™
BURNS UNCOVERED - COVERED7/9/12 Day 5 post burn day 2 post debridement Biobrane
BLISTER MANAGEMENT
Option 2- Incise blister
Day 1 Deep dermal burn - hot water scald
BLISTER MANAGEMENTOption 2 – Incise blister, Acticoat application
DEEP PARTIAL THICKNESS BURN
Comfeel wafer™
Acticoat Metallic nano crystaline silver Broad spectrum antimicrobial
including gram pos/neg, MRSA, Fungi
minimizing the bacterial colonization of wounds
800 mcg/day Agryia Reacts much more slowly with
chloride and thus is deactivated less rapidly in wounds – change every 2 -3 days
Silvazine/Flammazine Ion ic s i lver Active against Gram neg and
positive bacteria minimizing the bacterial
colonization of wounds Forms a pseudo-eschar over
burn 3025 mcg/day rapidly deactivated by wound
exudate (especially chloride ions), thus requiring daily application
Contains sulphur - al lergies Slows wound healing ( Wasiak
2009 The Cochrane Col laborat ion)
BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
Hypoperfusion: Full thickness burn - can not expand (protein denaturation and oedema). Perfusion is reduced therefore necessary to release burn surgically - escharotomy
CASE STUDY: KUNUNURRA
BURNS UNCOVERED THEN COVERED
Neuropathic Pain- Hyperalgesia, Allodynia
◦ Anti convulsants e.g. Gabopentin ◦ Anti depressants e.g.
Amitriptaline◦ Paracetamol◦ Tramadol8 days post contact burn
7 weeks post burn18 days post burn
Burn Wound dressings, Skin Substitutes and Bioengineered Skin
Donor sitesDuoderm $2.34 10cm2Mepilex Transfer $7.42 10cm2
BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
BIOBRANE• Outer silicone membrane with a nylon fabric • Porcine collagen incorporated into both layers which aids adherence to the wound•. Temporary protective semi permeable skin substitute•
Partial Thickness burns/Dermal Burns
BURN WOUND DRESSINGS, SKIN SUBSTITUTES AND BIOENGINEERED SKIN
Cultured Epithelial Autografts - CEA
Skin biopsy for Cultured Epithelial AutograftsCEA
Burn Wound dressings, Skin Substitutes and Bioengineered Skin
Triad of critical careHypothermia 33 ⁰cvasoconstriction/hypoperfusionCoagulopathy (ineffective platelet function)
Myocardial performance Impairment of wound healing
(Fredrikson 2011)
BURNS UNCOVERED - COVERED
57
WOUND PROGRESSION
Day 1 post burn
Day 3
Day 7 post burn, day 4 post Biobrane
74 yr old female, hot water scald
“My head looked like The Elephant Man... On the end of my shoulders was this thing like a Star Wars movie. It was disgusting… I was so embarrassed… my head blew up, so as the night went on I became uglier and uglier. It was like nothing I’d ever seen”
Wound healing trajectory
BURNS UNCOVERED - COVERED