burns training module

7/30/2019 Burns Training Module

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Region 5- Just-in-Time Burn Training Module -Part I

Contents: I. Initial Assessment

II. General Principles in Management

III. Airway Management

IV. Wound Management

V. Burn Center Transfer

I. INITIAL ASSESSMENT OF THE BURN PATIENT

A. Introduction

1. Like all other trauma patients, emergency care of the burn patient begins with the

initial assessment and treatment of life-threatening injuries.

2. The dramatic appearance of burns and the characteristic odor of burnt flesh should not

distract the care provider from priorities of patient care.

B. Initial assessment

1. Airwaya. A primary concern in the burned patient, especially a patient with inhalation

injury. Observe for:1) Stridor. Stridor is an ominous sign that suggests the patients upper

airway is at least 85% narrowed.2) Facial burns

3) Soot in the nose or mouth

4) Singed facial hair or nasal hair

5) Edema of the lips and oral cavity

6) Coughing

7) Hoarse voice

8) Circumferential neck burns

2. Breathing

a. Evaluate:

1) Rate2) Depth

3) Presence of wheezes, rales, or rhonchi

4) Presence of dyspnea

b. Pulse oximetry (may be inaccurate in the presence of carbon monoxide)CO-Oximeter reading if available

3. Circulation

a. Assess for presence, rate, and rhythm of pulses

b. Evaluate capillary refill, skin color, and temperature

c. Look for obvious arterial bleeding

4. Disability/Neurological status

a. Use AVPU and carefully evaluate deviations from normal for underlying cause

1) Hypoxia2) Decreased cerebral perfusion from hypovolemia

3) Cerebral injury resulting from head trauma

b. Check pupils

c. Check that the patient can move all extremities

5. Exposure/Environmental Control

a. Remove all clothing and jewelry

b. Keep patient warm

c. Cover patient with dry sterile sheet and tuck in sides.

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C. History

1. After completing the initial assessment, obtain a history of the event while performing

a physical examination.

a. An accurate history from the patient or bystanders can help determine:

1) The potential for inhalation injury

2) Concomitant trauma

3) Preexisting conditions that may influence the physical examination or

patient outcome

2. When obtaining the patient history, determine:

a. What is the patients chief complaint (e.g., pain, dyspnea)?

b. What were the circumstances of the injury?

1) Did it occur in an enclosed space?

2) Were explosive forces involved?

3) Were hazardous chemicals involved?

4) Is there related trauma?c. What was the source of the burning agent (e.g., metal, liquid, chemical)?

d. Does the patient have any significant medical history? SAMPLE

e. What medication does the patient take (including recent ingestion of illegal

drugs or alcohol)?

f. Did the patient lose consciousness at any time? (Suspect inhalation injury)

g. What is the status of tetanus immunization?

D. Physical examination/Complete head to toe exam

1. Obtain a complete set of vital signs

2. Blood pressure should be obtained in an unburned extremity, if possible

3. Patients with severe burns or preexisting cardiac or medical illness should be

monitored by electrocardiogram (ECG)

4. Determine severity of the burn

a. Burn extent

1) Rule of Nines

2) Lund & Browder chart

3) Palm method

b. Burn depth5. Determine any associated illness or injury

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II. GENERAL PRINCIPLES IN BURN MANAGEMENT

A. Initial burn management

1. Goals of initial burn management:

a. Preventing further tissue injury

b. Maintaining a patent airway

c. Administering oxygen and ventilatory support

d. Providing fluid resuscitation and pain management

e. Using clean technique to minimize patients exposure to infectious agents

f. Providing psychological and emotional support

2. Burned patients should also be evaluated for:

a. Other types of life-threatening trauma

b. Additional injuries associated with the burn event

1) Blunt or penetrating trauma sustained in automobile crashes

2) Blast injury3) Skeletal or spinal injury from attempts to escape the thermal source or

contact with electrical current

B. Stopping the burning process

1. The first step in managing a burn is to stop the burning process

2. Minor first-degree burns < 20%

a. Cool the local area with cool water (but not ice cold)/moist dressings

3. Severe burns

a. Move the patient rapidly from the burning source to an area of safety

4. If the persons clothing is in flames or is smoldering

a. Place the patient on the floor or ground

b. Roll patient in blanket to smother flames or douse with large quantities of

cleanest available water

1) Contaminated water sources (e.g., a lake or river) should be avoided

c. Never allow the patient to run or remain standing

1) Running may fan the flame

2) An upright position may increase the likelihood of the patients hair

being ignitedd. Completely remove the patients clothing while cooling the burn so that heat is

not trapped under smoldering cloth

1) Cut (do not pull) away any smoldering cloth that has adhered to the

skin

2) Melted synthetic fabrics should be soaked in cold water to stop the

burning process

5. After the burn is cooled, the patient with a large BSA injury should be covered with a

dry clean (preferably sterile) sheet

C. Airway, oxygen, and ventilation

1. Administer high-concentration humidified oxygen to any patient with severe burns-

100% oxygen via non-rebreather mask2. Assist ventilation as needed

3. If inhalation injury is suspected, closely observe the patient for signs of impending

airway obstruction

a. Life-threatening laryngeal edema may be progressive and may make tracheal

intubation difficult or impossible. Do not delay intubation in these patients

4. Pulse oximetry. CO oximetry if needed and available5. ABG if needed and available

6. Baseline chest x-ray if available

7. Bronchoscopy 6-12 hours later if needed to assess lower respiratory tract (if available)

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D. Circulation

1. The need for fluid resuscitation is based on the following:

a. The severity of injury

b. The patients vital signs

2. In the critically burned patient, prompt initiation of IV therapy is essential to prevent

long-term complications such as burn shock and renal failure

3. IV therapy

a. If possible, use a large-bore catheter in an unburned upper extremity

b. If an unburned site is not available, the catheter may be inserted through

burned tissue

c. take care to secure the catheter with a dressing

4. Other patient procedures that may be required

a. NG tube placement

b. Bladder catheterization

E. Pain Management & other medication

1. After initiation of fluid resuscitation pain management and sedation must be

considered a priority. Administration of pain medication is an early intervention. It is

recommend that patients with large burns be given IV analgesia

2. Titrate doses of analgesia and sedation based on the patients hemodynamic stability,

pain scale and comfort level. Follow agency protocol for the pain management and

sedation guidelines

3. Other pharmacological therapy that may be given include antibiotics, tetanus, and

proton blockers

4. Medications should be given IV initially:

a. GI function is slowed or impaired because of shock or paralytic ileus

b. IM injections are not well absorbed

F. Special considerations

1. Burns of the face swell rapidly and may be associated with airway compromise

a. Elevate the head of bed at least 30 degrees (if not contraindicated by spinal

trauma) to minimize the edema

2. Avoid use of a pillow if patients ears are burned3. Extremity burns

a. Remove all rings, watches, and other jewelry to prevent vascular compromise

with increased wound edema

b. Assess peripheral pulses frequently

c. Elevate the burned limb above the patients heart, if possible

4. Circumferential burns

a. Can pose a threat to the patients life

b. Can produce a tourniquet-like effect on an extremity

1) May quickly compromise circulation and cause irreversible damage to

the limb

c. Circumferential burns to the chest can severely restrict movement of the thorax

and may impair chest wall compliance1) Depth of respirations may be reduced, tidal volume decreased, and

lungs may become difficult to ventilate

d. Definitive treatment is in-hospital escharotomy where incisions are made

through deep burns

5. Older patients heal slower & have more difficulty with rehab

a. Common complications1) infection & pneumonia

2) preexisting illnesses: cardiovascular, pulmonary, or renal disease

3) DM or PVD is at increased risk for gangrene & poor healing

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III. AIRWAY MANAGEMENT AND SMOKE INHALATION INJURY

A. Introduction

1. Smoke inhalation injury is present in 20% to 30% of all patients admitted to burn

centers

a. More than 50% of the 12,000 fire deaths each year are directly related to

smoke inhalation or inhalation injury-inhaling hot air or noxious chemicals

2. Considerations include:

a. Recognition of the dangers inherent in a fire environment

b. Pathophysiology of inhalation injury

c. Early detection and treatment of impending airway or respiratory problems

3. Commonly occurs in a closed environment (building, automobile, airplane) and is

caused by the accumulation of toxic products of combustion

4. Dangers that contribute to inhalation injury in a fire environment are:

a. Heatb. Consumption of oxygen by fire

c. Production of carbon monoxide

d. Production of other toxic gases

e. Inhalation injury also may occur in the absence of significant thermal injury

from exposure to toxic gases (e.g., carbon monoxide)

B. Pathophysiology

1. Smoke inhalation and inhalation injury compose a broad group of consequences

secondary to combustion

2. Consequences are classified as carbon monoxide poisoning, inhalation injury:

a. Above the glottis

b. Below the glottis

3. Carbon monoxide poisoning

a. Carbon monoxide is a colorless, odorless, tasteless gas produced by incomplete

combustion of carbon-containing fuels

b. Carbon monoxide does not physically harm lung tissue but causes a reversible

displacement of oxygen on the hemoglobin molecule, forming

carboxyhemoglobin (COHb). The result is low circulating volumes of oxygendespite normal partial pressures

c. Carbon monoxide has an affinity for hemoglobin 250 times that of oxygen

1) Small concentrations of carbon monoxide can result in severe

physiological impairments

a) Tissue hypoxia

b) Inadequate cellular oxygenation

c) Inadequate cellular and organ function

d) Eventually death

d. Physical effects of carbon monoxide poisoning are related to the level of

COHb in the blood

1) Levels less than 10% do not usually cause symptoms

2) At levels of 20% a healthy patient may complain of headache, nausea,vomiting, and loss of manual dexterity

3) At 30% the patient may become confused and lethargic, ECG

abnormalities may be present

4) At levels between 40% and 60% coma may develop

5) Levels above 60% are most often fatal

e. Tachypnea and cyanosis are not usually present in these patientsf. Patients with high COHb levels may have a skin appearance that is bright red

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g. Treatment

1) Ensure a patent airway

2) Administer high-concentration oxygen

a) The half-life of carbon monoxide can be reduced from 4 hours

at room air to 30 to 40 minutes if 100% oxygen and adequate

ventilation are provided

b) Pulse oximeter use in patients with carbon monoxide

poisoning is unreliable

3) Pharmacological therapy may include sodium thiosulfate; 12.5 g for

severely poisoned patients

h. Besides carbon monoxide, other volatile byproducts (e.g., cyanide, hydrogen

sulfide) may be released when some materials are burned

1) Inhalation of these toxins can result in inhalation poisoning (e.g.,

thiocyanate intoxication) and may require pharmacological therapy (e.g.

Cyanide Poison Kit)4. Inhalation injury above the glottis

a. Upper airway structures are particularly susceptible to injury if exposed to high

temperatures- inhaling hot air, steam, or smoke

1) Upper airway is very vascular and has a large surface area, allowing it

to normalize temperatures of inspired air

2) Because of this design, actual thermal injury to the lower airway is

rare

3) Thermal injury to the airway can result in immediate edema of the

pharynx and larynx, and can rapidly progress to complete airway

obstruction

b. Signs and symptoms include:

1) Facial burns

2) Singed nasal or facial hairs

3) Carbonaceous sputum

4) Edema of the face, oropharyngeal cavity, or both

5) Signs of hypoxemia

6) Hoarse voice

7) Stridor8) Brassy cough

9) Grunting respirations

10) Painful swallowing

c. Initial care

1) Prompt recognition and protection of the airway is critical

a) Early nasotracheal or orotracheal intubation may be

warranted; however, progressive edema can make emergency

intubation extremely hazardous, if not impossible

5. Inhalation injury below the glottis

a. The two primary mechanisms of direct injury to the lung parenchyma are:

1) Heat-rare

2) Toxic material inhalationb. Thermal injury to the lower airway is rare but may be caused by:

1) Inhalation of superheated steam has 4000 times the heat-carrying

capacity of dry air

2) Aspiration of scalding liquids

3) Explosions, which occur as the patient is breathing high

concentrations of oxygen under pressure

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c. Signs and symptoms may be immediate but more are frequently delayed

(beginning several hours after exposure > appear 12-24 hours post exposure)

1) Wheezes

2) Crackles or rhonchi

3) Productive cough

4) Signs of hypoxemia

5) Spasm of bronchi and bronchioles

d. Initial care should be directed at:

1) Ensuring a patent airway

2) Providing high-concentration oxygen and ventilatory support

3) Pulse oximetry. CO oximetry if needed and available.

4) ABG if needed and available

5) Baseline chest x-ray if available

6) Bronchoscopy 6-12 hours later if needed to assess lower respiratory

tract if available7) If able-high fowlers position-cough & deep breathe every hour, turn q

1-2 hours, chest physiotherapy, suction prn

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IV. SHOCK AND FLUID RESUSCITATION

A. Burn shock review

1. Shock after thermal injury results from edema and accumulation of vascular fluid in

the tissues in the area of the injury

2. Locally, there is an initial decrease in blood flow to the area during the emergency

phase, followed by a marked increase in arteriolar vasodilation

a. A concurrent release of vasoactive substances from the burned tissue causes

increased capillary permeability, this produces intravascular fluid loss and wound

edema

b. The fluid loss into the injured tissues and the marked increase in evaporative

fluid loss secondary to the break in the epithelial barrier contribute to produce

hypovolemia

3. The greatest loss of intravascular fluid occurs in the first 8 to 12 hours. Followed by a

continued, moderate loss over the next 12 to 16 hours4. At some point within 24 hours the extravasation of fluid greatly diminishes in the

resolution phase and equilibrium between the intravascular space and the interstitial

space is reached

5. Shock and organ failure can occur from hypovolemia, the most common being renal

failure

6. In response to hypovolemia, the body attempts to compensate for diminished

circulating blood volume with a reduction in cardiac output and an elevation in peripheral

vascular resistance. With volume replacement, cardiac output can increase to levels

above normal

B. Fluid replacement

1. Within minutes of a major burn injury all of the capillaries in the circulatory system,

not just those in the area of the burn, lose their capillary seal

2. This increase in capillary permeability prevents the creation of an osmotic gradient

between the intravascular and extravascular space, allowing colloid solutions to quickly

equilibrate across the capillary barrier and into the interstitial tissue

a. The process of burn shock continues for about 24 hours, at which time the

capillary seal is restored3. Therapy for burn shock is aimed at supporting the patient through the period of

hypovolemic shock

a. Crystalloid solution (e.g., Lactated Ringers [LR] solution) is usually

considered the fluid of choice in initial resuscitation

4. Estimate the burn size based on the rule of nines or based on patients hand palmer

surface size, palm and fingers (1%TBSA) to calculate the resuscitation fluid volume

5. Burns < 15% can be resuscitated orally (unless patient has an electrical injury or

associated trauma)

Burns 15-40% need at least one large bore IV line in upper extremity

Burns > 40% need two large bore IV lines in upper extremities

6. Lactated Ringers solution at 3ml/kg/%TBSA burn = mls in first 24 hours; with of

this total given in the first 8 hours post injury and the remaining given in the next 16hours. Titrate to maintain urinary output as well

7. In children


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o 100 ml/kg for first 10 kg 10 kg x 100 ml = 1000ml

o 50 ml/kg for each kg between 11 and 20 kg 2 kg x 50 ml = 100ml

o 20 ml/kg for each kg between 21 and 30 kg --- none needed ----

=1100ml/24hours

Do not give dextrose solutions (except for maintenance fluids in children)-

they may cause an osmotic diuresis and confuse adequacy of resuscitationassessment.

C. Nutritional Therapy

1. Fluid replacement takes priority over nutritional needs in initial management

2. Burn > 20% insert NG for feeding, Burn > 40% insert central line3. NG tube inserted and connected to low intermittent suction for decompression

a. when bowel sounds return (48-72 hours) after injury, start with clear liquids

and progress up to diet high in proteins & calories

1) Immune formula- glutamine, arginine & protein

a) Glutamine-protein synthesis > skeletal muscle, nutrient >

enterocytes, macrophage, lymphocytes

b) Arginine-promotes wound healing2) Formula- (25 x wgt in kg) + (40 x TBSA burn)

Example for 50 kg patient with 50% TBSA burn:

(25 x 50) + (40 x 50) = 1250 + 2000 = 3250 Kcals

4. Daily weights will assist in evaluating the nutritional needs

V. WOUND MANAGEMENT

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A. Introduction

1. There is no one product or technique that is right for every burn patient. As the bodys

largest organ, the skin is the bodys first line defense against infection & dehydration.

It is more than just a physical barrier > it helps control temperature and is an important

sensory organ

2. Burn wounds occur when there is contact between tissue and an energy source, such as

heat, chemicals, electrical current, or radiation

3. The resulting effects of the burn are influenced by the:

a. intensity of the energy

b.duration of exposure

c. type of tissue injured

4. Wound repair begins within the first 6-12 hours post injury

5. Wound care can wait until airway is patent, circulation is adequate & fluid

resuscitation is in place6. Staff should wear appropriate gloves, gowns, masks when wounds are exposed as

much as practical

7. Use of aseptic technique is crucial

8. Careful hand washing is necessary

B. Cleansing & Debridement

1.Can be done in tank, shower or bed

2. Bath should be given with surgical detergent, disinfectant, or cleansing agent to reduce

pathogenic organisms

3. Debridement may be done in surgery

C. Wound dressing

1. Open method- burn covered with thin topical antibiotic and has no dressing

2. Closed method- burn covered using sterile gauze impregnated with or laid over a

topical antibiotic. Dressings must be changed 2-3 times q 24 hours

3. Silver sulfadiazine 1%

a. Advantages- broad spectrum, painless

b. Disadvantages- transient leukopenia, doesnt penetrate eschar4. Sulamylon 11%

a. Advantages- broad spectrum, penetrates eschar

b. Disadvantages- allergic reactions, painful, carbonic anhydrase activity

5. Bacitracin/polymycinB/neomycin

a. Advantages- painless, colorless so easy to inspect wound

b. Disadvantages- antimicrobial coverage less than alternatives

6. Silver nitrate 0.5%

a. Advantages- complete antimicrobial coverage, painless

b. Disadvantages- black staining when exposed to light, electrolyte imbalance

7. Gentaderm- for gram negative infection

8. Mupirocin (Bactroban)- for MRSA

9. Impregnated burn dressings dont need daily changes (3-5 days)a. Acticoat

b. Aquacel Ag

c. Urgotul silver sulfadiazine

d. Mepitel

D. Other issues

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1. Use open method on the face as much as possible

2. Use artificial tears and saline rinses for eye care

3. Use slings and splints on hands and arms to maintain them in functional positions and

assist with elevation therefore reducing edema

4. Perineum must be kept clean & dry

5. Start physical therapy immediately to maintain joint function

VI. BURN CENTER TRANSFER

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A. Minimal Criteria for Transfer to a Burn Center

1. Partial thickness burns > 10% Total Body Surface Area (TBSA)

2. Third degree burns in any age group

3. Electrical burns, including lightning injury

4. Chemical burns

5. Inhalation burns

6. Burn injury in a patient with pre-existing medical disorders that could complicate

management, prolong recovery, or affect mortality

7. Any patient with burns and concomitant trauma (such as fractures). If trauma poses

more of a mortality risk, then consider stabilization at a trauma center prior to transfer to

a burn center

B. Secondary Criteria

1. Burns involving face, hands, feet, genitalia, perineum, or major joints2. Burn injury in patients who will need special social, emotional, and/or long-term rehab

intervention

C. Preparation for Transfer

1. Primary and secondary assessments complete

2. Initial treatments for respiratory, circulatory, GI, burn wounds, pain management

accomplished

3. Documentation complete and copied: to include Hx, PE, lab results, flowsheet with

fluid resuscitation, pain management, all medications, nutritional therapies recorded

4. Contact with verbal report given to receiving Burn Center, both physician-to-physician

and nurse-to-nurse; as well as nurse-to-transporting agency EMT/PM/RN

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burns training module

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