Initial Care of Burns

Connie Handel RNUniversity of Wisconsin Hospital and Clinics

Objectives

Discover who’s getting burned? Discuss Burn pathophysiology. Understand why some treatments are better

than others. Review treatment options.

Skin Structures

Epidermis – outermost layer of keratinized cells Dermis – contains skin appendages, vascular supply

and nerve endings Subcutaneous Tissue

Functions of the Skin

Barrier to infection

Protection from external injury

Temperature control

Control of body fluids

Sensory organ

Determines identity

What is a burn?

Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

Burn Depth

First Degree Burns

Epidermis affected only Red or pink, dry, painful,

blanches to touch Epidermis is intact Spontaneous healing

within 7 days. Outer injured epithelial cells peel

Seldom clinically significant

Superficial Partial Thickness

Entire epidermis & portion of dermis (Papillary dermis)

Homogenous pink Painful Blisters Blanches Hair usually intact Does not scar, may pigment

differently

Sup 2nd degree

Deep partial thickness

Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft

Deep Partial Thickness

Deep dermal

Full Thickness: 3rd degree

May go into fat or deeper

Red, white, brown, black

Inelastic and leathery painless or numb Heals only from the

periphery Always excise and graft

Full-thickness

Etiology

Types of burns

Circumstances of injury

Where do burns occur

Admissions by age

% of admissions vs. burn size

Inhalation Injury

Exposure to heat and toxic products of combustion

50% of fire deaths are related to inhalation injuries Asphyxia/Carbon Monoxide displacement of oxygen

Inhalation injury diagnosis

Closed-space fire Face burns

Terminology

Inhalation injury “nonspecific”– Thermal injury

Upper airway Heat and toxic fumes

– Local chemical irritation Throughout airway Primarily toxic fumes

– Systemic toxicity CO

Signs and symptoms

Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing

Conjunctivitis Carbonaceous

sputum Singed hairs Stridor Bronchorrhea

Pathophysiology

The main factor responsible for mortality in thermally injured patients

Carbon monoxide the most common toxin– 200 times greater affinity– Competitive inhibition with cytochrome P-450

Poison management = CO

500 unintentional deaths each year Persistent Neurologic Sequelae

– May improve over time

Delayed Neurologic Sequelae– Relapse later

Carbon Monoxide Poisoning

10% COHb – asymptomatic, seen most often in smokers, truck drivers, traffic police

20% COHb - headache, nausea, vomiting, loss of dexterity

30% COHb - confusion & lethargy, possible ECG changes

40-60% COHb - coma 60% + - usually fatal

Poison management = CO

Treatment– CO level means nothing to predict outcome– Length of hypoxia is the determining factor– Oxygen– HBO

No studies show benefit in treatment

Reduction of CO

0

20

40

60

80

0 20 40 60 80

Time in Minutes

% C

O

Room Air100% Oxygen3 ATM

Determine Burn Severity

% BSA involved Depth of injury Age Associated/pre-existing

disease or illness Burns to face, hands,

genitalia

Difficulties with accurate initial assessment of burn size & depth

Soot, blisters, adherent clothing or debris obscure wound

Burns are dynamic…Progression is always a risk

Burn Extent

Total Body Surface Area (TBSA)?

Rule of nines Lund and Browder chart Patients palm = about 1% TBSA

Extent of Burn :“Rule of Nines”

Adult anatomical areas = 9% BSA (or multiple)

Not accurate for infants or children due to larger BSA of head & smaller BSA legs.

Burn diagrams illustrate adult – child differences

Lund & Browder Chart

Extent of Burns

Patient’s palmar surface (hand + Patient’s palmar surface (hand + fingers) = 1% TBSAfingers) = 1% TBSA

Burn Depth

Factors

Temperature Duration of contact Dermal thickness Blood supply Special Consideration: Very young and

very old have thinner skin

Burns begin at 44 degrees C

6 hours for burns to occur at

111 degrees F (44 C)

1 second of burns to occur at

140 degrees F (60 C)

Time For Full Thickness Burns To Occur In Scalds

5 seconds in water @ 140 F (60 C)

30 seconds in water @ 130 F (55 C)

5 minutes in water @ 120 F (49 C)

Pain control

Ice Pack-----DO NOT USE EVER

DOES NOT– Reverse temperature– Inhibit destruction– Prevent edema

DOES– Delay edema– Reduce pain

Non-medication methods

Cover burns with plastic wrap– Wet dressings will stick and cause more pain– Other burn dressings are expensive and not

necessary– Quik Clot is expensive and will not provide any

patient benefit

Medication

Medications– Opioids– Narcotics– Pain medications– IV Analgesia

Resuscitation

IV access

< 15% TBSA – oral resuscitation 15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s IV’s should be in the upper extremities Suture IV’s started through burns

Field resuscitation

Start IV with LR, through burn OK

– < 6 years = 125mL/hr– 6-13 years = 250mL/hr– >13 years = 500mL/hr

Contact

Contact Burn

Scald Burn

Flame Burn

Grease Burn

ABA Burn Referral Criteria

The ABA identifies the following as injuries requiring a Burn Center referral:

2nd degree burns > 10% TBSA Burns to face, hands, feet, genitalia, perineum, major joints 3rd degree burns Electrical injury Chemical burns Inhalation injuries Burns accompanied by pre-existing medical conditions Burns accompanied by trauma, where burn injury poses greatest

risk of morbidity or mortality. Burns to children in hospitals without pediatric services. Patients with special social, emotional or rehabilitative needs.

UWHC Burn CenterVerified by the American Burn Association

7 ICU beds General care bed

expansion available as needed

Open to all burns, all ages, all times

Capability of providing specialized care for all patients, from pediatrics to geriatrics

Full time Surgical

Staff, House Staff, Nursing, Respiratory, Occupational and Physical Therapists, Social Worker, Nutritionist, Health Psychologist, Child Life and Pharmacist

UWHC Burn CenterVerified by the American Burn Association

Closely integrated inpatient, rehabilitation and outpatient services

Outreach programs– Burn Support Group– Burn Camp– Burn Buddies– Juvenile Fire Starters

Program– School Reintegration– Burn Education to School

and Community Groups