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Terms in this set (81)
Burns are worse for which people?
very old (less subcut tissue) and very young (greater body surface area)
Pathophysiology of Burns...what happens?
-plasma seeps out into the tissue because of increased capillary permeability therefore the person can go into a fluid volume deficit quickly (this all happens in the first 24 hours)
-pulse increases with FVD
-Cardiac output decreases because of FVD (less volume to pump out)
-Urine output decreases because kidneys are either trying to hold onto fluid or they are not being perfused
-Epinephrine is secreted and makes you vasoconstrict, which shunts blood to the vital organs
-ADH (retain water) and aldosterone (retains sodium and water) are secreted to hold onto fluid, therefore, the blood volume will go up.
Misc info on Airway injury with burns
-Normally, O2 binds with hgb
-CO (carbon monoxide) travels faster than O2 and binds to hgb first, causing hypoxia
-Treat this with 100% O2
-We might have to intubate or insert a trach
What is the most common airway burn injury?
Carbon Monoxide poisoning
Do we retain more CO2 in an open or closed space?
Classifying Burn Injury Rule of 9's
-Head and Neck: 9%
-Trunk Front: 18%
-Trunk Back: 18%
-Each Arm: 9%
-Each Leg: 18%
-Genital Area: 1%
What is one of the most important aspects of burn management?
Why is timing important?
Fluid therapy (for the first 24 hours) is based on the time the injury occurred, not when the treatment was started. Therefore, you should know what time the burn occurred.
Common Rule: Calculate what is needed for the first 24 hours and give half of that during the first 8 hours of treatment
Ex: (4ml of LR) x (body weight in kg) x (% of TBSA burned) = total fluid requirement for the first 24 hours after the burn
1st 8 hours= 1/2 of total
2nd 8 hours= 1/4 of total volume
3rd 8 hours= 1/4 of total volume
If client is restless it could be 3 things...
inadequate fluid replacement, pain, or *hypoxia (priority)
What would you chose to determine if a client's fluid volume is adequate in the burn patient?
urine output (anyone else...use the weight)
Emergency management for burns out in the field
-wrap in blanket to stop burning (also acts as a second skin to keep germs out)
-poor cool water (not cold...don't want to vasoconstrict)
-remove jewelry because swelling occurs and metal gets hot
-Remove non-adherent clothing and cover with clean, dry cloth
Signs of airway injury with burn
-singed facial or nose hair
-soot on face
-coughing up black secretions
-blisters around mouth
What acid base imbalance would an airway burn patient have most likely?
Respiratory acidosis-because the respirations are shallow and they are retaining CO2
Why give albumin to burn patients?
-holds water in the vascular space
-vascular volume and kidney perfusion increases, causing BP and CO to increase
-Helps correct the fluid volume deficit because it pulls fluid into the vascular space.
-workload of heart increases (at first this is good! But if it is too much, wet lung sounds...CO starts going down, no good!)
In a client who is receiving fluids rapidly, what is a measurement that you could take hourly to ensure that you are not overloading them?
Central venous pressure (in heart)
Pain Management with Burns
-give the smallest amount of narcotics necessary to relieve someone's pain
-IV pain meds are preferred over IM because you need good blood perfusion to the muscles for IM to work and people with pain don't necessarily have that.
Immunization for burns
-Tetanus toxoid (active immunity)-takes 2-4 weeks for patient to develop their own antibodies
-Immune globulin: immediate protection but it is passive (giving you antibodies)
What should you do if there is a circumferential burn?
Check pulses because these burns can destroy blood vessels and cut off circulation
-relieves pressure and restores circulation
-cut through the escar
-relieves the pressure and restores the circulation, but the cut is much deeper than the escharotomy
-Cut goes through the eschar and the fascia
Circulatory check (4 things)
Inserting a foley in a burn patient (things to remember)
-monitor foley q1h
-kidneys may not give any urine (retain fluids or not perfused)
-diurretic may be ordered to flush kidneys (mannitol)
-After 48 hours, the client will begin to diurese because fluid is going back into the vascular space. Now we have to worry about fluid overload
-Diuretic (use with burns)
-observe for crystals
What does it mean if a burn patient's urine is brown or red?
Call the doctor. This is normal, but you should worry, because it means that myoglobin has been released and could clog and damage the kidneys.
Potassium balance and Burns
-potassium is normally on the inside of the cells
-with a burn, the cells are lysed
-The number of K ions in the serum increases as the cell is lysed.
Burns and GI system
-order medications to prevent stress ulcers
-NPO and hooked to suction to prevent paralytic ileus (decreased perfusion to GI, normal stress response, hyperkalemia promotes muscle weakness)
-needs more calories (esp protein and vit C)
-measure gastric residuals when you start GI feedings
Lab work to ensure proper nutrition and positive nitrogen balance
prealbumin (most sensitive to nutritional status)
tp prevent stress ulcers
Aluminum Hydroxide Gel (Amphogel)
Magnesium Hydroxide (milk of magnesium)
to prevent stress ulcers
Proton Pump Inhibitors
To prevent stress ulcers
Burns create problems with the integumentary system
-partial and full thickness burns can cause contractures
Superficial Partial Thickness Burns
formerly called first degree burns; damage only to the epidermis; red skin caused by sun burn; relieved by cold water; no scarring when healed; heels in 1 week
Deep Partial Thickness Burns
TISSUE DAMAGE: formerly called second degree burn; damage to the entire epidermis and varying depths of the dermis: Blisters and whipping edema; use sterile sheets and overbed cradles to minimize contact with the air. Morphine sulfate or other opiates analgesics given IV to control pain; Pain med is given IV to provide quick pain relief and to prevent over medicating; heels in 2-4 weeks
Full Thickness Burns
TISSUE, MUSCLE, BONE....formerly called third degree burn; damage to the entire dermis and sometimes fat; Patient may not be in pain due to dead nerves; Can develop hypovolemic shock, hyperkalemia and anemia; Urine may be burgundy in color (myoglobinuria) which means hemodialysis is needed to prevent tubular necrosis and acute renal failure
How do we treat the hands and neck to prevent complications like contractures caused by burns?
-wrap each finger separately
-use splints to prevent contractures (position limbs in a natural form)
-Hyper extend the neck and do not use a pillow
With a perineal burn, what is the number one complication?
What is eschar?
dead tissue; we need to have it removed! Bacteria likes to grow on eschar and so it is an infection risk. If it is not removed, then new tissue cannot regenerate.
What type of isolation is used with a burn patient?
Reverse or protective (neutropenic)
Sutilanis (Travase) or Collagenase (Santyl)
-enzymatic drugs that eat dead tissue
-Don't use on face or over large nerves
-Don't use if area is opened to a body cavity
-Don't use if pregnant
Treatment for burns that debride the wound
Like a whirlpool
Medicate the patient first for pain
Common Drugs used for burns (name 4)
1. Silver Sulfadiazine (Silvadene)
2. Mafenide Acetate (Sulfamylon)
3. Silver Nitrate
4. Providone-Iodine (Betadine)
*Remember Silver, Sulfa and Iodine)
Silver Sulfadiazone (Silvadene)
soothing drug for burns; apply directly. If it rubs off, apply more, can lower the WBCs and can cause a rash
Mafenide Acetate (Sulfamylon)
Drug used for burns; can cause acid base problems, it stings, if it rubs off, apply more
Keep dressings with this drug wet; it can cause electrolyte problems
This burn drug stings, stains, can cause allergies and acid-base problems
You should alternate burn drugs. Why?
Because bacteria can build tolerance and resistance
Why avoid broad spectrum abx with burns?
Prevent superinfections and secondary infections. However, we should use them in the beginning before the cultures are back in order to start fighting the bacteria.
Mycin antibacteria drugs we worry about...
-BUN or creatinine increases
-Hearing loss (ototoxic)
Skin Grafting with Burn Injuries
-remove the burned dead tissue until healthy tissue is seen
-Good skin is taken from the healthy donor site and placed over burned area
-Transparent dressing is applied on the donor site until bleeding stops, then donor site is left open to air
-If well nourished, patient can reharvest tissue from the donor site q12-14 days
What to do/think if the skin graft becomes blue or cool?
This means that there is poor circulation. The doctor might order for you to roll sterile Q tips over the graft with steady, gentle pressure from the center to the edges in order to get the air bubbles and exudate out so that it adheres to the site.
What to do with a chemical burn
Remove client from chemical and begin flushing (think Nicole)
Flush for 15-20 minutes
What to do with an electrical burn
-Put on a heart monitor for the first 24 hours (patient at risk for V-fib)
-May place patient on a spine board with a C-collar (may happen with a shock and fall)
-possible amputation (ruined circulation)
What complications can arise with an electrical burn?
-V-fib heart rhythms
-myoglobin and hemoglobin may build up and can cause kidney damage
-many occur in high places and can cause shock and a fall
-shocks can cause muscle contractions and the force can throw the victim forcefully
-Ruined circulation can occur, and then amputation is necessary
you don NOT want an electrical burn!
What is unique about electrical burn wound?
There are two wounds...the entrance and exit wounds
Lund and Browder Method
measures TBSA in children (percentage of burn parts of body)
Palm method of measuring burns
Use the palm of hand to measure the size of burn area with the entire palm measuring 1%
Onset of Burn>ABC>give fluids for 24hours>Airway>Treat the burn shock(fluid loss)
what phase of burn: extinguish burn, soak in cold water to rid pain, remove jewelry & clothes, cover wound with sterile dressing to minimize bacteria growth
if eyes are burned with chemicals?
irrigate immediately and follow up with an ophthalmologist quick; if not, you can potentially get blister in your eyes or corneal ulcers
When you get burned do the following?
-AIRWAY/BREATHING: may need a trach and ventilation for oxygen
-CIRCULATION: check for slow capillary refill, drop in blood pressure and decreased in urinary output
-may need to insert a large bore catheter for a IV fluids
-calculate fluid replacement
-insert a foley catheter to determine hourly output
-NG tube to low suction to lower aspiration and help with feeds to increase caloric intake
-elevate extremities to prevent edema
What does carbon monoxide poisoning look like and what is the interventions?
Carbon monoxide binds to the cells way quicker than oxygen because its a vasodilator, its makes your body look like a cherry tomato. Give VENTILATION or intubation and place at 100%
Fluid replacement formulas are calculated when?
from the time of injury rather than the time of the emergency room arrival
48-72 hours(2-3 days later)
-lots of peeing going on(diuresis/increase urinary output)
-check Central venous pressure to determine fluid status
-remove eschar and other cellular debris from the burned area
How do you read CVP pressure?
in supine position at at the 4th intercostal space mid axillary line or referred to the phlebostatic axis
Normal cvp pressure?
High & low CVP means
fluid overload= High CVP
fluid volume deficit = low CVP
infections represent a major threat to the post-burn client. As a rule, avoid what
systemic antibiotics are avoided unless an actual infections exists
wash away burned skin in the tub with "santyl" or mild soap. Do not use enzymatic debridement for burns greater than 10% TBSA for burns near the eyes or on musles
After debridement, you must use ointment before placing a dressing on the wound. What ointments are used
-Silvadenesulfadiazine) (: antibioctic ointment that soothes and cools the burn area, but does not stop infection
-Silver nitrate: Stops bacteria growth
-Mafenide Acetate (Sulfamylon): painful ointment that stops pseudomonas infections
Standard wound dressing for burns
sterile dressing thats changed every day or every shift
Biologic dressing or biosynthetic dressing
-human (homograft) or animal tissue(heterograft/xenograft
-used for partial thickness or granulating full thickness injuries
-taken from human cadaver and obtained through the skin bank
-risk for blood borne infections
-most common is "pig skin" most compatible with human skin
used for full thickness burns because it sticks to the skin immediately
-can cover large wounds
biopsy epidermal cells taken from unburned portions of the body
-the cells are grown in the lab and made to be used as permanent skin
synthetic and animal collagen becomes apart of the client's skin
-helps eliminate the need for compression dressing like the jobst garment durning the rehab phase of care
skin taken from an unburned area of your body and placed on the burned area
-painful because of the nerves at the unburn sites
-need pain meds
-monitor the burn and donor site for infections
-begins the day client enters the hospital
with the closure of the burn to full level functioning
-focus is toward reaching full pre injury life or help client adjust to the changes
CBC- looks at anemia
CMP- looks at fluid volume deficit
Urinalysis-looks at fluid volume
Chest X-ray- looks at inhalation deficit
Glucose levels does what during the emergent phase
High, due to stress
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