Skin Functions

protect from infection & injury prevent loss of
fluids & electrolytes temp regulation
sensation appearance

Burns - Description

thermal, chemical, electrical vasoconstriction,
thrombosis, ischemia hypothermia worsens condition
(potential coding), never let it get cold third spacing,
blister, edema fluid loss 12-24hrs, hypovolemia huge
problem if pt. is on pressors = sign they will do poorly

Burns
>20% - Systemic Reaction

immune suppression hypermetabolism
cardio: dec. circulating vol, dec. C.O.,
hypotension, hypoperfusion, hypovolemia, tachy
pulm: tissue damage w/ local edema, inc. shunting,
inc. O2 needs, PE
GI: dec. peristalsis & absorption, low blood
flow
Renal: dec. UOP, Hgb or myoglobin clogging, low
fluid vol, diuresis after 48-72hr

Burn Depth

determined by: temp, exposure length, dermal thickness, injury
location kids & elderly: thin skin, less exposure
needed appearance varies, hard to determine initially

Use Standard Precautions

gown mask gloves cap
goggles or face shield chemical injuries - special
precautions

Precedence
Over Burns

ABCs - airway obstruction, cardiac arrest spinal /
head injury open chest wounds severe abdominal
trauma

Primary
Assessment - A

Airway w/
C-Spine Protection:

positioning remove obstruction, suction 100%
FiO2 w/ non-rebreather elevate HOB if no c-spine
probs
ped. airway: get intubated quickly, obstruct easily
& decompensate, small O2 reserve, weaker acc.
muscles, avoid hyperextension

Primary
Assessment
- B

Breathing

assist w/ bag-valve-mask intubate if need or in doubt
(largest ET size poss.) circumf. chest/neck/face burns will
compromise airway/breathing

Primary
Assessment - C

Circulation,
Card. Status, CPR

control hemorrhage CPR if indicated BP &
HR (adult norm 110-120) hypotension - late sign of
hypovolemia, lack of distal pulses w/ circ. burns not
hypotension cardiac monitor - especially w/ elect. burns
Fluids - 2 lg bore IV's - adults >20% or peds
>15%
IV site: unburned periph if poss. or if not burned
periph, central lines - femoral only, intraosseous

Primary
Assessment - D

Disability,
Deformity, Neuro Deficit

baseline neuro - GCS score LOC - hypoxia, carbon
monoxide, head injury AVPU -
alert, responsive to
verbal stimuli, responsive to
painful stimuli,
unresponsive able to move & feel all 4
extremities electrical or blast injury -> disability or
deformity

Primary
Assessment - E

Expose,
Examine, Environment

stop burn process - cool burn (5min max, no ice)
remove chemicals w/ dry brush & rinse for 20min, exception -
chemical, tar/asphalt burn, no ointments or dressings
remove all: clothing, diapers, jewelry, metal quick
observation for obvious injuries keep pt
warm (at least 101 deg before debridement) &
clean, dry cover, no gel-type blankets or dressings

Secondary Survey

accurate "dry weight" for fluid/med dose
head to toe/gadgets - log roll, ECG, pulse ox Hx
Interventions, fluids started, Tx pt responses (UOP, VS, LOC
change)

Burn
Percentage (TBSA)

Lund & Browder Chart Rule of 9's Hand as
guide for %

Fluid Resuscitation

fluids based on wt. & TBSA calculations = starting
point, titrate up or down based on UOP LR is preferred
peds <10kg (hypoglycemia prone) - D5LR
1/2 of 24hr amt - given 1st 8hr & other 1/2 given over next
16hr special needs: high voltage electrical, inhalation,
delayed resuscitation, assoc.trauma, pre-existing dehydration, ECOH
use, meth lab

Fluid Resuscitation

Myoglobinuria / Hemoglobinuria

deep red / port wine color urine
causes: high voltage injuries, extensive full
thickness burns, trauma assoc. crush injuries, muscle damage

Urine Output

most reliable indicator of adequate fluids insert
urinary catheter
UOP Goals:
adults/over 40kg = 30-50ml/hr <40kg =
1ml/kg/hr adult high-voltage burn = 75-100ml/hr

Head to Toe
/ Gadgets

inspect, auscultate, palpate log roll pt VS,
ECG, pulse ox urinary catheter NG (adults >20%,
peds >15%, intubated, assoc. trauma)

Pt History

pre-hospital observations & documentation injury
mechanism assoc. trauma or chemical exposure potential
substance abuse abuse or neglect intentional
injuries (criminal, suicide, gang-related, arson)

Interventions - Meds

pain Tx - IV only (morphine, dilaudid, versed) avoid
over medication - resp depression, mask assoc. injuries Sx, limit pt
ability to make decisions

Wound Management

pt warm & dry - clean, dry covering, maintain temp
no cleanse or debride before transfer to burn center
don't apply ointments or creams don't wrap individual
body parts delayed transfer: contact burn center for
guidance

ABA Referral Criteria

partial thickness >10% TBSA or 3rd deg all ages,
especially burned children functional areas - face, hands,
feet, genitalia, perineum, major joints electric &
lightning, chemical, inhalation injuries burns w/ other
trauma pre-existing med d/o special social,
emotional, or long-term rehab intervention

Transfer
& Transport - Documentation

Hx & physical labs & x-ray EKG
VS I&Os Tx & response HCP/nurse
notes adv. dir./DPOA

Early Burn
Mgmt Pitfalls

missing assoc. trauma or inhalation injury over or
under-estimation burn size over or under fluid
resuscitation inadequate pain & anxiety Tx
hypothermia

Injury
Outcome Factors

age TBSA% & burn depth inhalation
injury pre-existing Hx Tx timely, appropriate
adequate fluids largely dependent on pre-transfer
care

Burn Zones

Zone of hyperemia: partial thickness-superficial
(1st)
Zone of stasis: partial thickness (2nd)
Zone of coagulation: full thickness (3rd)

Partial
Thickness-Superficial (1st)

epidermis only pink-red (like sunburn), painful, no
blisters not inc. in TBSA % Tx: tylenol or
ibuprofen, aloe vera

Partial
Thickness (2nd)

most likely affected by vasoconstriction, hypothermia, inadeq.
fluid, inadeq. tissue perfusion

Full
Thickness (3rd)

full thickness eschar can't accommodate edema ->
escharotomy
assess: periph. pulses, doppler pulse ox (change
extremities), gradual loss of pulses, Sx of circ. compromise
if burn is bleeding unless escharotomy, some other cause
Monitor 5 P's: pain, pallor, pulselessness,
progressive paresthesia, paralysis

Full
Thickness (3rd) Tx

debridement (mech., surg., enzyme. - SSD) surgical
intervention temp coverings: allograft (cadaver), dermal
substitutes autografts: mesh or sheet (face), temp
adhered CEA - piece of pt. skin sent off, grown in lab, used
later secondary intention (scarring)

Circumferential Burn Mgmt

elevate burned extremities remove clothes &
jewelry monitor: doppler, pulse ox, 5 P's
escharotomy, debridement, grafts

Peds Burns

kids <5yr: leading cause of unintentional injury & death
at home, 2x as likely to die from fire fire deaths dec.,
but not for kids

Peds - Burn Causes

<4yr: scalds - tap water & cooking, contact burns, low
volt electrical burns 5-8yr: flame burns, fire play -
matches, flammable liquids, high voltage electrical teens:
cooking related @ home/work, MVCs

Peds
Considerations / Patho

greater evap. water loss cerebral edema thin
skin, little insulation small glycogen stores
decompensate suddenly psychologically immature

Elderly Burns

smoking w/ O2, scalds d/t neuropathy & not
realizing water temp or burn reg. adult assess: normal
phys. changes, pre-existing problems, malnutrition, dehydration,
psychological thinner skin abuse or neglect

Abuse Considerations

kids, elderly, domestic violence, special needs scalds
(immersion, pour, running water), contact mandatory
reporting
document: initial Hx, repeat Hx, social Hx eval,
photos, parental interaction w/ kid

Abuse S/S

inconsistent stories, blame on siblings, delay seeking Tx,
instincts & observations bruises/burns - diff. stages
of healing
patterns:
even depth, circumference burns unusual, hidden,
mult. locations definitive pattern, lines of
demarcation sock or glove-like line water level
apparent areas of sparing, V-shaped perineal burns
injuries inconsistent w/ story

Inhalation Injury

resp tract damage, airway close d/t edema inc. mucus,
suction needs significant mortality predictor
hemodynamic instability (up to 50% more fluid needs)
3 types: upper airway (thermal), lower airway
(smoke, chemical), systemic toxicity (carbon monoxide, cyanide)
Pulse ox doesn't distinguish b/t O2 &
CO2

Inhalation
Injury Sx

Sx not always present initially
face/neck burns singed nasal/facial hair
hoarseness, sore throat cough dysphagia
soot in sputum SOB, dyspnea wheeze,
stridor hypoxia Sx (disoriented, restless, confused,
agitated)

Inhalation Injury

Carbon Monoxide

low level Sx: HA, fatigue, flu-like, weak, dizzy,
nausea, blurred vision, appear intoxicated
high level Sx: vomit, confusion, heart
palpitations, progress to seizures, coma, death
Tx: 100% O2 - non-rebreather mask

Burn Types

thermal: flame, contact, scald, steam, tar
chemical: acid, alkali, organic compounds
electrical: high or low voltage, lightning

Thermal Burns

temp & time to burn relationship tar - 250-500 F,
Tx - cooling & stop burning process, remove clothing,
tar/asphalt removal done later, Tx may inc. Medisol or SSD

Chemical Burns

unintentional: prevention w/ use of PPE &
clothing
intentional: abuse, neglect, assault
injury cause: absorption, poss. chem & thermal
w/ scald/flame, inhalation, ingestion
injury severity: age, concentration / depth,
volume, mech. of action, contact duration (tissue destroyed until
chemical removed)

Chemical
Burns - Acids

pH 1-7 (1-4 = extensive tissue destruction) tissue
damage depth limited (except hydrofluoric acid), tanning effect
causes: bathroom, pool, agriculture & drain cleaners, rust
removers

Chemical
Burns - Alkalis

pH 8-14 tissue damage more severe continues
to spread, may start as superficial & become full thickness in
2-3 days causes: oven & drain cleaners, fertilizers,
sports line markers, anhydrous ammonia, cement

Chemical
Burns - Alkali Types

organic compounds: flammable, can go systemic, inc.
phenols/disinfectants (extended exposure) & petroleum
products
cement / concrete: pH wet =12, bluish tint, unaware
of burn, then worsens
Anhydrous Ammonia: pH >12 / strong base,
liquefied gas, fertilizer, indust. refrigerant, meth lab, colorless,
pungent odor, storage temp = -28 to -77 F (frostbite), rapidly
absorbed by eyes, throat, lungs (lg secretions), skin (deceptive
depth & pain), eyes (burning, tearing, severe pain, perm. damage
to cornea & lens)

Chemical
Burns - Meth

pt paranoid, unpredictable, violent booby-trapped
environment fire & explosion hazards Haz Mat -
decontamination: people, scene, transport vehicles, hospital Tx
areas

Chemical
Burns Tx

protect self stop injury progression, remove clothing,
irrigate 20-30min (eyes if exposed)
neutralizing agents - burn specific, incorrect use can cause
damage pH tests eyes - Morgan lens, saline
proper decontamination & disposal

Electrical Burns

electrocution: killed by electric
shock most frequent Burn Service cause of amputations
high risk: males, linemen, electricians, crane operators

Electrical
Burns - 3 Poss. Components

caused by current flow electrical arch: current passed
from source to object, temp 4000 deg C, flash burn, clothes may
catch on fire flame injury: ignition of clothing or
surroundings

Electrical
Burns

Low &
High Voltage Injuries

low voltage <1000v
household DIY projects kids - mouth & hand
burns appliances into water
high voltage >1000v
occupational: line workers, electricians, firefighters, EMS,
law enforcement during & following storms
recreation: kites, climb trees risk-taking
behaviors lightning

Electrical
Burns

Tissue Resistance

Iceberg Effect: what's seen on outside not = to injury
inside
most to least:
bone, fat, tendon, skin, muscles, vessels, nerve

Electrical
Burns

Injury Types

cutaneous muscle cardiovascular (V-fib,
arrest) respiratory skeletal (Fx &
dislocations) neurologic renal failure (early)
abdominal viscera orthopedic ocular &
otic hematologic

Electrical
Burns Tx

remove from electrical current, turn off current, use
non-conductor to separate pt from source protect self,
don't become part of current flow initial mgmt: ABC's, UOP
(75-100ml/hr)

Burn Center /
Critical Care Tools / Tech

VDR ventilators bi-level ventilation CRRT -
continuous renal replacement therapy Vit C (dec. amt of
fluid needed for resuscitation) heparinized breathing
Tx

Wound Mgmt

hydrotherapy early excision & grafting,
non-contact laser doppler, water powered mech. debridement
new topicals - silver products dermal substrates -
intergra, oasis, alloderm CEA topical negative
pressure scar mgmt

Wound
Mgmt - Temp Coverings

dermal substitutes: neodermis generation, covered with
ultra-thin, widely meshed STSG, "artificial skin"

Wound
Mgmt - CEA

(Cultured
Epithelial Autografts)

from pt's own cells no dermal component very
fragile takes a while to grow, expensive can be
combined with dermal substrates

Wound
Mgmt - NPWT

indications: chronic, acute, subacute, traumatic, &
dehisced wounds diabetic pressure ulcers
flaps grafts wound vac - change q3days
advantages: promotes wound healing, removal of
fluids & infectious materials, dec. pain d/t fewer dressing
changes, conforms to wound bed, helps hold grafts more firmly in
place, dec. LOS, inc. blood flow to area, may be done w/ home
care

Wound Mgmt -
Scarring & Contractures

hypertrophic scarring: excessive scar formation that rises
above level of skin, stays w/in boundaries of wound, common on
sternal, upper back, shoulder, & dorsal foot burns
masks worn if facial grafts to dec. scarring scar &
contracture mgmt: positioning, splinting, pressure garments

Wound Mgmt -
Necrotizing Fasciitis

infections: group A streptococcus, mixed infections
sources: sore throat, paper cut, hot tubs, unknown (most
common) S/S: red, swollen, hot, severe pain, blisters &
black skin

Wound Care
in Burn Center

includes care for major wounds, multi-organ failure, &
hypermetabolic response select physicians strong
knowledge base specialized wound care & products
less tissue loss less surgery improved
outcome