Burn Management all Phases
PRE-HOSPITAL BURN MANAGEMENT
1. Small thermal (<10% TBSA) - cool, clean, damp towel
2. Large thermal
ABCs
- airway patency, soot around nares, singed hair
- breathing adequacy
- pulse presence, regularity
3. Chemical
remove chemical (brush off)
lavage; blot dry
remove clothes
clean sheet
4. Electrical
remove from source
ABCs
C-spine precautions
exit/entry site
distal pulses
assess for injury (d/t falls, muscle contractions)
dry, clean sheet
EMERGENT PHASE
Phase during which immediate problems are addressed/resolved
Fluid loss/edema formation until fluid mobilization/diuresis
Pathophysiologic Problems
Fluid and electrolyte shifts:
Burn injury > increased blood flow > release of vasoactive substances > increased capillary permeability > water, Na, plasma protein shifts to interstitial and surrounding tissues > decreased intravascular volume > hypovolemic shock and its S&S.
Insensible losses (evaporation) - up to 400 ml/hour
RBCs:
- hemolyze d/t direct injury and circulating factor
- Hct elevated d/t hemoconcentration (r/t fluid loss)
- Net anemia (evident after fluid replacement)
Electrolytes
- K+ released from injured cells > hyperkalemia
- Na > interstitial spaces
RX: fluid resuscitation restores capillary normal permeability > stpos fluid losses and edema > interstitial fluid returns to vascular space > diuresis
Inflammation and Healing
leukocytes/monocytes accumulate
wound repair 6-12 hours after injury
Immunologic Changes: High infection risk d/t:
loss of protective skin barrier
reduced levels immunoglobulins
reduced #/function WBCs
Clinical Manifestations (Emergent Phase)
pain & hypovolemia > S/S shock
blisters (partial thickness burns)
edema
adynamic ileus (r/t trauma and K+ shift)
shivering (heat loss, anxiety, pain)
altered mental status (r/t hypoxia -- smoke inhalation; medications)
Complications (Emergent Phase)
CVS
shock, arrythmias
impaired circulation to extremities r/t circumferential burns/edema > ischemia, necrosis, gangrene
RX: Escharotomy (incision through eschar to restore
circulation
Increased blood viscosity > sludging
Respiratory
Upper airway burn > obstruction > asphyxia
Inhalation injury: alveolar damage d/t inhalation of chemical fumes or smoke > edema interferes with oxygenation
Renal
Hypovolemia >renal obstruction > ARF
Myoglobin (from muscle breakdown) & hemoglobin (RBC breakdown) can occlude renal tubules > ARF. Prevent with fluid replacement and diuretics
Management: Emergent Phase
ABC: intubate before respiratory failure develops; extubate when edema resolves. Escharotomy may be performed
Circulation:
- IV access
- Fluid replacement if > 20% TBSA with crystalloids
- Parkland Formula
- Second 24 hours: Colloids
Goal:
- U/O 30-50 ml/hr
- SBP > 90-100 mm Hg (via arterial line)
- HR < 100/mon
- Alert and oriented
WOUND CARE
Stabilize first
Cleanse and debride
Wound RX methods: Open or closed
Wound closure via graft
- heterograft
- homograft
- autograft
- cultured epithelial graft
PHARMACOLOGICAL MANAGEMENT
Analgesics/sedatives (IV)
Tetanus
Antimicrobials: Topical
- Flamazine, Acticoat, Gentamycin/Garamycin topically,
Bactigras, Porcine
NUTRITIONAL MANAGEMENT
Nasogastric tube for paralytic ileus until bowel sounds
Clear fluids > progress (high cal/protein)
Hypermetabolic: needs 5000 cal/day
ACUTE PHASE
Time from fluid mobilization/diuresis until burns are completely covered or healed (Duration: weeks/months)
Edema resolves
Burned areas more evident:
- partial thickness: pink-red, waxy/shiny, painful
- full thickness: dry, waxy white-dark brown, no sensation
Bowel sounds return
Healing begins; necrotic tissue sloughs
Clinical Manifestations:
Eschar separates: debride and graft
Partial thickness: self-healing
Hypo/hypernatremia
Hyper/hypokalemia
Complications (Acute Phase)
Infection
Cardio-pulmonary (as for Emergent Phase)
Neuro: extreme disorientation
Musculoskeletal: high risk for contractures***
GI:
- diarrhea (feedings, antibiotics)
- constipation (narcotics, immobility)
- ileus (sepsis)
- ulcers (stress): prevent with H2 histamine blockers
Endocrine: stress diabetes
Management Acute Phase:
Fluid therapy
Wound care
- Debridement (enzymatic, surgical)
- Excision and grafting: sheet graft, mesh graft
- Cultured epithelial autograft
- Artificial skin
Pain Management
- Partial thickness: excruciating
- Full thickness: no pain, except at margins (partial
thickness)
- Narcotic, psychotrophics
- Adjuncts: relaxation, imagery, etc.
Nutrition: high caloric needs; formula; supplements(po, TPN)
Emotional support (pain, disfigurement, body image, functional capacity, rehab)
REHABILITATIVE PHASE
Begins when wounds covered with skinor are healed; self-care begins!
Healed skin: pink and flat > then raised and hyperemic
New tissue: needs ROM to prevent contractures
Pressure garments to keep scars flat
Complications:
Contractures: keep body parts extended
EMOTIONAL SUPPORT!!!!!