Curtin University Applied Bioscience Burn Injury Module PDF

Applied Bioscience for Health Complexity 2 (GMED3009) Burn Injury Module Learning outcomes Define burns Describe the mechanisms of burn injury Describe the classification of burn injury Describe the pathophysiology of burn injury Describe the methods of estimating the e...

Applied Bioscience for Health Complexity 2 (GMED3009) Burn Injury Module Learning outcomes Define burns Describe the mechanisms of burn injury Describe the classification of burn injury Describe the pathophysiology of burn injury Describe the methods of estimating the extent of burn injury Describe the complications of burn injury Explain the management of a patient with burn injury 3  Review- anatomy of the skin Layers Epidermis Dermis Subcutaneous Underlying Structures Fascia Nerves Tendons Ligaments Muscles Organs Definition Aburn is defined as a traumatic injury to the skin or other organic tissue primarily caused by heat or exposure to electrical discharge, friction, chemicals, and radiation. 5 Mechanisms of burns Heat Chemicals Associated with flames, hot liquids, hot solid objects, Injury is caused by a wide range of caustic reactions and steam The duration of exposure, the nature of the agent Most thermal burns involve the epidermis and part of will determine injury severity the dermis Contact with acid causes coagulation necrosis of the Thermal injury is related to contact temperature, tissue, while alkaline burns generate liquefaction duration of contact of the external heat source, and necrosis the thickness of the skin Local damage can include the full thickness of skin Electrical discharge and underlying tissues Electrical energy is transformed into heat as the Radiation current passes through poorly conducting body Radio frequency energy or ionizing radiation can tissues The magnitude of the injury depends on the pathway cause damage to skin and tissues The most common type of radiation burn is the of the current, the resistance to the current flow through the tissues, and the strength and duration of sunburn the current flow Common in patients receiving therapeutic radiation Friction therapy and excessive radiation from diagnostic Occurs due to a combination of mechanical disruption procedures of tissues as well as heat generated by friction Inhalation injury Airway thermal burn Toxic Inhalation  Supraglottic structures absorb heat and  Synthetic resin combustion prevent lower airway burns  Cyanide & Hydrogen Sulfide  Moist mucosa lining the upper airway  Systemic poisoning  Injury is common from steam  More frequent than thermal  Risk Factors inhalation burn  Standing in the burn environment Carbon monoxide poisoning  Screaming or yelling in the burn environment  Colorless, odorless, tasteless gas  Trapped in a closed burn environment  Byproduct of incomplete  Symptoms combustion of carbon products  Stridor or “Crowing” inspiratory sounds  Singed facial and nasal hair  Suspect with faulty heating unit  200x  Black sputum or facial burns greater affinity for  Progressive respiratory obstruction and hemoglobin than oxygen arrest due to swelling  Hypoxemia & Hypercarbia Classification of burns by depth Superficial or epidermal burns involve only the epidermal layer of skin. Partial-thickness burns involve the epidermis and portions of the dermis. Full-thickness burns extend through and destroy all layers of the dermis. Deeper (fourth-degree) burns extend through the skin into underlying soft tissues such as fascia, muscle, and/or bone. Classification of burns by depth Types of burn injury. A, Partial-thickness thermal hand burn. B, Full-thickness thermal hand burn. C, Full-thickness scald burn to the buttock and lower back secondary to immersion in hot water. Source: Courtesy Judy A Knighton, Toronto, Canada. Copyright © 2020 Copyright 2020 Elsevier Australia. Pathophysiology- Thermal burns Heat changes the molecular structure of tissue Denaturing (of proteins) Extent of burn damage depends on Temperature of agent Concentration of heat Duration of contact Pathophysiology- Thermal burns Jackson’s theory of thermal wounds Zone of Coagulation Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels Zone of Stasis Area surrounding zone of coagulation is characterized by decreased blood flow Zone of Hyperemia Peripheral area around burn that has an increased blood flow. Pathophysiology- Thermal burns Body’s response to burns Emergent phase (Stage 1)  Pain response  Catecholamine release  Tachycardia, tachypnea, mild hypertension, mild anxiety Fluid shift phase (Stage 2)  Length 18-24 hours  Begins after Emergent Phase  Reaches peak in 6-8 hours  Damaged cells initiate inflammatory response  Increased blood flow to cells  Shift of fluid from intravascular to extravascular space Massive oedema Pathophysiology- Thermal burns Hypermetabolic phase (Stage 3)  Last for days to weeks  Large increase in the body’s need for nutrients as it repairs itself Resolution phase (Stage 4)  Scar formation  General rehabilitation and progression to normal function Signs & symptoms Pain Burnt hair Changes in skin condition at Oedema affected site Haemorrhage Blisters Other soft tissue injury Sloughing of skin Musculoskeletal injury Hoarseness Dyspnea Dysphagia Chest pain Dysphasia Extent of burn injury A thorough and accurate estimation of burn size is essential to guide therapy and to determine when to transfer a patient to a burn centre The extent of burns is estimated and expressed as the total percentage of body surface area (TBSA) Methods of estimating extent of burn injury The two commonly used methods of assessing percentage TBSA in adults are the Lund-Browder chart and Wallace Rule of Nines The Lund-Browder chart is the recommended method in children because it considers the relative percentage of body surface area affected by growth Superficial (first-degree) burns are not included in percentage TBSA burn assessment. Lund-Browder The most accurate method for estimating TBSA for both adults and children Childrenhave proportionally larger heads and smaller lower extremities, so the percentage TBSA is more accurately estimated using the Lund-Browder chart Methods of estimating extent of burn injury Wallace Rule of Nines For adult assessment, the most expeditious method to estimate TBSA in adults is the "Rule of Nines“ The head represents 9 percent TBSA Each arm represents 9 percent TBSA Each leg represents 18 percent TBSA The anterior and posterior trunk each represent 18 percent TBSA Guides for determining the extent of a burn. A, Lund-Browder chart. By convention, areas of partial-thickness injury are coloured in blue and areas of full-thickness injury in red. Only areas of skin loss are calculated. B, Rule of Nines chart. Knighton, Judy, Lewis’s Medical-Surgical Nursing ANZ, Chapter 23, 505-533 Copyright 2020 Elsevier Australia. Complications Hypothermia  Disruption of skin and its ability to thermoregulate Hypovolemia  Shift in proteins, fluids, and electrolytes to the burned tissue  General electrolyte imbalance Eschar  Hard,leathery product of a deep full thickness burn  Dead and denatured skin  Complications Infection  Greatest risk of burn is infection Organ Failure  Release of myoglobin Ongoing hypermetabolism  Elevated glucose levels Hypertrophic scarring and keloid formation Contractures  Assessment of thermal burns Initial Assessment Airway Breathing Circulation Disability Environment Assessment of thermal burns Focused and rapid trauma assessment  Accurately approximate extent of burn injury  Rule of Nines or Lund and Browder  Depth of burn  Area of body effected Any burn to the face, hands, feet, joints or genitalia is considered a serious burn  Age of patient affected Management of thermal burns Minor burns  Local cooling  Remove clothing  Cool water immersion 20 minutes  Consider analgesics  Clean wound with 0.1% Aqueous Chlorhexidine or Normal saline,  Remove all foreign, loose and non viable skin/tissue Management of thermal burns Moderate to severe burns  Dry sterile dressings  Maintain warmth  Prevent hypothermia  Consider aggressive fluid therapy  Burns over IV sites  Place IV in partial thickness burn site. Management of thermal burns  Caution for fluid overload  Frequent auscultation of breath sounds  Consider analgesic for pain  Morphine  Fentanyl  Prevent infection Management of thermal burns Parkland Burn Formula 3-4 mL IV fluid x Pt wt in kg x % TBSA = Amt of fluid over 24 hours administered in the following order: Pt should receive ½ of this amount in first 8 hrs. Remainder in 16 hrs Nursing care IV access (Multiple) Manage perfusion needs by parameters of CVP, BP and Urinary Output Pain management Once vital signs have stabilized, pain medication should be used (ie morphine, or fentanyl, benzodiazepines as indicated ) Curlings ulcer prophylaxis (Peptic Ulcer) Proton Pump inhibitors (esomeprazole) start first 6 hours Tetanus prophylaxis Is immunization out of date Nursing care Wound Care (sterile technique) Escharotomy Debridement Anti-microbial application Nanocrystalline silver (acticoat) Closed dressing except face & perineum Graft Wound Allograft Escharotomies of the chest and arm Split thickness skin graft full thickness graft Source: Courtesy Judy A Knighton, Toronto, Canada. Knighton, Judy, Lewis’s Medical-Surgical Nursing ANZ, Chapter 23, 505-533 Copyright 2020 Elsevier Australia. Management of thermal burns Inhalation Injury  Provide high-flow O2 by non-rebreather mask  Consider intubation if swelling  Consider hyperbaric oxygen therapy Assessment & management of electrical, chemical & radiation burns Electrical injuries  Safety  Turn off power  Energized lines act as whips  Establish a safety zone  Lightning strikes  High voltage, high current, high energy  Lasts fraction of a second  No danger of electrical shock to EMS Assessment & management of electrical, chemical & radiation burns Assess patient Entrance & exit wounds Remove clothing, jewellery, and leather items Treat any visible injuries Thermal burns ECG monitoring Bradycardia, Tachycardia, VF or Asystole  Advanced Cardiac Life Support Protocols Treat cardiac & respiratory arrest Aggressive airway, ventilation, and circulatory management. Consider fluid bolus for serious burns Nursing care - Evaluation ABC assessment Airway – stridor Breathing – use of accessory muscles, lung sounds Circulation – CVP’s, BP, Pulse-Oximetry Fluids& Electrolytes/Renal Urinary output, labs, specific gravity, osmolarity, myoglobin (AKI) Pain Infection (? Gram negative or positive sepsis) Nutrition Weight, ulcer management Multi-disciplinary care References Australian New Zealand Burn Association www.anzba.org.au Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2019). Lewis's Medical-surgical Nursing ANZ: Assessment and Management of Clinical Problems (5th ed.). Elsevier Australia. LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., Reid-Searl, K., et al. (2020). Medical-surgical nursing: Critical thinking in client care (4th Aus. ed.). Frenchs Forest, NSW: Pearson Australia