UCalgary Burns Lecture 2024 PDF

Burn Care Basics Lindsay Burnett MN NP CBRN A little bit about me: Graduated from the University of Alberta in 2006 Completed final preceptorship in Burns in Calgary Clinical Teaching Scholar- collaborative between AHS, UofC & MRU CNE Ortho x 1 yr CNE for Burns MN thesis (UCalgary 2...

Burn Care Basics Lindsay Burnett MN NP CBRN A little bit about me: Graduated from the University of Alberta in 2006 Completed final preceptorship in Burns in Calgary Clinical Teaching Scholar- collaborative between AHS, UofC & MRU CNE Ortho x 1 yr CNE for Burns MN thesis (UCalgary 2013) NP (Acute Care, UCalgary 2022) Certified Burn Registered Nurse (2023) Burn Survivor Program (Phoenix Society SOAR Coordinator) Canadian Association of Burn Nurses/Canadian Burn Association American Burn Association Goals by the end of the session: 01 02 03 04 Discuss the Define Describe Assess pathophysiol airway and treatment knowledge – ogy related inhalation priorities case studies to burn injury injuries  Normal Skin What are some important functions of skin? Figure 41.1(Power-Keen et al., 2023, p. 1022) Innate: First Line of Defense (Power-keen et al., 2023)  “Epidermis is life, dermis is quality of life” Chua, 2016 Traditional Depth Classification: First Degree Second Degree Third Degree Fourth, fifth, six…? …a poor classification Classification of burns by depth Requires surgery / New terminology Old terminology Healing time skin grafting typical? Superficial 1st degree 2-3 days No Superficial partial 2nd degree 14 days No thickness Deep partial 2nd degree > 21 days Sometimes thickness Full thickness 3rd degree Never Yes Sub dermal 4th degree Never Yes 1. American Burn Association (2017) Burn Depth Figure 27.3(Kwong et al., 2023, p. 522) Jescke, et al. 2020. Superficial Burn Epidermis only – Red, dry, blanches with pressure – Minimal swelling, no blisters – Painful! Healing: – within 2-5 days – No scar. No pigment change. Superficial Partial Thickness Burn All of epidermis and into papillary dermis – Pink - red, moist, moderate swelling, Figure 41.27 (Power-Keen et blisters. al., 2023, p. 1044) – Painful! Healing: – within 21 days; +/- scar Figure 27.1 (Kwong etal., 2023, p. 520) Deep Partial Thickness Burn All of epidermis and into reticular dermis – Red to white, blistered, moist, moderate swelling Healing: – takes longer than 14 days, and usually 3-8 weeks to heal. – will usually result in hypertrophic scarring. Figure 27.1 (Kwong etal., 2023, p. 520  Figure Full 27.1(Kwong et al. 2023, p. Thickness 520) Burn All of epidermis and dermis and into subcutaneous tissue White or black, charred, leathery Does not blanch Swollen Pain is variable Healing: Long time to heal, if at all will definitely form a hypertrophic scar Figure 41.29(Power-Keen et al. 2023, p. 10  1 5 ”Mixed Depth” Superficial Partial thickness Deep Partial thickness  Zones of Injury Zone of Coagulation Central portion of the burn wound Most intimate heat contact Coagulation necrosis Temp>45C No cellular recovery possible Severity decreases from the surface of the skin to deeper layers Zone of Stasis Heat injured but viable Injured microvascular circulation Thrombosed and patent vessels Can easily convert to nonviable tissue if any further insults are obtained Release of TXA2 and O2 free radicals leads to progressive ischemia The inflammatory response in the zone of stasis is responsible for burn edema Zone of Hyperemia Viable tissue Responding to injury by inflammation Recover in 7-10 days Are there any tools to help predict burn depth? Laser Doppler Mechanis ms of Injury Thermal (Flame, Contact, Scald) Chemical Electrical Friction Cold injuries (frostbite) *Degloving *Necrotizing Soft Tissue Infections (Necrotizing Fasciitis) *E. Skin Diseases (SJS/TEN) Severity of the Burn Important in determining the seriousness of the injury:  The location of the wounds  The age of the patient  The causative agent  Duration of contact  Temperature  The presence of respiratory involvement  The general health of the patient Checkpoin t: Burn depth assessment is a skill that takes time to learn and even the most experienced burn care providers aren’t 100% accurate Burn depth can evolve based on many factors, more of that to come…  How do we manage burns that present for care? Principles of Acute Burn Life Support (ABLS) Initial Assessment & Management Primary Survey Secondary Survey TBSA Fluid Resuscitation Assessment and monitoring requirements  Primary survey A= airway and cervical spine support B= breathing and ventilation C= circulation and cardiac status D= disability, Neurologic Deficit, and Gross Deformity “AVPU” E= exposure and environmental control (undress patient) 26  Secondary survey History Pre-Burn Weight Head to Toe Circumstances of the injury (how The burn is often the most did it occur?) obvious injury, but other Medical History: serious and even life- A (allergies) threatening injuries may be present. M (medications) A complete neurologic P (past medical history, pregnancy) examination performed, and any L (last meal) associated/indicated E (events/environment leading up radiologic and laboratory to injury) studies are obtained T (tetanus) 27 Airway and Inhalation Injury Inhalation of superheated gases, steam, and/or products of combustion Increases mortality (accounts for ~75% of all burn- related deaths) What history would be important? How would you assess? American Burn Association, 202 Carbon Monoxide Poisoning Odorless gas Binds hemoglobin with an affinity 200x greater than oxygen Decreases delivery of oxygen to tissues Plasma carboxyhemoglobin level essential to diagnose CO poisoning Treatment: 100% oxygen American Burn Association, 20 CO level (%) Symptoms 0-10 None 10-20 Tension in forehead, dilation of skin vessels 20-30 Headache, pulsating temples Severe headache, blurred vision, nausea, vomiting, 30-40 collapse As above plus syncope, increased respiratory/heart 40-50 rate As above, plus coma, seizure, Cheyne-Stokes 50-60 respirations Coma, seizures, weak respirations and pulse, possible >60 death American Burn Association, Cyanide Poisoning Gas generated from combustion of synthetic products such as plastics Inhibits cellular oxidative mechanism Causes lactic acidosis Antidote: Hydroxocobalamin Brand Name: Cyanokit American Burn Association, 2  Secondary Survey Determine Severity of Burn- Depth 32 Carrougher, Secondary Survey Determine Severity of Burn- EXTENT ABA, 2023 Figure 41.30(Power-Keen, 2023, p. 1044) 33 Lund & Browder Figure 27.8(Kwong et al., 2023, p. 528) ABA, 2022 Any Burn. Any Time. Local vs Systemic Inflammatory Response Release of inflammatory mediators, causing: Vasodilation Increased capillary permeability Increased coagulation Local to the burn in small burns Systemic in large burns >20% This Photo by Unknown Author is licensed under CC BY-ND Why burns make people sick… Systemic Inflammatory Response As the TBSA of the burn increases (>20%) and the depth increases, the likelihood of the entire body being affected increases Burns affect many body systems and can lead to a systemic inflammatory response syndrome (SIRS) Body temp >38 or 90 RR >20 WBC >12 or