Burn Trauma.pdf

Burn Trauma Presented by Lea Elder, RN Burn ICU Santa Clara Valley Medical Center 408-885-6666 SCVMC Burn Center Background SCVMC Burn Center open since 1970 8 bed critical care unit, can accommodate additional overflow pts in ICUs, TCU, Med Surg Accepting stable and unstable pts, adults and childre...

Burn Trauma Presented by Lea Elder, RN Burn ICU Santa Clara Valley Medical Center 408-885-6666 SCVMC Burn Center Background SCVMC Burn Center open since 1970 8 bed critical care unit, can accommodate additional overflow pts in ICUs, TCU, Med Surg Accepting stable and unstable pts, adults and children Multidisciplinary team consists of RNs, MD, Burn tech, RTs, PTs/OTs, Social Workers, Child Life Specialist, Case Managers, Registered Dietician, Psych American Burn Association verified Burn Center Also care for patients with Stevens Johnson syndrome, TENS, plastic surgery, reconstruction, flaps, contracture releases, and large and/or complicated wounds. Steven Johnson & TENS WHO GETS BURNED? THE VERY YOUNG THE VERY OLD THE VERY UNLUCKY THE VERY CARELESS 71% are men 17% admitted to burn centers are less than 5 yo FUNCTIONS OF SKIN Protective Water loss, environment Thermoregulatory Keep pt room warm Radiant warmers Immunologic Reverse isolation Anatomy of Intact Skin TERMINOLOGY SUPERFICIAL = 1ST DEGREE PARTIAL THICKNESS = 2ND DEGREE FULL THICKNESS = 3RD DEGREE Superficial Burn (First Degree) Affects epidermis/ 1st layer of skin Pink to red Mild to moderately painful Heals 3-7 days, no scar No blistering Does not count in TBSA Partial Thickness (Second Degree) Entire epidermis and upper layers of dermis Pink or cherry red Healing times 7-21 days, severity of scarring varies Superficial Partial (Second Degree) Epidermis and upper dermis Pale pink to red Blisters, wet appearance Blanches Painful Heals 7-14 days Deep Partial (Second Degree) Entire epidermis, most of dermis Fewer viable epidermal elements (slower healing) Pale pink to red Sensation may be diminished Blanching sluggish or absent No blisters, more dry Can convert Dense scarring Surgery, skin grafting Deep Partial (Second Degree) Full Thickness (Third Degree) Epidermis and entire dermis destroyed, extends to subcutaneous layer White, charred, black eschar Non-blanching Fixed Hemoglobin Thrombosed vessels Dry, leathery Insensate Requires skin grafting Full Thickness (Third Degree) Full Thickness Burn Injury Circulation assessment – palpate distal pulses and assess capillary refill Loss or diminished pulses/delayed capillary refill = shock, inadequate resuscitation (fluid), or constriction of the extremity d/t circumferential burns Such constriction is a surgical EMERGENCY and requires prompt intervention (escharotomy or fasciotomy) Escharotomies Escharotomy The Three Zones of Burn Injury Zone of Coagulation (Necrosis): Cell death, requires debridement Zone of stasis: Compromised circulation, cell damage, may convert (die) or recover Zone of hyperemia: Minimal Injury, Inflammation, increased perfusion TOTAL BODY SURFACE AREA (TBSA) Do not count superficial burn injury Rule of 9’s for adults 1% palm rule Lund and Browder chart BURN REFERRAL/CONSULT At Santa Clara Valley Medical Center, if you have a patient with ANY type of burns (any mechanism or size), make sure the Burn Team is consulted to assess burns. Burn team will monitor for conversion and will intervene EARLY. INITIAL MANAGEMENT OF BURN INJURIES TRAUMA MANAGEMENT Stop the burning process Airway (with cervical spine protection) Breathing – Administer 100% O2 for suspected inhalation injuries Circulation – Are there circumferential areas? Disability, Neurological Deficit, and Gross Deformity Exposure/Examine/Environment – Completely undress the patient, Examine head to toe, and maintain a warm environment INITIAL MANAGEMENT OF BURN INJURIES TRAUMA MANAGEMENT Burns are a distracting injury Head injury, c-spine Cardiac tamponade Hemo/pneumothorax Abdominal trauma Fractures, hemorrhage Labs: Chem 10 (electrolytes tend to be low), CBC, ABG, CO, Urine toxicity Burn Management: Airway and Breathing Inhalation Injury Inhalation injury is present in 2-14% of burn admissions When present, inhalation increases mortality greater than that predicted by age and TBSA or the cutaneous burns Burn Management: Airway and Breathing Concern for inhalation injury: History Enclosed space injury Toxic fumes/smoke Loss of consciousness Concern for CO (give 100% oxygen) Concern for cyanide poisoning (Treat with Cyanokit) Burn Management: Airway and Breathing Concern for inhalation injury: Physical Appearance Facial burns Singed scalp, nasal, and/or facial hair Soot on face, tongue, teeth, oropharynx Carbonaceous sputum Vocal quality Wheezing, stridor Agitation (hypoxia) Burn Management: Airway and Breathing Concern for inhalation injury: Edema S/sx may be absent on admission. Obstruction or closure may occur up to 24 hours post injury Heat produces edema Large body burns and subsequent fluid requirements increase edema Burn Management: Airway and Breathing Burn Management: Airway and Breathing Concern for inhalation injury: Edema EXTERNAL AND INTERNAL EDEMA HAVE A PARALLEL TIME COURSE. Swelling in the neck and face may indicate swelling in the airway. Nasopharyngoscopy to assess airway Burn Management: Airway and Breathing Burn Management: Airway and Breathing Inhalation Injury: Intubation What may be easy and safe when done in a timely manner may be impossible later Maintain a high index of suspicion for potential airway closure in any burn patient INTUBATE EARLY! Burn Management: Airway and Breathing Concern for inhalation injury: Interventions Elevate HOB Aggressive pulmonary toilet Careful fluid resuscitation Nebulizers Bronchodilators Circulation: Burn Shock and Fluid Resuscitation Burn shock = hypovolemic shock (especially in burns >20% TBSA) Hemodynamic changes: Generalized capillary leak Decreased plasma volume Decreased cardiac output Decreased end-organ perfusion Metabolic acidosis Multisystem organ failure Death Circulation: Resuscitation Phase Fluid shifts with inflammatory responses & 3rd spacing Insensible losses Electrolyte imbalances Hypothermia Goal is to keep the fluid in the vessels & avoid overresuscitation (pulmonary edema, ARDS, compartment syndrome), or under-resuscitation (Acute Kidney Injury, hypovolemic shock) Precise fluid management: Utah Protocol Circulation: Resuscitation Phase Adjusted IV fluid rate for burns >20%TBSA: Calculate 24 hr volume. Give half the volume in first 8 hrs post injury. Category Age and weight Adjusted Fluid Rate Flame or scald Adults and children >14y.o. 2mL LR x kg x TBSA Children 20%TBSA Infants may become hypoglycemic and require glucose Low body glucose reserves Therefore, add maintenance D5LR to resuscitation fluid Pediatric Burn Injury: Circulation Resuscitation formula does not factor insensible losses nor maintenance fluid needs, so add maintenance rate for pts < 30kg. Pediatric Burn Injury: Circulation ABA’s 24 h Maintenance Fluid Formula 1-10 kg = 100 ml D5LR/kg 11-20 kg = 50 ml D5LR/kg >20 kg = 20 ml D5LR/kg Pediatric Burn Injury: Circulation ABA’s 24 h Maintenance Fluid Formula Example 20% TBSA burn of 25 kg child 10 x 100 = 1000 mL D5LR 10 x 50 = 500 mL D5LR 5 x 20 = 100 mL D5LR = 1600 mL D5LR/24 hours = 67 mL/hr MAINTENANCE FLUID Pediatric Burn Injury: Circulation Total Fluid Resuscitation Formula Example: 20% TBSA burn of 25 kg child 67 mL/hr MAINTENANCE FLUID + 94 mL/hr RESUSCITATION FORMULA = 161 mL/hr for FIRST 8 hours post-burn Pediatric Burn Injury: Circulation Avoid bolusing Begin with the formula Make small, incremental changes based on urine output. Avoid BIG jumps up and down in infusion rate Small adjustments = big results Recognition of Pediatric Burn Abuse Scald is the most common non-accidental burn trauma Scald is the most common mechanism for children less than 5 yrs old who are hospitalized in US burn centers: Glove, stocking, and dip burns Instrument/Object Burns Guidelines for pediatric burn abuse apply to abuse of all ages. Recognition of Pediatric Burn Abuse Documentation Document “story” word for word Objective documentation of parent/caregiver/child interactions Photos of all burns, marks, bites, bruises Recognition of Pediatric Burn Abuse Reporting Required by the penal code. Failure to report can result in criminal penalties Call Child Protective Services (CPS) Notify your charge nurse, the attending physician, the nursing supervisor, the social worker, risk manager, and the appropriate police agency. Burn Wound Assessment and Management Primary and Secondary Survey ABC’s Remove all clothing and jewelry Head-to-toe, Front-to-back assessment Pain Management Pharmacologic New Admission Do not use IM medications Fluid shifts during emergent phase can cause unpredictable results. Use IV medications Dilaudid, Fentanyl, Versed, Propofol Intubated patients are on continuous drips Depending on if the patient is intubated or not, may also give oral analgesics and sedatives (oxycodone, valium, versed) Subsequent dressing changes: First use oral analgesics/sedatives then add IV as needed Pain Management Non-Pharmacologic Distraction Visualization Family or Significant Other Virtual Reality Phone, iPad Psychologist or Child Life Specialist present for dressing change Wound Assessment and Management Assess wounds for area and depth Photograph wounds and associated injuries Bathe unburned skin Shave hair 1-2 inches from burn surfaces Debride and cleanse wounds Apply appropriate topical treatment Burn Topical Medication Silver Sulfadiazine (SSD) Is a broad-spectrum antimicrobial cream Used on non-blanching, full thickness wounds, and deeper partial thickness. Can cause decrease in white blood cell count (neutropenia) Sulfamylon Cream aka “SMC Cream” Sulfamylon cream is an antimicrobial cream Used for cartilaginous areas such as nose and ears d/t greater penetration ability Can cause acidosis. Burn Topicals Bacitracin Ointment Partial-thickness wounds Mix with xeroform gauze Synthetic Burn Topical Treatment Mepilex Ag Use on donor sites, TENS/SJS pts, partial thickness burns Acticoat Used on post-op grafting Both contain silver ions for antimicrobial effect Biologic Wound Management Skin grafting terms Tangential excision: “TE” Split thickness skin graft: “STSG” Autograft=pt’s own skin Allograft=cadaver skin Mesh vs. Sheet grafts Harvest of donor site(s) Tangential Excision Allograft Cadaver skin Aids in thermoregulation, pain control, and helps prep wound bed for autografting Used as a skin replacement and held with staples until patient and/or wound bed ready for autograft or wound heals on own Rejected by body in 7-21 days. Might need to be trimmed in meantime. Consult with burn RN. Allograft Biologic Wound Management Autograft: can meshed or sheet Meshed skin grafts Graft taken as sheet and meshed to cover a larger surface area Graft stapled into place Bolster and/or dressing to immobilize graft and prevent shearing Biologic Wound Management Autograft Split thickness autograft video Biologic Wound Management Sheet Graft No meshing done Held w/ glue, steri-strips, staples Bolster and/or dressing to immobilize graft and prevent shearing Stages of Burn Grafting from Initial Debridement to Full Closure Rehabilitation Rehabilitation begins on admission Goals of Rehabilitation: Maintain/restore function Control scarring and contracture Improve proficiency in ADL’s Initiate psychosocial support Rehabilitation Functional Interventions Elevate the affected extremities!! Decreases pain, edema, bleeding, loss of fluid Rehabilitation Functional Interventions Splinting: wounds contract as they heal. They will continue to contract for up to a year or more. Surgery may be needed to release contractures Place splints according to therapist directions Long leg splint Wrist extension contracture Neck and airplane splints Rehabilitation Functional Interventions Exercise: Active and Passive ROM Prevents atrophy, stretches skin, prevents pneumonia, and pressure ulcers Up to chair, walk, therapy gym Nutrition Metabolism increases up to twice basal rate Wounds need building blocks of protein in order to make cells. Vitamins needed to assist in this function. High protein, high calorie diet needed depending on patient’s weight and %TBSA. Dietician consult. Patient may eat on own and/or feeding tube inserted to supplement or sustain nutrition needs Emotional Adjustment Many losses Nightmares, flashbacks, depression Going back to school/work/society May take years Family adjustment Stress on relationships Anger/frustration/guilt Role changes in the family Waiting for things to get back to normal? Support for Burn Survivors 1. SCVMC Burn Center Peer Support Group meeting at SCVMC Burn library the first Tuesday of every month. 408-885-6666 For adult burn survivors and their support persons. Back to school programs for kids. 2. Alisa Ann Ruch Burn Foundation: http://www.aarbf.org/index.htm For all ages. Events throughout the year, including Holiday party. Week-long Champ Camp for kids, young adults and adults can volunteer. Young adult retreat. Adult retreat. Family camp. Adult survivors and non-survivors can offer volunteer services. 3. Phoenix Society: http://www.phoenix-society.org/ National organization for adult burn survivors. Annual conference – World Burn Congress. 4. Survivors Offering Assistance in Recovery (SOAR): http://www.phoenix-society.org/our-programs/soar Peer support program - Adult burn survivors offer support to other burn survivors. Hospital-based (SCVMC), Phoenix Society program 5. San Jose Firefighters Burn Foundation: http://www.sjfirefightersburnfoundation.org Events throughout the year for all ages, adults can volunteer. Weekend camp for kids. Annual Gala and silent auction with the SCVMC Burn Center. Goal is reintegration back into life… RESOURCES FOR HEALTHCARE STAFF 1. Santa Clara Valley Medical Center (SCVMC) Burn Center: 408-885-6666 2. SCVMC Burn Clinic: 408-793-2600 3. Advanced Burn Life Support (ABLS) classes available twice per year in March and September at SCVMC Burn Center. Maaike: [email protected] Marianne: [email protected] Call 408-885-6670. 4. American Burn Association (ABA): www.ameriburn.org 5. Monthly Burn HCP Support group via Zoom by AARBF