Burns - Lecture notes Topic 15 PDF

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Burns, chemical, thermal, skin infections christopherson, 430...

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● Types of Burn Injury ○ Chemical Burns ■ Immediate care ● Chemical should be quickly removed from the skin ● Clothing containing chemical should be removed ● Tissue destruction may continue up to 72 hours after chemical injury ○ Tissue death isn’t instantaneous, it goes on in the body ○ Electrical Burns ■ Severity of injury depends on electrical factors ● Coagulation necrosis caused by intense heat generated from an electric current ● May result from direct damage to nerves and vessels, causing tissue anoxia and death ● Vital organs produce more life-threatening sequelae ● Difficult to assess, most damage occurs beneath skin→ “Iceberg effect” ● Muscle spasms strong enough to fracture bone ■ Patients are at risk for ● Dysrhythmias or cardiac arrest→ VF, cardiac standstill ○ Continued risk for 24 hours after injury ● Severe metabolic acidosis ● Myoglobinuria ■ Myoglobin and hemoglobin from damaged RBCS travel to kidny ● AKI ● Atn ● Classification of burn injury ○ Severity of injury is determined by ■ Depth of burn ● Burns in past defined by degress (first, second third, and fourth) ● ABA advocates categorizing burn according to depth of skin destruction → partial thickness burn or full thickness burn ● Superficial partial thickness burn ○ Involves epidermis ● Deep partial thickness burn ○ Involves Dermis

● Full thickness burn ○ Involves all skin elements, nerve endings, fat muscle, bone ■ Extent of burn in percent of TBSA ● Two commonly used guides for determining ■ Location of burn ● Severity of burn injury is determined by location of burn wound ○ Face, neck, chest → respiratory obstruction ○ Hands, feet, joins, eyes → self care

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○ Ears, nose, buttocks, perineum → infection ● Circumferential burns of extremities can cause circulation problems distal to burn ● Patients may also develop compartment syndrome ■ Patient risk factors ● Older, younger, co-morbidities =greater risk ● Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene ○ Will take longer to heal ● Physical weakness ● Drugs ● Alcohol ● Smokers Prehospital Care ■ Remove person from source of burn and stop burning process ■ Rescuer must be protected from becoming part of incident ■ Electrical injuries ● Remove patient from contact with source ■ Chemical injuries ● Brush solid particles off skin ● Use Water lavage ● Tissue destruction may continue for up to 72 hours after ● Don’t rub them during wash, let water rinse them off. Rubbing can make it worse. Small thermal burns ■ Cover with clean, cool, tap water- dampened towel Large thermal burns ■ circulation , airway, breathing ■ Cool burns Inhalation injury-previously covered

■ Watch for signs of respiratory distress ■ Treat quickly and efficiently ■ 100% humidifed oxygen is CO poisoning is suspected ○ Emergent Phase ■ Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury ■ Up to 72 hours ■ Primary concerns ● Hypovolemic shock ● Edema ● Ends when fluid mobilization and diuresis begin ■ Fluid and electrolyte shifts ● Greatest threat is hypovolemic shock ○ Caused byy a massive shift of fluids out of blood vessels as a result of increased capillary permeability ● Fluid ● Normal insensibile loss: 30-50 mL/hr ● Severly burned patient: 200-400 mL/hr ● Facial edema Before and after Fluid resuscitation ● Net result of fluid shift is intravascular volume depletion ○ Edema ○ Dec blood pressure ○ Inc pulse ● RBC are hemolyzed by a circulating ■ Conditions leading to Burn shock ● At the time of major burn injury, there is increased capillary ● Burn Management ○ Patho ■ Emergent phase ● Inflammation and healing ○ Neutrophils and monocytes accumulate at site of injury ○ Fibrolasts and cologen ● Immunologic changes ○ Immune system is challenged when burn injury occurs ■ Skin barrier is destroyed ■ Bone marrow is depressed ■ Circulating levels of immune globulins are destroys

■ WBCs ● Clinical Manifestations ○ Shock from hypovolemia ○ Blisters ○ Paralytic ileus ● Complications ○ Cardiovascular system ■ Dysrhythmias an dhypovolemica shock ■ Impaired circulation to extremitiescircumferential ■ Impaired microcirculation and increased viscosity → sludging ■ Venous thromboembolism ■ Escharotomies of chest ● They do not feel pain ● Eschar does not bleed ● Keep cutting til we get viable tissue ○ Respiratory ■ Upper airway burns ● Edema forms ● Treatment ○ Airway managment ■ High fowler’s if possible ■ Early intubation ○ Fluid therapy ■ Two large -bore IV lines for >tbsa ■ >30% central line needed ■ Type of fluid replacement ● Parkland formula Practice ○ Step 1 ■ 40% BSA burned x ■ 165 lb= 75 kg x ■ 4 mL == 24 hour volume ○ Step 2 ■ ½ over 8 hours = ? mL ■ = ? mL/hr x8 hours ○ Step 3 ■ ½ over

Part 2 powerpoint ● Acute phase ○ Complications ■ Musculoskeletal ■ [ ○ Treatment ■ Wound care ● Appropriate coverage of graft ○ Gauze is ■ Excision and grafting ● Eschar is removed down to subcutaneous tissue or fascia ● Graft is place on clean, viable tissue ● Wound is covered with autograft ● Donor Skin is takne with a dermatome ● Split-thickness ● Sheet skin Graft to hand ● Grafts are attached with ○ Fibrin sealant ○ Sutures or staples ○ Negative pressure wound therapy ● With early excision, function is restored, scar tissue minimized ● Artificial skin ○ Life ■ Emotional therapy ■ Pain management ● Patients experience two kinds of pain ○ Continuous background pain ■ IV infusion ■ Physical and occupational therapy ● Good time for exercise is during wound cleaning ● Passive and active ROM ● Splint should be custom-fitted ■ Nutrition ● Meeting daily caloric requirements is crucial ● Albumin, pre albumin ● Rehabilitation phase ○ Patho ■ Begins when ● Would healing ● Ajfkda

■ In approx 4-6 weeks, area becomes raised and hyperemic ■ Mature healing is reached about 12 months ■ Skin never completely regains its original color ■ Discoloration of scar fades with time ■ Scar contour elevates and enlargesNewly healed areas ○ Treatment ■ Encourage both patients and cargivers to participate ● No oil ● Don’t scratch the graft off ■ Spiritual and cultural needs ■ All aspec of life affected ■ Constant encouragment and reassurance primary Cellulitis What causes it, how do we take care of it ● Contact dermatitis ○ Allergic reaction ● Psoriasis-can take you to cellulitis ● Vancomycin-SJS read article ○ Sjs or is there something going on ○ Sudden onset or happened 3 months ago. ○ Stop the drug ● Psoriatic arthritis ● Furbuncle ● Carbuncle...