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Burns
- injury to body tissues, caused by the following:
- - thermal
- - chemical
- - electrical current- heat
- - radiation source
- occur when heat energy is transferred to tissues
- effects depends on temp of burning agent, duration of contact time and type of affected tissue
- estimate about 500,000/yr
- incr survival d/t coordinated national programs, child resistant lighters, nonflammable children clothing- more educated, more protection for children
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mechanism injury- thermal
- exposure contact with flame, scalds/hot liquids, steams or hot objects, most common
- think about abuse sometimes with kids and elders
- boiling hot water
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mechanism injury- chemical
- skin contact with caustic chemical compounds such as strong acids, alkali organic compounds
- think abuse
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Electrical
- what determines the extent of damage incurred with electrical current burns
- - amt of voltage
- - length of exposure
- - type of current and contact
- - pathway flow and tissue resistance
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Mechanism of injury- electrical burn
- heat generated travels thru body, causing internal tissue damage
- AC (alternate contact) more dangerous than DC (direct contact)
- - asso tetanic muscle contration, VFib
- - this is d/t low voltage so you hold on to it a little bit longer
- Myoglobin release from tissue may lead to tubular necrosis/ARF
- - myoglobin release and cause acute renal failure
- heat goes thru body- only see entrance and exit. there is more damage internally
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Mechanism injury- smoke/inhalation
- smoke/inhalation
- inhalation of noxious chemicals, hot air from flames causing injury to resp tract
- common injury: carbonmonoxide poison
- radiation: least common
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Patho of burn
- Burn-
- - inc vascular permability
- - dec intravascular volume- oozing out- blood shift
- - inc hematocrit- bc plasma leaves
- - inc viscosity
- - incr peripheral resistance (burn shock- fluid rescustation)
- also
- - inc vascular permability
- - edema
- - dec blood volume (dec BP, shifting fluid)
- - inc peripheral resistance
- - burn shock
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Patho- neuro
- generally no neuro sequelae unless
- - associated with trauma
- - dec perfusion to brain
- - hypoxia
- - inhalation injury
- brain no glucose or oxygen
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Patho- cardiovascular/respiration
- inc HR and PVR
- dec CO- think inc hematocrit viscosity- fluid resusciatation
- after 24h, CO returns to normal d/t hydration to meet metabolic needs
- respiratory:
- if smoke inhalation injury
- - edema risk greatest 6-8 h after injury
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patho- GU/GI
- GU:
- - initial oliguria
- - w/adequate hydration, ARF may occur- due to myoglobin release
- GI:
- - dec mesenteric flow, dec gut motility/absorption- risk of ileus- NG tibe to suction
- - UGI ischemia- superficial erosions
- - untreated, leads to ulcers & GIB curling's ulcers)
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Patho- immune
- ** primary defense lost **
- decreased lymphocyte activity
- dec immunoglobulin production
- alterned neutrophil & macrophages functioning
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Patho- metabolic
- increased H2o loss causes surface cooling
- basic metabolic rate inc to generate more heat & inc temp
- leads to negative nitrogen balance
- inc cal and protein
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Patho- psychological response
- 4 stages (Lee)
- - impact- immediately- shock- disbelief overwhelmed (dont teach)
- - retreat- depression, denial: F. R monitor, avoid infection
- - acknowledgement- acceptance, mourning
- -- support groups helpful
- reconstructive- limitations accepted , realistic plans made
- pt will need to talk about work, kids etc
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Patho- burn pain
- Background pain
- - at rest or w/minimal movement
- - continuous, low intensity, may last entire course
- Procedural pain
- - r/t therapeutic procedures
- - acute, high intensity
- pain meds during peak time work with patient
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Patho- inhalation injury
- trauma to respiratory tissue
- facial burns, erythema, swelling of oropharynx/nasopharynz, singed nasal hairs, agitation, anxiety, tachyapnea, flaring nostrils, stridor, wheezing, hoarse voice, sooty sputum
- fiberoptic bronch/lung scan to confirm
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Patho Carbonmonoxide CO poisoning
- Hbg has 100x more affinity for CO than O2
- CO binds w/hbg & displaces O2, becoming carbonxyhemoglobin- causes cerebral hypoxemia
- change is MS, cherry- red color on skin esp mucous membrane
- check ABG's
- rx w/100% O2, hyperbaric chamber
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Depth of burn- partial thickness
- superficial (1st degree)- epidermis
- - erythema pain @ burn site, no blisters
- deep (2nd degree)- epidermis & dermis
- - wet, shiny, weepy skin, blisters, severe painful, white- red skin
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depth of burn- full thickness
- 3rd degree- thru SC tissue, blood vessels
- - deep red, white, black, brown skin, dry, no blanching, insensate to touch
- 4th degree- thru to bone
- - color variable, charring in deepest areas, insensate to touch
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Extent of burn (size)
- extent of burn size helps/guides the treatment decisions
- two commonly charts used to determine TBSA (total body surface area)
- - Rule of nines chart ** different parts of the body with certain %
- - lunder-bowder chart- pedi
- usually, first degree burns/sunburn not inclusive
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location of burn
- head, trunk, neck, chest,- frequent pulmonary complications
- hands, feets, joints, eyes affects self care
- ears and nose- inc risk for infection
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patient risk factors
- age- higher mortality in children < 4 adults older than > 65
- preexisiting medical disorders inc risk complications
- asso injuries inc risk of complications
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management (severity)
- Minor
- - ER tx then outpatient
- - < 15% TBSA if < 40 yrs < 10% if > 40 yo
- considers burn depth, size, location, victim's age, general health, mechanism of injury
- place the area in cool water
- Moderate
- - hosp for care
- Mjor
- - burn specialized unit
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Management- Emergent phase
- starts from onset of burns even until pt is hemodynamically stabilized, collaborative care
- - first aid at scene- ABC's
- - stop/drop/roll
- - flush chemical burns with water
- - transport to the hospital
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Emergent phase- ABC and Fluid resurcitation FR
- assess s/s inhalation injury, CO poisoning
- IV FR- for > 15% TBSA
- - 2 large + IV thru non burn skin
- - % of burn calculated & FR initiated
- - insert urinary catheter
- - monitor urine output
- Photos often taken
- Monitor- BP, HR, urine output
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Emergent phase- FR
- imperative
- Parkland formula most common
- Type of FR is determined by
- - size/depth
- - age, pre-existing chronic illness (cardiac pt- fluid pay attention)
- FR with crystalloids (LR) & colloids (albumin)
- assess response to FR
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Emergent phase- wound care
- strict hand washing with soap and water** infection
- wear gown and mask during procedure
- daily shower, wound cleansing
- change invasive tubing daily
- maintain sterile technique
- assess extent/depth of wound
- monitor CSM/cap refill- eschar
- escharotomy
- - initiate abx
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Eschar
- is an area of dead tissue on the skin. the tissue is often necrotic, or created as a result of the early death of otherwise health skin cells such as in burn injury
- if eschar is noted, escharotomy must be done
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echarotomy- indications
- circulation to distal limb is in danger d/t swelling
- - slowing capillary refill/pedal pulses
- - progressive loss of sensation/motion in hand/foot
- - progressive loss of pulse in the dital extremity by palpation/doppler
- in circumferential chest burn, pt might not be able to expand chest enough to ventilate and might need escharotomy, the skin in chest
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Acute phase wound care
- cleansing, debridement, shaving, culturing
- asso of infection/adequate circulation
- hydrotherapy- immersion, showering, spraying < 30 min
- debridement- mechanical, enzymatic, surgical
- topical antimicrobials- silver sulfadiazine, Sulfamylon
- * may reduce renal buffering and can cause metabolic acidosis
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wound care
- open dsg- antimicrobial cream, OTA
- closed dsg- gauze impregnated w/antimicrobial applied to wound
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wound care 2
- grafts- dec fluid loss, protection, dec pain, speed healing
- - temporary- like dsg- biologic, biosynthetic synthetic
- - autografts- pts own skin grafted
- care for donor site as well
- immoblized extremity for adherence, elevate x 3-7d
- cultured epithelial autografts- massive burns
- - pts skin grown in lab x 20-30d, then applied
- monitor- s/s, sterile procedure, position pt correctly
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Acute phase- nutrition
- essential- promotes normal healing
- poor nutrition- negative impact on
- - immune response
- - wound healing, metabolic fxn and survival
- diet, tube feeding, PPN, TPN, alone or combined
- enc oral route for nutritional replacement
- assess healing, healing wound, skin tugor
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Acute phase- pain management
- partial thickness & newly harvested skin- very painful
- full thickness- no pain as no nerve endings
- IV analgesics ** no SC or no IM- don't know tissue damage inside
- hypnosis, guided imagery, biofeedback, music therapy
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acute phase- psychological support
- therapeutic listening- support
- inc self reliance
- group meetings for pts and families
- - once at acknowledgment stage
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acute phase- physical therapy
- to maximize functional recovery
- wound contracture & hypertrophic scarring can become problems
- therapeutic positioning- generally not comfortable
- ** no pillows to dec neck contraction**
- medicate pt before this
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