Speaker Disclosure Emergent Burn Care I, Debbie Harrell, MSN, RN, NE BC, have no financial relationships to disclose.

Transcription

1 Speaker Disclosure Emergent Burn Care I, Debbie Harrell, MSN, RN, NE BC, have no financial relationships to disclose. Debbie Harrell RN, MSN, Shriners Hospitals for Children Cincinnati Cincinnati, Ohio At a Glance OBJECTIVES Spokane Montreal Boston 90-year-old organization, founded in 1922 due to the polio epidemic in children 1. Identify the immediate priorities of the initial stabilization following of thermal injury. 2. Discuss types of burn injuries and different degrees of burn injuries. 3. State three complexities of the burn injury and the American Burn Association criteria for referral. Portland Salt Lake City Northern California Los Angeles Springfield Twin Cities Chicago Erie Philadelphia Cincinnati St. Louis Lexington Greenville Shreveport Houston Network of 22 healthcare facilities that provide compassionate, high-quality, familycentered pediatric medical and surgical care Galveston Tampa Honolulu Mexico City Thermal Injuries 75% of burns are 10% or less 60% of burns are children 5 and under 90% of burns can be managed on an outpatient basis 1

2 Flame Injuries The use of smoke detectors has significantly reduced the severity of burn injuries. 80% reduction in mortality 74% decline in injuries from residential fires Initial triage Stop the Burning Process for 3 to 5 minutes (never use ice) Remove all clothing completely Cover with a warm dry dressing Prevent Hypothermia Increase temperature of ambient air Keep covered as much as possible Warm IV fluids Bair hugger Continuous temperature monitoring A burn injury, even 100% may not render a victim unconscious If the patient is unconscious or incoherent, look for a cause other than the burn. Head injury Anoxia Stroke Delay in treatment?????? Assessment of Inhalation Injury Airway Management Predisposing Factors Closed space Decreased mentation Diagnostic Tests ABG, CO-Hb Fiberoptic Bronchoscopy Chest X-ray Physical Examination Facial burns, singed hairs Mucosal edema of nose and mouth Carbonaceous sputum Hoarseness, stridor (laryngeal) Dyspnea, wheezing (small airway) 2

3 SMOKE Heat Inhalation Injuries Dry gas Upper Airway Orofacial surface burns Steam Edema <24 Carbon Monoxide Toxic Gases Hypoxia Cardiopulmonary arrest <24 hrs Lower Airway Atelectasis Pulmonary edema (24-72 hrs) Bronchopneumonia ARDS - pulmonary parenchymal failure (1 week - 1 month) Carbon monoxide Affects of Edema on Airway Treatment for CO Poisoning is removal from source, followed by 100% O 2. Infant Normal Edema 1mm Resistance increase 16x Diameter Decrease 75% Adult 3x 44% Edema & Burn Shock Burn damage causes increased capillary permeability. This increase in capillary permeability and the accompanying inflammatory process causes leakage into the interstitial space = edema Small burns have localized edema like a blister - but burns >20% will result in systemic edema including areas not burned Post burn day 1 Post burn day 7 3

4 Size of Burn Injury Total Body surface Area TBSA 4

5 Adult Rule of Nines Modified for Age years 1 year Estimation of Small Burns Palmar Method Patient s palm including fingers is equal to 1% of their Total Body Surface Area (TBSA) Indications for Fluid Resuscitation Fluid Replacement TBSA > 20% adults TBSA > 20% Children Age >65 y/o or < 2 y/o any size burn Large Bore IV Crystalloid Solution Lactated ringers Begin as soon as possible 5

6 Pain Control Partial Thickness In the ER, small incremental doses of morphine can be given IV & titrated to effect. Oxycodone/APAP, Tylenol, or similar analgesics, are usually effective for discharge. Medicate 30 minutes before dressing change. Remember that the pain is more intense when the burn is open to the air. Managing anxiety in pediatrics is key. Early Fluid Management Pre hospital/primary survey in the hospital < 5 y/o 125ml/hr of LR 6-14 y/o 250ml/hr of LR > 15 y/o 500ml/hr of LR Resuscitation Calculations Calculated Resuscitation requirement 3ml x kg x % burn = estimated total fluids for 24 hours Resuscitation Fluid per 8 hours Half of total in first 8 hours Remaining amount in next 16 hours Parkland Formula 3ml x 20kg x 90% = 7200ml/24 hours 1 st 8 hours 3600 = 450ml/hr 2 nd 8 hours 1800 = 250ml/hr 3 rd 8 hours 1800ml = 250ml/hr Adequate Fluid Resuscitation Based on urine output Pediatric.5ml to 1ml/kg/hr Adults (>15yr) 30ml to 50ml/hr Urine Output Urine output inadequate Increase total body fluids by 10% Do not bolus Urine output to high Decrease total body fluids by 10% 6

7 Escharotomy Incision made into the eschar to relieve pressure on compartment Chest escharotomies allow for easier ventilation of pt. Can be life saving Lateral incision mid-axillary line Across chest and abdomen if involved Escharotomy Vascular impairment from circumferential burns Laterally & Medially Across involved Joints Types of Burns Contact Scalds Flame Chemical Electrical 7

8 Post burn day 3 Post burn 20 Tar Burns Tar creates a thermal injury, not a chemical one Bitumen compound not absorbed, not toxic» Cool tar to stop the burning process» Facilitate removal with use of a petroleum based ointment or medically safe solvent to emulsify the tar Scald Injuries Time of contact and water temperature to cause a burn degrees 5 minutes degrees - 30 seconds degrees - 5 seconds degrees - instantaneous Young children and older adult may burn deeper faster because their skin is often very thin 8

9 Scald Burns Accidental Splash marks present Non-Accidental No splash marks Irregular pattern of burn Consistent history Clear demarcation Inconsistent story Post burn day 1 Post burn day 10 Post burn day 20 Non accidental 9

10 Flash and Flame Injuries Flash burns Intense heat for a short period Clothing protective unless ignited Generally not full thickness Flame burns Deep dermal or full thickness Proportional to time of contact Post burn day 1 Post burn day 7 Chemical Stop Burning Process Brush Away vs. Flush Away Flushing 20 minutes continuous 10

11 Electrical Injuries Low-voltage <1,000 V Localized to area surrounding the area High-Voltage >1,000 V Deep extension and underlying tissue damage 11

12 High Voltage Monitor for Cardiac Dysrhythmias Monitor Peripheral Pulses Fluid Resuscitation 3 ml X kg X %TBSA Urine Output if myoglobin present Adult ml/hr Children 1 ml/kg/hr Myoglobinuria Presence of myoglobin and hemoglobin in the urine. Pigmented urine darker than light pink Indicative of significant muscle and tissue damage Presents the risk of renal failure, it must be cleared. Maintain UOP at 100ml for adults 1mg/kg for kids May add one amp sodium bicarb to each unit of resuscitation fluid 12

13 Other Conditions Frostbite Frostbite Dog bite Friction burns Road rash Avulsion Area of necrosis noted to wound flap on the right side needing demarcation. Returned to OR on June 7 th for application of split thickness skin graft. Friction burn Road rash 13

14 1 st degree Involves epidermis Reddened, painful, No blisters Heals within 3-10 Days No scarring Care Lotion for comfort Superficial 2 nd degree Involves epidermis/part of dermis Partial Thickness Painful, red, blisters Most often heals within 14 days Treatment 1 2 Administer pain medication Remove any wet or cold dressing. Cover with a dry dressing Wash with soap and water. Wound care Transfer directly to a burn unit. Cover the burn with a clean dry dressing. Going home, place antibiotic ointment/vaseline/aquaphor on a dressing cover the burn. Dressing Preparation 3 4 Dressing Application 5 6 Post burn day 2 tx with silver sulfadiazine Post burn day 5 tx with Bacitracin 14

15 PBD 1 PBD 7 PBD 14 Full Thickness 3 rd degree Epidermis/Dermis No pain/blanching Whitish/leathery/red Will not heal Post burn day 2 Post burn day 14 15

16 Post burn day 5 Post autograft 1 Post autograft 3 months Sheet Autograft A strip of donor site is taken and transferred without alteration to the excised burn area. Advantages: more durable than mesh grafts more cosmetic contracts less than mesh grafts Disadvantages: bacteria may collect under the graft causing graft loss. Scar Management Hypertrophic Scar Keloid 16

17 Guidelines for compression therapy Post burn 6 months Healing time <10 days no compression days monitor >21 days compression Post burn 1 month Post Burn 14 months Plastic Surgery Cleft Lip and Palate Brachial Plexus Injury Hand Malformations Hairy Nevus Port Wine Stains Breast Deformities Ear Deformities Vascular Malformations Hidradenitis Ear Reconstruction 17

18 Congenital Hairy Nevus Type of mole present at birth Often pale at birth; darken and grow with the child Can have regular or uneven borders Most are benign, but they do have potential to become malignant Gynecomastia Breast Asymmetry 18

19 Within the App 19