At the conclusion of this course the learner will be able to

Transcription

1 Objectives At the conclusion of this course the learner will be able to 1. Discuss basic anatomy and pathophysiology of burns 2. Describe burn injuries in terms of size, depth, coloration and characteristics 3. Describe the treatment course for the management of minor burn injuries in pediatric patients.

2 Burn Center Referral Criteria 1. Partial thickness burns greater than 10% total body surface area (TBSA). 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third degree burns in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality 8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols 9. Burned children in hospitals without qualified personnel or equipment for the care of children 10.Burn injury in patients who will require special social, emotional, or rehabilitative intervention American Burn Association Advanced Burn Life Support (ABLS)

3 Assessing Burns: Where do you begin?

4 Like any other injury: ABCs take priority Airway Breathing Circulation Disability Exposure

5 Airway/Breathing * Assess for adequacy and patency of airway * Assess for inhalation injury There are three main types of burn-related airway injuries: 1. Carbon monoxide poisoning 2. Inhalation injury above the glottis 3. Inhalation below the glottis

6 Identifying an Inhalation Injury Assess for signs of inhalation injury. Clothing ignition Singed nasal hairs, eyebrows, or hairline Palate erythema Face, neck, chest burns Stridor Increased carboxyhemoglobin levels

7 Circulation Assess heart rate, blood pressure, skin color, sensation, pulses & capillary refill Fluid resuscitation necessary in patients with >20%TBSA injuries. Is the injury circumferential?

8 Wound Assessment

9 What do you need to know? What kind of burn is it? How severe is the burn? How big is the burn? (Type) (Depth) (%TBSA)

10 Burn Types Thermal Chemical Electrical Radiation 5 Sub-Types of Thermal Burns Flame Scald Steam/Flash Contact Hypothermic

11 Initial first aid for burns Stop the Burning Process!!! Remove from hot liquid and remove clothing. Cool the injury with cool tap water no ice Many home remedies tend are ineffective and potentially harmful

12 Thermal Burns Scald

13 Thermal Burns Scald

14 Thermal Burns Scald

15 Thermal Burns Steam/Flash

16 Contact Burn

17 Thermal Burns Contact

18 Thermal Burns Contact

19 Thermal Burns Contact

20 Hypothermic/Frostbite Occurs when the normal protective mechanisms of the skin are overcome by severe cold. Treatment involves rapid moist re-warming and localized wound care.

21 Chemical Burn First Aid Flush area with large quantities of water to dilute and remove the chemical from the skin. Eyes should be flushed with water or saline from the inner canthus laterally for at least 20 minutes and in transport. Dry chemicals should be brushed off the skin, then the area irrigated with large quantities of water. Take precautions to protect yourself and others from the chemicals.

22 Chemical Burn/Flash

23 Chemical Burn/Flash

24 Electrical Injury First Aid Do NOT touch the victim if still in contact with the current source. Turn off current. Seek emergency care

25 Electrical Burn May cause damage to skin and to internal tissues. EKG should be done on all patients with electrical burns. May see rhythm abnormalities after patient is stabilized.

26 Radiation Burn

27 Friction Injury

28 What do you need to know? What kind of burn is it? How severe is the burn? How big is the burn? (Type) (Depth) (%TBSA)

29 Depth of Burn Lay Classification First Degree Burn Classification Superficial Second Degree Superficial Partial Thickness Third Degree Fourth Degree Deep Partial Thickness Full Thickness

30 Depth of Burn All of these terms indicate the depth of injury in the layers of the skin

31 Skin Physiology Largest Organ 1-5 mm in thickness Number of functions Protection Immunologic Thermo-regulation Fluid & Electrolyte balance Metabolism Neurosensory Social & Interactive

32 Depth of Burn Superficial Burn Causes: Scalds, flash, flame, contact, chemical, UV light Surface Appearance: Dry, no blisters, minimal or no edema, erythematous. Pain: Painful Healing Time: 3-7 days with no scarring; may have discoloration

33 Depth of Burn Superficial Partial Thickness Burn Causes: Scalds, flash, flame, contact, chemical, UV light Surface Appearance: Moist blisters, underlying tissue reddened, wound BLANCHES Pain: Painful Healing Time: 7-21 days; generally no scarring and minimal discoloration

34 Depth of Burn Deep Partial Thickness Burn Causes: Scalds, flash, flame, contact, chemical Surface Appearance: Moist open blisters, underlying tissue mottled red or yellow eschar, with poor blanching Pain: Painful, may have decreased sensation in center Healing Time: days with no infection, scarring likely

35 Depth of Burn Full Thickness Burn Causes: Scalds, flash, flame, contact, chemical, electrical Surface Appearance: Dry, leathery eschar. Mixed white, waxy, pearly in color. Pain: Insensate in center but painful at edges Healing Time: Very long without grafting and always scars. Small areas may heal without grafting but scarring will be severe.

36 What do you need to know? What kind of burn is it? How severe is the burn? How big is the burn? (Type) (Depth) (%TBSA)

37 Calculating % TBSA 9% 9% 36% 9% Lund & Browder Chart 13% 15% 1% 18% 18% 33% 9% 9% 18% 18% 33% 9% 9% 17% 17% 17% 35% 9% 9% 15% 15% 18% 9% 9% 36% 14% 14% Adult Infant

38 Calculating % TBSA Lund & Browder Chart Do not include superficial burns in TBSA calculation.

39 Calculating % TBSA Palmar Method 1% TBSA = Surface area of the PATIENT S Palm = 1%

40 Lund & Browder 17.5% TBSA Entire Chest/Abdomen Less than half of chest approx. 8%

41 Palmar Method 1%

42 Abuse & Neglect According to the US Department of Health and Human Services (2010) An estimated 695,000 children were found to be victims of child abuse and neglect in 2010 Approximately 1,560 children died in the U.S. in 2010 from abuse and neglect.

43 Treatment of Burn Wound

44 Initial Wound Care Remove burned clothing and all jewelry if possible Elevate burned extremities to 45 to decrease swelling Apply sterile DRY dressings if patient is being transferred to a burn center. Do not apply ice, ointments, or creams for transport. Do not apply tight or elastic bandages (i.e. coban) Maintain body heat wrap in blankets, prevent unnecessary exposure of body for large burns

45 Antibiotic Ointments Use to treat superficial partial thickness wounds

46 Chemical Debriding Agents Used to treat deep partial thickness and some full thickness burns Collagenase: Enzymatic Debriding Agent

47 Antimicrobials Antimicrobial Creams

48 Dressing Materials Dry sterile wrap Gauze dressing Occlusive dressing Silver Gauze Wound Open to Air

49 Crystallized Silver Gauze Used treat partial thickness burns Acticoat (layered) Aquacell (hydrofiber)

50 Infection Control Hand hygiene Antibiotic prophylaxis NOT needed Match the Bug with the Drug

51 Infection Control An infected burn wound may demonstrate: Increase in wound size or amount of drainage Tender to touch, more red than usual Swollen, smells foul, red streaks present, a pink, warm, swollen area surrounding the wound Fever may also be present

52 Follow-Up Evaluation Frequency of follow-up/wound assessment will depend on size, depth, and characteristics of burn. Partial thickness burns should be re-assessed within at least hours, as it takes approximately 2-3 days for a burn wound to declare itself. Injury may initially appear as a superficial partial thickness burn that will heal without grafting 72 hours later, may have increased eschar that requires excision and grafting This is not an incorrect initial diagnosis, it is part of the progression of a burn. It may be helpful to prepare families for this possibility at the initial visit.

53 Comfort Management Outpatient pain management of burn wounds: Tylenol Motrin Codeine

54 Itching Itching is a common problem with newly healed skin. Can be caused by dryness of the skin. It may be worse at night or in the heat Perspiration can cause itching These are some ways to decrease the itching: Cream the areas frequently with non-perfumed moisturizing cream or lotion. Avoid direct sunlight on the newly healed skin, even in the cooler weather. If a child is going outside, apply a strong sun block frequently (at least 30 SPF).

55 Outpatient management of itch: Creaming/ Massaging Aveeno baths and lotion Benadryl Atarax Loratadine (Claritin) Allow skin adequate time to dry after bathing and skin care prior to pressure garments and splints

56 Scars Scarring is common after a burn. Generally, burns that heal within 14 days without grafting, are unlikely to scar. Each child heals differently. It is impossible to predict how the child will heal and re-pigment. Scars will appear to get worse before they get better: Raised and pink initially The scars are at their peak at 4 to 6 months, Children are often fitted with pressure garments to decrease scarring. Over time, the scars will get softer and less red (mature). This generally takes about 1 year

57 Outcomes Partial Thickness Burn Admission 2 years later

58 Thank you! Rob Sheridan