Burn Priorities of Care: Triage/Treatment/Transfer. Via Christi Regional Burn Center Sarah Fischer, MSN, RN

Transcription

1 Burn Priorities of Care: Triage/Treatment/Transfer Via Christi Regional Burn Center Sarah Fischer, MSN, RN

2 Disclosure I have nothing to disclose

3 Objectives Identify American Burn Association referral criteria Explain the difference between partial and full thickness burns Calculate TBSA using Rule of Nines Explore the priorities of initial assessment and management of the burn patient Describe best practice for patient transport

4 74 y.o. male 46% TBSA flame burn What are your greatest concerns? Is there any other information you want to know? What is your priority intervention?

5 Function of the Skin

6 Superficial Burn 1 st degree Epidermis only Pink to red Painful No blisters Heals in 3-5 days Not included in calculation %TBSA

7 Partial Thickness Burn 2 nd degree Epidermis and part of dermis Heal without surgical intervention Blisters Large or small May not appear initially Continue to develop Wet and weepy Very painful Blanches Heals in 7-21 days

8 Partial Thickness Burn 2 nd degree Admission Day 11 Day 4

9 Full Thickness Burn 3 rd degree Epidermis, dermis, subcutaneous tissue Surgical intervention Insensate No blanching or capillary refill Charred, bright red, marbled, leathery, tan, waxy, or pearly white Tight, non-elastic

10 Full Thickness Burn 3 rd degree

11 Rule of Nines

12 Primary Assessment: Life and Limb Airway Maintain c-spine precautions Breathing Circulation, cardiac status, CPR Disability, Deformity, Neurological Deficit Expose, Examine, Environment Stop the burning process Keep warm and dry Secondary assessment does not start until all of these elements are accounted for Including calculated fluid resuscitation

13 Precedence Over Burns Airway obstruction Cardiac arrest Spinal or head injury Open chest wounds Severe abdominal trauma Burn Center works closely with trauma for multisystem injuries Consult with Burn Center physician to ensure concurrent trauma activation

14 Primary Assessment - Airway Positioning Remove obstructions Suction 100% 02 per NRB Inhalation injury Supraglottic vs. Subglottic Intubate Loss of airway in the presence of upper airway edema is catastrophic

15 Intubation Clinical judgment Feel free to discuss with Burn Center Weigh the risks and benefits Laryngeal injury, tube misplacement, stenosis, fistula, swallowing impairment Err on the side of safety Loss of airway in the presence of upper airway edema is catastrophic Special considerations for end of life

16 Intubation Rapid Sequence Intubation By the most experienced person Route Orotracheal vs. nasotracheal Size of endotracheal tube Use standard sizes for age/body type Place the largest recommended size possible Secure the tube Place NG/OG

17 Primary Assessment - Airway

18 Primary Assessment - Airway

19 Pediatric Considerations Airway obstructs easily Avoid hyperextension Smaller oxygen reservoirs Limited compensatory mechanisms Weaker accessory muscles Intubation Be proactive Use appropriate size tube Cuffed endotracheal tube Secure tube

20 Primary Assessment Breathing Assess rate, depth, lung sounds Monitor for circumferential chest/torso burns Compromise of chest wall excursion and ventilation

21 Chest Escharotomies

22 Primary Assessment - Circulation CPR if indicated Control hemorrhage BP and pulse Normal pulse: bpm Hypotension: late sign of hypovolemia Edema can affect readings Circumferential burns Cardiac monitor

23 Fluid Resuscitation Two large bore IVs Adults > 20% TBSA Children > 15% TBSA Site selection Burned vs. unburned Peripheral vs. central Intraosseous Lactated Ringers D5LR for children < 30kg

24 Fluid Resuscitation Initial fluid resuscitation for major burns < 5 years old: 125 ml/hour 5-14 years old: 250 ml/hour > 14 years old: 500 ml/hour Consider an increased need with associated trauma and inhalation injury No boluses or diuretics Consult with burn physician Consensus Formula Fluid rates for minor burns

25 Consensus Formula Adult thermal and chemical 2 ml/kg/tbsa Pediatric (< 14 years old) 3 ml/kg/tbsa D5LR for children < 30kg High voltage injury (any age) 4 ml/kg/tbsa

26 Primary Assessment - Disability Glascow Coma Scale Level of consciousness Carbon monoxide Head injury Hypoxia Drugs & alcohol AVPU Deformity Disability

27 Primary Assessment - Environment Remove clothing, diapers, jewelry, metal Stop the burning process briefly Tar Chemicals No ice Cover with clean, dry sheet Keep warm Avoid hypothermia No gel-type blankets or dressings

28 History Mechanism of injury Associated injuries Chemical exposure Substance abuse Abuse or neglect Intentional injuries AMPLET Allergies Medications Past medical history Last meal or drink Events and environment Tetanus

29 ABA Referral Criteria Partial thickness burns > 10% Face, hands, feet, genitalia, perineum, joints Full thickness burns, any size Electrical injury, including lightning Chemical burns Inhalation injury Preexisting medical disorders that could complicate recovery Burns with concomitant trauma Children Social, emotional, rehab needs

30 Transport Monitor vital signs Assess extremity perfusion Administer pain medication Cover burns with clean linens Do not apply special dressings Saran Wrap Maintain body temperature Hypothermia can be lethal Documentation

31 Transport Physician to physician communication Referring physician provides: Demographic and historical data Result of primary and secondary surveys Receiving physician will give recommendations for transport Nurse to nurse communication Transport by trained personnel

32 74 y.o. male 46% TBSA flame burn What are your greatest concerns? Is there any other information you want to know? What is your priority intervention?

33 A: What might make you choose not to intubate? B: Ventilation becomes difficult. Now what? C: Where do you place sites? Does a history of CHF change fluid approach? D: Right radial pulse is absent. Priority interventions? E: HR is 72bpm. Are you concerned? Interventions? Secondary: What do you really want to know about history? Transport: When do you initiate transfer? Communication

34 References American Burn Association. (2016). Advanced burn life support. Herndon, D. (2012). Total burn care (4 th ed.). Edinburgh: Saunders Elsevier.

35 Thank You! Sarah Fischer, Burn Program Coordinator Via Christi Regional Burn Center Via Christi Dispatch